Every finding on record at Andrew Residence

Based on observation, interview, and document review, the facility failed to ensure the proper use of beard restraints during food preparation and meal service. This had the potential to affect all 191 residents who received food from the kitchen.Findings include:During observation and interview on 8/26/26 at 7:15 a.m., cook (C)-A was observed to have gray whiskers covering his chin and lower cheeks which were approximately 1/2 inch in length. He took the temperatures of oatmeal and scrambled eggs without wearing a beard restraint. When asked about beard restraints, C-A stated, Am I supposed to be wearing one?. He said no one in the kitchen wore beard coverings and would not even know where to find one if it was required.During observation and interview on 08/26/2026 at 7:20 a.m., C-B was observed to have black whiskers covering his chin and cheeks which were approximately one to two inches in length. He stirred separate pots of vegetables and chicken to be used in soup without wearing a beard restraint. C-B stated kitchen staff never wore beard coverings, and the facility had never required this. He said, We probably should be wearing them, since it's foodservice and all.During observation and interview on 08/26/2026 at 10:20 a.m., kitchen lead (KL)-A stated he thought beard restraints were required. When asked to indicate where staff could find beard restraints, KL-A specified a set of shelves in the kitchen which were designated for hygiene supplies. While the shelves had disposable gloves, hair restraints, and aprons, there were no beard restraints. KL-A stated it looked like they did not have any beard coverings and he would include this item on his next order. KL-A stated employees are required to keep all hair covered when preparing and serving food.The facility did not have a Food Service Director (FSD) on staff at the time of survey, and the Registered Dietitian (RD) was unavailable for interview.A policy titled Infection Control of the Food Service Department dated 6/19/19, directed staff to wear hair coverings and to keep mustaches, sideburns, and beards neatly trimmed.

Based on observation, interview, and document review, the facility failed to ensure hazards were removed for R1 per their care plan and failed to provide R2 with the necessary supervision to prevent elopement after being care planned to require supervision in the community. These failures resulted in Immediate Jeopardy (IJ) for two of two residents when R1 attempted suicide after identified care plan interventions were not thoroughly implemented and when R2 left the facility multiple times without staff knowledge with an increase in suicidal ideation and in dangerously high temperatures. The Immediate Jeopardy (IJ) began on 7/16/26 when it was identified the facility failed to thoroughly implement R1's safety plan of a personal belonging search after recent history of suicidal ideations and attempts to overdose on medication. R1 procured a bottle of Tylenol and alerted staff that they ingested it, which R1 previously indicated was their plan to do; and continued when the facility failed to implement appropriate supervision for R2, who had suicidal ideations to jump off a bridge, eloped on multiple occasions and was unable to be found for extended periods of time. On 7/28/26 at 4:38 p.m., the administrator, director of nursing (DON), second floor program director, third floor program director, fourth floor program director, clinical development coordinator, clinical coordinator, evening nurse manager, nursing services coordinator, and, over the phone, the director of clinical services was notified of the IJ. The IJ was removed on 7/30/26, after it was verified, the facility implemented an acceptable removal plan. However, non-compliance remained at a lower scope and severity of D, no actual harm, with potential for more than minimal harm.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses that included non-traumatic brain dysfunction, recurrent severe major depressive disorder without psychotic features, and autistic disorder. R1 had no cognitive impairment, had hallucinations, and demonstrated other behavioral symptoms not directed towards others which occurred 4 to 6 days during 7-day assessment period but less than daily. The MDS further identified R1 was independent with activities of daily living (ADLs).R1's Initial Treatment Plan dated 2/13/26, identified R1 had chronic passive suicidal ideation, with one noted escalation involving a plan (starving), daily visual hallucinations, low motivation for hygiene tasks, and mild anxiety related to adjustment. R1's Vulnerability Summary identified R1 had a pattern of drug/alcohol use or unprescribed use of over-the-counter drugs. R1 reported lack of urges to use and lack of funds kept R1 from thinking about purchasing substances. Interventions included discussing urges to use in weekly meetings and staff knowledge of historical use. The summary included R1 had severe psychiatric symptoms or cognitive deficits which significantly impaired judgment and functioning and displayed suicidal or self-injurious behaviors and/or thoughts which included previous suicide attempts of strangulation, overdose of medication, and starvation. R1 had reported daily passive suicidal ideation, with one instance of active suicidal ideation with a plan to starve, which R1 reported after the feeling passed. Interventions included regular check-ins about suicidal ideation in weekly meetings, knowledge of previous attempts, and when to increase monitoring.In review of R1's record, documentation pertaining to location checks, shift checks, and room checks were documented in progress notes if/when the tasks were performed.During interview on 7/22/26 at 10:17 a.m., mental health worker (MHW)-B stated the facility tracked residents who left the facility through an LOA (leave of absence) binder. Residents were supposed to sign out with staff via the binder, request medications needed ahead of time and indicate a return time. MHW-B stated she reviewed resident care plans if there was an increase in behavioral symptoms to ensure she followed proper interventions. MHW-B stated she completed a suicide risk assessment and created a safety plan when a resident made a suicidal statement to determine if the suicidal ideation was passive or active. MHW -B stated residents who needed more frequent than one hour location checks were sent to emergency services. MHW -B indicated shift checks were documented in the progress notes. Location checks were on a physical paper and documented in progress notes.R1's progress note dated 3/4/26 at 9:53 a.m., identified R1 had brief urges to use [substances] but felt the feelings were easy to ignore due to not having money available and was not sure how their self-control would be after R1 had money. A suicide risk assessment was completed after R1 disclosed they had increased suicide ideation over the weekend, and R1 was identified at low risk.R1's progress note dated 3/10/26 at 11:14 a.m., identified R1 had a psychiatrist appointment and increased dose of antipsychotic medication, attended therapy groups, and played games the past week.R1's progress note dated 3/11/26 at 4:44 p.m., identified R1 had suicidal ideation with a plan, indicated the hospital could make [R1] eat if it [came] down to it, and went to a psychiatric emergency unit.R1's progress note dated 3/11/26 at 11:03 p.m., indicated R1 returned from the psychiatric emergency unit at 5:30 p.m. and was placed on shift checks.R1's progress note dated 3/13/26 at 11:13 p.m., indicated R1 reported an increase in suicidal ideation, tried coping skills, and thoughts were still bad. R1 was assessed by a mobile mental health crisis intervention program and transferred to an emergency psychiatric unit.R1's MDS tracking entry dated 3/13/26, identified R1 had an unplanned discharge from the facility and a return was anticipated.R1's admission MDS dated [DATE], identified R1 admitted to the facility 4/22/26 with diagnoses which included schizophrenia, post-traumatic stress disorder, borderline personality disorder, obsessive-compulsive disorder, and attention-deficit hyperactivity disorder.R1's Initial Treatment Plan dated 4/22/26, identified R1's Vulnerability Summary remained similar to the 2/13/26 summary, which indicated R1 had pattern of drug/alcohol use or unprescribed use of over-the-counter drugs, severe psychiatric symptoms or cognitive deficits which significantly impaired judgment and functioning, and displayed suicidal or self-injurious behaviors and/or thoughts.R1's care plan intervention dated 4/22/26, directed staff to conduct safety checks to remove items which could be used to engage in self-harm, which included plastic garbage bags. Safety checks were to occur when R1 reported an increase in suicidal ideation (frequency was not defined), suicidal ideation with a plan, and/or urges to engage in self-injurious behavior. Staff will be aware at baseline, R1 reported experiencing suicidal ideation daily, primarily passive in nature. R1 indicated approximately once or twice per month, R1 had episodes which involved more active planning and became increasingly withdrawn. R1 identified coping strategies, such as art, knitting, drawing, and programming.R1's progress note from psychologist dated 5/4/26, indicated R1 had a suicidal plan, but no intent or behavior, multiple risk factors, and few protective factors. Plan was to refer R1 to mental health treatment program, continue psychiatric care, and utilize emergency resources if needed.R1's psychiatric visit After Visit Summary (AVS) dated 5/7/26, indicated R1's psychiatrist reviewed R1's medications, had an appointment scheduled 5/13/26 for a mental health treatment program, and was to return for a follow-up visit around 6/4/26.R1's progress note dated 5/20/26 at 5:13 p.m., indicated R1 reviewed goals of medication management, receiving money from GA (general assistance; a program which provides monthly cash grants for vulnerable persons), budgeting, money management, recognizing early warning signs and reporting substance use urges to staff.R1's psychiatric visit AVS dated 6/4/26, indicated R1's psychiatrist ordered changes to R1's medications and a follow-up visit around 7/2/26. The summary identified group visits/day treatment groups for R1 to attend. R1's psychiatric referral form, identified R1 reported their symptoms were stable and had an improved baseline for passive suicidal ideation. R1 indicated they were able to distract themselves from daily fleeting thoughts.R1's Suicide Risk Assessment on 6/14/26 at 11:36 a.m., identified R1 expressed suicidal ideation and/or thoughts of self-harm and was assessed as a low risk with no suicidal plan, intent or behavior and had modifiable risk factors and strong protective factors. R1 identified dreaming about family members triggered strong emotions. R1 stated when they got paid next early next month they would purchase eye drops to drink because they have a poison in them. The note identified R1 saw an individual therapist and attended day treatment, and R1 did not have money at the time to act on their plan. R1 planned to knit and listen to music.In review of R1's record, although R1's care plan directed staff to conduct safety checks to remove items that could be used for self-harm when R1 expressed increased suicidal ideation, suicidal ideation with a plan, and/or urges to engage in self-injurious behavior, following R1's disclosure on 6/14/26 of a specific plan to ingest eye drops after receiving money, there was no documentation staff completed a room safety check, removed potentially harmful items, implemented additional coping interventions, or evaluated whether revisions to R1's existing safety plan or care plan were effective.On 6/14/26 at 2:28 p.m., R1 identified plans to walk to a bridge, and R1 agreed to transfer to a hospital for assessment and potential admission. R1's mental health hospital after visit summary dated 6/14/26 indicated R1's admitting diagnoses were major depressive disorder, recurrent, moderate. The summary included a [NAME]-Brown safety plan dated 6/18/26 identified R1 had racing thoughts, inability to stop worrying, and obsessive thoughts were R1's warning signs a crisis was beginning or getting worse. R1 identified internal coping strategies, such as deep breathing, grounding skills, and listening to music. R1's Plan for Lethal Means Safety identified talking to staff about less financial independence and chemical management, such as taking medications and not drinking too much caffeine.R1 returned to the facility on 6/19/26 following psychiatric hospitalization after expressing plans to ingest eye drops and jump from a bridge. While the hospital safety plan identified reducing access to potentially lethal means and discussing reduced financial independence, the facility documentation did not identify whether these strategies were implemented upon R1's return.R1's progress note dated 6/19/26 at 2:58 p.m., indicated R1 returned to the facility around 1:30 p.m. and identified excessive caffeine intake led to a panic attack and hospitalization due to increased suicidal ideation. R1 planned to knit, watch YouTube, and relax.R1's progress notes dated 6/19/26 to 6/21/26, indicated R1 was on shift checks post hospitalization and did not have increased suicidal ideation.R1's care plan intervention dated 6/21/26 (three days after hospital discharge), directed staff to provide education related to the impact of caffeine on psychiatric symptoms and subsequent suicidal ideation and support consumption reduction at least monthly.R1's progress note dated 6/21/26 at 3:16 p.m., indicated R1 had a bright and friendly affect, felt good, and would approach staff if R1 needed anything. R1 indicated they were going to walk the beach and knit for a few hours with a return time of 3:00 p.m. The progress note identified R1 was out for a majority of the day. R1's Vulnerability Assessment and Abuse Prevention Plan, originally initiated on 2/11/26 and updated throughout R1's admission, served as an ongoing assessment of resident-specific safety risks and vulnerabilities. The assessment evaluated multiple areas affecting resident safety, including the ability to safely function in the community, recognize safety hazards, manage medications, substance use, psychiatric symptoms, suicidal thoughts and behaviors, and leaving the facility without returning within the designated timeframe. Review of the assessment in effect on 6/21/26 identified R1 was documented as Not Vulnerable for the ability to safely conduct activities in the community and Not Vulnerable for leaving the facility without following facility procedure or returning within the designated timeframe, despite documentation elsewhere in the assessment identifying chronic suicidal ideation, multiple prior suicide attempts, severe psychiatric symptoms, and recent psychiatric hospitalization.In review of R1's record before R1 left the facility, the available record did not identify documentation explaining how R1's recent psychiatric hospitalization and escalating suicide-related risks and vulnerabilities were considered in the facility's determination that R1 could safely leave the facility independently.R1's progress note dated 6/21/26 at 10:47 p.m., indicated R1 did not return around 3:00 p.m. and phone calls to R1 were unsuccessful. The police were notified and arrived at the facility at 10:20 p.m. to complete a Missing Person Report.R1's progress note dated 6/22/26 at 7:09 a.m., indicated R1 called the facility at approximately 11:40 p.m., and R1 indicated they had run away. R1 gave their location, so the police could find R1. Around 12:30 a.m. on 6/22/26, R1 confirmed they were with the police and transferring to the hospital.Hospital notes dated 6/22/26 were requested but not provided. R1's progress note dated 6/22/26 at 3:02 p.m., indicated R1 returned to the facility at 9:30 a.m. and continued to have suicidal ideation via starvation, dehydration, and/or consumption of poisonous chemicals/medications. A mobile mental health crisis intervention program met with R1 from 11:10 a.m. to 12:00 p.m. to create a safety plan, and R1 was placed on one hour safety checks.R1's Suicide Risk Assessment on 6/22/26 at 5:21 p.m., identified R1 expressed suicidal ideation and/or thoughts of self-harm. R1 planned to jump off a bridge with no intent, starve themselves, and poison themselves with eye drop solution with no means. The assessment identified R1 was at moderate risk due to having a suicidal plan but no intent or behavior. The assessment lacked documentation of a room check per care plan.R1's progress note dated 6/22/26 at 8:54 p.m., indicated R1 was transferred to an emergency psychiatric unit after R1 indicated they had no desire to follow the safety plan, rather only said so because that's what staff 'wanted to hear', endorsed feeling a 'fascination with death', and R1 had no intent to refrain from making plans associated with [suicidal ideation].In review of R1's record on 6/22/26, R1 again identified multiple suicide methods, including jumping from a bridge, starvation, and ingesting poisonous eye drop solution. Although R1's care plan directed staff to complete room safety checks when suicidal ideation with a plan was expressed, the record did not contain documentation that a room safety check was completed before R1 was transferred for psychiatric evaluation.R1's emergency department AVS dated 6/22/26 to 6/23/26, indicated R1 arrived on 6/22/26 at 8:17 p.m. for diagnosis of post-traumatic stress syndrome. The summary indicated there were no medication changes. The summary included [NAME]-Brown Safety Plan dated 6/23/26, identified additional internal coping strategies and social setting to provide distraction. The plan identified the facility could make the environment safer by securing medications and removing items R1 could use to hurt self.R1's progress note dated 6/23/26 at 9:07 p.m., indicated a nurse assessed R1 after R1 engaged in self-harm by using yarn to choke self. R1 had bruising around front and sides of neck and did not appear to be in physical distress. A mobile mental health crisis intervention program was called to the facility.R1's progress note dated 6/23/26 at 10:23 p.m., indicated R1 returned from the hospital and reported high suicidal ideation and no plan or intent. R1 was on shift checks post Missing Resident Incident Report on 6/21/26 and hospitalization on 6/22/26, as well as one hour location checks. Around 6:15 p.m., R1 reported increased suicidal symptoms and an attempt to self-harm by tightening a string of yarn around their neck. Staff completed a room search and called the mobile mental health crisis intervention program.R1's Incident Report dated 6/23/26, identified staff completed a room search while waiting for a mobile mental health crisis intervention program to arrive and removed the following items from R1's room: a bunch of yarn, three pairs of scissors, two razors, and cables. A mobile mental health crisis intervention program arrived at 7:40 p.m., and R1 agreed to transfer to the psychiatric emergency unit. R1 indicated they felt safer at the hospital due to having less access to 'things.R1's acute psychiatric unit After Visit Summary dated 6/23/26, indicated R1 was seen for suicidal ideation and was admitted to the emergency department for observation. The summary directed R1 to follow-up with day treatment and with emergency services if symptoms worsen. R1's emergency department arrival time was noted as 6/23/26 at 8:37 p.m. and discharge on [DATE] at 2:11 p.m. Facility did not provide pages six through ten.R1's progress note dated 6/24/26 at 11:07 p.m., indicated R1 returned to the facility at 2:27 p.m. and reported they felt so -so. R1 indicated the hospital says I'm fine and told R1 to keep doing what R1 was doing such as engaging in groups and initiating a therapist. The note indicated R1 and facility staff created a safety plan which involved R1 approaching staff if they had drastic changes in their plans and to stay curious about therapy. R1 was on shift checks as well as one hour location checks.R1's care plan was revised with intervention dated 6/24/26 that directed staff will assist R1 in initiating trauma-focused therapy to support the development of coping skills and help manage on-going symptoms related to suicidal ideation.R1's progress note dated 6/25/26 at 3:59 p.m., indicated R1 had a blunted affect and continued feelings of overwhelm. R1 lacked desire to eat/drink, indicated they felt safe and had no specific plan of suicide at the time. R1 was provided with water and a snack and then ate lunch. R1 agreed to come to staff if symptoms worsened.R1's progress note dated 6/26/26 at 2:39 p.m., indicated R1's location checks were changed from one hour to two hours, and R1 reported no current suicidal ideation and no safety concerns.R1's progress note dated 6/26/26 at 10:54 p.m., indicated R1 felt ok and had a little passive suicidal ideation. R1 was encouraged to notify staff for support if needed and R1 agreed.R1's progress note dated 6/27/26 at 10:53 p.m., indicated R1's location checks were changed from two hours to four hours. R1 indicated they had passive suicidal ideation and was able to come to staff if needed.R1's progress notes dated 6/28/26, indicated R1 felt ok with no increases in suicidal ideation. No concerning observations or symptoms were noted.R1's progress note dated 6/29/26 at 7:09 a.m., indicated R1's location checks were discontinued, and staff continued shift checks and was seen without concern during the two location checks.R1's progress note dated 6/29/26 at 3:05 p.m., indicated R1 had passive suicidal ideation with no plan or intent and was eating normally again.R1's progress note dated 6/30/26 at 3:08 p.m., indicated R1 reported no suicidal ideation beyond baseline and was encouraged to reach out to staff if R1 felt they needed anything. Shift checks were discontinued.Review of R1's June 2026 record identified that although R1's documented suicide risk continued to increase, including multiple psychiatric hospitalizations, repeated suicide plans involving different methods, a Missing Person incident associated with suicidal ideation, a recent self-harm attempt involving yarn around the neck, and newly identified suicide plans involving ingestion of eye drops for poisoning, and jumping from a bridge, the facility progressively reduced and ultimately discontinued monitoring and safety interventions. The record did not identify how R1's cumulative history of suicidal behaviors, identified suicide methods, and recurring psychiatric crises was evaluated in determining that reduction of monitoring and safety interventions and continued independent community access remained appropriate and/or effective.R1's progress notes dated 7/2/26 at 5:52 a.m., indicated R1 approached a nurse around 12:20 a.m. and told the nurse they ingested four bottles of Visine eye drops (active ingredients: tetrahydrozoline hydrocholoride 0.05%), total 60 mL [milliliters] around 9:00 p.m. to kill themselves. R1's skin was cold and clammy. Vitals were 99 degrees Fahrenheit (F) via tympanic (ear) temperature, blood pressure 162/98 mmHg (millimeters of mercury) standing, pulse 49 bpm (beats each minute), respiration rate of 20 breaths per minute, and oxygen saturation on room air was 98 percent. Staff called poison control, called 911, and R1 was taken to the emergency room around 12:50 a.m. Staff conducted a room search and found three empty bottles of Visine (15 mL per bottle).R1's care plan revised on 7/6/26 included interventions that informed staff of R1's ingestion of Visine and directed staff to remove Visine during safety checks (frequency as identified on 4/22/26 care plan).R1's care plan intervention dated 7/8/26, directed staff to assess R1's suicidal ideation and develop a safety plan before withdrawing money or using bank card. A safety plan could include room safety check, requesting purchase receipts, staff support to make purchases, and precaution checks. Another intervention indicated R1 would discuss planned money withdrawals with the program manager or an alternative staff member to ensure R1's safety before money withdrawal process.On 7/10/26, the facility educated staff on shift report documentation guidelines. The education directed staff to discuss previously identified suicide methods and determine if the method remained relevant before returning a resident to routine monitoring. Staff were to document clinical rationale to support discontinuation of precaution checks. Staff were directed to document when a resident identified a new suicidal plan and care plan intervention.R1's hospital notes and summary dated 7/2/26 to 7/16/26, indicated R1 presented after consumption of Visine; upon arrival at 8:16 a.m. R1's blood pressure was 86/52 (normal) the summary indicated R1 was calm, cooperative and pleasant. R1 was disappointed their suicide attempt failed and wanted to see what the afterlife was like. R1 indicated they continued to have thoughts about death despite day treatment, therapy, and medications. R1 stated they wanted to buy eight bottles of Visine but the store only had four available. R1 indicated they had a concealed plan to overdose on Tylenol and jump off a bridge upon discharge to the facility. R1 was placed on a one-to-one in the hospital until psychiatric clearance. R1 indicated they read Visine ingestion lowered blood pressure and could be fatal and was ruminating on Visine ingestion two to three weeks before R1 acted on the thought.R1's hospital inpatient behavioral health treatment plan, initiated 7/2/26, identified a problem of inadequate coping. Goals included improving R1's ability to verbalize feelings related to emotional state, verbalize adaptive coping mechanisms, and identify personal strengths. Interventions included encouraging R1 to verbalize feelings, fears, stressors, and problems; participate in care and diversionary activities; engage in physical activity as tolerated; collaborate with mental health services; and utilize adaptive coping strategies, such as distraction and deep-breathing exercises.Upon R1's return to the facility, R1's Vulnerability Assessment identified the Visine ingestion with no other changes documented on the assessment.R1's Suicide Risk Assessment on 7/16/26 at 12:21 p.m., indicated R1 was a low risk and identified passive baseline suicidal ideation with no plan or intent.R1's progress note dated 7/16/26 at 2:52 p.m., identified R1 returned to the facility around 10:30 a.m. Staff searched through R1's belongings and removed deodorant. R1 had medication changes, an initial therapy appointment scheduled for the next week, and opened a bank account with the facility to create a safety plan. R1 was on shift checks post-hospitalization. Staff initiated a conversation with R1 about whether the facility was the right environment for them.R1's progress note dated 7/16/26 at 10:58 p.m., indicated licensed social worker (LISW)-A and R1 created a plan for R1 to order snacks with a virtual card and staff would check the bag. Staff checked the bag when the snacks arrived and no concerns were documented. R1 shared plans to rest in room and watch YouTube. R1's progress note dated 7/17/26 at 2:47 p.m., indicated R1 felt less anxious and stressed, and more relaxed since a medication change. R1 indicated they had passive not active suicidal ideation and no plan or means.R1's care plan intervention dated 7/17/26, indicated R1 had funds in an online application and would review purchases weekly with the program manager. The program manager would provide additional prompts if R1 reported an increase in suicidal ideation. R1 would notify staff when a purchase was made, and staff would conduct a search of the purchased items to remove any items identified as a safety risk.R1's progress note dated 7/18/26 at 2:30 p.m., indicated R1 felt unsafe and reported they ingested a whole bottle of Tylenol and just now feeling the effects. Staff transported R1 to the emergency department around 1:00 p.m. and found one empty bottle of 100 capsules of Tylenol extra strength 500 mg (milligrams) each.R1's progress note dated 7/18/26 at 3:05 p.m., R1 came up to staff around 12:30 p.m. (7/8/26) and reported they hid a bottle of Tylenol in a bag of donuts when they ordered snacks and took the whole [bottle of Tylenol] on 7/16/26 around 10:00 p.m. (approximately 12 hours after hospital return.)R1's progress note dated 7/18/26 at 11:06 p.m., indicated R1 was admitted to the hospital due to elevated serum Tylenol levels and suicidal ideation.R1's progress note dated 7/19/26 at 10:31 a.m., indicated R1 was in the hospital with a one-to-one at bedside for safety.R1's progress note dated 7/22/26 at 9:36 a.m., indicated R1 was medically cleared and waiting for an open bed in the inpatient psychiatry area. R1 had a one-to-one for elopement and safety risk in the hospital.R1's Medicine Discharge summary dated [DATE], indicated R1 admitted [DATE] after intentional ingestion of approximately 100 tablets of acetaminophen 500 mg over 7/16/26 and 7/17/26. Initial R1's acetaminophen (Tylenol) blood level was 76 mcg/mL (therapeutic blood concentration is 10-30 mcg/mL; treatment decisions after an overdose are based on the time since ingestion and the Rumack-[NAME] nomogram rather than the blood level alone). R1's liver function tests and International Normalized Ratio (INR), a measure of the blood's ability to clot, remained within normal limits. R1 was treated with intravenous N-acetylcysteine (NAC), the antidote used to prevent acetaminophen-induced liver injury. Repeat acetaminophen level was less than 5 and AST/ALT (liver function blood tests) remained normal. R1 was medically stable for inpatient psychiatry transfer. Review of R1's record following Tylenol ingestion identified although the facility implemented and revised suicide prevention interventions following multiple psychiatric crises, the record demonstrated a recurring pattern of temporary stabilization followed by renewed suicidal ideation requiring additional emergency intervention. The record did not consistently identify how the effectiveness of previously implemented interventions including coping strategies was evaluated before modifying/discontinuing supervision or environmental safety interventions including supervision. During interview on 7/22/26 at 4:45 p.m., MHW-C stated R1 was usually quiet and stayed in their room a lot. R1 had continuous, passive suicidal ideation. MHW-C stated R1 was fascinated with afterlife and was sent to the hospital when they had an increase in suicidal ideation and then would be discharged from the hospital back to the facility and then sent back to the hospital. MHW-C stated she looked through R1's snacks on 7/16/26. MHW-C indicated she placed R1's tote on a desk, unzipped the bag, and moved items around to see two bags of donuts, three Mountain [NAME], and Sun Chips. MHW-C did not note any items of concern.During interview on 7/22/26 at 1:47 p.m., mental health worker (MHW)-A reviewed R1's plans to jump off a bridge and ingest eye drops on 6/14/26 and stated the facility moved R1's money to the facility to help track purchases but was unsure what date the intervention was added to the care plan. MHW-A reviewed R1's attempt to tighten yarn around their neck and was unsure where R1 got the yarn. MHW-A stated R1 came to him around 2:00 p.m. on 7/18/26 and indicated they had not been honest with staff about their level of suicidal ideation, had ingested Tylenol, and felt physically unwell. MHW-A stated R1 was on shift checks following hospitalization, staff followed R1's care plan by looking through R1's snacks after the purchase on 7/16/26, and he completed a room search on 7/18/26 after R1's report, finding an empty bottle of Tylenol and a bag of donuts with a resealable opening. MHW-A stated program managers were assigned to each resident, and the program manager worked with the resident to create an initial treatment plan using the resident's history, hospital records, and assessments completed by the social workers. The treatment plan identified resident vulnerabilities, which were discussed during weekly staff meetings, through emails, and by review of the care plan and progress notes. MHW-A stated check-ins were completed immediately when a resident returned from hospitalization. Shift checks were completed for nine shifts following any psychiatric-related hospitalization and included talking with the residents about suicidal ideation and symptoms. Location checks varied from every one hour to every eight hours and did not require conversation with the residents.During interview on 7/27/26 at 12:04 p.m., social worker (SW)-B staff completed vulnerability assessments and basic living skills assessments to determine if residents could be safe in the community. SW-B stated the vulnerability assessment was completed upon admission and then updated as needed.During interview on 7/23/26 at 12:47 p.m., registered nurse (RN)-A stated staff did not hold R1's supplies, and R1 kept knitting supplies in their room until after the incident when R1 tightened the yarn around their neck. RN-A indicated residents with a history of self-injurious behavior, such as strangulation, and increased suicidal ideation should not have rope-like items in their room, such as yarn, and staff should remove anything sharp or any other objects which could be used in the wrong way.During interview on 7/23/26 at 1:38 p.m., RN-B indicated residents with a history of strangulation should not have yarn in their room. RN-B indicated supplies which could be used for strangulation should be kept behind the staff desk, and residents could use identified supplies with supervision. RN-B stated she had not completed many bag searches but would put on gloves, open bag, and complete a visual inspection to ensure there were not any items which were stick-like or pointed.During interview on 7/22/26 at 3:32 p.m., licensed independent clinical social worker (LICSW)-A, who was the program manager for R1 and the program director for the floor where R1 resided, stated R1 was good the first few months at the facility and was honest and open about increased suicidal symptoms. R1 was readmitted to the facility on [DATE] after a hospitalization, which exceeded the facility's 18-day bed hold pol

Based on interview, observation, and record review the facility failed to immediately respond, investigate timely, and implement resident protections for 4 of 4 residents (R1, R2, R3, R4) after an allegation of sexual abuse of R1 by R2 was reported, which resulted in subsequent sexual abuse for R3 and R4. The immediate jeopardy began on 11/7/25 at 1:30 p.m., when R1's family member (FM)-A reported unwanted sexual touching, by R2 to R1 while the residents were in R1's room, to the Social Worker (SW)-A and the facility failed to timely report the incident to the State Agency, begin an investigation, and place resident protections to ensure other vulnerable residents at risk of sexual abuse were safe. The director of clinical services (DCS)-A and director of nursing (DON) were notified of the immediate jeopardy at 5:02 p.m. on 11/20/25. The immediate jeopardy was removed on 11/21/25, but noncompliance remained at the lower scope and severity level D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses that included bipolar disorder, (a mental health condition characterized by extreme shifts in mood, energy and activity levels), anxiety, post-traumatic stress disorder and depression, and borderline personality disorder (a mental health condition characterized by long-term patterns of unstable emotions, relationships, and self-image, leading to impulsive and self-destructive behavior.)R1's care plan dated 10/3/24 indicated R1 was at risk for and/or had a history of sexual victimization and dated 5/27/25 indicated R1 exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her. R1's Interpersonal Skills Assessment (IPS) assessment dated [DATE], indicated a history of sexual trauma and victimization related to being sexually trafficked. R1's progress notes dated 11/13/25 at 1:35 p.m., entered as a late entry for 11/7/25 at 1:30 p.m., revealed R1's family member called the facility, spoke to SW-A, and reported someone had gone in R1's room and made sexual advances towards R1.R2 R2's annual MDS dated [DATE] indicated intact cognition and diagnoses that included paranoid schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a break from reality that may include symptoms of paranoia, false beliefs, seeing or hearing things that are not there, disorganized thinking and speech, and lack of normal emotional expression.) R2's care plan dated 11/13/25, indicated R2 displayed sexually exploitive behavior with interventions that included restriction from visiting all other residential floors, and consider precaution checks as needed. On 11/17/25, the care plan was adjusted to restrict R2 from other residential floors, female rooms, and the short hall of R2's residential floor and for staff to remind R2 weekly and as needed of behavioral expectations related to not exposing himself or asking other residents to engage in any sexual activity.R2's IPS assessment dated [DATE] indicated when R2 was symptomatic, misperceived communication from others resulting in interpersonal conflict. R2 had a history of participating in unwanted physical contact and violating no-contact orders. R2 understood others must have the capacity to consent to sexual activity before and throughout the activity and demonstrated knowledge of consent. The Assessment indicated no care plan in place for sexual exploitation or other vulnerability related to sexual health at the time of assessment. The assessment lacked indication of a care plan to address behaviors when symptomatic, despite a history of unwanted physical contact and violations of no-contact orders.R2's progress notes indicated the following:-11/12/25 at 10:58 p.m., indicated a resident [R4] reported unwanted advancements from R2. Staff spoke to R2, who stated he was getting mixed signals from the other resident but agreed to respect others' boundaries. Staff restricted R2 from visiting R4's floor (3rd).-11/13/25 at 6:56 a.m., R2 was noted to be on the 3rd floor, found in R4's room having consensual sex with her roommate. Progress note did not indicate any immediate action or supervision to ensure R2's stayed off 3rd floor.-11/13/25 at 3:15 p.m., indicated R2 was placed on 1-hour location checks and shift checks due to multiple incidents of inappropriate interaction with numerous residents.-11/17/25 at 11:00 p.m., indicated staff met with R2 after R2 exposed himself to another resident (R3). R2 was prohibited from entering other residential floors, female rooms, and the other hall of his own floor. Staff included police in the discussion with R2.-11/18/25 at 6:44 a.m., indicated R2 remained on 1-hour location checks and shift checks due to multiple incidents on 11/12/25, 11/13/25, and 11/17/25 and post SA reports on 11/13/25 and 11/17/25 related to R2's poor sexual boundaries.-11/19/25 at 10:49 p.m., indicated interventions were added to R2's care plan - R2 was restricted from visiting other residential floors, female rooms, and the short hall of his own residential floor.During an interview on 11/20/25 at 10:59 a.m., FM-A stated on 11/7/25, R1 reported a male resident came into her room and made sexual advances towards her, would back off, and then would try again. R1 did not want FM-A to report the incident to the facility but FM-A called the facility on 11/7/25 and reported the incident to the SW-A so it would not happen to anyone else. During an interview on 11/20/25 at 1:03 p.m., SW-A stated she became aware of an incident between R1, and R2 after FM-A called on 11/7/25, and reported unwanted touch by R2 to R1. SW-A stated she attempted to call R1 several times after the report to inquire about the details of the incident but was unable to reach her as she was already on leave from the facility. SW-A stated she reported the incident to an evening staff, but didn't recall who, and acknowledged she had not documented the report from FM-A, the report to the evening staff, or the attempted phone calls to R1. SW-A further stated she did not tell administrative staff about FM-A's report because without talking to R1 first about the details of the incident, there was not enough information at the time to make a report to the State. SW-A stated she told the program director (PD)-A about the incident in passing on her way out of the building, after her shift but had not documented that either. SW-A acknowledged if a resident reported unwanted touch by another resident, the event would be reportable within two hours of the incident or within two hours of staff knowing about the incident, but thought she would need to obtain full details of the incident before making the report. SW-A was then off work for four days and started to follow up on the report when she returned to work on 11/12/25.During an interview on 11/21/25 at 11:01 a.m., R1 stated she reported the incident to her parents because authority figures at the facility freak me out. [R2] went further than he should have. R1 informed her parents she was harassed, and had to yell at R2 and threaten to pull the alert cord to get staff's help because R2 would not leave her room. R1 stated she went to R2's room to look at something he wanted to sell and then left his room and went back to her own room. About 5 minutes later, R2 came to R1's room with a scarf he thought R1 would like, and R1 stated she wanted the scarf. R1 showed R2 old pictures from her high school yearbook, and thought maybe R2 liked her because she showed him pretty pictures of herself. R1 stated she allowed R2 to lay on her bed with her but stated she did not want anything sexual to happen, did not want to kiss, and kept saying no. R1 told R2 she never wanted to have sex with him and R2 was shocked and asked, Never? R1 said no, she was gay and was not interested in any man. R1 told R2 she didn't like any penis, and R2 kept saying R1 might like to see it, and then R2 exposed himself and told R1 she had never tried sex with him, and she might like it. R2 reached across R1, who was lying on her bed and, He used that opportunity to kind of grind on me. R1 yelled at R2 and threatened to use the pull cord to summon staff, and R2 left the room. R1 stated she had a long, extensive history of sexual trauma. During an interview on 11/20/25 at 11:59 a.m., R2 stated R1 invited him to lay on her bed with her, showed him her stomach, and allowed R2 to touch it. R2 asked if R1 had ever been with a boyfriend, and R1 stated she had but it never ended well. R2 stated he didn't know what to do because he was confused after R1 let R2 touch her stomach, so he pulled his pants down, and reached across both R1 and the bed to look for something. R2 stated R1 told him to leave or R1 was going to pull the call light to get staff assistance. R2 stated he took that seriously and left the room. R3R3's annual MDS dated [DATE] indicated intact cognition and diagnoses that included anxiety, borderline personality disorder, and depression.R3's care plan dated 1/23/17 indicated a risk and/or history of sexual victimization with an update on 11/17/25 to notify staff of distressing interactions, use her pull cord to get help from staff as needed, and to discuss safety planning weekly and as needed.R3's IPS assessment dated [DATE], indicated R3 struggled to set appropriate boundaries and had a history of sexual abuse.R3's progress notes dated 11/17/25, indicated R3 reported R2 walked across her room naked to close the door when he was visiting R3's roommate, and then later, she was left alone with R2, and R2 engaged in inappropriate sexual conversation with R3 and he exposed himself, which made R3 very uncomfortable. R4R4's quarterly MDS dated [DATE] indicated moderate cognitive impairment and diagnoses that included depression, anxiety, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-a thought disorder such as delusions and hallucinations with symptoms of a mood disorder like bipolar disorder or depression.)R4's care plan dated 6/11/25, indicated risk and/or history of sexual victimization. On 8/15/25, the care plan indicated staff would monitor for interactions in common spaces between R4 and R2 and intervene to assist R4 in setting boundaries, and on 11/12/25, the care plan was updated with an intervention to restrict R2 from R4's residential floor.R4's IPS assessment dated [DATE], indicated a history of physical and sexual abuse and R4 as a victim of sexual exploitation. R4's progress notes indicated the following:-11/12/25 at 10:37 p.m., indicated R2 embraced R4 in R4's room doorway and staff intervened due to R2's history of poor boundaries. R4 reported R2 kissed R4 on the cheek and it was unwanted, and the same behavior occurred a few times in the previous week. Staff discussed boundary-setting with R4, and R4 acknowledged difficulty setting boundaries. Prior to this incident, R4 was observed to be spending time with R2, and reported that the relationship was consensual and that she had the ability to place boundaries. When asked about her safety, R4 confirmed feeling safe and did not express any concerns related to this. She expressed general annoyance and frustration with R2's clinginess.-11/13/25 at 6:53 a.m., indicated R4 was on shift checks due to an uncomfortable interaction with her peer.-11/13/25 at 2:40 p.m., indicated R4 requested a meeting with staff and indicated she was unable to maintain boundaries with R2 and asked for staff assistance to maintain distance from R2. An intervention was added to R2's care plan to restrict R2 from R4's residential floor. A state agency reported five-day report from the facility dated 11/18/25 at 2:18 p.m., indicated R3 (via a confidant) reported on 11/17/25 that on 11/16/25, R2 exposed himself to her after he had consensual sex with R3's roommate and her roommate had left the room. R3 reported R2 additionally exposed himself to her several days earlier. The report also stated R2 was involved in an incident on 11/12/25 where he kissed R4 without permission. Additionally, the report indicated on 11/12/25 R2 kissed R4 without permission. During staff follow-up discussions with R2, R2 displayed limited insight into the impact and distress caused by exposing himself to another resident and acknowledged exposing himself after R1 explicitly told him she did not want to engage in sexual relations with him. During an interview on 11/19/25 at 2:50 p.m., R4 stated R2 tried to kiss her on two different occasions. The first was when R2 asked R4 to come to his room to show R4 his TV but then R2 wouldn't stop touching or kissing R4. After that incident, R2 was banned from R4's residential floor (3rd floor) (progress notes indicate this occurred 11/12/25). R4 stated the second incident was when R2 kissed her in the hallway outside her room, R4 said no, R2 kissed her again, and staff intervened. R4 stated R2 was supposed to be banned from her floor but was there anyway (progress notes indicate this occurred 11/13/25). During an interview on 11/20/25 at 11:59 a.m., R2 stated he kissed R4 on the cheek, R4 said no and R2 kissed R4 again. R2 confirmed he was already restricted from being on R4's residential floor from a different incident but had forgotten about the restriction and went there anyway. R2 stated he was not allowed to have sexual relations with women in the facility, and stated, They [staff] are acting like it was all my fault, like I am a hungry, thirsty, sex fiend just looking to f**k. They [the female residents] wanted to be friends and invited me over. During an interview on 11/19/25 at 4:55 p.m., R3 stated R2 exposed himself to her twice, but could not recall the dates (second incident 11/16/25 via report from confidant, other date unknown). R3 stated she was in the room when R2 and her roommate, were together, R2 walked across the room with his penis exposed, and didn't say anything to R3 at the time. The second incident was after R2 and R3's roommate had sex with R3 in the room. Afterwards her roommate left the room, and R2 exposed himself to her (R3). R3 stated she was uncomfortable with the incident, she didn't want to see R2's penis, was afraid of R2 and that he, Would try something with me. R3 stated R2 asked her personal questions, asked if she wanted to touch it or suck it (penis), and she told R2 she did not want to. R3 then stated R2 put his penis away, but stayed in the room, sat on her bed, and continued to make her feel uncomfortable so she thought R2 still wanted something from her.During an interview on 11/20/25 at 11:59 a.m., R2 stated he had been having sexual encounters with R3's roommate, and afterwards she left the room he was alone with R3. R2 asked to sit on R3's bed, asked R3 if she ever had sex with someone and if she thought about having sex, and offered to show R3 his penis. He indicated she said no, but he still thought maybe she wanted to see it, so he took his penis partially out of his pants and R3 looked. R2 then asked her if she wanted to see the rest of it, and since R3 didn't say no, he took his penis fully out of his pants. R2 stated it was his duty to ask if R3 was uncomfortable but hadn't and thought R3 looked confused and uncomfortable. R2 put his penis back in his pants and left the room.During an interview on 11/21/25 at 9:11 a.m., program manager (PM)-A stated she was informed of the incident involving R1 from SW-B but was unsure of the date. The PM-A stated if someone made sexual advances towards a resident, staff should interview the resident, inquire if they needed additional support, perform an investigation, and make a State Agency report. Adding If it were her, she would report advances right away. When in doubt, report and then look into it right away. We would want immediate action. During an interview on 11/21/25 at 9:39 a.m., SW-B stated she was informed R2 forced himself into R1's room and tried to force himself on her on 11/14/25. SW-B stated staff should have interviewed R1 on 11/7/25, when they knew of the incident and should have contacted her mental health providers on 11/7/25 as well. SW-B stated it sounded like a traumatizing experience, but especially so with R1's history. SW-B indicated R1 may not have the capacity to consent for sexual contact and may not be able to consent well due to impulsivity and making decisions to distract from her own feelings.During an interview on 11/20/25 at 1:34 p.m., the PD-A stated she became aware of the incident involving R1 on 11/13/25, when SW-A informed her about the report from FM-A received on 11/7/25. The PD-A stated the primary focus and direction around the event was R1 had asked the person to leave, and they did, but the facility needed to know more about the unwanted touch before it was reportable to the SA. The PD-A stated the expectation was for SW-A to get clarification with R1's treatment team immediately about who would follow up. The PD-A acknowledged no one followed up, the incident was not relayed to other staff, the incident should have been investigated sooner. The PD-A stated she was not sure a full-on investigation was needed, but the facility needed more details, and if the follow-up had occurred on 11/7/25, interventions could have been implemented to protect R1 and other residents. PD-A stated after the facility had more information the State report was filed on 11/13/25. PD-A acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved from 11/7/25 to 11/13/25. During an interview on 11/20/25 at 12:49 p.m., the mental health worker (MHW)-A stated staff was doing hourly checks on R2 due to multiple incidents with other residents and demonstrated compliance with the hourly checks with the staff signature sheets for the checks, except one missed check on 11/19/25 at 3:00 p.m.The Vulnerability Adult Reporting Policy and Procedure dated 9/28/22, indicated when there are occurrences of resident - to - resident abuse, the facility shall take immediate action to protect the resident(s) involved.The policy stipulates abuse included sexual abuse, and is willful, meaning the individual acted deliberately, and is any non-consensual contact of any type with a resident.Any facility associate who has knowledge of the maltreatment of a resident, or has a reasonable cause to believe that a resident has been maltreated, shall immediately make a verbal report to the supervisor or person in charge and complete an incident report. The person in charge shall inform the administrator. Allegations of abuse shall be reported immediately, but not later than 2 hours after the allegation is made or after forming the suspicion to the State Agency. Reporting is a two-step process, initially reporting and then submitting an investigative report, within 5 working days of the incident.After an internal report of maltreatment is made, the Director of Clinical Services shall investigate the incident. The immediate jeopardy that began on 11/7/25 was removed on 11/21/25, when it was verified, the facility completed the following actions:-Reviewed and revised policies and procedures related to reporting and investigating allegations of abuse and neglect.-Educated all staff and leadership on the above policies and procedures with competency before next shift worked.-Interviewed all residents R2 had access to, including residents on other floors. -Identified a plan to assess and monitor female residents with impaired cognition for possible abuse.-Identified a care plan intervention for medication non-compliance to ensure adequate safeguards are in place related to sexual defiance/deviation.

Based on interview, observation, and document review the facility failed to ensure 4 of 4 residents (R1, R2, R3, R4) reviewed for abuse were free of sexual abuse when R1, R3 and R4 were subjected to unwanted sexual touch by R2.Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses that included bipolar disorder, (a mental health condition characterized by extreme shifts in mood, energy and activity levels), anxiety, post-traumatic stress disorder, and depression, and borderline personality disorder (a mental health condition characterized by long-term patterns of unstable emotions, relationships, and self-image, leading to impulsive and self-destructive behavior). R1's care plan dated 10/3/24 indicated R1 was at risk for and/or had a history of sexual victimization and dated 5/27/25 indicated R1 exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her. R1's Interpersonal Skills Assessment (IPS) assessment dated [DATE], indicated a history of sexual trauma and victimization related to being sexually trafficked. R1's progress notes dated 11/13/25 at 1:35 p.m., entered as a late entry for 11/7/25 at 1:30 p.m., revealed R1's family member called the facility, spoke to SW-A, and reported someone had gone in R1's room and made sexual advances towards R1. R2's annual MDS dated [DATE] indicated intact cognition and diagnoses that included paranoid schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a break from reality that may include symptoms of paranoia, false beliefs, seeing or hearing things that are not there, disorganized thinking and speech, and lack of normal emotional expression). R2's care plan dated 11/13/25, indicated R2 displayed sexually exploitive behavior with interventions that included restriction from visiting all other residential floors, and consider precaution checks as needed. On 11/17/25, the care plan was adjusted to restrict R2 from other residential floors, female rooms, and the short hall of R2's residential floor and for staff to remind R2 weekly and as needed of behavioral expectations related to not exposing himself or asking other residents to engage in any sexual activity. The care plan lacked interventions to protect other residents from unwanted advances after being informed of the behavior on 11/7/25. R2's IPS assessment dated [DATE] indicated when R2 was symptomatic misperceived communication from others resulting in interpersonal conflict. R2 had a history of participating in unwanted physical contact and violating no-contact orders. R2 understood others must have the capacity to consent to sexual activity before and throughout the activity and demonstrated knowledge of consent. The Assessment indicated no care plan in place for sexual exploitation or other vulnerability related to sexual health at the time of assessment. The assessment lacked indication of a care plan to address behaviors when symptomatic, despite a history of unwanted physical contact and violations of no-contact orders. Further, the assessment lacked indication of an update after R2's behaviors changed. R2's progress notes indicated the following:-11/12/25 at 10:58 p.m., indicated a resident [R4] reported unwanted advancements from R2. Staff spoke to R2, who stated he was getting mixed signals from the other resident but agreed to respect others' boundaries. Staff restricted R2 from visiting R4's floor. -11/13/25 at 3:15 p.m., indicated R2 was placed on 1-hour location checks and shift checks due to multiple incidents of inappropriate interaction with numerous residents.-11/17/25 at 11:00 p.m., indicated staff met with R2 after R2 exposed himself to another resident [R3]. R2 was prohibited from entering other residential floors, female rooms, and the other hall of his own floor. Staff included police in the discussion with R2. -11/18/25 at 6:44 a.m., indicated R2 remained on 1-hour location checks and shift checks due to multiple incidents on 11/12/25, 11/13/25, and 11/17/25 and post SA reports on 11/13/25 and 11/17/25 related to R2's poor sexual boundaries. -11/19/25 at 10:49 p.m., indicated interventions were added to R2's care plan - R2 was restricted from visiting other residential floors, female rooms, and the short hall of his own residential floor. During an observation on 11/20/25 at 11:54 a.m., R1 was in his room asleep. Staff awakened R2 while performing a schedule check on him. R3's annual MDS dated [DATE] indicated intact cognition and diagnoses that included anxiety, borderline personality disorder, and depression. R3's care plan dated 1/23/17 indicated a risk and/or history of sexual victimization with an update on 11/17/25 to notify staff of distressing interactions, use her pull cord to get help from staff as needed, and to discuss safety planning weekly and as needed. R3's IPS assessment dated [DATE], indicated R3 struggled to set appropriate boundaries and had a history of sexual abuse.R3's progress notes dated 11/17/25, indicated R3 reported R2 walked across her room naked to close the door when he was visiting R3's roommate, and then later, she was left alone with R2, and R2 engaged in inappropriate sexual conversation with R3 and exposed himself, which made R3 very uncomfortable. The subsequent SA 5-Day report dated 11/18/25 at 2:18 p.m., indicated R2 exposed himself to R3, R2 had sexual relations with R2's roommate, and boundary concerns were expressed about R2 on 11/12/25 involving R2 kissing R4. The report also revealed a separate incident in which R2 exposed himself days earlier but was not reported at the time. During staff follow-up discussions with R2, R2 displayed limited insight into the impact and distress caused by exposing himself to another resident and acknowledged exposing himself after R1 explicitly told him she did not want to engage in sexual relations with him. R4's quarterly MDS dated [DATE] indicated moderate cognitive impairment and diagnoses that included depression, anxiety, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-a thought disorder such as delusions and hallucinations with symptoms of a mood disorder like bipolar disorder or depression). R4's care plan dated 6/11/25, indicated risk and/or history of sexual victimization. On 8/15/25, the care plan indicated staff would monitor for interactions in common spaces between R4 and R2 and intervene to assist R4 in setting boundaries, and on 11/12/25, the care plan was updated with an intervention to restrict R2 from R4's residential floor. R4's IPS assessment dated [DATE], indicated a history of physical and sexual abuse and R4 as a victim of sexual exploitation. R4's progress notes indicated the following: -11/12/25 at 10:37 p.m., indicated R2 embraced R4 in R4's room doorway and staff intervened due to R2's history of poor boundaries. R4 reported R2 kissed R4 on the cheek and it was unwanted, and the same behavior occurred a few times in the previous week. Staff discussed boundary-setting with R4, and R4 acknowledged difficulty setting boundaries. -11/13/25 at 6:53 a.m., indicated R4 was on shift checks due to an uncomfortable interaction with her peer. -11/13/25 at 2:40 p.m., indicated R4 requested a meeting with staff and indicated she was unable to maintain boundaries with R2 and asked for staff assistance to maintain distance from R2. An intervention was added to R2's care plan to restrict R2 from R4's residential floor. During an interview on 11/19/25 at 2:50 p.m., R4 stated R2 tried to kiss her on two different occasions. The first was when R2 asked R4 to come to his room to show R4 his TV but then R2 wouldn't stop touching or kissing R4. After that incident, R2 was banned from R4's residential floor. R4 stated the second incident was when R2 kissed her in the hallway outside her room, R4 said no, R2 kissed her again, and staff intervened. R4 stated R2 was supposed to be banned from her floor but was there anyway. During an interview on 11/20/25 at 11:59 a.m., R2 stated he kissed R4 on the cheek, R4 said no and R2 kissed R4 again. R2 stated he was already restricted from being on R4's residential floor from a different incident, but had forgotten about the restriction and went there anyway. R2 stated he was not allowed to have sexual relations with women in the facility, and stated, They [staff] are acting like it was all my fault, like I am a hungry, thirsty, sex fiend just looking to f**k. They [the other residents he had approached for sex] wanted to be friends and invited me over. During an interview on 11/20/25 at 10:59 a.m., FM-A stated on 11/7/25, R1 reported a male resident came into her room and made sexual advances towards her, would back off, and then would try again. R1 did not want FM-A to report the incident to the facility but FM-A called the facility on 11/7/25 and reported the incident to the SW-A so it would not happen to anyone else. During an interview on 11/20/25 at 1:03 p.m., SW-A stated she became aware of an incident between R1 and R2 after FM-A called on 11/7/25, and reported unwanted touch by R2 to R1. SW-A stated she attempted to reach the R1 for more information but was unsuccessful, did inform other staff on shift and told the Program Director (PD)-A in passing but had not documented any of that information. SW-A confirmed no investigation or protections were started or considered until she returned to work on 11/12/25. During an interview on 11/21/25 at 11:01 a.m., R1 stated she reported the incident to her parents because authority figures at the facility freak me out. [R2] went further than he should have. R1 informed her parents she was harassed, and had to yell at R2 and threaten to pull the alert cord to get staff's help because R2 would not leave her room. R1 stated she went to R2's room to look at something he wanted to sell and then left his room and went back to her own room. About 5 minutes later, R2 came to R1's room with a scarf he thought R1would like, and R1 stated she wanted the scarf. R1 showed R2 old pictures from her high school yearbook, and thought maybe R2 liked her because she showed him pretty pictures of herself. R1 stated she allowed R2 to lay on her bed with her but stated she did not want anything sexual to happen, did not want to kiss, and kept saying no. R1 told R2 she never wanted to have sex with him and R2 was shocked and asked, Never? R1 said no, she was gay and was not interested in any man. R1 told R2 she didn't like any penis, and R2 kept saying R1 might like to see it, and then R2 exposed himself and told R1 she had never tried sex with him, and she might like it. R2 reached across R1, who was lying on her bed and, He used that opportunity to kind of grind on me. R1 yelled at R2 and threatened to use the pull cord to summon staff, and R2 left the room. R1 stated she had a long, extensive history of sexual trauma. During an interview on 11/20/25 at 11:59 a.m., R2 stated he had been asleep in his room all morning while wearing headphones and had not left his room. R2 stated R1 invited him to lay on her bed with her, showed him her stomach, and allowed R2 to touch it. R2 asked if R1 had ever been with a boyfriend, and R1 stated she had but it never ended well. R2 stated he didn't know what to do because he was confused after R1 let R2 touch her stomach, so he pulled his pants down, and reached across both R1 and the bed to look for something. R2 stated R1 told him to leave or R1 was going to pull the call light to get staff assistance. R2 stated he took that seriously and left the room. During an interview on 11/19/25 at 4:55 p.m., R3 stated R2 exposed himself to her twice, but could not recall the dates. R3 stated she was in the room when R2 and her roommate, were together, R2 walked across the room with his penis exposed, and didn't say anything to R3 at the time. The second incident was after R2, and her roommate had sex with her in the room. Afterwards her roommate left the room, and R2 exposed himself to her. R3 stated she was uncomfortable with the incident, she didn't want to see R2's penis, was afraid of R2 and that he, Would try something with me. R3 stated R2 asked her personal questions, asked if she wanted to touch it or suck it (penis), and she told R2 she did not want to. R3 then stated R2 put his penis away, but stayed in the room, sat on her bed, and continued to make her feel uncomfortable so she thought R2 still wanted something from her. During an interview on 1120/25 at 11:59 a.m., R2 stated he had been having a sexual encounters with R3's roommate, and afterwards she left the room he was alone with R3. R2 asked to sit on R3's bed, asked R3 if she ever had sex with someone and if she thought about having sex, and offered to show R3 his penis. He indicated she said no, but he still thought maybe she wanted to see it, so he took his penis partially out of his pants and R3 looked. R2 then asked her if she wanted to see the rest of it, and since R3 didn't say no, he took his penis fully out of his pants. R2 stated it was his duty to ask if R3 was uncomfortable but hadn't and thought R3 looked confused and uncomfortable. R2 put his penis back in his pants and left the room. During an interview on 11/20/25 at 1:34 p.m., the PD-A stated she became aware of the incident on 11/13/25, when SW-A informed her about the report from FM-A received on 11/7/25. The PD-A acknowledged no one followed up, the incident was not relayed to other staff, the incident should have been investigated sooner. The PD-A stated she was not sure a full-on investigation was needed, but the facility needed more details, and if the follow-up had occurred on 11/7/25, interventions could have been implemented to protect R1 and other residents. PD-A stated after the facility had more information the State report was filed on 11/13/25. PD-A acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved from 11/7/25 to 11/13/25. The Vulnerability Adult Reporting Policy and Procedure dated 9/28/22, indicated when there are occurrences of resident - to - resident abuse, the facility shall take immediate action to protect the resident(s) involved. The policy stipulates abuse included sexual abuse, and is willful, meaning the individual acted deliberately, and is any non-consensual contact of any type with a resident. Any facility associate who has knowledge of the maltreatment of a resident, or has a reasonable cause to believe that a resident has been maltreated, shall immediately make a verbal report to the supervisor or person in charge and complete an incident report. The person in charge shall inform the administrator. Allegations of abuse shall be reported immediately, but not later than 2 hours after the allegation is made or after forming the suspicion to the State Agency. Reporting is a two-step process, initially reporting and then submitting an investigative report, within 5 working days of the incident.After an internal report of maltreatment is made, the Director of Clinical Services shall investigate the incident.

Based on interview and document review, the facility failed to report an allegation of alleged sexual abuse immediately (within two hours) to the State Agency (SA) for 3 of 4 residents (R1, R2) when R2 was alleged to make unwanted sexual advances towards R1 and R4. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses that included bipolar disorder, (a mental health condition characterized by extreme shifts in mood, energy and activity levels), anxiety, post-traumatic stress disorder, and depression, and borderline personality disorder (a mental health condition characterized by long-term patterns of unstable emotions, relationships, and self-image, leading to impulsive and self-destructive behavior). The State Agency report dated 11/13/25, indicated R1's family member (FM)-A reported on 11/7/25 an incident of romantic overtures by R2 in R1's room to social worker (SW)-A. R2 exposed himself to R1 and R2 and pushed his pelvis against R1's hip. Per the SA report, the facility began the investigation on 11/12/25, and no report for alleged abuse was filed for R1 until 11/13/25. R1's care plan dated 10/3/24 indicated R1 was at risk for and/or had a history of sexual victimization and also indicated R1 exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her, dated 5/27/25.R1's Interpersonal Skills Assessment (IPS) assessment dated [DATE], indicated diagnoses that included post-traumatic stress disorder and further indicated a history of sexual trauma and victimization related to being sexually trafficked. R1's progress notes dated 11/13/25 at 1:35 p.m., entered as a late entry for 11/7/25 at 1:30 p.m., indicated R1's family member called the facility, spoke to SW-A, and reported another resident went into R1's room and made sexual advances towards R1. During an interview on 11/20/25 at 10:59 a.m., FM-A stated on 11/7/25 R1 reported a male resident came into her room and made sexual advances towards her, would back off, and then would try again. R1 did not want FM-A to report the incident to the facility but FM-A called the facility on 11/7/25 and reported the incident to SW-A so it would not happen to anyone else. During an interview on 11/20/25 at 1:03 p.m., SW-A stated she became aware of an incident between R1 and R2 after FM-A called on 11/7/25 and reported unwanted touch by R2 to R1. SW-A stated she attempted to call R1 several times after the report to inquire about the details of the incident but was unable to reach her as she was already on leave from the facility. SW-A stated she reported the incident to an evening staff, but didn't recall who, and acknowledged she had not documented the report from FM-A, the report to the evening staff, or the attempted phone calls to R1. SW-A further stated she did not tell administrative staff about FM-A's report because without talking to R1 first about the details of the incident, there was not enough information at the time to make a report to the State. SW-A stated she told the program director (PD)-A about the incident in passing on her way out of the building, after her shift but had not documented that either. SW-A acknowledged if a resident reported unwanted touch by another resident, the event would be reportable within two hours of the incident or within two hours of staff knowing about the incident but thought she would need to obtain full details of the incident before making the report. SW-A was then off work for four days and started to follow up on the report when she returned to work on 11/12/25. During an interview on 11/20/25 at 1:34 p.m., the PD-A stated she became aware of the incident between R1 and R2 on 11/13/25, when SW-A informed her about the phone call from FM-A on 11/7/25. SW-A tried to reach R1 on 11/7/25, and the primary focus and direction around the event was R1 had asked the person to leave, and they did, but the facility needed to know more about the unwanted touch before it was reportable. The PD-A stated the expectation was for SW-A to get clarification with R1's treatment team about who would follow up. The PD-A stated no one followed up, and it was not relayed to other staff, but acknowledged it should have been investigated sooner. The PD-A stated she was not sure a full-on investigation was needed, but the facility needed more details, and if the follow-up had occurred on 11/7/25, interventions could have been implemented to protect R1 and other residents. PD-A stated after the facility had more information the State report was filed on 11/13/25. PD-A acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved from 11/7/25 to 11/13/25. During an interview on 11/21/25 at 9:11 a.m., program manager (PM)-A stated she was informed of the incident between R1 and R2 from SW-B but was unsure of the date. The PM-A stated if someone made sexual advances towards a resident, staff should interview the resident, inquire if they needed additional support, perform an investigation, and make a State Agency report of abuse. During an interview on 11/21/25 at 9:39 a.m., SW-B stated staff informed her of the incident between R1 and R2 on 11/14/25 and was told a resident forced himself into R1's room and tried to force himself on her. SW-B stated staff should have interviewed R1 on 11/7/25 when they knew of the incident. SW-B stated it sounded like a traumatizing experience, but especially so with a sexual trauma history and unwanted sexual contact would be difficult for any resident. During an interview on 11/21/25 at 11:01 a.m., R1 stated she reported the incident to her parents because authority figures at the facility freak me out. [R2] went further than he should have. R1 informed her parents she was harassed and had to yell at R2 and threaten to pull the alert cord to get staff's help because R2 would not leave her room. R4's quarterly MDS dated [DATE] indicated moderate cognitive impairment and diagnoses that included depression, anxiety, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-a thought disorder such as delusions and hallucinations with symptoms of a mood disorder like bipolar disorder or depression). R4's care plan dated 6/11/25, indicated risk and/or history of sexual victimization. On 8/15/25, the care plan indicated staff would monitor for interactions in common spaces between R4 and R2 and intervene to assist R4 in setting boundaries, and on 11/12/25, the care plan was updated with an intervention to restrict R2 from R4's residential floor. R4's IPS assessment dated [DATE], indicated a history of physical and sexual abuse and R4 as a victim of sexual exploitation. R4's progress notes indicated the following:-11/12/25 at 10:37 p.m., indicated R2 embraced R4 in R4's room doorway and staff intervened due to R2's history of poor boundaries. R4 reported R2 kissed R4 on the cheek and it was unwanted, and the same behavior occurred a few times in the previous week. Staff discussed boundary-setting with R4, and R4 acknowledged difficulty setting boundaries.-11/13/25 at 6:53 a.m., indicated R4 was on shift checks due to an uncomfortable interaction with her peer.-11/13/25 at 2:40 p.m., indicated R4 requested a meeting with staff and indicated she was unable to maintain boundaries with R2 and asked for staff assistance to maintain distance from R2. An intervention was added to R2's care plan to restrict R2 from R4's residential floor. During an interview on 11/19/25 at 2:50 p.m., R4 stated R2 tried to kiss her on two different occasions. The first was when R2 asked R4 to come to his room to show R4 his TV but then R2 wouldn't stop touching or kissing R4. After that incident, R2 was banned from R4's residential floor. R4 stated the second incident was when R2 kissed her in the hallway outside her room, R4 said no, R2 kissed her again, and staff intervened. R4 stated R2 was supposed to be banned from her floor but was there anyway. During an interview on 11/20/25 at 11:59 a.m., R2 stated he kissed R4 on the cheek, R4 said no and R2 kissed R4 again. R2 stated he was already restricted from being on R4's residential floor from a different incident, but had forgotten about the restriction and went there anyway. R2 stated he was not allowed to have sexual relations with women in the facility, and stated, They [staff] are acting like it was all my fault, like I am a hungry, thirsty, sex fiend just looking to f**k. They [the other residents he had approached for sex] wanted to be friends and invited me over. During an interview on 11/20/25 at 3:57 p.m., the director of clinical services (DCS)-A stated R1 was not always a strong self-advocate. R1 talked to the program manager about the incident on the 11/12/25, but didn't fully disclose the details until 11/13/25, when the incident was reported. The DCS-A stated the facility staff should have asked R1 about the incident sooner if the SW knew about the incident on 11/7/25. The DCS-A further stated the facility didn't report the incident to the SA until 11/13/25 because the facility didn't have the full details to report. The DCS-A stated the facility did not have to ask R1 about the details again after R1 declined to give the details on 11/12/25, but the facility did ask again, which was good on their part. The DCS-A stated potentially R1 could have disclosed the details sooner if she had been asked about it sooner. Additionally, when asked about the abuse staff observed between R2 and R4, DCS-A stated, [R4] and [R2] just kissed and staff intervened immediately. That was not reportable. The Vulnerability Adult Reporting Policy and Procedure dated 9/28/22, indicated when there are occurrences of resident - to - resident abuse, the facility shall take immediate action to protect the resident(s) involved. The policy stipulates abuse included sexual abuse, and is willful, meaning the individual acted deliberately, and is any non-consensual contact of any type with a resident. Any facility associates who has knowledge of the maltreatment of a resident or has a reasonable cause to believe that a resident has been maltreated shall immediately make a verbal report to the supervisor or person in charge and complete an incident report. The person in charge shall inform the administrator. Allegations of abuse shall be reported immediately, but not later than 2 hours after the allegation is made or after forming the suspicion to the State Agency.

Based on observation, interview, and document review, the facility failed to ensure its system for medication reconciliation was adequate to ensure timely identification of loss or diversion of non-narcotic, controlled medications for 8 of 8 medication carts. Findings include: During an observation and interview with mental health worker (MHW)-A and MHW-B on 9/9/25 at 3:18 p.m., the two fifth-floor medication carts were reviewed. The non-narcotic, controlled medications were observed in a permanently affixed lock box in each locked medication cart. A count of the non-narcotic, controlled medications was observed to be completed with no discrepancies noted. MHW-B stated staff reconciled the non-narcotic, controlled medications every shift and demonstrated this in an observed controlled medication three-ring binder containing loose three-hole punched paper. MHW-B stated that if facility staff had a concern regarding a drug count, they would reference the medication administration record to verify medication administration. During an observation and interview with MHW-C and MHW-D on 9/10/25 at 7:20 a.m., the two fourth-floor medication carts were reviewed. The non-narcotic, controlled medications were observed in a permanently affixed lock box in each locked medication cart. A count of the non-narcotic, controlled medications was observed to be completed with no discrepancies noted. MHW-C confirmed staff reconciled the non-narcotic controlled medications every shift in an observed controlled medication three-ring binder containing loose three-hole punched paper. During an interview on 9/10/25 at 2:33 p.m., the director of nursing (DON) confirmed the current practice for non-narcotic, controlled medication reconciliation and tracking involved using a three-ring binder with loose paper and did not have a current plan in place to change this practice. On a follow-up interview on 9/11/25 at 11:11 a.m., the DON confirmed the facility had been working on updating its controlled medication storage and reconciliation practices after recent concerns for possible drug diversion. The DON stated that after the surveyor helped raise concern yesterday about the use of a three-ring binder to reconcile and track controlled medication, she was going to order bound books to track both the narcotic and non-narcotic medications and acknowledged the limitations in the timely identification of the diversion of controlled medications when using a three-ring binder.During an interview on 9/10/25 at 2:45 p.m., MHW-E confirmed that she assisted with completing the reconciliation of non-narcotic, controlled medications at shift change. MHW-E stated that when she reconciled non-narcotic, controlled medications, she would reference the controlled drug three-ring drug binder and the count of the medication itself. MHW-E stated she was unsure how staff would know if someone took a sheet out of the controlled medication three-ring binder with the corresponding medication, as you could not tell when the sheet was removed. MHW-E then stated she hoped that the staff completing the medication reconciliation were familiar enough with what medications were supposed to be in the locked non-narcotic controlled medication box to realize a medication had gone missing, based on memory of counting the medications in the past.During an interview and observation on 9/11/25 at 7:40 a.m., two medication carts with corresponding controlled medication three-ring binders were observed on the third floor. MHW-F confirmed that he assisted with completing the reconciliation of non-narcotic controlled medications at shift change, and the three-ring binders were used to accomplish this. MHW-F stated that staff would compare the counts of non-narcotic medications in the locked box to the count of the correlating sheet in the three-ring controlled medication binder, and if a discrepancy was noticed, staff would reference the medication administration record. MHW-F stated he was unsure how staff would notice if a non-narcotic controlled medication sheet and the correlating medication card were removed and referred further questions to registered nurse (RN)-B. At 7:45 a.m., RN-B demonstrated how staff marked a date and time next to every medication bubble that was emptied for the non-narcotic controlled medication administration and that could be checked against the medication administration record and controlled drug three-ring binder. RN-B stated that if a medication card and the controlled medication sheet were taken out of the three-ring binder for an as-needed medication, it would not be noticed until the next time the medication was administered, and the medication was no longer found in the locked box. During an interview and observation on 9/11/25 at 7:55 a.m., two medication carts with corresponding controlled medication three-ring binders were observed on the second floor. RN-C confirmed these binders were used for the tracking and reconciliation of non-narcotic, controlled medications. The facility's Controlled Medications- Schedule C policy dated 1/20/23, indicated a count of the quantity of the controlled medication on hand would be completed at the change of shift and documented on the controlled drug record and the C-drug Count Acknowledgement Form. The policy did not indicate whether this record or form would be kept in a three-ring binder with loose paper or a bound book.

Based on observation, interview, and record review, the facility failed to ensure equipment was in proper working order for 1 of 2 washing machines on the 5th floor. Furthermore, the facility failed to provide a sanitary environment in laundry room. Findings include: During interview on 9/8/25 at 12:47 p.m., R4 stated concern the facility washing machines were frequently broken. R4 stated they had been intermittently working for the last few months, however, this time it had been over 2 weeks. The staff had been updated about the broken machine. R4's MDS indicated cognitively intact, independent with activities of daily living. During interview on 9/8/25 at 3:42 p.m., R141 stated the washing machine on the 5th floor had been broken, it was intermittently repaired for the last 3 months or so. However, it had been about 2 weeks since they reported the broken machine with standing water in it. R141 stated it was unacceptable 5th floor residents only had an intermittent functioning washing machine. It was difficult doing laundry due to the lack of supervision and accountability for usage. R141's MDS indicated cognitively intact, independent with activities of daily living. During interview on 9/10/25 at 8:28 a.m., maintenance-A stated the process for repairs was residents notified staff, staff fill out a TELS ticket, explained what, where and the situation for repairs. The TELS report were reviewed every morning and organized most to least important. During interview on 9/11/25 at 8:47 a.m., mental health worker (MHW-G) stated they were aware the washing machine had been broken for a few weeks, however, did not know there was standing water in the machine. She filed 3 TELS reports on the washing machine in the past 3 months. During interview on 9/11/25 at 9:35 a.m., MHW-H stated washer and dryer combo was approximately 2 yrs old, the machines got used continually. Staff checked to see what the issues were then filed a TELS report. It had been a few weeks of issues. However, MHW-H was unaware there was standing water in it. During interview on 9/11/25 at 11:05 am, MHW-E stated, the washing machine had been in and out of order all summer, waiting for parts, then repaired, worked 1 to 2 days then broke again. MHW-E stated they were unaware of standing water in the washing machine. On 9/9/25, she filed a TELS request. The facility was looking into purchasing new combo machines. However, the area for the combo units were small for the new units. It was their understanding, a mother board for the washer was the issue and needed repair. Due to the fact that the issue was ongoing, there was a breakdown of communication from residents, to staff, to TELS report, and repair. During observation on 9/8/25 at 4:40 p.m., the laundry room on the 5th floor had 2 sets of stackable washer and dryers. The washing machine labeled B had an OUT OF ORDER sign on it. Inside the lid was standing dark grey water with white floating chunks in the water and film layer coated the top of the water. Housekeeping-A confirmed findings. During observation on 9/9/25 at 11:20 a.m., two maintenance employees (unknown) were in the 5th floor laundry room. After they left, inside the lid of washing machine B, still had dark grey standing water with white particles floating in it. During observation on 9/10/25 at 7:58 a.m., washing machine B on 5th floor still had dark grey standing water with white floating particles in it. An OUT OF ORDER sign was not visible. Housekeeping-A stated the washing machine looked like it was broken, no OUT OF ORDER sign, she stated the water inside of machine was dark, cloudy with fuzzy stuff floating around. Usually if item was broken, there was a sign, and maintenance came right away. However, it had been a while that the machine had been broken. During observation on 9/10/25 at 8:29 a.m., maintenance-A was attempting to repair washing machine B, he asked for an OUT OF ORDER sign at desk, placed linen in machine, and attempted to run the washing machine. He stated he was unaware of how long the washing machine had been broken. During observation on 9/11/25 at 9:39 a.m., washing machine B on 5th floor was dry, no standing water in machine, an OUT OF ORDER sign was visible, housekeeping A verified observation. During record review, the TELS report received had one documented report on 7/26/25 for the 5th floor washing machine, report closed on 7/28/25. Requested a complete TELS report, did not receive. Maintenance-B provided an email that stated the timeline for work order regarding washing machine B on the 5th floor was on 9/9/25 at 10:08 a.m., work order created, on 9/10/25 at 6:09 a.m., work order assigned to maintenance-A.

Based on interview and record review the facility failed to ensure accurate Minimum Data Set assessments (MDS) were completed for 2 of 3 residents (R2, R7) reviewed for accuracy of assessments. Findings include: R2’s quarterly MDS dated [DATE], indicated R2 was cognitively intact and had diagnoses of diabetes. Furthermore, R2’s MDS indicated R2 had seven days of insulin injections. R2’s medication administration record (MAR) dated 7/2025, lacked indication R2 received insulin injections. When interviewed on 9/11/25 at 10:08 a.m., registered nurse (RN)-D stated information was gathered from the observation period, staff, the residents medical record and the resident when completing their MDS assessment. RN-D verified R2 had a diagnosis of diabetes and was on Metformin (an oral medication to help lower blood glucose) and Victoza (non-insulin injectable medication) for diabetes. RN-D looked up Victoza and verified it was not an insulin and should not have been included in the insulin injections of the MDS. When interviewed on 9/11/25 at 11:03 p.m., the Director of Nursing (DON) verified Victoza should be classified as a hypoglycemic medication and should not be included for an insulin injection. R7's quarterly MDS dated [DATE], indicated in Section I: Active Diagnoses that R7 was diagnosed with non-Alzheimer's dementia (e.g., Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases). R7's medical record was reviewed, and documentation indicating R7 had a diagnosis of non-Alzheimer's dementia was not found. During an interview on 9/11/25 at 11:07 a.m., the DON confirmed she had reviewed R7's medical record and was not able to find that R7 had a diagnosis of dementia. The DON further stated it was an error, referring to R7’s MDS coding of a dementia diagnosis, and the MDS would need to be corrected.

Based on observation, interview, and document review the facility failed to identify baseline SpO2 (blood oxygen levels), and parameters for use based on resident specific risk factors for 1 of 1 resident (R176) reviewed for O2 therapy.Findings include:R176's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no staff assistance was needed for activities of daily living. Diagnoses included non-traumatic brain dysfunction and chronic obstructive pulmonary disease (COPD) which is an ongoing lung condition caused by damage to the lungs. No oxygen use was identified on the MDS.R176's care plan dated 9/11/25, identified problems of COPD and chronic bronchitis, goal of no SOB (shortness of breath) as evidenced by respirations of 14 - 20 per minute. Interventions included monitor vital signs and SpO2 monthly and more frequently as needed, and effective 6/12/25; O2 concentrator as needed per physician order 4 liters per minute (L/min) via nasal cannula. The care plan lacked parameters for when to use or discontinue and lacked baseline SpO2.R176's Physician Orders dated 8/20/25 through 9/11/25, identified Oxygen Concentrator 4L/min and lacked parameters for when to use or discontinue, and lacked baseline SpO2.R176's Treatment Administration Record (TAR) dated 8/1/25 through 9/11/25, identified SpO2 levels ranging from 91% to 99% but lacked identification if supplemental O2 was in use. During an interview and observation on 9/8/25 at 5:14 p.m., R176 pointed to his O2 concentrator and stated it was new. R176 stated he used it a few times when he had shortness of breath related to COPD. During an observation on 9/10/25 at 11:46 a.m., R176 was in bed with his eyes closed, O2 was on at 4 L/min with the use of a nasal cannula. During an interview on 9/10/25 at 1:00 p.m., registered nurse (RN)-A reviewed R176's O2 orders and agreed there were no parameters for use or baseline SpO2 levels in place. RN-A stated over-oxygenation could be a risk for COPD without parameters in place.During an interview on 9/11/25 at 1:08 p.m., the director of nursing (DON) stated she would expect a flow rate, parameters for use, when to initiate and discontinue along with baseline Sp02 levels to be included on O2 orders. The DON stated with a diagnosis of COPD over-oxygenation and reduced O2 drive could be risk factors when supplemental O2 was in use. The DON stated their O2 policy was currently under revision. The facility's Oxygen Concentrator policy dated 11/8/99, identified continuous O2 therapy was not provided, and the nurse would assess the resident as compliant with O2 treatment. The policy lacked method to identify baseline SpO2 (blood oxygen levels), and parameters for use based on resident specific risk factors.

Based on observation, interview, and document review, the facility failed to revise the care plan to include a smoking-related safety intervention for 1 of 3 residents (R1) reviewed for safety. Findings include: R1's facesheet dated 5/7/25, indicated he had diagnoses including schizoaffective disorder (chronic illness causing changes in thoughts, moods, and behaviors) and tobacco use. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1 was independent with activities of daily living (ADLs) and mobility, had behavioral symptoms not directed towards others, and currently used tobacco. R1's physician orders included an order dated 10/25/24, to observe forearms for self-inflicted burns or picking two times per day and to notify nurse if present. R1's physician note from psychiatrist dated 4/15/25, indicated R1 had a history of schizoaffective disorder and baseline included some ongoing paranoia and anxiety. Further, he has preservative focus on his hair and skin, resulting in picking and [NAME] [sick, burning] hair in the past. R1 denied recent issues with hair/removal and substance use included pipe tobacco. R1's Vulnerability Assessment and Abuse Prevention Plan dated 4/23/25, identified he was unable to recognize unsafe smoking behavior with status of vulnerable. The summary noted R1 had a history of sustaining burns to skin and clothing due to unsafe smoking and to prevent burns he was provided with flameless lighters which were kept behind the staff desk. The assessment also identified R1 had severe psychiatric symptoms or cognitive deficits that significantly impair judgment and functioning with status of vulnerable. The summary noted on 7/27/21 R1 was observed to burn his arm hair with a lit cigarette, on 4/23/22 R1 burned his arm with a flameless lighter, and on 6/9/22 staff observed micro burns to his arms from flameless lighter and staff to begin assisting with hair removal twice monthly. R1's Tobacco and Electronic Delivery Device Use Screening dated 4/24/25, identified R1 was vulnerable for unsafe smoking behaviors and had a history of intentionally burning himself with cigarettes in an attempt to remove body hair. The assessment included, as outlined in [R1's] treatment plan, he is discouraged to utilize cigarettes . instead encouraged to use his pipe and loose tobacco. He may request his flameless lighter at program times. Before providing his flameless lighter, staff ask [R1] if he endorses urges to burn his hair or engage in other unsafe smoking behaviors. Smoking and vaping materials used by the resident on assessment included pipe and filtered cigarettes. Visual observation of tobacco use identified no concerns though it is important to note that he refused to follow through with his care plan and utilized a cigarette rather than a pipe. R1's progress note dated 5/1/25, noted at 8:45 p.m. staff conducted a routine skin check after administering bedtime medications and observed a number of wounds down R1's forearms. R1 reported he had used a lit cigarette to attempt to remove the hair on his forearms. Nursing staff assess R1, provided wound care, and made notifications. R1 was to be placed on one hour precaution checks, smoking patio restrictions, and shift checks. Facility Incident Report dated 5/1/25, indicated staff completed a routine skin check on R1 and observed a significant number of wounds on his forearms. R1 reported that he had used a lit cigarette to attempt to remove the hair on his forearms. Identified antecedents or triggers to the incident included R1 reporting to his program manager (PM) on 4/19/25 that his pipe was broken and he had thrown it away, stated he did not know what his plan was for smoking since he did not have another pipe, and when asked directly he described no plan to smoke until he purchased a pipe. The incident's outcome and follow-up (to include interventions/corrective action implemented) noted R1 reported having two boxes of cigarettes, did not want them discarded, and gave them to his unit's program director (PD). R1 and the PD developed a plan to store the cigarettes behind the staff desk, request one cigarette and flameless lighter at program times, and then be escorted outdoors by staff for 1:1 [one-to-one] observation to ensure safety. R1 reported he received personal funds that day and was open to purchasing a new pipe and tobacco and re-engaging with his previous smoking plan which had been effective in preventing burns with last burns from a cigarette in 2022. The report's interventions implemented section included a list of possible interventions. Selected interventions included 1:1 staff support. R1's care plan problem dated 5/29/18, identified he was unable to recognize unsafe smoking behavior. Interventions included: - Staff will notify/consult with psychiatric provider, primary health care provider, and/or other community professionals as needed, dated 5/29/18. - Staff will provide education on smoking risks and encourage smoking cessation, dated 5/29/18. - Provide and encourage use of smoking cessation aides, dated 5/29/18. - Staff will discourage R1 from obtaining cigarettes from others and smoking cigarette butts, dated 5/29/18. - Staff will encourage R1 to refrain from spending time in smoking areas, dated 5/29/18. - Provide R1 with options for positive replacement activities as an alterative to smoking, dated 5/29/18. - Staff will provide and encourage use of adaptive smoking/lighting equipment, dated 5/29/18. - Staff will encourage R1 to allow staff to assist in hair removal as needed, dated 5/1/25. Staff will encourage R1 to have his pipe and loose tobacco with him before going downstairs to smoke, dated 5/2/25. Staff will encourage R1 to seek out staff available on the first floor if in need of immediate assistance/support in order to address concerns without having to return to the floor, dated 5/2/25. R1's care plan problem dated 12/10/18, identified he had severe psychiatric symptoms or cognitive deficits that significantly impair judgment and functioning. Interventions included: - Staff will visualize R1's arms for new burns twice a day. If new burns are present, staff will notify the charge nurse and person in charge immediately, dated 6/9/22. Staff will request that R1 checks out/in a flameless lighter immediately before/after he smokes. Lighters will be kept behind the staff desk. Before providing a lighter, staff will ask R1 if he has any urge/intention to use lighter/cigarette to remove hair, ask to show staff his pipe and loose tobacco, remind to refrain from obtaining cigarettes from others and remind to turn in his lighter within 20 minutes. After receiving a lighter, staff will ask R1 if he used lighter/cigarette to remove hair, dated 5/4/23. - PM will meet with R1 to discuss hair removal needs and assist with removing hair weekly. If R1 declines, PM will provide education about history of hair removal incidents and strongly encourage his agreement to shave in the moment, dated 5/2/25. - Staff will encourage R1 to utilize as needed (PRN) medication when endorsing increased anxiety, impulses related to unwanted hair, and as needed, dated 5/2/25. - Staff will encourage R1 to notify staff as soon as possible when feeling urges to remove unwanted hair from his body, dated 5/2/25. R1's care plan did not identify or include the implemented intervention of staff escorting him outside for one-to-one observation when smoking cigarettes. Coffee/Cigarettes & Programs signage, undated, posted behind the staff desk identified the daily program times for smoking. Additional undated signage titled Smoking Plan for [R1], identified R1 could check e-lighters in/out at the desk. The plan noted before checking a lighter out, staff were to ask if R1 had any urge/intention to use lighter/cigarettes to remove hair, ask to show staff R1's pipe and loose tobacco, remind to refrain from obtaining cigarettes from others, and remind to turn in his lighter within 20 minutes. After checking a lighter in, staff were to ask if he used lighter/cigarette to remove hair. During an interview on 5/5/25 at 2:04 p.m., mental health worker (MHW)-B stated if someone was deemed unsafe to smoke a vulnerability care plan was created. Staff knew which specific interventions or assistance a resident needed based on the care plan and smoking safety assessment. MHW-B stated the care plan was always updated to fit individual resident needs. MHW-B stated R1 had a smoking program where he checked lighters in/out from staff and staff asked him safety questions. MHW-B noted R1's pipe broke recently and he had been smoking cigarettes instead until obtaining a new pipe. During an interview on 5/5/25 at 2:36 p.m., registered nurse (RN)-B stated she looked at care plans to see what interventions or assistance residents needed for smoking. RN-B stated if R1 didn't have a flameless lighter or pipe he would be at an increased risk of being unsafe with smoking. During an interview on 5/5/25 at 3:56 p.m., MHW-C stated she was working when R1's recent burns happened, she noted the burns when completing his evening skin check, and he had reported burning himself with a cigarette. MHW-C stated R1 usually smoked a pipe and that's part of his care plan as well because he didn't burn himself with a pipe. MHW-C noted after R1's pipe broke the plan was to get him a new pipe. While smoking cigarettes, MHW-C stated staff were helping him more frequently with hair removal. MHW-C identified additional interventions for R1's smoking safety while using cigarettes included checking in with him more frequently. MHW-C stated R1 was now back to smoking a pipe. During an observation on 5/5/25 at 4:39 p.m., R1 approached the staff desk to request smoking materials. Program director (PD)-A asked if he wanted a cigarette or his pipe and R1 stated he wanted a cigarette. PD-A asked R1 safety questions and confirmed no intent or urges to burn. PD-A retrieved two cigarettes from storage behind the staff desk and a flameless lighter, and escorted R1 off the floor to smoke. During an interview on 5/5/25 at 4:42 p.m., therapeutic recreation intervention specialist (TRIS)-A was seated at the staff desk and present when R1 retrieved cigarettes from PD-A. TRIS-A noted R1 usually only smoke a pipe and hadn't always had cigarettes stored behind the desk but must right now. TRIS-A noted if R1 asked for a cigarette, staff would have to make sure someone was available to go outside with him. During an interview on 5/7/25 at 9:07 a.m., MHW-A stated she was R1's program manager (PM). MHW-A stated R1 had been smoking cigarettes after his pipe broke and she had completed a safety assessment and observed him smoke a cigarette. MHW-A noted staff need to be hyper vigilant when he [R1[ is using cigarettes because that is not part of his care plan. Regarding interventions for R1 when smoking cigarettes, MHW-A stated, let me check the care plan, I don't know if anything new was added specifically for that, but what I would do personally is observe him and escort him. During an interview on 5/7/25 at 9:47 a.m., MHW-D stated R1 was smoking cigarettes and had to be on one-to-one's for cigarettes and had to be supervised because he had used a cigarette to burn himself. R1 did not require supervision if smoking a pipe. MHW-D stated he was positive the one-to-one supervision with cigarettes was an intervention on R1's care plan and it would be on someone's care plan if they required a staff escort for smoking. MHW-D reviewed R1's care plan and did not see where this intervention was located. During an interview on 5/7/25 at 3:55 p.m., R1 stated he recently got a new pipe but had some cigarettes left, almost two packs that he bought a while ago. R1 stated I always go out with staff if I smoke them, they want me to go out with them. He noted staff checked in with him and asked him how he was doing before smoking when he went to the desk to retrieve a lighter. R1 had a bandage on his left forearm, did not identify the source of the wound, but stated it was doing okay. During an interview on 5/7/25 at 10:22 a.m., PD-A stated R1 started smoking cigarettes when his pipe broke in mid-April. R1 still had some cigarettes, agreed to keep them behind the desk, had obtained a new pipe, but continued smoking the cigarettes. PD-A stated, any time he is going to smoke a cigarette he is on a one-to-one with staff until the cigarettes are gone. PD-A stated staff were aware of this intervention because it was discussed verbally and was in R1's progress notes and incident report. PD-A stated this documentation identified he needed a one-to-one escort for cigarettes, but it's not in his care plan at this time. Further, PD-A noted, she would expect this to be on the care plan and it would have been a helpful care plan intervention. During an interview on 5/7/25 at 1:48 p.m., the director of nursing (DON) stated she would expect to see one-to-one staff escorts for smoking identified on a resident's smoking vulnerability care plan. The DON noted if this was not on the care plan staff would know R1 needed a one-to-one escort because it would be included in the staff communication log and on a resident's individual program sheet for smoking. The DON was not aware R1's individual Smoking Plan sheet at the staff desk lacked this information. The DON stated the director of clinical services (DCS) had been more involved in R1's recent burn incident and knew more. During an interview on 5/7/25 at 3:04 p.m., the DCS stated since R1's recent burn incident he had been on a one-to-one with staff if smoking cigarettes. The DCS stated she would expect to see the intervention of a one-to-one staff escort on the care plan. The DCS noted staff had been effective in providing one-to-one supervision for R1 with cigarettes and it one hundred percent makes sense for it to be care planned, for the continuity and consistency. The DCS confirmed she did not see this intervention on R1's care plan. Facility policy titled Smoking and Vaping Policy and Procedure dated 2/25/25, indicated residents were assessed on admission and quarterly for unsafe smoking and vaping behavior in the Vulnerability Assessment and Abuse Prevention Plan. If assess to be vulnerable in this area, would have a vulnerability plan outlined in the Vulnerability Assessment and Abuse Prevention Plan and interventions may be documented in the resident's treatment plan. Facility policy title Tobacco and Electronic Delivery Device Use Screening Procedure dated 2/25/25, indicated this screening was to screen for a resident's ability to safely smoke and utilize an electronic delivery device. The information gathered from the screening would be shared with the treatment team in order to determine whether the resident is able to use tobacco without intervention due to a low burn risk or requires intervention to reduce burn risk and/or use an electronic delivery device safely. If determined to require intervention due to burn risk, the treatment team would make recommendations as to how to best ensure resident safety and a subsequent Vulnerability Care Plan will be created. The Vulnerability Care Plan would be reviewed quarterly and as needed to ensure [NAME] practices were being followed.

Based on observation, interview, and document review, the facility failed to ensure professional standards of practice for documentation were followed during transcription and administration of a standing order medication for 2 of 2 residents reviewed (R1, R2) with wounds requiring antibiotic ointment. Findings include: Facility policy titled Standing Medication and Treatment Orders dated 5/18/22, included a copy of the facility standing orders list. Non-oral/topical routine treatments included: bacitracin zinc (antibiotic used to treat minor skin injuries such as cuts/scrapes/burns) ointment, apply topically to affected areas up to three times daily PRN, with a seven-day time limit. R1 R1's annual Minimum Data Set, dated dated dated [DATE], indicated R1 admitted to the facility on [DATE] with primary diagnosis of schizoaffective disorder (chronic illness causing changes in thoughts, moods, and behaviors) and did not have any ulcers, wounds, or skin problems. R1's care plan included a problem dated 5/1/25, of burns to bilateral arms. Interventions included administer analgesics as ordered. R1's care plan included a problem dated 5/6/25, of scratch to right fourth finger. Interventions included provide skin care as indicated. R1's care plan included a problem dated 5/7/25, of abrasion to left hand. Interventions included apply sterile bandage as needed. Physician orders in R1's electronic health record (EHR) included order dated 11/27/1998, for medications noting [facility] PRN [as needed] list OK. R1's progress note dated 5/1/25 at 10:16 p.m., indicated R1 sustained self-inflicted burns to both forearms totaling 82 burns. Both forearms were cleaned with dermal wound cleanser and thin coating of bacitracin to all burns of both arms. R1 declined application of dressings. R1's progress note dated 5/2/25 at 2:13 p.m., indicated two open areas on left forearm and the site was cleansed using a BZK (benzalkonium chloride) wipe but R1 would not allow application of a bandage. It did not indicate if bacitracin was applied or refused. R1's progress note dated 5/2/25 at 8:52 p.m., indicated the burns on left forearm were cleansed with an antiseptic wipe and transparent dressings applied to all blisters on left forearm. It did not indicate if bacitracin was applied or refused. R1's progress note dated 5/3/25 at 9:14 a.m., indicated two open areas on left forearm were cleansed with wound cleanser spray, and bacitracin and 2x2 island dressing [gauze bandage] placed on top of both open areas. R1's progress note dated 5/3/25 at 8:27 p.m., indicated affected areas were cleansed with wound cleansing spray, bacitracin applied, and covered with two 2x2 island dressings. R1's progress note dated 5/4/25 at 9:14 a.m., indicated three open areas on left forearm were cleansed with BZK, and bacitracin and 2x2 island dressing placed over top of all three wounds. Areas were healing without concern with plan to decrease physical health checks from twice to once daily for monitoring and daily dressing changes. R1's progress note dated 5/5/25 at 9:58 a.m., indicated one of the three open areas had scabbed over and they were cleansed with BZK and bacitracin and 2x2 island dressing placed over top of all three wounds. R1's progress note dated 5/6/25 at 10:36 a.m., indicated three open areas on left forearm were cleansed with a BZK wipe, thin layer of bacitracin ointment applied, and all three areas covered with island dressings. R1's progress note dated 5/6/25 at 12:58 p.m., indicated R1 sustained a scratch on his right fourth finger. The area was cleansed with a BZK wipe, a thin layer of bacitracin applied, and covered with a Band-aid. Plan to place on once daily physical health checks to monitor healing. R1's progress note dated 5/7/25 at 1:44 p.m., indicated the scratch on R1's right fourth finger was cleansed with BZK wipe with bacitracin and Band-aid placed over top. R1's progress note dated 5/7/25 at 1:45 p.m., indicated three wounds on left forearm were cleansed with BZK wipes with bacitracin and an island dressing placed over top. R1's progress note dated 5/7/25 at 2:00 p.m., indicated R1 presented with a bleeding superficial abrasion on left hand that occurred while staff assisted with shaving. Wound was cleansed with BZK with bacitracin and Band-aid placed over top. R1's paper medication and treatment administration records (MAR/TAR) dated month of May 2025, included an order noting facility PRN list okay with note FYI (for your information). The MAR/TAR did not include an order for bacitracin zinc ointment to be applied topically to affected areas up to three times daily PRN with a seven-day time limit, as identified in the referenced standing orders list. The MAR/TAR lacked identification of the medication's prescribing practitioner's name, full medication name, dosage, route of administration, frequency, duration, specific indication for use, or date of medication order for the administrations of bacitracin documented in progress notes as follows: -5/1/25 once to both arms -5/3/25 twice to left arm -5/4/25 once to left arm -5/5/25 once to left arm -5/6/25 once to left arm and right finger -5/7/25 once to left arm, right finger, and left hand Physician orders in R1's EHR did not include transcription of the specific standing order for bacitracin including the prescribing practitioner's name, medication name, dosage, route of administration, frequency, duration, indication for use, or date of medication order. During an interview on 5/5/25 at 2:36 p.m., registered nurse (RN)-B stated she had been providing wound care for R1's forearm burns. The wound care was cleaning it with an antiseptic wipe, putting a little bacitracin ointment on, and then a small bandage. During an observation on 5/7/25 at 8:45 a.m., R1 had a new small bleeding cut on the back of his left hand and presented to the nursing station. RN-A cleansed the area with a BZK wipe, applied bacitracin, and placed a Band-aid on top. During an interview on 5/7/25 at 8:53 a.m., RN-A stated she believed bacitracin was a medication and it was once of the facility's standing orders. RN-A stated staff documented in a resident's MAR if they had active wound care and we would write down the specifics of like cleanings, bacitracin, and then would sign for it in the MAR. We would write in the standing order for the bacitracin and sign for it there. RN-A stated she had applied bacitracin to R1's forearm wounds over the previous weekend and documented this in progress notes but not in his MAR. She confirmed the bacitracin standing order should have been transcribed into R1's MAR. She noted the process for standing orders was to have a nurse assess the need for it and, if indicated, write it into the paper MAR, date it, sign it, then administer and document it. On 5/7/25 at 10:03 a.m., RN-A stated if nursing staff enter an order on the paper MAR, you also put it into the physician orders in [EHR]. RN-A reviewed R1's paper MAR and the physician orders in R1's EHR and confirmed she did not see an order for bacitracin in either location. R2 R2's quarterly MDS dated [DATE], indicated R2 admitted to the facility on [DATE] with no ulcers, wounds, or skin problems. R2's care plan included a problem dated 5/2/25, of burn to right middle finger. Interventions included administer analgesics as ordered. Physician orders in R2's electronic health record (EHR) included order dated 12/8/24, for medications noting [facility] PRN list OK - Has different melatonin and nicotine lozenge order prescribed by [provider name]. R2's progress note dated 5/2/25 at 8:54 a.m., indicated R2 sustained a burn on his right middle finger. The area was cleansed with an antiseptic wipe and aloe vera and a Band-aid applied. R2's progress note dated 5/3/25 at 12:31 p.m., indicated bacitracin and a bandage were applied to the finger. R2's progress note dated 5/3/25 at 8:41 p.m., indicated bacitracin and a bandage were applied to the finger. R2's progress note dated 5/4/25 at 9:19 am, indicated bacitracin and a bandage were applied. Physical health checks were decreased from twice daily to daily to monitor healing and continue daily dressing changes. R2's progress note dated 5/5/25 at 8:34 a.m., indicated the burn was cleansed and bandage applied. Further noted will put a daily wound care/Band-aid change in his MAR and reduce physical health checks to Monday, Wednesday, Friday. R2's progress note dated 5/7/25 at 9:22 a.m., indicated the burn was cleansed and bandage applied. Daily wound care and bandage changes in the MAR were ongoing. R2's paper MAR/TAR dated month of May 2025, included an order noting facility PRN list okay with note has different melatonin and nicotine lozenge order. The MAR/TAR also included an order for daily wound care (cleanse with BZK wipe, apply bacitracin ointment) and Band-aid change to right third finger until healed scheduled for a.m. (morning) with start date 5/5/25. Administrations were documented on 5/5/25 and 5/7/25. The application of bacitracin identified in progress notes twice on 5/3/25 and once on 5/4/25 was not documented, as they were prior to the wound care order start date of 5/5/25. Wound care documentation, including application of bacitracin, dated 5/6/25 was blank. Further, while the wound care order identified the use of the bacitracin, the MAR lacked transcription of the specific order for the bacitracin including the prescribing practitioner's name, full medication name, dosage, route of administration, frequency, duration, specific indication for use, or date of medication order for the administrations of bacitracin documented in progress notes and wound care order. In addition, the wound care order did not identify the parameters included in the standing order for bacitracin limiting its use to seven days. Physician orders in R2's EHR did not include transcription of the specific standing order for bacitracin including the prescribing practitioner's name, medication name, dosage, route of administration, frequency, duration, indication for use, or date of medication order. On 5/7/25 at 10:10 a.m., R2 stated he accidentally burnt his middle finger four or five days ago. R2 stated staff looked at it that morning and they put some bacitracin and the Band-aid on it. The middle finger on R2's right hand had a Band-aid present. During an interview on 5/7/25 at 12:56 p.m., RN-C stated if a resident had a minor wound, it would be treated per nursing judgement with treatment orders written on the MAR for type of treatment and frequency. This would include identifying use of bacitracin and the type of dressing used. RN-C stated resident MARs typically included a physician order noting the facility's standing orders were okay to administer and would note exceptions, so she did not transcribe the individual orders into the EHR. If a resident had standing orders and a new medication from the list was administered, she would transcribe it onto the paper MAR. During an interview on 5/7/25 at 1:48 p.m., the director of nursing (DON) stated the process for using standing orders included staff first checking a resident's MAR to see if it included an order directing it was okay to use facility standing orders. The DON stated wound care based on standing orders included bacitracin as an antibiotic as indicated by the type of concern. She noted this was not expected to be documented on the MAR but would be part of progress notes for wound treatment, including the type of ointment or bandaging and wound care provided. The DON confirmed bacitracin is an ordered medication and medications should be documented on the MAR. The DON was unable to articulate further explanation as to why the specific standing order for bacitracin administration was not transcribed onto the MAR but noted she saw the rationale and opportunity for changing this practice. The DON was not able to articulate how this aligned with professional standards of practice. The DON noted if a resident was transferred to a different facility it wouldn't be abundantly clear if bacitracin was being used on a wound. The DON confirmed the standing order for bacitracin included a seven-day time limit for use. When asked how staff were adhering to this parameter if they were not transcribing the order and documenting the administration she replied, they aren't. The DON noted it had been facility practice to refer to all medications in the standing orders collectively as the facility's standing orders within the physician orders in the EHR rather than transcribing individual orders upon utilization. She further noted in an emergency transfer, individual medications administered from standing orders would not be identified in the EHR physician orders and it was not facility practice to provide a copy of standing orders. The DON then noted for a standing order used for the first time, nurses needed to transcribe the order onto the paper MAR prior to administration. Facility policy titled Standing Medication and Treatment orders dated 5/18/22, indicated the orders were entered into the electronic medical record system as [Facility] Standing Orders O.K. Any standing medication and treatment order that was administered would be entered on the MAR individually if it was utilized. Facility policy titled Medication Orders: Communication and Transcription dated 10/13/23, indicated following specific procedures in transcribing medication orders would reduce the potential for medication error, which was the purpose of the policy. A complete medication order was identified to include the following elements: resident name, prescribing practitioner's name, medication name, dosage, route of administration, frequency, duration, indication for use, date of medication order. Facility policy titled PRN Medication Administration dated 4/13/09, indicated PRN medication orders would be filed in a resident's chart and documented on the MAR.

Based on observation, interview, and document review, the facility failed to use appropriate personal protective equipment during high-contact cares for 1 of 1 resident (R1) reviewed with enhanced barrier precautions implemented. Findings include: Enhanced Barrier Precautions (EBPs): the use of personal protective equipment (PPE) including gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. R1's facesheet dated 5/7/25, indicated R1 had diagnoses including bladder disorder, urethral stricture (narrowing of urethra), benign prostatic hyperplasia (BPH, enlarged prostate), bladder neck obstruction, and overactive bladder. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had an indwelling catheter. R1's care plan dated 2/8/24, indicated R1 had altered urinary elimination related to urinary retention, BPH, urethral stricture with outlet obstruction requiring suprapubic catheter, and history of atonic bladder (weak bladder muscles). Interventions included: annual urinary assessment, suprapubic catheter care per medical provider instructions, labs and diagnostics per physician order, encourage limiting fluids and caffeine in the evening, provide incontinence pads as needed, instruct regarding proper disposal of soiled items and assist as needed, provide education about proper technique for emptying catheter bag, assessment by physician as needed, and instruct to notify staff if experiencing hematuria (blood in urine) or pain at catheter site. The care plan did not identify that EBPs were implemented for R1 due to his indwelling catheter. R1's Activities of Daily Living Documentation Record dated May 2025, instructed staff to shave R1's head and body with full staff assist twice monthly. Documentation noted R1's arms, pubic area, and buttock were shaved on 5/7/25. EBP signage on R1's door undated, indicated everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toilet use, when caring for or using devices, and when caring for wounds. During an observation on 5/7/25 at 8:29 a.m., Mental Health Worker (MHW)-A stated she was a nursing assistant (NA) and trained medication aide (TMA). MHW-A stated she assisted R1 with shaving every Wednesday. MHW-A noted the EBP sign on R1's door (a room shared by three residents) was because R1 had a catheter. Outside of R1's door were drawers containing gowns, masks, and glasses but no gloves or hand sanitizer. MHW-A entered R1's room without completing observed hand hygiene or donning (putting on) PPE including gloves or gown, though had gloves with her along with shaving supplies. MHW-A noted there was hand sanitizer present on R1's bedside table at the far end of the room, with R1's bed the farthest from the door. MHW-A put gloves on once inside the room and proceeded to shave R1's inner thigh/pubic, buttock, and arm hair. Upon completion, MHW-A exited the room without completing hand hygiene and carrying soiled shaving supplies in her gloved hands down the hallway. During an interview on 5/7/25 at 9:07 a.m., MHW-A stated she had completed online training about EBPs and received information about EBPs at orientation. MHW-A stated all staff members should be taking those precautions and anyone providing direct care with a resident should wear gloves. She stated PPE needed for shaving R1 was definitely gloves but staff don't need to gown up or anything like that. MHW-A noted when shaving R1 earlier, she had used hand sanitizer and obtained gloves at the nursing station prior to walking to R1's room. She stated she didn't put on a gown when shaving him, I don't ever do that. When shaving him I clean my hands and use gloves. She stated she had not ever been told to put on a gown for shaving R1. During an interview on 5/7/25 at 1:48 p.m., the director of nursing (DON) stated the facility had a new infection preventionist starting tomorrow and she was currently assuming those responsibilities. The DON confirmed EBPs were needed for residents with indwelling devices, including suprapubic catheters. She noted staff needed hand hygiene, gloves, and a gown when providing direct care to residents and anyone providing high contact activities needed to adhere to EBPs. The DON confirmed staff needed to perform hand hygiene and wear gloves and a gown when shaving R1. The DON noted the risk of not doing so included MDROs and though R1 did not have an MDRO he was at an enhanced risk for infection due to his indwelling device. The DON stated EBPs should be part of the care plan for an indwelling device, and she would expect to see EBPs on the care plan. Facility policy titled Enhanced Barrier Precautions Policy dated 8/14/23, indicated EBPs would be implemented during high-contact resident care activities when caring for residents with an increased risk of acquiring an MDRO such as residents with wounds, indwelling medical devices, or residents infected or colonized with an MDRO. EBPs required gown and glove use for residents with indwelling medical devices during specific high-contact resident care activities including bathing/showering, device care or use, and providing hygiene cares. Indwelling medical devices included urinary catheters. In addition, an isolation care with PPE was to be immediately outside the resident room and alcohol-based hand sanitizer both inside and outside the resident room.

Based on observation, interview, and document review, the facility failed to conduct regular inspections of hospital bed frames, mattresses and bed rails as part of a preventative maintenance program for 1 of 1 resident (R49) reviewed who had a broken bed rail affixed to the frame. Findings Include: R49's quarterly Minimum Data Set (MDS) dated [DATE], identified R49 had severe cognitive impairment and was independent with all activities of daily living. R49's diagnoses sheet printed 8/1/24 listed the pertinent diagnoses of undifferentiated schizophrenia (experiences psychotic symptoms) and lymphedema (swelling caused by buildup of lymph fluid). R49's care plan dated 6/14/23, indicated R49 was at risk for falls with an intervention of utilizing a hospital bed (electric adjustable bed) with transfer assist bars for sleeping. During observation on 7/29/24 at 3:05 p.m., R49's bed had two pivoting assist devices (PAD) attached to the adjustable bed frame. The left PAD was in the upright position. The right PAD was swung down where the top of it was touching the floor. The right PAD was not in the line with the frame and pulled away from the bed. The PADs were connected to the bed frame by one bolt and utilized a pivot stop handle (pull out to rotate) as the locking mechanism. During observations on 7/30/24 at 7:57 a.m. and 12:52 p.m., the PAD positions remained unchanged. During interview on 7/31/24 at 8:10 a.m., registered nurse (RN)-A verified the right PAD was broken and did not know how long it was in that condition. RN-A confirmed staff round in the rooms daily and someone should have seen this. During interview on 7/31/24 at 9:38 a.m., maintenance engineer (ME)-A stated there were no scheduled maintenance checks for R49's bed and they kept no logs. ME-A stated the normal process was to wait on a call from the floor to address concerns. ME-A stated that the right PAD on R49's bed was broken due to a sheared bolt. During a follow up observation and interview on 7/31/24 at 10:46 a.m., ME-A was tightening the bolt on the left PAD on R49's bed. ME-A stated they had not reviewed the manual first and they do not have the manual because the director of nursing (DON) does. When asked about proper installation of the left PAD, ME-A replied, I don't know, it's just bolts. During interview on 8/1/24 at 8:07 a.m., the account manager (AM)-C for Direct Supply was unable to verify how often the Direct Supply Panacea 1000 adjustable-Height Low Bed and Direct Supply Panacea Pivoting Assist Device should be inspected. AM-C stated they would have to reach out to their manufacturing group to find out what periodic meant from the user manual. A clarification call-back was requested but not received. During interview on 8/1/24 at 9:30 a.m., the DON stated the bed went in use the same date as the care plan intervention, 6/14/23. A bed maintenance policy and maintenance bed inspection logs were requested but were not received. Owner's manual regarding Direct Supply Panacea 1000 Adjustable-Height Low Bed dated 8/13, recommended periodic inspections which included inspecting all bolts and fasteners and visual examination of all bed components for damage or excessive wear.

Based on observation, interview, and document review the facility failed to ensure resident call light was within reach from the bathroom floor in a multi -resident bathroom for 3 of 3 residents (R135, R193, R39,) reviewed for call light accessibility. Findings include: R135 R135's quarterly Minimum Data Set (MDS) dated [DATE], identified R135 had intact cognition and diagnosis which included seizure disorder, anxiety, and schizophrenia. MDS identified R135 was independent with activities of daily living (ADL's) which included transfers, toileting, and showering. R135's fall risk assessment dated [DATE], identified R135 was a moderate risk for falls related to medication use. Further identified R135 had three falls in the past year, one with an injury from striking her head. R135's care plan dated 12/10/21, identified R135 was at risk for falls related to medication use and history of falls. Care plan instructed to encourage use of emergency call-light system as needed, for immediate and urgent staff assistance. During an observation on 7/29/24 at 7:00 p.m., the multi-resident bathroom was noted to have a call light on the wall to the right side of the shower with a cord that that was approximately three feet from the floor and a call light on the wall to the left side of the toilet with a cord that was approximately two feet from the floor. During an observation on 7/30/24 at 8:22 a.m., the multi- resident bathroom continued to have a call light on the wall to the right side of the shower with a cord that that was approximately three feet from the floor and a call light on the wall to the left side of the toilet with a cord that was approximately two feet from the floor. During an interview on 7/30/24 at 11:34 a.m., R135 confirmed she used the toilet and shower independently in the multi-resident bathroom. R135 stated she would not be able to reach the emergency call light if she fell on the floor while using the toilet or the shower. R135 stated she had a history of falls and should have access to a call light if she were to fall on the floor while in the bathroom. R193 R193's quarterly MDS dated [DATE], identified R193 had intact cognition and diagnosis which included post-traumatic stress disorder (PTSD), anxiety, and schizophrenia. MDS identified R193 was independent with activities of daily living (ADL's) which included transfers, toileting, and showering. R193's fall risk assessment dated [DATE], identified R193 was a high fall risk related to functional impairments and a fall in the past 30 days. Further identified R193 was not able to transfer safely or safely sit in a shower/tub chair. R193's care plan dated 3/19/24, identified R193 was at significant risk for falls related to medication use and obesity. Care plan instructed to encourage use of emergency call-light system as needed, for immediate and urgent staff assistance. During an interview on 7/30/24 at 11:39 a.m., R193 confirmed she used the toilet independently in the multi-resident bathroom and at times used the shower in the multi-resident bathroom independently. R193 stated she would not be able to reach the emergency call light if she fell on the floor while using the toilet or the shower. R193 stated she had a history of falls and feels it was important for her to be able to reach the call light from the floor in the bathroom. R39 R39's quarterly MDS dated [DATE], identified R39 had intact cognition and diagnosis which included schizophrenia, asthma, and hyponatremia (low sodium blood levels). MDS identified R39 was independent with activities of daily living (ADL's) which included transfers, toileting, and showering. R39's fall risk assessment dated ,d+[DATE], identified R39 was a moderate risk for falls relation to medication use. R39's care plan dated 9/14/21, identified R39 was at risk for falls related to clutter. Care plan lacked evidence of the use of the emergency call system. During an interview on 7/30/24 at 11:44 a.m., R39 stated she used the toilet independently in the multi-resident bathroom. R39 stated she was unsure if she would be able to reach the call light if she was on the floor in the bathroom but felt it was important for her to be able to reach the call light from the floor in the bathroom. During a joint interview on 7/30/24 at 12:10 p.m., mental heath worker (MHW) and licensed practical nurse (LPN)-A verified R135 and R193 were all fall risk and used both the toilet and the shower independently in the multi-resident bathroom and R39 was also a fall risk and used the toilet independently in the multi- resident bathroom. MHW and LPN-A stated all three residents were able to use the call system but would not be able to access the call light system if they were on the floor in the bathroom. During an interview on 7/30/24 at 3:07 p.m., director of nursing (DON) stated call lights may not be within reach in the multi- resident bathroom if R135, R193, or R39 were on the floor. [NAME] further stated she was unsure if there was a need for a resident to be able to access the call light from the floor because of the highly ambulatory population of the residents. A facility policy titled Emergency Monitoring System dated 4/23/14, identified pull station transmitters were located in resident rooms, bathroom, and other common areas. Further identified all activations of the system shall be responded to in a timely fashion by staff members.

Based on observation, interview and document review the facility failed to ensure specific triggers for post-traumatic stress disorder (PTSD) were comprehensively reassessed and care planned for, including medical and psychiatric interventions. This resulted in repeated seizures, numerous falls with head strikes and hospitalization s for 1 of 1 resident (R179) reviewed for trauma informed care. Findings include: R179's Record of Admission indicated R179 was admitted to the facility on [DATE] with several medical diagnoses to include bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, PTSD (a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving a disturbance of sleep and constant vivid recall of the experience), and opioid use. R179's Quarterly Minimum Data Set (MDS), dated [DATE], indicated R179 was cognitively intact and independent with all activities of daily living (ADLs). R179's progress notes indicated R179 had 26 seizures, increasing in frequency, in the past 65 days requiring 11 hospitalization s and were documented as follows in the progress notes. On 6/1/23, it was documented R179 was hospitalized on ,d+[DATE] for seizure activity in the community. On 6/3/23, in was documented R179 had seizure activity for 8 minutes. On 6/12/23, it was documented R179 was hospitalized from 6/5 - 6/12 due to a concern for seizures and respiratory failure. On 6/6/23, it was documented R179 had a seizure in the hospital requiring intubation (placement of an artificial airway). On 6/10/23, it was documented R179 called the facility, stating she wanted to come home (to the facility) and not be in the hospital anymore. On 6/18/23, it was documented R179 had intermittent seizures from 11:06 a.m. to 11:42 a.m. lasting 15 seconds to 6 minutes. On 6/18/23, it was documented facility staff found R179 seizing in her bed and after 45 minutes was sent to the hospital. On 6/19/23, it was documented R179 had seizure activity from 2:59 p.m. to 4:29 p.m. and from 7:39 p.m. to 7:59 p.m. On 6/20/23, it was documented R179 had seizure activity from 7:27 a.m. to 8:03 a.m. and 2:00 p.m. to 2:40 p.m. and at 5 p.m. for approximately five minutes. On 6/24/23, it was documented R179 had seizure activity from 8:16 p.m. to 8:27 p.m. On 6/29/23, it was documented R179 had seizure activity at 1:32 p.m. for an hour. On 7/1/23, it was documented R179 had seizure activity in the community and was sent to the hospital. On 7/7/23, it was documented R179 was sent to the hospital for a 30-minute seizure. On 7/9/23, it was documented R179 had a seizure in community and was sent to hospital. On 7/10/23, it was documented R179 reported having a good weekend other than having to go to the hospital this weekend after having a seizure in the community. On 7/11/23, it was documented R179 had seizure activity from 5:07 p.m. to 5:38 p.m. and from 7:20 p.m. to 7:42 p.m. On 7/14/23, it was documented R179 was found on floor seizing at 6:57pm and seizure activity stopped at 7:03. R179 was sent to hospital for severe neck pain/headache and confusion post seizure/fall. On 7/16/23, it was documented R179 had seizure activity lasting approximately five minutes after being found on the floor after a loud audible fall and was sent to the hospital. On 7/20/23,it was documented R179 had two seizures, each lasting approximately seven minutes. On 7/21/23, it was documented R179 met with the primary care provider who had concerns for a possible traumatic brain injury due to numerous falls with head strike. On 7/31/2,3 it was documented R179 had seizure activity with flashbacks. On 8/1/23, it was documented R179 came out of her room at 9:15 p.m. and collapsed with a head strike, was nonresponsive for 10 minutes which was followed by two seizures. R179 was sent to the hospital. On 8/2/23, it was documented R179 was sent to hospital twice for seizure activity. R179's care plan lacked a specific focus area for PTSD. It did indicate R179 was at risk for injury related to seizures but lacked resident specific medical or psychiatric interventions to prevent seizures including specific triggers to avoid. R179's electronic medical record (EMR) lacked comprehensive reassessments of R179 to include patterns of events leading up to R179's seizures, interventions to prevent PTSD episodes and seizures including what interventions have worked or not worked in the past. The EMR overall lacked proactive steps to take to prevent seizures which were believed to be caused by stress and anxiety according to R179's 2nd quarter treatment plan, dated 2/2/23. During an interview on 8/2/23 at 8:24 a.m., R179 stated staff talk with her a lot but have not asked about what specifically triggers her PTSD and seizures, although she was unsure what they may be. During an interview on 8/2/23 at 1:52 p.m., program director (PD)-A stated residents with a diagnosis of PTSD should be assessed using a user defined assessment (UDA) for PTSD which would be used to create a PTSD care plan with specific triggers. PD-A was unable to find a UDA for R179 related to her PTSD. PD-A stated R179 had an appointment set up with neurology and is working with her psychiatrist but no other changes have been made to R179's plan of care after repeated seizures and subsequent hospitalization s. PD-A stated R179's primary provider is updated via fax after each episode of seizure activity. The PD-A further stated specific triggers would be discussed as a staff meeting but these meetings were not documented. During an interview on 8/3/23 at 8:19 a.m., registered nurse (RN)-D stated the seizure protocol was to wait five minutes and if the seizure continued then to call emergency medical services (EMS). RN-D stated during an active seizure the nurses monitored vital signs. RN-D confirmed they did not have a specific seizure protocol for R179. During an interview on 8/3/23 at 9:55 a.m., RN-D stated when a resident had a seizure, the staff took notes of what occurred, which would be recorded as a progress note, but there was not specific flow sheets or a protocol to use during or post seizure. During an interview on 8/3/23 at 10:21 a.m., the assistant director of nursing (ADON) stated the facility's medical director was a psychiatrist who deferred medical concerns to the patient's primary care provider, and when they could not be reached to the emergency department at the hospital. The ADON stated the expectation for staff during a seizure was to monitor vital signs and call 911 after a resident was actively seizing for 5 minutes. The ADON stated staff are expected to keep the resident safe during a seizure and use oxygen if needed. The ADON acknowledged that R179's seizures were increasing in frequency stating that R179 was seeing a psychiatrist and neurology soon. During an interview on 8/3/23 at 10:40 a.m., R179's primary care provider and medical doctor (MD)-A stated R179 had a very complex case and her seizure disorder was consistent with pseudoseizures (psychogenic nonepileptic seizures, previously known as pseudoseizures, usually have a psychological cause, such as severe mental stress. They are different from epilepsy and do not involve changes to electrical impulses in the brain) but that neurology would need to clear her of any true epileptic seizure disorder. MD-A stated pseudoseizures are typically managed with medical and psychiatric care and while R179 was seeing her in clinic she struggled with how to manage her care. MD-A stated R179 needed a complex protocol with medical and psychiatric interventions in place, stating she would love to collaborate with the facility and R179's psychiatrist but that had not been arranged. MD-A further stated the facility was good at updating her about seizure activity via fax, but stated it would be nice if she could touch base with facility staff in person or via phone for collaboration. MD-A stated R179 ultimately needs more help and is unstable stating she would benefit from an inpatient psychiatric unit or extensive psychiatric outpatient program. During an interview on 8/3/23 at 11:15 a.m., MD-A stated she spoke with R179's psychiatrist who is going to reach out to her (psychiatrist's) supervising doctor to see, what more we can be doing to prevent R179's seizures and hospitalization s acknowledging that repeated hospitalization s was not beneficial to R179. During an interview on 8/3/23 at 12:21 p.m., the ADON stated she had not contacted R179's primary care provider or psychiatrist via phone and did not believe the floor staff had either, stating they tried to call but often had to fax due to not being able to get ahold of the doctor. The ADON further stated waiting for the doctors to call back is challenging and frustrating. During an interview on 8/3/23 at 1:06 p.m., the administrator stated facility staff are expected to use the resident's physician or on call physician for medical needs and to utilize the emergency department when they cannot be reached timely. The administrator confirmed the facility did not have a physician rounding group because they are a facility for mental health services and the facility does not have enough money for a rounding physician group. The administrator acknowledged that many residents admitted to the facility also had complex medical conditions. During and interview on 8/3/23 at 1:35 p.m. the MD stated because the facility was designated a MHI, no care providers were able to go into the facility and therefore, all residents had their own psychiatrist who handled their mental health and a separate primary care provider (PCP) who handled the resident's medical conditions. The MD stated all PCPs had 24 on-call services the staff could contact in the event of a medical emergency; however, many psychiatrists do not have 24 hour availability; therefore the staff could call the MD 24 hours a day and she would help them problem solve. The MD stated if she was unable to problem solve with the staff, the resident could wait until the following day, or the staff could send the resident to the emergency department. The MD stated in a very rare case she may refill a psychiatric medication over the weekend, but she only provided consultation to staff regarding resident psychiatric care. The MD stated she did not provide medical care for the residents and was not involved in the development of any medical policies or procedures such as diabetic or seizure care; and did not know who was. A facility policy titled Seizure Procedure, dated 2/11/2002, indicated the nurse would initiate a Seizure Log and Neurological Assessment and Vital Sign Flow Record Form during a resident seizure, indicating the safety of the resident experiencing a seizure would be the priority of staff witnessing the seizure. A policy on trauma informed care was requested but not provided. A course description of Trauma Informed Care training was provided, indicating the course examined best practices as well as how to avoid actions that may be unknowingly harmful to clients.

Based on observation, interview, and document review the facility failed to ensure dishware and cooking utensils were properly sanitized (i.e., high temperature) in 1 of 1 commercial dishwashers observed in the main production kitchen. This had potential to affect all 206 residents, visitors, and staff who consumed food from the kitchen. Findings include: On 7/31/23 at 11:31 a.m., an initial kitchen tour was completed. A single ProPower commercial dishwasher machine was present in the kitchen and dishwasher (DW)-A was removing various items, including various dishware and cooking utensils, which had just been put through the machine for cleaning and sanitization. A series of three white-colored gauges were present on the machine which displayed wash temperature(s) and one labeled, Final Rinse. On the soiled side of the machine (i.e., dirty), DW-B loaded another hard plastic rack with various kitchen items and loaded them into the machine for cleaning and sanitization; however, when the final rinse of the soiled cookware had completed the white-colored gauge displayed the final rinse temperature was only 178 F (Fahrenheit). DW-B then loaded another rack with various dishware and loaded it into the machine; however, the final rinse temperature gauge displayed the final rinse temperature as only 176 F. DW-B was interviewed and expressed they were not sure if the machine was a high-temperature or chemical sanitization method adding nobody had ever directed or instructed them to check the gauges on the machine during the wash and rinse cycles. DW-B added they knew nothing about the gauges. DW-A continued to remove the cleaned items and place them back in shelving and cupboards for future use. On 8/2/23 at 8:38 a.m., a subsequent kitchen tour was completed. The same commercial dishwasher was in use with food service worker (FSW)-A loading various dishware and cooking utensils into the machine for cleaning. The machine completed the wash cycle and then activated the final rinse, however, the final rinse temperature displayed on the analog gauge was only 175 F. FSW-A loaded another rack with other, soiled kitchenware and dishware items and placed it into the machine. However, again, the final rinse temperature displayed on the gauge was 175 F. FSW-A was interviewed and expressed they were unsure if the machine was a high temperature or chemical sanitization method adding, That's a good question. FSW-A then left the dishwasher area and returned with the food service manager (FSM) who reviewed the machine. FSM verified the dishwasher was a high-temperature sanitization method and the white-colored gauges were the ones used to monitor and check the machine' function. FSM then loaded a rack with soiled silverware and an empty silverware basin and ran it through the machine, however, the final rinse temperature only recorded 174 F which FSM verified. FSM stated the final rinse cycle should be reaching 180 F to ensure the dishware was properly cleaned adding the machine had not been serviced in awhile but was due. FSM explained the staff had been using test strips on various loads to ensure it was reaching proper temperature, and retrieved these strips from the dining room before handing them to the surveyor. FSM stated they tested the machine using these strips on a weekly basis. A package of orange-colored [NAME] test strips were provided with directions to attach a test strip to a utensil or rack and washing the items with the strip attached. It directed, If the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. These strips were removed and were orange-colored with large font present reading, 180 F, and, Pass When Blue Bar Turns Orange. At 8:58 a.m., the food service director (FSD) joined the interview and demonstration of the dishwasher. A test strip was attached to a metallic utensil and ran through the machine on a rack. The final rinse, again, did not hit 180 F and the attached strips remained with a blue-tint upon exiting the machine. FSD stated they believed the machine to be functioning correctly and hitting the correct temperature adding the issue was more than likely the gauge being incorrect. A three compartment sink was adjacent to the dishwasher machine which FSD stated used the same hot water lines which fed the dishwasher. A new test strip was placed under the running hot water of the three compartment sink, and the strip turned orange with no blue-tint present on the strip as had been the result when ran through the dishwasher. FSD acknowledged the strip color difference between the two but expressed they felt it was only faintly different adding the test strips used for quality monitoring on the dishwasher were not saved and immediately discarded. A clipboard with a Dish Machine Temperature Log, dated 8/2023, flow sheet attached was then provided. The flow sheet identified a series of rows and columns which provided space to recorded the wash temperature, rinse temperature, and initials of staff recording the data for three meals on each respective calendar day with the third meal labeled, Dinner, including an additional column labeled, Surface Temp Reading. The rinse column identified the temperature should be, min[imum] of 180, and all the recorded temperatures ranged 180-181 F. The only recorded surface temperature was listed as, 160. An additional Dish Machine Temperature Log, dated 7/2023, flow sheet was included outlined the same series of rows and columns to record the data for the machine. The final rinse column recorded temperatures which ranged 180 F to 182 F, and the surface temperatures recorded ranged from 155 F to 181 F. FSD stated they had not been told and were unaware of any concerns with the commercial dishwasher not getting to 180 F during the final rinse cycle, but expressed it was important the machine did to kill the bacteria and germs which could remain on the dishware and cooking items. FSD reiterated the 180 F temperature importance, and stated a company was scheduled to review the dishwasher the same day (8/2/23) as the machine had developed some sheeting and was not removing rinse aide correctly which resulted in spotting on some pans and dishware. FSD stated the machine was supposed to be serviced every four months, however, had not been serviced in seven [or] eight months now due to the outside company having various issues. When interviewed on 8/2/23 at 9:43 a.m., the registered dietician (RD) explained the facility' dishwasher was a high-temperature sanitization machine, and it had been on our radar off and on for several months due to the gauges potentially not reading correctly. RD stated the water entering the machine was kept at 180 F so they were not sure how the temperature could be falling out of range. RD explained they were onsite at the center the previous week and, at the time, the machine had been hitting the temperatures required (i.e., 180 F). RD stated they would recommend the machine, including the gauges, be inspected to ensure proper function adding they didn't realize the machine had been temping out that low as the surveyor observation. RD verified the test strips being used (i.e., [NAME]) should turn bright orange if the temperature was obtained and FSD had also been testing the surface temperature of various dishware to ensure the rack level minimum temperature (i.e., 160 F) was obtained on the final rinse cycle. RD verified the final rinse cycle should be hitting 180 F (via gauge) or 160 F (via rack level) as that's when the sanitization happens to reduce the risk of foodborne illness adding, It's clearly an important step. On 8/2/23 at 1:29 p.m., a return visit to the kitchen was completed with FSD and FSM present. FSD verified they had been testing the surface temperature (i.e., rack level) of the machine and retrieved a handheld yellow-colored, infrared-style thermometer from the dining room area. A metallic pan was then loaded into a rack and ran through the dishwasher with the gauge labeled, Final Rinse, again only hitting 175 F. Immediately as the metallic pan emerged from the dishwasher, FSD then used the thermometer to check the surface temperature of the dishware which resulted, 156 [F], at the highest point. FSD verified the surface temperature did not hit, at minimum, the 160 F to demonstrate proper rack level rinse temperature. A provided Cleaning and Sanitizing Food Contact Surfaces policy, undated, identified a purpose of preventing foodborne illness by ensuring all food contact surfaces were properly cleaned and sanitized. A section labeled, 6. If a dishmachine is used, directed to check with the manufacturer to ensure the data plate (i.e., gauges) was correct and to use the data plate to determine wash and final rinse temperatures, if applicable. Further, the policy outlined, Ensure that food contact surfaces reach a surface temperature of 160 F or above if using hot water to sanitize.

Based on interview and document review the facility failed to ensure the medical director (MD), who was a psychiatrist, actively participated in the development, implementation, and review of policies and procedures related to resident medical care. This had the potential to affect all 206 residents residing in the facility. Findings include: During an interview on 8/3/23 at 10:21 a.m., the assistant director of nursing (ADON) stated each resident had their own psychiatrist for mental health treatment and their own primary provider for medical care. ADON further stated, due to the facility being classified as a Mental Health Institute (MHI), although they were licensed as a nursing facility, the facility did not allow any providers to come into the facility to provide care and/or assessments to residents because the expense would not be covered by Medicaid. The ADON stated the facility tried to make appointments for the residents to see their personal psychiatrist every 60 days for their mental health and attempted to get into contact with their primary provider for their medical conditions; however, they did not always get a response from the primary providers. During an interview on 8/3/23 at 1:45 p.m., the director of clinical services (DCS) stated the facility medical policies were created many years ago when the medical director of the facility was both an internist (medical physician) and a psychiatrist. The DCS stated the director of nursing (DON) and other non-physician staff reviewed the policies to ensure they were consistent with the regulations. The DCS further stated if a policy or procedure that was out of their scope needed to be updated, the facility would try to find someone to review it, but the DCS was unsure who that would be. The DCS verified the facility medical director was not involved in the review of policies and procedures related to the medical care of the residents. During an interview on 8/2/23 at 2:28 p.m., the consulting pharmacist (CP) stated because the resident's all had their own primary care provider (PCP), she often did not get a response to her recommendations and therefore, only made medication recommendations once a year. If the CP made a recommendation, she would set a reminder for herself in six months to review the resident's chart to see if the recommendations were addressed. The CP further stated some physicians were completely unresponsive, and the facility had never found a good way to follow up. During an interview on 8/3/23 at 1:06 p.m., the administrator stated because the facility was an MHI, providers could not go into the facility to see the residents. The administrator stated after hours, staff would attempt to call the resident's PCP, however, it was very difficult to get a call back timely. The administrator stated staff could also call the MD who would attempt to get ahold of the resident's PCP also. The administrator further stated if staff were unable to contact the PCP or their on-call provider, the resident would be sent to the emergency department. During and interview on 8/3/23 at 1:35 p.m. the MD stated because the facility was designated a MHI, no care providers were able to go into the facility and therefore, all residents had their own psychiatrist who handled their mental health and a separate primary care provider (PCP) who handled the resident's medical conditions. The MD stated all PCPs had 24 on-call services the staff could contact in the event of a medical emergency; however, many psychiatrists do not have 24 hour availability; therefore the staff could call the MD 24 hours a day and she would help them problem solve. The MD stated if she was unable to problem solve with the staff, the resident could wait until the following day, or the staff could send the resident to the emergency department. The MD stated in a very rare case she may refill a psychiatric medication over the weekend, but she only provided consultation to staff regarding resident psychiatric care. The MD stated she did not provide medical care for the residents and was not involved in the development of any medical policies or procedures such as diabetic or seizure care; and did not know who was. Review of the facility seizure procedure dated 2/11/02, indicated any resident who had a seizure would be monitored for 24 hours. Residents requiring more acute medical attention would be sent to the emergency department for evaluation. The procedure also indicated residents with a seizure disorder were to use a shower rather than a tub for hygiene. If a tub was necessary, the resident would be monitored in the tub if bathing assistance was needed; otherwise, staff were to sit outside the tub room. No further interventions regarding the treatment of a resident having a seizure was documented, including maintaining a resident's airway, lowering them to the ground for safety, measures to ensure the resident did not aspirate during seizure activity, or the administration of oxygen. Refer to: F684 Based on observation, interview, and document review, the facility failed to ensure hospital discharge records were reviewed to provide continuity of care and appropriate medication administration for 1 of 1 residents (R113) after they returned to the facility from the emergency department (ED). In addition, the facility failed to comprehensively assess and provide care in accordance with professional standards for 1 of 1 residents (R113) who had repeated episodes of hypoglycemia (low blood sugar). F697 Based on interview and document review, the facility failed to ensure reported complaints of neuropathic (i.e., nerve) and joint pain were comprehensively assessed and, if needed, interventions to promote comfort provided for 1 of 2 residents (R188) reviewed who reported severe pain during the survey. F699 Based on observation, interview and document review the facility failed to ensure specific triggers for post-traumatic stress disorder (PTSD) were comprehensively reassessed and care planned for, including medical and psychiatric interventions. This resulted in repeated seizures, numerous falls with head strikes and hospitalization s for 1 of 1 resident (R179) reviewed for trauma informed care.

Based on observation, interview and document review, the facility failed to ensure structural repair recommendations from an outside pest control contractor were acted upon and completed timely to reduce the risk of rodent or pest entrance into the care center. This had potential to affect all 206 residents, visitors and staff at the facility. Findings include: A Centers for Disease Control (CDC) How to Control Wild Rodent Infestations article, dated 1/2023, identified rats and mice were known to carry various diseases which could be spread to a human population. These diseases included salmonellosis, monkeypox, and tularemia. Further, the article outlined it was important to seal gaps or holes in exterior walls adding, mice can fit through a hole the width of a pencil (1/4 inch or 6 millimeters in diameter). R106's annual Minimum Data Set (MDS), dated [DATE], identified R106 had intact cognition. On 7/31/23 at 1:58 p.m., R106 was interviewed and expressed the care center had a little bit of a mouse problem. R106 explained they had seen mice within the nursing home, off and on, for a couple months including within the dining room which was next to the kitchen. R106 stated they thought the home had brought in an outside company to help address the issue, and explained even the food service director (FSD) had reported they turn the lights on in the dining room and the mice just scatter in the early morning hours. R106 stated they felt the issue had resolved until just last week when another female in the home screamed aloud they had saw a mouse run into the kitchen from the dining room. R165's quarterly MDS, dated [DATE], identified R165 had intact cognition. On 7/31/23 at 2:29 p.m., R165 was interviewed. R165 stated the care center had mice and, as a result, they had several traps present within their room. R165 stated they had reported mice activity to the maintenance department who, in turn, then placed additional traps in their room but expressed nothing else about plans to correct the issue. When interviewed on 8/3/23 at 8:19 a.m., living skills instructor (LSI)-A stated a male resident on the 2nd floor had reported a mouse in their room just a day or two prior, which had been reported to the maintenance department. LSI-A stated they had not noticed or heard of concerns with mice or rodents prior. On 8/3/23 at 8:26 a.m., mental health worker (MHW)-A was interviewed, and expressed they had never personally observed mice or rodents at the center, however, residents had complained about them off and on adding they had last heard a complaint a few months prior. MHW-A stated the maintenance department would be notified of any such complaints and then it was in their hands after that. When interviewed on 8/3/23 at 8:30 a.m., FSD stated they had seen mice in the dining room area but felt it had been awhile, adding the last time was at least a month ago. FSD stated the maintenance department was aware of the issue and, as a result, had EcoLab (an outside company) coming in and addressing it to their knowledge. On 8/3/23, the reports from the outside pest control agency were requested and a blue-colored binder was provided. Inside, a series of paperwork was identified for each month work and/or inspection had been completed. These included: A printed Ecolab Customer Service Report, dated 4/25/23, identified the care center was serviced and listed a section, Pest Activity Found, which outlined no rodent activity had been located adding, Spoke with and showed [[NAME]] structural concerns and findings related to rodent activity . informed me of rodent catches in patient rooms and sightings in kitchen/dining area. A section was labeled, Structural Concerns, which outlined a hole/gap was located around the wires entering the building for ventilation and fans on the East side of the building adding, Gaps are large enough for rodent entry. Please seal to prevent pest entry. A corresponding column labeled, Action Taken/Needed, identified, Seal to prevent pest entry . will reduce the numbers of pests entering the area. The report was signed by both the EcoLab service technician and maintenance personnel (MP)-A. An additional printed EcoLab Customer Service Report, dated 5/16/23, identified the care center was again serviced and listed a section, Pest Activity Found, which identified rodent activity was found in the exterior of the building, inside a storage room, and in the ceilings. The section labeled, Structural Concerns, identified a hole/gap on the East side of the building was identified surrounding the area where air conditioning (AC) hoses entered the building, and a gap under the double doors by the garbage area which lead into the building. The report directed both areas should be sealed to prevent rodent entry and harborage. The report was signed by both the EcoLab service technician and maintenance personnel (MP)-A. Further, a subsequent Ecolab Customer Service Report, dated 7/13/23, identified the care center was serviced and listed a section, Pest Activity Found, which outlined mice had been found in exterior stations (i.e., traps). These traps were inspected and serviced. The section labeled, Structural Concerns, outlined a hole/gap was found near the wall/ground junction on the northeast side of building between the AC unit and side door into the center. The area was treated and temporarily sealed with added dictation, Please seal hole with more permanent material. The corresponding area marked, Action Needed/Taken, outlined, Seal to prevent pest entry or harborage . measures here will reduce the number of pests entering the area. The report continued and another concern was listed which outlined a hole/gap was located in the back of the building next to the garbage area at the right base of the double doors entering the care center due to worn away concrete. This area was also treated and temporarily sealed which dictation present, Please seal permanently. The report was signed by both the EcoLab service technician and maintenance personnel (MP)-A. On 8/3/23 at 10:55 a.m., the maintenance director (MAD) and director of operations (DOO) were interviewed. MAD stated they had just started working the center about two months prior, and MP-A would likely the best person to visit with about follow-up to the printed Ecolab reports as they had typically walked with the technician for each visit. DOO stated there had been a more expansive issue with mice and rodents during the pandemic as residents were eating more in their rooms. As a result, they had a building walk-through with an outside pest control agency who, at that time, helped seal up various openings and fix identified structural concerns. DOO explained the technician would review the reports with them at the end of each visit adding the previous MAD was more involved with the process. MAD and DOO both expressed any needed follow-up from the reports was Ecolab's responsibility to address adding the care center maintenance department had not acted to address any of the recommendations on the reports (dated 4/2023, 5/2023, 7/2023). However, DOO expressed they felt the mice and rodent situation at the center had improved tremendously from years prior. A telephone call was placed to the EcoLab service technician on 8/3/23, with the request of a return call. However, a return call was never received. On 8/3/23 at 11:42 a.m., an exterior tour of the care center was completed with MP-A and the MAD present. MP-A explained they tracked mouse or rodent reports using a flowsheet and, when reported, would place sticky traps on the patient rooms or area until the next Ecolab visit happened. MP-A verified they typically walked with the EcoLab technician and observed the areas outlined on the reports with the surveyor. The East side of the building had a large AC unit placed in the landscaping with black-colored wires running into the brick building, along with other empty holes present in the brick. MP-A observed this area and expressed it had been sealed at one time, however, the mice had chewed it up again. MP-A stated the area did not appear sealed or patched within the past several months as any work the Ecolab technician completed typically was more evident and of better quality. The area next to the garbage dumpster, located outside a double door which lead into the hallway/kitchen area of the center, was then observed. A gray-colored metallic tubing was visible entering the building with a dark-gray colored material present on one-half of the hole in the brick. However, the tubing was moveable and not secured which lead to visible openings between the material and tubing. In addition, the identified area under the double doors where concrete had been worn away had a piece of steel wool shoved inside with no other visible, more permanent, sealing material present. MP-A verified they had not completed any of the repairs, as outlined the the printed Ecolab reports, as the repairs were Ecolab's responsibility adding that's what we're paying them for. A provided Insect and Rodent Control in the Food Service Area policy, dated 6/2016, identified the director of support services would ensure a licensed pest control performed inspections and pest control procedures on, at minimum, monthly basis. However, the policy lacked wording or dictation outlining who would make or was responsible for any needed repairs or actions.

Based on observation, interview, and document review, the facility failed to ensure hospital discharge records were reviewed to provide continuity of care and appropriate medication administration for 1 of 1 residents (R113) after they returned to the facility from the emergency department (ED). In addition, the facility failed to comprehensively assess and provide care in accordance with professional standards for 1 of 1 residents (R113) who had repeated episodes of hypoglycemia (low blood sugar). Findings include: Continuity of care R113's discharge Minimum Data Set (MDS) dated [DATE], indicated R113 did not have a Brief Interview for Mental Status (BIMS) completed and was independent with all activities of daily living (ADLs). R113's diagnoses included anxiety, depression, post traumatic stress disorder (PTSD), attention deficit disorder (ADD), alcohol abuse, diabetes, insomnia, transient ischemic attack (TIA) and cerebral infarction (causing temporary stroke symptoms and injury to the brain due to a lack of blood flow), high blood pressure, asthma, right knee replacement, polyneuropathy (decreased sensation to multiple extremities) and chronic pain. R113's care plan dated 12/21/22, indicated R113 had pain related to a total right knee replacement, lower back disc degeneration, left shoulder pain and neuropathy. Interventions included administering medications as ordered. R113 also had high blood pressure. Interventions included receiving medications as ordered and promoting physical activity. R113 also had a history of drug (opioid) and alcohol abuse. The care plan also indicated R113 had neuropathy related to diabetes. Goals included managing R113's pain to maintain function of ADLs and participation in activities. Interventions included promoting diabetes management. R113 also had impaired memory related to a TIA and PTSD. Goals included maintaining her current level of functioning. No further interventions were indicated. The care plan lacked indication of, and interventions for, R113's use of antipsychotic medications, or R113's history of anxiety and depression. R113's Care Area Assessment (CAA) dated 12/30/22, indicated R113 triggered for cognitive loss/dementia, ADL function, psychosocial well-being, behavior symptoms, falls, activities, psychotropic drug use, and pain. R113's orders dated 12/21/22, indicated R113 took the following afternoon and evening medications: -Furosemide 40 milligrams (mg) at 9:00 p.m., a diuretic (to control fluid retention) for high blood pressure. -Montelukast sodium 10 mg at 9:00 p.m., for asthma. -Lyrica 150 mg at 4:00 p.m. and 9:00 p.m., for polyneuropathy. -Propranolol 80 mg at 9:00 p.m., for high blood pressure. -Rosuvastatin 20 mg at 9:00 p.m., for high cholesterol. -Methocarbamol 500mg at 4:00 p.m. and 9:00 p.m., for muscle spasms. -Tylenol 1000mg at 4:00 p.m. and 9:00 p.m., for chronic pain. -Quetiapine fumarate 100 mg at 9:00 p.m., for anxiety. -Amitriptyline 100 mg at 9:00 p.m. for depression. -Trazadone 200 mg at 9:00 p.m., for depression. -Buspirone 30 mg at 9:00 p.m., for anxiety. -Clonazepam 1 mg at 9:00 a.m. and 4:00p.m., for anxiety. During an observation on 8/1/23 at approximately 12:00 p.m., R113 was seen unconscious, lying face up on the floor outside the fifth-floor elevators. Staff assessing R113 reported her oxygen level to be 90% and all other vital signs within normal limits. No trauma was noted; 9-1-1 was called and R113 was transported to the hospital. R113's ED provider note dated 8/1/23, indicated R113 was discharged with no medication changes and received only 1000 milliliters of intravenous normal saline fluid while in the ED. No other medications were indicated as being administered. R113's progress note dated 8/2/23 at 6:45 a.m., indicated R113 returned from the ED at approximately 11:00 p.m. without discharge paperwork. R113 requested, and was given, an as-needed (PRN) Percocet (an opioid) for pain. At 11:30 p.m., R113 requested propranolol and Clonazepam, stating she did not receive any medications while in the ER. The note indicated Due to the lack of paperwork so staff could not determine what, if anything, she received at the hospital, as well as the late hour, it was determined to provide her with the propranolol, but not the Clonazepam. During an interview on 8/2/23 at 7:59 a.m., R113 was in bed with a blanket covering her body and pulled over her head while a nurse was administering her insulin. R113 stated when she returned from the hospital the previous night, staff would not give her her afternoon or evening medications because it was too late and they could not call the hospital to verify what she received while she was there. R113 stated she was feeling anxious and just bad all over because she had missed her medications. R113's progress note dated 8/2/23 at 3:30 p.m., indicated R113 did not see the exercise specialist that morning and declined her physical therapy appointment that day due to 7/10 pain. During an interview on 8/2/23 at 9:45 a.m., registered nurse (RN)-C stated when R113 returned from the hospital on 8/1/23 at around 11:00 p.m., the phone line they usually call would have been closed. Although, RN-C verified the staff could have called the ED to clarify what medications R113 was given while she was there. RN-C further stated staff had access to the hospital's computer system and could have looked up R113's hospital medical record and discharge summary to determine what had occurred during R113's hospital visit and what medications she had received, if any. During an interview on 8/3/23 at 10:21 a.m., the assistant director of nursing (ADON) stated there was always a nurse at the facility who had access to the hospital medical record system. The ADON also stated staff should have looked at R113's hospital record to see what medications and treatments she received to ensure she did not overdose or miss doses of her medications, and to ensure continuity of care. A facility policy regarding resident transfers from the hospital was requested but not received. Hypoglycemia management. The Centers for Disease Control and Prevention webpage titled, Diabetes dated 12/30/22, indicated standard blood sugar (BS) levels were: -80-130 milligrams per deciliter (mg/dl) before a meal. -Less than 180 mg/dl two hours after a meal. BS levels below 54 mg/dl were classified as severe and may lead to altered mental status, seizures, vision changes and weakness. The CDC webpage also indicated uncontrolled BS levels can lead to serious health problems including heart disease, vision loss, kidney disease, coma, and death. R113's care plan dated 12/21/22, indicated R113 had a chronic foot ulcer related to diabetes that resulted in the amputation of four toes and osteomyelitis and a history of hypoglycemia. Interventions included administering medications as ordered, promoting well-balanced meals to include protein and non-concentrated sweets, consulting medical professionals as needed, doing blood sugar (BS) checks as ordered, promoting daily physical activity. The care plan also indicated R113 had neuropathy related to diabetes. Goals included managing R113's pain to maintain function of ADLs and participation in activities. Interventions included promoting diabetes management. R113 also had impaired memory related to a TIA and PTSD. Goals included maintaining her current level of functioning. No further interventions were indicated. R113's orders dated 12/21/22, indicated R113 had a Dexcom sensor device for glucose data management (a small device attached to the body with adhesive and a sensor wire just below the skin to monitor blood glucose levels. (The device alarms when BS levels are outside the resident's normal range and can be accessed through the resident's smart phone.) The orders also indicated to administer 1 milliliter (ml) of glucagon intramuscularly (IM) for signs of hypoglycemia and repeat after 15 minutes if signs persisted. The orders further indicated accuchecks (finger sticks) to be completed as needed for signs of hyper/hypoglycemia (high or low blood sugar). The orders indicated R113 was to have an A1c (blood test used to determine blood sugars over a period of time) drawn every three months to monitor her long-term blood sugar levelsand the next lab draw was ordered for 6/21/23. R113's Lab Medication Administration Record (MAR) dated June 2023, lacked indication R113 had a blood draw completed for her ordered A1c on 6/21/23. R113's diabetic progress note dated 6/8/23 at 3:45 a.m., indicated R113's Dexcom alarmed and indicated her BS was 41 mg/dl and a verifying fingerstick indicated it was 61 mg/dl. R113 ate a fig bar and drank apple juice and milk. The progress note lacked indication of R113's signs and symptoms. At 4:15 a.m., R113's Dexcom indicated a BS of 66 mg/dl. No further notes were documented to indicate further monitoring, treatment, or provider notification were done. During an interview on 8/3/23 at 1:09 p.m., the assistant director of nursing (ADON) stated she was unable to find documentation that R113's provider was notified of her low BS on 6/8/23. R113's diabetic progress note dated 6/24/23, indicated R113 missed her 7:00 a.m., BS check and insulin due to resident sleeping and not responding to three attempts to wake her. After R113 woke up at 9:00 a.m., R113's BS was checked, and she was administered insulin. R113's diabetic progress note dated 7/26/23, indicated at 12:45 a.m., R113's BS was 41 mg/dl and she was displaying signs of hypoglycemia including altered mental status and lethargy. R113 was given a glucagon IM injection and at 12:50 a.m., R113's BS was 52 mg/dl. R113 was given Boost (a nutritional drink) and at 12:55 a.m., R113's BS was 76 mg/dl and no longer symptomatic. No further monitoring or treatment was documented, and no note was written to indicate R113's provider was notified. R113's interdisciplinary (ID) progress note dated 7/26/23, indicated R113's roommate notified staff R113's Dexcom monitor was beeping, and showing R113 had a BS of 41 mg/dl. Upon entry to R113's room, staff found R113 difficult to awaken. Staff injected glucagon IM at 12:50 a.m., and at 12:55 a.m., R113 was more alert and able to chew a glucose tab and drink Boost. At 12:55 a.m., R113's BS was 76 mg/dl and her mental status was at baseline. R113 then went outside to smoke and was given more glucose tabs to chew in case her BS dropped again. At 1:45 a.m. R113's fingerstick was 174; however, at 3:30 a.m. her BS was down to 106. Staff indicated they would recheck R113's BS in two hours. The note lacked indication R113's provider was notified. R113's ID progress note dated 7/26/23 at 7:03 a.m., indicated when staff attempted to recheck resident's BS at 5:30 a.m., they were unable to find where R113's the Dexcom monitor was located on her body and therefore did not recheck her BS; however, R113 appeared to be sleeping with no issue. At 6:30 a.m., R113 was no longer on the unit. R113's ID note dated 7/27/23 at 2:29 p.m., indicated R113 had been experiencing multiple episodes of hypoglycemia and had declined physical therapy that day due to being tired. R113's IDT note dated 7/28/23 at 1:50 a.m., indicated at 11:32 a.m., R113 had a BS of 55 mg/dl and was dizzy, lethargic and confused. At 11:43 a.m., R113's BS was 115 and R113 was asymptomatic. Dexcom and fingerstick do not always match. Review of a facsimile dated 7/28/23, indicated R113's provider was notified R113 had a recent increase in hypoglycemic episodes. R113's provider responded on 8/1/23, with an order to decrease R113's Novolog (insulin) from 50 units to 40 units at bedtime and to make an appointment with endocrinology (hormone/diabetic specialist). During an interview on 8/2/23 at 9:45 a.m., registered nurse (RN)-C stated providers were sometimes notified of a resident's change in condition by a facsimile (fax) or a phone call. Staff were expected to write a progress note or on the back of the resident's paper, diabetic MAR to indicate if a provider was notified. When a resident's blood sugar (BS) level was between 55-70 milligrams/deciliter (ml/dl), and the resident was able to swallow, staff were to provide a snack with a mix of carbohydrates and protein, then recheck their BS after 15 minutes to ensure the resident maintained their BS above 70 mg/dl. If the resident's BS remained below 70 mg/dl, staff were to continue to provide snacks, notify the provider, and consider sending the resident to the emergency room . RN-C also stated giving only sugary snacks would be a concern because the resident's BS would increase initially but drop again after a short period of time. RN-C further stated staff were expected to attempt to wake a resident to check their BS, by knocking on the door and/or nudging them three times. No further instructions were provided if staff were unable to wake the resident. During an interview on 8/3/23 at 10:21 a.m., the ADON stated if a resident's BS was 40 mg/dl they should be given food if they were able to eat or an intramuscular (IM) glucagon injection and their BS should be checked 15 minutes later, and the resident should continue to be monitored. The ADON stated she was unaware of a protocol for monitoring a resident who had low BS throughout the night but that it should be checked. The ADON further stated because the Dexcom monitor was not always accurate, any BS below 70 mg/dl should have been verified with a fingerstick. During an interview on 8/3/23 at 2:00 p.m. R113 stated although she occasionally did not respond when staff attempted to wake her to check or recheck her BS, and if staff were unable to access her Dexcom, she wanted staff to do a fingerstick to ensure she was not hypoglycemic, causing her to be unconscious rather than sleeping. R113's medical provider was not available for an interview. During and interview on 8/3/23 at 1:35 p.m. the MD stated because the facility was designated a MHI, no care providers were able to go into the facility and therefore, all residents had their own psychiatrist who handled their mental health and a separate primary care provider (PCP) who handled the resident's medical conditions. The MD stated all PCPs had 24 on-call services the staff could contact in the event of a medical emergency; however, many psychiatrists do not have 24 hour availability; therefore the staff could call the MD 24 hours a day and she would help them problem solve. The MD stated if she was unable to problem solve with the staff, the resident could wait until the following day, or the staff could send the resident to the emergency department. The MD stated in a very rare case she may refill a psychiatric medication over the weekend, but she only provided consultation to staff regarding resident psychiatric care. The MD stated she did not provide medical care for the residents and was not involved in the development of any medical policies or procedures such as diabetic or seizure care; and did not know who was. The facility Management of Hypoglycemia Protocol indicated the following procedures: -Level 1 = BS >/= 55 mg/dl but < 70mg/ml -Level 2 = BS < 55 mg/dl -Level 3 = A resident displaying altered mental status or a physical status requiring emergent intervention for the treatment of hypoglycemia. Level 1 treatment included: -Following interventions as noted by the resident's physician. - Provide oral glucose (15-20 grams). The procedure lacked indication to withhold oral glucose if the resident had difficulty swallowing or had altered mental status. -If BS remains below 70 mg/dl, repeat oral glucose and notify the physician. Also see Standing Orders. Level 2 treatment included: -Following intervention as noted by the resident's physician. -Administer IM glucagon and repeat one time after 15 minutes if BS remains below 55 mg/dl or the resident remains symptomatic. See Standing Orders. -Re-check BS within 15 minutes. -If BS is within the established reference range, provide a meal or snack -If BS remains below 70 mg/dl repeat oral glucose and notify the physician for further orders. -Notify the provider. Level 3 treatment included: -Follow interventions as noted by the resident's physician. -Call 911 -Administer IM glucagon and repeat one time after 15 minutes if BS remains below 55 mg/dl or the resident remains symptomatic. See Standing Orders. -Notify the provider. -Documentation should include the resident's BS before and after interventions, notification of the provider, any provider orders for treatment, plan of care for acute or chronic conditions, and a complete assessment. The frequency and duration of continued monitoring will be determined by nursing clinical assessment and/or consultation with management and in conjunction with the resident's provider. The facility Standing Orders dated 5/18/22, indicated to administer glucose 4 gram tabs (chew four tabs) for hypoglycemia and recheck BS after 15 minutes. Repeat if BS remains below 70 mg/dl. Administer 1 mg of IM glucagon for hypoglycemia: may repeat x 1 after 15 minutes if the resident remains symptomatic. No further instructions were present regarding what hypoglycemia symptoms were or withholding oral treatment in the event the resident had altered mental status or difficulty swallowing.

During observation, interview and document review the facility failed to reassess a resident for safe smoking practices to prevent acute injury for 1 of 1 resident (R1) reviewed for smoking. Findings include: R1's annual Minimum Data Set, dated dated dated , 6/21/23 indicated R1 was cognitively intact and was independent with activities of daily living (ADLs). R1's Client Diagnosis Report dated 9/8/1993, indicated R1 was admitted to the facility with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). R1's most current smoking assessment dated [DATE], indicated R1 was assessed safe to smoke independently. R1's progress notes dated 7/25/23, indicated a burn hole was noticed on R1's shirt by facility staff during a weekly meeting. R1 stated it was from tobacco and it was documented her speech became pressured and R1 further stated, it happens too much. I'm klutzy with my smoking, it ruins my clothes and I hate it. During an interview and observation on 7/31/23 at 12:59 p.m., R1 stated she often goes outside to smoke during the day independently. R1 had multiple holes in her shirt that were circular in nature approximately the size of a pencil eraser with charred, blackened edges. During an interview on 8/1/23 at 1:08 p.m., social worker (SW)-B stated smoking assessments are done annually which would include a safe smoking assessment, observation of the resident smoking, and education on safe smoking practices. SW-B stated the expectation would be to reassess at any time if changes were noticed in a resident's condition or concerns were noticed such as burn holes in a resident's clothing. SW-B confirmed the most recent smoking assessment was 7/21/22. During an interview on 8/3/23 at 8:48 a.m., program manager (PM) and social worker (SW)-C stated it was the PM who would conduct the safe smoking assessment to ensure the resident was not at risk for acute injuries from smoking materials. SW-C stated he did not know the specific threshold for reassessment but stated if staff were seeing burn holes in a resident's clothing, it should be brought to the interdisciplinary team and the resident should be reassessed for safe smoking practices. During an interview on 8/3/23 at 12:21 p.m., the assistant director of nursing (ADON) stated she was unaware of the smoking assessment policy and expectation as the program managers managed that. A policy titled Smoking and Vaping Policy and Procedure, dated 11/18/22, indicated residents were assessed for safe smoking upon admission to the facility and quarterly thereafter.

Based on observation, interview and document review, the facility failed to identify and implement interventions for R2 upon admission who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 sexually abused R1 and R3. R1 experienced psychosocial harm as a result of the abuse. The IJ began on 9/20/21, when the facility failed to identify and implement interventions to protect residents when admitting R2 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administrator, director of nursing (DON), and director of program services were notified of the IJ on 10/29/21, at 4:47 p.m. The IJ was removed on 11/2/21, at 11:37 a.m. but noncompliance remained at a lower scope and severity G, actual harm that is not immediate jeopardy. Findings include: R2 R2's Pre-Admission Intake Form dated 8/26/21, indicated social services (SS)-C indicated a history of aggression which he was accused of grabbing/groping a person's breast. The intake indicated alleged 5th degree sexual conduct. R2's Criminal/Traffic/Petty Case Record Search Results dated 9/15/21, indicated R2 had been convicted of criminal sexual conduct- 5th degree-nonconsensual sex contact. R2's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition with minimal risk for depression. Daily R3 had behavior symptoms not directed toward others. R2 admitted on [DATE]. R2 was independent in all areas of activities of daily living (ADL)'s. R2's admission Care Area Assessment (CAA) dated 9/29/21, indicated R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 reported a couple of assault charges which were dropped including when he tried to stab his brother. R2 maintained poor boundaries and required redirection and reinforcement of boundaries. The facility Incident Report dated 10/18/21, indicated R3 informed staff at 6:40 p.m. that R2 was creeping her out. R3 explained that R2 kissed her earlier in the afternoon in her room and asked her to be his girlfriend. R3 described the kiss as non-consensual, R3 felt not safe with interactions with R2 and felt threaten by R2. R3 wanted to move rooms as R2 knew where she slept. The facility Incident Report dated 10/18/21, indicated R2 was informed R3 felt uncomfortable with some of their interactions which seemed confusing to R2. R2's vulnerability assessment (plan of care) was updated 10/21/21, to include displayed sexually exploitive behavior so that additional care, support, and observation would be provided for R2. The facility Brainboard Report dated 10/18/21, indicated R2 stated he may have come off too strong with his interaction with R3. R2 stated, You've got to be careful these days and referenced the Me-Too movement on how woman exaggerate charges to land men in jail. The facility Brainboard Report dated 10/19/21, indicated R2 expressed statements of confusion about the incident with R3. R3 stated, Why is this such a big deal if literally nothing happened? R2 stated he sent R3 an apology text message earlier in the day but did not receive a response. The facility Brainboard Report dated 10/20/21, indicated R2 was up at 2 a.m. and was not in his bed at 4 a.m. R2 was on and off the floor throughout the evening shift. R2 was observed looking at and greeted R3. In the evening, R2 stated he felt that the incident with R3 was unresolved and he was confused on what he had done wrong. The facility Incident Report dated 10/21/21, at 6:16 a.m. indicated R1 reported to the floor registered nurse (RN)-B that shortly after midnight she had been sexually assaulted twice. RN-B called PIC-A who discussed the incident with R1. R1 reported this man had twice grabbed her behind while walking past her as she stood in front of the announcements board on the way to the commons around 11:30 p.m. R1 then saw this man sit in a chair, pretending to be asleep and the man grabbed her behind again. Later, the man stood in the hallway by the menu, and appeared to be masturbating. R1 reported neither she nor the man spoke during any of these interactions, except when he appeared to be masturbating and R1 stated, oh my god! On the evening of the incident R1 reported that R2 may have been the person who assaulted her, but she was not positive. On 10/25/21, 10/26/21, 10/28/21, R2 admitted that he had touched R1. The police department was contacted to add the additional information that R2 was the man who assaulted R1. R2's Plan of Care dated 10/21/21, indicated R2 displayed sexually exploitive behavior. Staff would provide education regarding personal boundaries and interpersonal skills; consider precaution checks as needed including one hour precaution check and location checks if there is concern of R2 engaged in immediate exploitative behaviors. R2' progress note (PN) dated 10/21/21, at 6:50 a.m. indicated on 10/20/21, R1 was seen outside the building pacing back and forth and R2 entered the building around 11:15 p.m. At 11:20 p.m. R2 followed R1 and PIC-A into the dining room with PIC-A but didn't appear to get anything. R2 stood and observed R1. R2 exited when he was asked to leave. At 11:45 p.m. a tablet was turned into staff that showed pornography sites and a dating application. At 12:30 a.m. R2 was asleep in his room and at 2:30 a.m. a door alarm was placed on stairway exit R2's PN dated 10/21/21, at 11:53 a.m. indicated a conversation was held centered on two incidents. The first incident was on the facility tablet, which R2 left unattended in the commons area and was discovered to have pornography and potentially a dating/chat application open. R2 was asked about the involvement in an incident which occurred the evening 10/20/21, in with R1 was inappropriately touched by a male peer. R2 was the only resident identified by R1 as having potentially being involved. R1 stated, I don't know nor did R1 elaborate further when asked if he had any interactions with female peers which may have been misinterpreted. R2's PN dated 10/21/21, at 2:44 p.m. R2 admitted and apologized for watching pornography on the facility tablet but denied this occurred in the commons. R2 was restricted from using facility tablets, restricted from all resident floors, restricted from the commons after 10:00 p.m., a door alarm was placed on his door, and placed on 1 hour location checks in addition to shift checks. The facility Brainboard Report dated 10/24/21, indicated R2 exhibited agitation toward staff when paged to the desk after not being located on one of his location checks. The report indicated R2 was changed to two-hour location checks. Staff noticed R2 left his door partly ajar and were unsure if this was intentional or an attempt to circumvent the doorbell. The facility Brainboard Report dated 10/25/21, indicated R2 grazed the butt of the 3rd floor nurse twice while getting an assessment. A room search was conducted which a resident peer's underwear were found. R2 grabbed his penis in a sexual way and reached out and grazed the nurses butt for a third time. R2 presented with a labile mood and touched his genitalia two more times. R2 PN dated 10/25/21, at 8:01 p.m. indicated staff searched R2's room and found woman's undergarment with initials from another female resident. R2 touched a staff member while she did an assessment. R2 admitted to sexually touching another resident and stated, Can I be honest? I touched her. R2 explained the difficulty he was having with reintegration to society post 2-year jail term. R2 put his left hand into his shorts near his groin when staff engaged in discussion of their expectations. R2 removed his hand when R2 was asked to take his hands out of his pants. R2 stated he wanted to masturbate all the time. R2's Record of Admission indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was discharged on [DATE]. R3 R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarter MDS dated [DATE], indicated intact cognition. There was no presence of disorganized thinking. R3 felt down, depressed, or hopeless half or more than half of the days. R3 was independent with ADL's. The facility Brainboard Report dated 10/19/21, indicated R3 felt weird about the situation with R2. R3 endorsed feeling anxious. R3 asked if she could permanently move to the room behind the nurse's station. R3 expressed understanding when explained that she was only moved until a permanent solution was organized. R3's progress note dated 10/27/21, at 9:25 p.m. indicated R3 was previously stressed about a negative experience with R2 but felt slightly better since he discharged . R1 R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly MDS dated [DATE], indicated intact cognition. R1 was independent with ADL's. R1 has a minimal risk for depression. R1's Plan of Care dated 10/21/21, indicated R1 was at risk for and/or had history of sexual victimization. R1 exhibited behaviors that allowed others to manipulate, exploit, victimize and bully. To reduce risk staff were to consider the following interventions: Encourage [R1] to report concerns related to relationships; Encourage R1 to report bullying and other manipulative behaviors; encourage to report any abuse to staff immediately; Staff would restrict visitors from R1's room and limit visits to common areas based on R1's preference; Engage R1 in discussion that define respectful relationships and develop assertiveness skills. R1's PN dated 10/21/21, at 6:16 a.m. indicated shortly after midnight R1 reported that she had been sexually assaulted twice. R1 reported that a man had grabbed her behind twice. While walking past her as she stood in front of the announcement board on the way to the commons areas around 11:30 p.m. R1 saw him sitting in a chair pretending to be asleep but peeked at her from the corner of his eye. A little later R1 was in the commons getting change from the vending machine and the man grabbed her behind again. Later the man stood in the hallway by the menu and appeared to be masturbating. R1 reported that neither she nor the man spoke during any of these interactions, except when he appeared to be masturbating, R1 said Oh my God! When PIC-A and R1 entered the elevator later to try to identify the man there appeared to be ejaculate on the elevator floor. R1 looked at R2's photo and said that might be him. The security cameras were nonfunctional overnight. R1 reported she felt unsafe. R1's PN dated 10/21/21, at 8:05 p.m. indicated R1 expressed feeling to be scared to leave the floor alone. R1's PN dated 10/22/21, at 11:19 a.m. indicated R1 expressed hesitancy to spend time in the 1st floor common areas. R1 was informed that R2 was restricted from all residents' floors and the common areas after 10:00 p.m. R1 stated she just wanted to get back to the floor as soon as possible after the incident on 10/20/21. R1's PN dated 10/22/21, at 11:18 p.m. indicated a resident peer accompanied R2 to get bagged dinner meal. R1's PN dated 10/23/21, at 5:42 a.m. indicated a male friend from another floor expressed concern that R1 had not eaten all day long. This friend waited for R1 outside her room and accompanied her downstairs to obtain a bag meal around 12:30 a.m. R1 stated that she was fearful to go downstairs alone. R1's PN dated 10/23/21, at 11:06 p.m. indicated R1 discussed the incident on 10/21/21, tearfully stated she should not experience that in her home and did not feel safe going around the building by herself. R1's PN dated 10/26/21, at 3:55 p.m. indicated R1 was informed that R2 who was involved with the incident on 10/21/21, discharged . R1 replied, I'm relieved. I don't have to feel scared to go downstairs anymore. R1 stated, It doesn't mean I won't still have flash backs. During an observation on 10/28/21, at 11:07 a.m. there were two female residents to the right, one female across and three females who resided left to R2's room prior to discharge. During an observation on 10/28/21, at 1:06 p.m. R3's room was directly behind the nurse's station. During an interview on 10/28/21, at 9:19 a.m. RN-A stated R1 was very anxious which caused issues interacting with others. RN-A stated R1 was an accurate reporter. During an interview on 10/28/21, at 9:23 a.m. R1 stated the night of 10/20/21, she went downstairs to get a bag meal. R1 stated a guy came and squeezed her buttocks while she read information on the big bulletin board by the commons area. R1 looked to see who would have done that. R1 stated the guy did not say anything but looked at her and walked away. R1 further stated the guy continued to look and watch her after he squeezed her buttock then left toward the stairwell. R1 stated she sat down in the lobby and this guy came back from the stairwell and sat down in the same room as her. R1 stated she looked at him, but he pretended to be asleep and R1 knew he was awake since he peeked out of one eye and watched her. R1 stated she got up and went to the cash machine which he came up to her and squeezed her buttock again. R1 stated she just stood there for a moment while he went up the ramp. R1 thought R2 went back into the stairwell. R1 stated little did she know, he was standing at the top of the ramp just after he touched her butt for the second time and was masturbating. R1 stated she said, Oh my God after she saw R2 masturbating and was worried. R1 further stated she was scared and was not sure if he was going to try to do something else to her since she was alone with him. R1 stated she was not sure if R2 was horny or what for her. R1 stated after she said oh my God he stopped and went into the stairwell which she went into the elevator and straight to her room. R1 stated she called her sister to tell her what happened then informed the floor nurse. R1 stated she received help to identify who the man was whom they found out was R2. R1 stated after the incident she saw this man [R2] in the lobby which was uncomfortable. R1 further stated after the incident the night of 10/20/21, incident she had a friend go with her downstairs to help her feel safe. R1 was relieved and felt safer now that R2 had been discharged . R1 further stated since he was gone, she would now feel comfortable again to go downstairs. R1 stated even with him gone she had flashbacks and still thinks about the incident. During an interview on 10/28/21, at 10:30 a.m. social services (SS)-B stated the facility was aware of R2's history of criminal sexual conduct where he tried to touch others and steal things. SS-B stated R2 was doing well upon admission, but things started to take a turn and there were two incidents where it was identified he was the individual who touched woman without their consent. SS-B stated there was an incident on 10/18/21, when R2 kissed R3 without R3's consent. SS-B stated after the incident on 10/18/21, R3 wanted to move to a new room to help her feel safe from R2. SS-B additionally stated R2 and R3 were educated to have no contact with another. SS-B stated R2 was placed on shift checks which consisted of staff to check in on R2 once a shift and document on his behavior. SS-B stated on 10/21/21, R1 initially was not able to identify whom touched her buttock but later believed it was R2 after she saw a picture of him. SS-B also stated the facility determined the man who touched her butt was R2 as through their investigation he was the only other male seen on the main floor at the time. SS-B stated after R2 touched R1 his shift checks were increased to hourly checks, an alarm was put on his door, Staff communicated to R2 that he was not allowed in the common areas after 10:00 p.m. and could only use the center stairwell. SS-B stated R2 continued to have a room near another woman after the incidents. SS-B stated there were 25 other females who resided on R2's floor. During an interview on 10/28/21, at 2:59 p.m. RN-B stated on 10/20/21, just prior to the incident she saw R2 follow R1 into the dining room. RN-B stated R2 quickly turned to get water when he saw a staff member. During an interview on 10/28/21, at 4:08 p.m. SS-B stated after the incident on 10/18/21, there were interventions put into place for R2's sexual behaviors which were added after the incident on 10/21/21. SS-B stated when residents admit to the facility with a history of behaviors the facility will have conversations with them to behave respectfully. SS-B stated prior to the incident on 10/18/21, there were no interventions in place for R2's sexual behaviors. During an interview on 10/29/21, at 8:31 a.m. mental health worker (MHW)-A stated she arrived to work on 10/21/21, for the night shift and was informed that R1 had been assaulted twice. MHW-A stated R1 expressed concern about how this could happen to in her home. MHW-A stated after the incident on 10/21/21, R1 was scared to leave her room and go downstairs alone. MHW-A further stated when she arrived to work on 10/22/21, R5 came from a different floor asked MHW-A if he could escort R1 downstairs since R1 had not eaten all day. MHW-A stated R5 escorted R1 downstairs as it was confirmed R1 had not eaten and missed meals that day. During an interview on 10/29/21, at 11:16 a.m. MHW-B stated she worked with R2 and was not aware of R2's sexual behaviors until an incident occurred on 10/18/21, with R3. MHW-B stated it was not surprising that R2 sexually assaulted the two women with his personality. MHW-B stated R2 was over confident and arrogant. MHW-B further stated R2 did what he wanted and did not care about others and could see R2 put his sexual desires over others. During an interview on 10/29/21, at 11:50 a.m. SS-C stated R2's paperwork indicated he had an incident of a groping charge prior to his admission and criminal sexual history. SS-C stated R2 admitted to her that he was the one whom assaulted R1 and R3. SS-C also stated after R2 kissed R3 without her consent R2 tried to contact R3 via text. During an interview on 10/29/21, at 12:21 p.m. R3 stated R2 creeped her out and wanted to be her boyfriend after she met him in the common area one time. R3 stated while they spoke R2 all of a sudden started to hug her. R3 stated when R2 hugged her he put her in a bear hug which made her very uncomfortable. R3 stated she was not able to get out of the bear hug and had to wait for him to let her go. R3 stated once R2 let her go she found an excuse and went to her room. R3 further stated R2 tried to come into her room, and she finally told staff after he came into her room and kissed her. R3 stated R2 would not have been in my room and tried to continue to go into her room after he kissed her. R3 stated after R2 kissed her the weirdness continued in the dining room where R2 rested his head on his hand and would stare at R3 from across the room. R3 stated she felt unsafe, weird, and annoyed after the incident as he continued to look at her. R3 stated she told staff as she was paranoid that he was always looking at her. R3 stated she was glad R2 was gone but she still thought about it, and it creeped her out. During an interview on 10/29/21, at 1:14 p.m. the director of nursing (DON) verified R2's care plan had no indication of an intervention for his sexual behaviors until 10/21/21. During an interview on 10/29/21, at 2:30 p.m. MHW-C stated she was not aware of R2's history of sexual behaviors. MHW-C stated she would go to R2's care plan to know a resident's various vulnerabilities and interventions. The facility Vulnerable Adult Reporting Policy and Procedure dated 6/28/17, indicated sexual abuse was non-consensual sexual contact of any type with a resident. The immediate jeopardy that began on 9/20/21, was removed on 11/2/21, at 11:37 a.m. when the facility assessed all residents and identified no new residents to be at risk for sexual abuse. The residents whom had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Program Services with other clinical staff reviewed the policy for new resident vulnerably plan development. Staff whom were responsible for vulnerability plan oversight had been educated on the expectation that a vulnerability plan to be in place for any identified vulnerability that may put resdient at risk for abuse or neglect. The facility policy was reviewed which addressed the need to have a vulnerability plan in place. The facility trained all direct care staff on abuse prevention as they are scheduled work effective 11/1/21. Direct care staff would have focused vulnerability planning training. Interviews with staff and document review verified the steps were taken for the removal of the IJ.

Based on observation, interview and document review, the facility failed to implement appropriate COVID infection control practices as identified by Centers for Disease Control (CDC) COVID guidelines related to the rooming of COVID positive with COVID negative residents. These practices resulted in an immediate jeopardy (IJ) due the potential risk for COVID outbreak for 13 of 53 residents (R10, R11, R12, R13, R14, R15, R7, R8, R9, R5, R6, R3, R4) on the second floor. In addition, the facility failed to assure appropriate personal protective equipment (eye protection and masks) were worn by staff, had cleaned equipment appropriately, and provided dedicated smoking areas for residents whom were quarantined. The IJ began on 11/13/20, when it was determined the facility failed to implement proper infection control (IC) standards when it was rooming residents who were COVID positive with residents who were COVID negative. The director of program services (DPS) and director of nursing (DON) were notified of the IJ at 5:35 p.m. on 11/13/20. The IJ was removed on 11/16/20, at 6:04 p.m., but noncompliance remained at a lower scope and severity level of E which indicated no actual harm but potential for more than minimal harm that is not immediate jeopardy. Findings include: Current CDC guidance indicates nursing home residents are at high risk of being affected by respiratory pathogens like COVID-19 due to older age and underlying chronic medical conditions. Residents with known or suspected COVID-19 should be placed in a private room with their own bathroom. Roommates of residents with COVID-19 might already be exposed and should be placed in another room, until 14 days after their exposure. Roommates R10, R11, and R12 R10's face sheet, indicated R10 was in a room (shared with R11 and R12 with a shared toilet and sink). R10's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's lab test, collected on 11/8/20, and reported on 11/9/20 at 5:10 p.m., indicated R10 tested positive for COVID. R10's progress note, dated 11/9/20, at 9:55 p.m., indicated R10 tested positive for COVID and was placed in isolation quarantine. But R10 remained the in the same room with R11 and R12. R10's plan of care, dated 11/9/20, indicated R10 was COVID positive and included resident to wear a mask when staff were in the room and staff to wear an N95 mask, face shield, gown, and gloves when they came into contact with R10. R11's face sheet, indicated R11 was in a room (shared with R10 and R12 with a shared toilet and sink). R11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's comorbidities placed R11 at higher risk to contract COVID. R11's progress note, dated 11/3/20, at 3:30 p.m., indicated R11 was having symptoms of COVID. R11's progress note, dated 11/3/20, at 7:25 p.m., indicated R11 was on isolation precautions because R11 was having symptoms of COVID, and remained in the same room with R10 and R12. There was no indication the facility tested R11 on 11/3/20 even though he was displaying COVID symptoms. R11's progress note, dated 11/9/20, at 10:01 p.m., indicated R11 tested negative for COVID but R11's roommate (R10) tested positive. R11 was notified he needed to remain in quarantine for two full weeks. Although R11 had not yet tested positive for COVID, R11 continued to share the same room with R10 whom was COVID positive. R11's lab test, collected on 11/11/20, and reported on 11/13/20 at 6:45 a.m., indicated R11 had now tested positive for COVID. R12's face sheet, indicated R12 was in a room (shared with R10 and R11 with a shared toilet and sink). R12's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's comorbidities placed R12 at higher risk to contract COVID. R12's progress note, dated 11/3/20, at 9:53 p.m., indicated R12 was in prophylactic quarantine (quarantine a resident whom had high risk exposure to COVID) because R12's roommate [R10] was having symptoms of COVID, and R12 remained in the same room. R12's lab test, collected on 11/11/20, and reported on 11/12/20, at 11:02 a.m., indicated R12 tested negative for COVID, and remained to be in the same room with R10 and R11 whom was COVID positive. R12's plan of care, dated 11/11/20, indicated R12 had high risk exposure to COVID and interventions included placement on droplet precautions. Roommates R13, R14, and R15 R13's face sheet, indicated R13 was in a room (shared with R14 and R15). R13's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's lab test, collected on 11/3/20, and reported on 11/4/20 at 8:13 p.m., indicated R13 tested positive for COVID. R13's progress notes, dated 11/3/20, at 3:19 p.m., indicated R13 was exhibiting signs and symptoms of COVID. R13's progress note, dated 11/5/20, at 4:16 a.m. indicated R13 tested positive for COVID. The note also indicated, Resident will remain in his room for isolation along with his roommates [R14 and R15]. R13's plan of care, dated 11/5/20, indicated R13 was positive for COVID, but did not include interventions involving quarantine, isolation, or other precautions to prevent the spread of COVID. R14's face sheet, indicated R14 was in a room (shared with R13 and R15 with a shared toilet and sink). R14's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's comorbidities placed R14 at higher risk to contract COVID. R14's progress note, dated 11/4/20, at 5:39 p.m., indicated R14 was negative for COVID but in prophylactic quarantine because R14's roommate (R13) had symptoms for COVID. R14's progress note, dated 11/5/20, at 9:24 a.m., indicated R14 was in quarantine because R14's roommate (R13) tested positive for COVID, even though R14 was COVID negative. R14's lab test, collected on 11/9/20, and reported on 11/10/20 at 8:08 p.m., indicated R14 tested positive for COVID. R14's progress note, dated 11/11/20, at 8:59 a.m., indicated R14 tested positive for COVID. R14's plan of care, dated 11/11/20, indicated R14 was COVID positive and included interventions of place on droplet precautions, which called for the resident to wear a mask when staff were in the room and staff to wear an N95 mask, face shield, gown, and gloves when they came into contact with R14. R15's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 11/16/20, at 12:10 p.m., the DON verified the COVID-19 status and room location of R15 was in a room room with R13 and R14. R15's progress note, dated 11/4/20, at 5:39 p.m., indicated R15 was placed in prophylactic quarantine because R15's roommates (R13, R15) was having symptoms of COVID. R15's progress note, dated 11/5/20, at 9:29 a.m., indicated R15 was on quarantine because his roommate (R13) tested positive for COVID. R15's progress note, dated 11/8/20, at 3:38 p.m., indicated an auditory alert system was added to R15's door because R15's roommate (R13) had difficulty adhering to quarantine procedures. R15's lab test, collected on 11/9/20 and reported on 11/10/20 at 8:08 p.m., indicated R15 tested positive for COVID. R15's progress note, dated 11/10/20, at 10:54 p.m., indicated that around 7:45 p.m., R15 reported he was losing it and was not doing well mentally. R15 requested to talk to staff and was directed to call the second floor desk because he was on quarantine [and] staff can't stay in this room more than 15 minutes. The note also indicated at 10:45 p.m., staff were notified R15 tested positive for COVID but did not inform R15 of his positive COVID test results because he was sleeping at the time and he reported he was not doing well. R15's progress note, dated 11/11/20, at 4:22 a.m., indicated at 12:30 a.m., R15 was awake and informed of COVID positive results. R15 reported [CONDITION(S)] at that time. R15's progress note, dated 11/12/20, at 10:51 a.m., indicated R15 was conflicted and having possible suicide ideation. The note further indicated R15 may be starting to have a mental health crisis due to the reality of recently being diagnosed with the covid-19 virus and notification of an extended quarantine as a direct result. R15's progress note, dated 11/12/20 at 5:02 p.m., indicated R15 was stressed by the COVID diagnosis, living with roommates who were positive for COVID, and isolation. R15 requested an increased frequency in R15's therapy sessions. R15's plan of care, dated 11/11/20, indicated R15 was COVID positive. Roommates R7, R8, and R9 R7's face sheet, indicated R7 was in a room (shared with R8 and R9.) R7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's comorbidities placed R7 at higher risk to contract COVID. R7's lab test, collected on 11/9/20 and reported on 11/10/20 at 8:08 p.m., indicated R7 tested positive for COVID. Although R7 was COVID positive, he continued to stay in a shared room with R8 and R9. R7's progress note (PN), dated 11/11/20, at 10:47 a.m., indicated R7 was in quarantine because R7 was COVID positive. The PN, 11/13/20, at 6:24 p.m., indicated R7 was transferred to the hospital. There was no indication of rationale of transfer to a higher level of care. R7's plan of care for R7's COVID positive status but did not include interventions involving quarantine, isolation, or other precautions to prevent the spread of COVID. R8's face sheet, indicated R8 was in a room (shared with R7 and R9.) R8's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's comorbidities placed R8 at higher risk to contract COVID. R8's lab test, collected on 11/11/20 and reported on 11/13/20 at 6:45 a.m., indicated R8 tested negative for COVID. R8 continued to share a room after R7's positive diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R8's plan of care, dated 11/13/20, indicated hia problem was, COVID positive with a goal of limit the spread to others and he was on droplet precautions. R9's face sheet, indicated R9 was in a room (shared with R7 and R8). R9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's comorbidities placed him at higher risk to contract COVID. R9's lab test, collected on 11/11/20 and reported on 11/13/20 at 6:45 a.m., indicated R9 tested negative for COVID. Although R9 was COVID negative, R9 continued to share the same room as R8 and R7, whom had tested positive for COVID. R9's progress note, dated 11/11/20, at 8:52 a.m., indicated the facility tried to contact R9's family to notify them R9 had been exposed to COVID because his roommate (R7) was positive for COVID. Roommates R5 and R6 R5's face sheet, indicated R5 was in a room (shared with R6 and a shared toilet, sink, and shower with R3, R4, and R6). R5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's lab test, collected on 11/4/20 and reported on 11/6/20 at 8:37 a.m., indicated R5 tested positive for COVID. Although R5 was COVID positive, R5 continued to stay in a shared room with R6. R5's progress note, dated 11/4/20, at 2:25 p.m., indicated R5 had the following temperatures: 102.4 at 9:00 a.m., 101.6 at 12:00 p.m., and 102.2 at 2:00 p.m. R5's progress note, dated 11/5/20, at 5:29 a.m., indicated R5 had the following temperatures: 99.6 at 12:15 a.m. and 99.3 at 5:20 a.m. R5's progress note, dated 11/6/20 at 1:41 p.m., indicated the facility informed R5 of R5's COVID positive test results. R5's plan of care for R5's COVID positive status but did not include interventions involving quarantine, isolation, or other precautions to prevent the spread of COVID. R6's face sheet, indicated R6 was in a room (shared with R5 and a shared toilet, sink, and shower with R3, R4, and R5). R6's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's comorbidities placed R6 at higher risk to contract COVID. R6's lab test, collected on 11/11/20 and reported on 11/13/20 at 6:36 a.m., indicated R6 tested negative for COVID. Although R6 was COVID negative, R6 continued to share the same room with R5 whom was COVID positive. R6's progress note, dated 11/6/20, at 6:35 p.m., indicated R6 was in quarantine because R6 had a high risk exposure to R6's roommate (R5 who was COVID positive). Roommates R3 and R4 R3's face sheet, indicated R3 was in a room (shared with R4 and a shared toilet, sink, and shower with R5, and R6). R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's lab test, collected on 11/4/20 and reported on 11/6/20 at 6:37 a.m., indicated R3 tested positive for COVID. Although R3 was COVID positive, R3 continued to stay in a shared room with R4, and shared common bathroom with R5 and R6. R3's plan of care identified he was COVID positive, but did not include interventions involving quarantine, isolation, or other precautions to prevent the spread of COVID. R4's face sheet, indicated R4 was in a room (shared with R3 and a shared toilet, sink, and shower with R5, and R6). R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's comorbidities placed R4 at higher risk to contract COVID. R4's lab test, collected on 11/11/20 and reported on 11/13/20 at 6:36 a.m., indicated R4 tested negative for COVID. Although R4 was COVID negative, R4 continued to share the same room with R3 whom was COVID positive on 11/6/20, and shared common bathroom facilities with R5 and R6. R4's progress note, dated 11/5/20, at 9:41 a.m., indicated R4 was on prophylactic quarantine because the roommate (R3) was COVID positive, and shared common bathroom with R5 and R6. During interview on 11/13/20, at 9:05 a.m., the director of nursing (DON) explained they had residents who were positive for COVID-19 sharing rooms with residents who were negative for COVID-19 because they were roommates at the time the resident who was positive for COVID tested positive. The DON stated the State Emergency Operations Center (SEOC) and the Infection Control Assessment and Response Program (ICAR) informed them it was okay to cohort residents who tested positive for COVID-19 with residents who tested negative for COVID-19. The DON reported they tested everyone for COVID-19 on Wednesdays and were still waiting for all results for the current week, but already had five residents and two staff test positive for COVID-19 that week. During interview on 11/13/20, at 10:14 a.m. on fifth floor, Program Director (PD)-C stated residents who were positive for COVID or who were symptomatic for COVID, were placed in isolation for 10 days and then they would go into prophylactic quarantine for 14 days. Residents who were exposed to COVID from a roommate or who shared a bathroom with someone who had COVID, were placed in prophylactic quarantine. PD-C explained some rooms had two residents and those two residents shared a bathroom (shower, toilet, and sink) with two residents in an adjoining room, similar to a dorm suite. The primary difference between isolation for COVID and prophylactic quarantine was COVID isolation included wearing a gown when entering the room. For prophylactic quarantine, a gown was only required for high contact activity like assisting with activities of daily living (ADL). During interview on 11/16/20, at 12:10 p.m., the DON verified the COVID-19 status and room location of the following residents, and that the roommates were kept together even after one tested positive for COVID-19 and the others remained negative for COVID-19: * On 11/6/20, the facility received notice R3 tested positive for COVID-19 and he stayed in his room. R3's roommate, R4, tested negative for COVID-19 and remained in the same room. * On 11/6/20, the facility received notice R5 tested positive for COVID-19 and he stayed in his room. R5's roommate, R6, tested negative for COVID-19 and remained in the same room. * On 11/10/20, the facility received notice R7 tested positive for COVID-19 and he stayed in his room. R7's roommates, R8 and R9, tested negative for COVID-19 and remained in the same room. * On 11/10/20, the facility received notice R10 tested positive for COVID-19 and he stayed in his room. R10's roommates, R11 and R12, tested negative for COVID-19 and remained in the same room. On 11/13/20, the facility received notice R11 tested positive for COVID-19. On 11/13/20, R12 was moved to a room with residents who were also negative for COVID. * On 11/4/20, the facility received notice R13 tested positive for COVID-19 and he stayed in his room. R13's roommates, R14 and R15, tested negative for COVID and remained in the same room. On 11/10/20, the facility received word R14 and R15 tested positive for COVID. During this interview, both the DON and the DPS reported residents were kept together based upon recommendations they received from the state health department's COVID-19 Provider Hotline and ICAR. The director of program services (DPS) and director of nursing (DON) were notified of the IJ at 5:35 p.m. on 11/13/20, related to cohorting COVID positive and negative residents in the same room. The IJ was removed on 11/16/20 at 6:04 p.m., but noncompliance remained at a lower scope and severity level of E which indicated no actual harm but potential for more than minimal harm that is not immediate jeopardy. SMOKING PATIO During interview on 11/13/20, at 11:30 a.m., R19 expressed concern about residents not wearing masks in common areas, especially those going out to smoke. R19 was very concerned because R19 heard several new residents and staff were positive for COVID and R19 was afraid R19 would get it because so many have it. During interview on 11/13/20, at 1:52 p.m., R2 stated the facility staff forced residents who were exposed to COVID, but didn't have COVID, to smoke in the smoking area designated for persons with COVID. R2 stated people don't wear masks to smoke and they stand close together. R2 expressed the desire to smoke on the patio with residents who did not have COVID, but staff would not let her. R2 was afraid of getting COVID from the residents who had it and were smoking on the patio. During an observation of the facility smoking patios on 11/13/20, at 2:10 p.m., program director (PD)-A motioned to the two smoking patios, one of the patio for residents whom COVID negative and another patio for residents who had COVID positive or exposed to COVID. The patios were on opposite sides of the building. During continuous observation of the COVID patio, on 11/13/20, at 2:13 p.m. through 2:18 p.m., five residents were observed smoking: R2, R6, R21, and two other unidentified residents. The two unidentified residents, R6, and R21 were not wearing masks and standing three to four feet from each other, engaged in conversation. No staff were present on the patio. Review of the records identified the following: R2's lab test, collected on 11/11/20 and reported on 11/13/20 at 6:45 p.m., indicated R2 tested negative for COVID. R19's lab test, collected on 11/11/20 and reported on 11/12/20 at 4:42 p.m., indicated R19 tested negative for COVID. R21's progress note, dated 11/7/20, at 8:04 p.m., indicated R21's roommate was symptomatic for COVID. R21's progress note, dated 11/9/20, at 1:37 p.m., indicated R21 wanted to go smoke and negotiated to go smoke at limited times, wearing gloves and a surgical mask, and notifying the desk before leaving R21's room. R21's lab test, collected on 11/11/20 and reported on 11/13/20 at 6:45 a.m., indicated R21 tested negative for COVID. During interview on 11/13/20, at 2:34 p.m., PD-A stated residents could come and go at any time to smoke, but if the resident had COVID, staff would try to go down with them [to the smoking area]. Staff would make sure the resident with COVID would keep six feet distance from other residents and try to get them to wear a mask when going to and from their room and the smoking patio. PD-A verified residents exposed to COVID did not need to be escorted to the smoking area, but they were expected to keep six feet distance from each other. During interview on 11/16/20, at 3:53 p.m., the DON verified there were two smoking patios, one for residents without COVID and one for residents with COVID or who were exposed to COVID, usually because they were roommates. The DON also verified if a resident had COVID, a staff would accompany them to smoke to assure they were maintaining social distance and were not sharing cigarettes. PPE, HAND HYGIENE, AND EQUIPMENT During continuous observation on 11/13/20, at 10:55 a.m. through 11:12 a.m., therapeutic recreation therapist (TRT)-A placed food in a plastic, square bucket and took to the room of R25 and R28, a room with prophylactic quarantine signs on the door. TRT-A called R28 to the door to get R28's meal and R28 was wearing a mask. TRT-A called R25 but R25 did not come to the door, so TRT-A stepped into the room and then back out. R25 came to the door without a mask and TRT-A handed R25 the bucket, who took it into the room. TRT-A returned to the nursing station, sprayed his gloves, rubbed the gloves together, and then picked up another bucket, in which he placed more food. TRT-A went to R16 and R17's room, which had signage indicating the residents were in isolation because of COVID. R16 came to the door, without a mask, and took food out of the bucket held by TRT-A. R17, with a mask, came to the door and took the bucket with food into the room. R17 returned to the door and handed TRT-A a bucket that had been in the room. TRT-A carried the contaminated bucket back to the nursing station and placed on the desk without disinfecting the bucket. During an observation on 11/13/20, at 10:12 a.m., social worker (SW)-A sprayed her glove with fluid from an unlabeled, pink spray bottle, rubbed her gloves together, and then prepared food to deliver to a room. SW-A did not remove her gloves or perform hand hygiene on her bare hands. During an observation on 11/13/20, at 10:13 a.m., RN-A, with a mask but no eye protection, walked from the nursing station down the hallway past two unidentified residents waiting for the elevator. RN-A exited the floor through the stairwell adjacent to the elevator. During continuous observation on 11/13/20, at 11:15 a.m. on fourth floor, mental health tech (MHT)-A exited R18 and R29's room, which had signage indicating the residents were in isolation for COVID. MHT-A removed the contaminated gown in the hallway and with her gloves still on, carried the gown to, nursing station, then back down the hallway, when PD-A assisted her to the dirty utility where the PD-A opened a trash bag for disposal of the gown. MHT-A returned to the isolation cart in front of R18 and R29's room where she removed her gloves and performed hand hygiene. MHT-A then went to the handwashing sink adjacent to the nursing station where she removed her face shield, where she sprayed the face shield and then left it on the side of the sink and walked down the hallway to the day room without eye protection. R19 and R2 were within four feet of MHT-A as she walked down the hallway. During continuous observation on 11/13/20, at 11:39 a.m. through 11:43 on third floor, Housekeeper (HK)-A was vacuuming in the hallway with mask and no eye protection. R20 and two other unidentified residents were in the hallway at different periods and within four feet of HK-A. During interview on 11/13/20, at 11:45 a.m., R20 expressed many concerns about the increasing number of residents and staff getting COVID. R20 was especially concerned so many residents and staff were not wearing masks when others were around them. R20 noted smokers and residents using the public phone were not wearing masks. R20 stated most of staff not wearing masks were on the first floor in the office area and staff were not distancing because the desks were too close. R20's concern was staff interact with residents and go from floor to floor, so they might spread COVID. During interview on 11/16/20, at 3:53 p.m., the DON verified staff should be performing hand hygiene after removing gloves and gloves should be removed before hand hygiene. The DON explained when the facility was running low on sanitizer, a local distillery provided hand sanitizer that was at least 70% alcohol and they used that to fill the pink spray bottles. The DON also verified when equipment (buckets) was removed from a room with residents who are positive for COVID, it should be disinfected immediately after taken from the room; once disinfected, it was to be kept on the unit in a storage area. The DON stated the expectation was for staff to wear masks and eye protection, especially when in close distance of one another. The DON stated they have had an increased emphasis on eye protection because contact tracing showed its importance. The facility had residents who were also workers as a part of the vocational program, were recently given surgical masks and face shields or goggles to wear when they were working. Three weeks earlier, they were still wearing cloth masks while working. The DON also verified the expectation staff entering rooms of residents who are positive for COVID should be wearing gown and gloves, in addition to mask and eye protection. She verified for rooms where one resident was positive for COVID and one was negative for COVID, staff don gowns and gloves for both residents. The DON verified gowns and gloves should be doffed and left in the isolation room with staff performing hand hygiene upon exiting the room. The facility's Personal Protective Equipment (PPE) Procedure, dated 6/2/97, indicated all staff were trained to know when PPE was necessary, what PPE was necessary, how to properly don and doff PPE, and dispose of PPE. The facility's Use of Masks During COVID-19 Pandemic policy, dated 5/5/20, indicated universal masking was required for all individuals entering the facility, including staff and residents. The policy further indicated cloth facial coverings could be used in non-clinical areas. The policy also indicated residents who were positive for COVID should wear surgical masks when in their room and staff were attending to their needs, or when out of the room. Finally, the policy noted residents and staff should follow strict social distancing measures. The facility's Comprehensive Preparedness Plan for COVID-19 policy, dated 7/15/20, indicated staff should maintain a social distance of at least six feet apart. The policy also indicated residents with COVID who smoked would be offered nicotine replacement and not allowed to leave their room to smoke. Finally, the policy indicated Isolation Quarantine (modified droplet precaution) would be used for residents with COVID, and residents exposed to someone with COVID was placed in Prophylactic Quarantine, but the policy did not include details of what PPE was required for each type of quarantine. A policy with all the facility's transmission based precautions was requested but not received. According to the Centers for Disease Control (CDC)'s recommendations, dated 4/30/20, residents with confirmed COVID should be moved to a dedicated unit, in a private room if possible, and the exposed roommate should be kept in a private room, if possible, or cohorted with other residents who had been exposed to COVID. According to the CDC's COVID-19 Pandemic, dated 7/15/20, health care facilities should implement universal source control measure which included health care personal (HCP) wearing a facemask at all times when in the facility and HCP working in facilities located in areas with moderate to substantial community transmission should wear eye protection in addition to their facemask. The Minnesota Department of Health, PPE Grid, dated 9/25/20 indicated all staff, including office staff, should wear surgical masks while in the building. The Grid also indicated all staff in care areas should wear a mask and eye protection.