Every finding on record at Christian Care Center of Medina

Based on facility policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when unlabeled, undated, and expired food items were stored. The facility had a census of 59 and 59 of the residents were served from the Kitchen. The findings include: 1. Review of the facility's policy titled, Food Receiving and Storage, dated October 2017, revealed .All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Review of the facility's policy titled, Food Safety - Infection Control, dated 9/25/2023, revealed .All food items must be labeled and dated.must have a label identifying the contents with the type of food item, the date received, and the date opened. Open food items must also include a use-by date. 2. Observation in the kitchen in the reach in refrigerator on 1/12/2026 at 8:03 AM, revealed the following: a. 1 plastic container with 3 boiled eggs with use by date 1/11/2026. b. 1 metal canister with pureed sausage with use by date 1/11/2026. c. 1 metal canister with pureed eggs with use by date 1/11/2026. 3. Observation in the kitchen in the walk-in refrigerator on 1/12/2026 at 8:05 AM, revealed the following: a. 1 canister of beets dated with use by date of 1/7/2026. b. 1 canister of tomato sauce with use by date of 1/7/2026 c. 2 half sheet pans of red Jelly-like substance covered with plastic wrap not labeled or dated. d. bowl of Jelly-like substance with a use by date of 1/11/2026. e. 1 undated peeled onion wrapped in plastic wrap. f. 1 opened container of chicken base (a concentrated flavoring) with a use by date of 1/8/2026. g. 4 (9x12) aluminum pans of cooked lasagna dated 12/16/2025. 4. Observation and interview in the kitchen on 1/12/2026 at 9:33 AM, revealed an unlabeled, undated glass containing a brownish colored liquid on a shelf in the reach in cooler. The Certified Dietary Manager (CDM) was asked what the brownish colored liquid was in the glass. The CDM stated, It was nectar thick tea. The CDM started to place the glass on the tray with the other items to be served to the residents. The CDM was asked if items should be labeled and dated prior to being stored. The CDM stated Yes. 5. Observation in the Kitchen on 1/12/2026 at 3:19 PM, revealed 4 (9x12) aluminum pans of cooked lasagna dated 12/16/2025 in the walk-in refrigerator. 6. Observation and interview in the Kitchen on 1/13/2026 at 8:25 AM, revealed 1 opened and outdated container of chicken base in the walk-in refrigerator. The CDM was asked if the container of chicken base should still be in the refrigerator with a use by date of 1/8/2026. The CDM shook her head No. 7. Observation and interview in the Kitchen on 1/12/2026 at 3:21 PM, revealed 4 (9x12) aluminum pans of cooked lasagna in the walk-in refrigerator. Dietary [NAME] B was shown the pans and asked the date on the lasagna. Dietary [NAME] B stated, 12/16/2025. Dietary [NAME] B was asked when it should be discarded. The Dietary [NAME] B stated, after 3 days. During an interview on 1/14/2026 at 12:00 PM, the CDM was asked how food should be stored. The CDM stated, It should be labeled and dated with a use by date and discarded after 3 days.

Based on facility policy review, observation and interview the facility failed to ensure medications were properly stored when medications were unsecure and unlabeled in 1 of 3 (200 Hall Cart) medication storage carts. The findings include: 1. Review of the facility policy titled, Storage of Medications, dated 4/2019, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, sanitary manner. Review of the facility policy titled, Administering Oral Medications, dated 10/2010, revealed .The purpose of this procedure is to provide guidelines for the safe administration of oral medications.Select the drug from the unit dose drawer or stock supply. Check the label on medication and confirm the medication name and dose with the MAR [Medication Administration Record]. Check the expiration dated.Check the medication dose.Prepare the correct dose of medication.Confirm the identity of the resident. Explain the procedure to the resident.Remain with the resident until all medication have been taken. 2. Observation during Medication Administration on 1/14/2026 at 7:08 AM, revealed Licensed Practical Nurse (LPN) A at the 200 Hall Medication Cart. The following medications were not properly stored: a. An unlabeled and unsecured medication cup contained the following medications: Depakote (used to treat seizure or behavior disorders) 125 milligram (mg) 2 capsules (cap), Magnesium Oxide (used as a dietary supplement) 400 mg 1 tablet (tab), Docusate Sodium (used to treat constipation) 100 mg , Acidophilus (used as a probiotic supplement) 175 mg 1 cap, Multi-vitamin (used as a dietary supplement) 1 tab, Omeprazole (used to treat indigestion) 40 mg 1 cap, and Paroxetine (used to treat depression) 40 mg 1 tab. b. An unlabeled and unsecured medication cup contained the following medications: Bupropion (used to treat depression) 300 mg 1 tab, Bupropion 125 mg 1 tab, Ferrous Sulfate (used to treat anemia) 325 mg 1 tab, Vitamin D3 (used as a dietary supplement) 125 micrograms (mcg) 1 tab, Carvedilol (used to treat high blood pressure) 3.125 mg 1 tab, Celecoxib (used to treat arthritis) 200mg 1 capsule, Plavix 75 mg 1 cap, Docusate sodium 100 mg 1 tab, Furosemide (used to treat swelling) 40 mg 1 tab, Multi-vitamin 1 tab, Potassium Chloride (used as a dietary supplement) 10 milliequivalent (meq) 2 tab, Spironolactone (used to treat swelling) 25 mg 1 tab, B12 (used as a dietary supplement) 250 mcg 1 tab, and Lactobacillus (used as a probiotic supplement) 1 cap. c. An unlabeled and unsecured medication cup with the following medications: Cyclobenzaprine (used to treat muscle spasms) 10 mg 1 tab, Aspirin (used to treat cardiac/circulation) 81mg 1 tab, Citalopram (used to treat depression) 40 mg 1 tab, Colace (used to treat constipation)100 mg 1 tab, Lamictal (used to treat seizures) 25 mg 2 tabs, Vitamin D3 50 mcg 1 tab, Bupropion 1 tab, and Levetiracetam (used to treat seizures) 500 mg 1 tab. d. An unlabeled and unsecured medication cup with the following medication was stored in a drawer of the medication cart: 1 Cyclobenzaprine 10 mg 1 tab. e. An unlabeled and unsecured medication cup with the following medications: Carvedilol 3.125 mg 1 tab, Clonidine (used to treat high blood pressure) 0.1mg 1 tab, Eliquis (used to prevent blood clots) 2.5mg 1tab, Ferrous Sulfate 325 mg 1 tab, and Levetiracetam 500 mg 1 tab. f. An unlabeled and unsecured medication cup with the following medications: Ferrous Sulfate 325 mg 1 tab, Vitamin D3 50 mcg 1 cap, Acetaminophen (used to treat pain) 650 mg 1 tab, Docusate Sodium 100 mg 1 tab, Hydroxyzine (used to treat anxiety or itching) 25 mg 1 tab, Methocarbamol (used to treat muscle pain) 500 mg 1 tab, Multivitamin 1 tab, Pantoprazole (used to treat indigestion) 40 mg 1 cap, Sertraline (used to treat depression) 50mg 1 tab, 25 mg 1 tab, Vitamin C (used as a dietary supplement) 500 mg 1 tab, and Zinc (used as a dietary supplement) 220 mg 1 tab. g. An unlabeled and unsecured medication cup with the following medications: Levothyroxine (used to treat hypothyroidism) 75 mcg 1 tab, Bupropion XL (extended release) 300 mg 1 tab, Quetiapine (used to treat mood or behavior disorders) 25 mg 1/2 tab, Vitamin D3 50 mcg 1 tab, Fluoxetine (used to treat depression) 40 mg 1 tab, Folic Acid (used as a dietary supplement) 1mg 1 tab, Tamsulosin (used to treat enlarged prostate) 0.4 mg 1 cap, Aspirin 81mg 1 tab, Depakote 250 mg 1 tab, Potassium 10 meq 2 caps, and Vitamin B1 (used as a dietary supplement) 100 mg 1 tab. h. An unlabeled and unsecured medication cup with the following medications: Lamotrigine Extended Release (ER) (used to treat seizure disorder) 50 mg 1 tab, Levothyroxine 25 mcg 1 tab, Carvedilol 6.25 mg 1 tab, Ferrous Sulfate 325 mg 1 tab, Namenda (used to treat dementia) 10 mg 1 tab, Multi-vitamin 1 tab, Vitamin D3 50 mcg 1 tab, Amiodarone (used to treat abnormal heart rhythms) 200 mg 1 tab, Aspirin 81 mg 1 tab, Eliquis 2.5 mg 1 tab, Calcium (used as a dietary supplement) 250 mg 1 tab, Lisinopril (used to treat high blood pressure) 5 mg 1 tab, Pantoprazole (used to treat indigestion) 40 mg 1 tab, and Venlafaxine (used to treat depression) 150 mg 1 tab. i. An unlabeled and unsecured medication cup with the following medications: Aspirin 81 mg 1 tab, Plavix (used to prevent blood clots) 75 mg 1 tab, Folic Acid 1 tab, and Vitamin C 1 tab. j. An unlabeled and unsecured medication cup with the following medications: Levothyroxine 125 mcg 1 tab, Docusate Sodium 100 mg 1 tab, Ferrous Sulfate 325 mg 1 tab, Sertraline 50 mg 1/2 tab, Famotidine 20 mg 1 tab, and Vitamin D 50 mcg 1 tab. k. An unlabeled and unsecured medication cup with the following medications: Levothyroxine 50 mcg 1 tab, Famotidine 40 mg 1 tab, Fluoxetine 40 mg 1 tab, Omeprazole 40 mg 1 tab, Aspirin 81 mg 1 tab, Losartan (used for high blood pressure) 25 mg 1 tab, and Multi-vitamin 1 tab. During an interview on 1/14/2026 at 7:40 AM, LPN A stated, I pulled all of my meds [medications] when I got here this morning. LPN A was asked when medications should be administered. LPN A stated, Medications should be administered after each one [resident] is pulled. During an interview on 1/14/2026 at 8:15 AM, the Director of Nursing (DON) stated all medications should be administered after removing the medications from the packs and they should not be replaced in the medication cart.

Based on medical record review, and interview, the facility failed to develop an accurate baseline care plan within 48 hours for 2 of 17 (Resident #47 and #412) sampled residents reviewed for baseline care plans. The findings include: 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Extended Spectrum Beta Lactamase (ESBL), Urinary Tract Infection (UTI), Dementia, Fracture of Upper and Lower End of Left Fibula, and Depression. Review of the admission Minimum Date Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #47 was severely cognitively impaired without behaviors. Review of the Baseline Care Plan dated 1/2/2025, revealed risk for complications related to cognitive decline/impaired communication. Resident #47 was on Antidepressants and Psychotropic medication. Resident had an altered thought process related to short- and long-term memory problem. Review of the Baseline Care Plan was not completed within 48 hours of admission. During an interview on 3/11/2025 at 3:28 PM, License Practical Nurse (LPN) B confirmed that Resident #47's care plan was not completed in a timely manner and should have been done within 48 hours of admission. During an interview on 3/11/2025 at 4:00 PM, Director of Nursing (DON) was asked when the baseline care plan should be completed. The DON replied, .The baseline care plan needs to be completed within 48 hours of admission of the resident . The DON was asked if this care plan was completed in a timely manner. The DON replied, .No, it should have been done within 48 hours of admission . 2. Review of the medical record Resident # 412 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Depression, and Diabetes. Review of the Physician's Orders dated 3/6/2025, revealed .Eliquis [used to treat and prevent blood clots] 5mg [milligrams] q [every] 12 hours for atrial fibrillation .embolism and thrombosis . Review of the Baseline Care Plan dated 3/6/2025, revealed facility failed to care plan resident for the use of anticoagulant therapy. During an interview on 3/12/2025 at 11:50 AM, the DON confirmed that Resident #412's Baseline Care Plan did not reflect the use of anticoagulant therapy. 51365

Based on review of rosemontpharma.com, Medlineplus.gov, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 6 (Licensed Practical Nurse (LPN) F and LPN C) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 28 opportunities, resulting in a medication error rate of 7.14%. The findings include: 1. Review of the rosemontpharma.com article titled, Information For Patients On The Dangers Of Tablet Crushing, dated 9/2023, revealed . The clinical consequences for the patient of crushing tablets or opening capsules can mean that the drug is less effective or more likely to cause side effects. When crushing disrupts a drug's sustained-release properties, the active ingredient is no longer released and absorbed gradually, resulting in overdose. When a gastro-resistant layer is destroyed by crushing, underdosing is likely . Enteric coatings .These stop the drug breaking down in the stomach, to protect either the stomach or the drug, or to enable it to be released further along the digestive process . Modified or prolonged release .These drugs - also known as extended release, slow release or controlled release - are steadily released, which means they don't have to be taken so frequently . Review of the Medlineplus.gov article titled, Sevelamer, dated 7/20/2024, revealed .Sevelamer is in a class of medications call phosphate binders. It binds phosphorus that you get from foods in your diet and prevents it from being absorbed into your blood stream .It is usually taken three times a day with meals. Follow the directions on your prescription .Take sevelamer exactly as directed . Review of the facility's policy titled, Medication Administration- Unit Dose Cart System, dated 1/2025, revealed .Objective .To correctly administer medications as prescribed .Verify right ordered time for administration . Review of the facility's policy titled, Medication Administration-Feeding Tube, dated 5/2024, revealed .Do not crush enteric coated, sustained-released or sublingual medications . 2. Review of medical record revealed Resident #413 was admitted to the facility on [DATE], with diagnoses including Thrombocytopenia, Dementia, Anxiety Disorder, Hypertension, and Heart Failure. Review of Physician Orders dated 3/7/2025, revealed Potassium Chloride 20 MEQ [milliequivalent] tablet, extended release .1 tablet oral twice a day. [Time: 8:00, 16:00] for Acute on chronic diastolic (congestive) heart failure . Review of Physician Orders dated 3/11/2025, revealed .Buspirone 5mg tablet .1 tablet oral twice a day. [Time: 8:00, 16:00] for generalized anxiety disorder, metabolic encephalopathy . Observation during medication administration on 3/11/2025 at 3:43 PM, revealed LPN F removed the following medications from the cart to administer to Resident #413. a. Buspirone 5 mg tablet 1 tablet. b. Furosemide 40 mg tablet 1 tablet. c. Potassium chloride 20 MEQ Extended Release 1 tablet. LPN F crushed the medications including the extended-release potassium, mixed in pudding, entered the room and administered medications to Resident #413, resulting in a medication error for crushing an extended-release medication. During an interview on 3/12/2025 at 11:43 AM, the Director of Nursing (DON) confirmed that extended-release medications should not be crushed. 3. Review of medical record revealed Resident #414 was admitted to the facility on [DATE], with diagnoses including Atrioventricular Block, End Stage Renal Disease, Cardiac Arrhythmia, Anemia, and Diabetes Mellitus. Review of admission MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #414 was cognitively intact. Review of Physician orders dated 3/10/2025, revealed .Sevelamer Carbonate [a phosphate binder used to prevent low levels of calcium for kidney disease] 800 mg [milligram] tablet .3 tabs [tablets] oral with bkfst [breakfast], lun [lunch], and din [dinner] [Time .17:00 [5:00 PM] for chronic kidney disease . Observation during medication administration on 3/11/2025 at 4:05 PM, LPN C removed the following medications from the cart to administer to Resident #414. a. Sevelamer Carbonate 800 mg tablet 3 tablets LPN C removed the medications from the cart, offered medications to Resident #414, resident asked about taking meds with meal, nurse instructed to take before the meal, medication administered, resulting in a medication error for not administering a medication at the scheduled time with the dinner meal. During an interview on 3/12/2025 at 11:43 PM, the DON confirmed that a physician order to administer a medication with meals is for an important reason and should be followed, and that administering a medication that is to be taken with food an hour before a meal is not following the order.

Based on review of rosemontpharma.com, Medlineplus.gov, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 6 (Licensed Practical Nurse (LPN) F and LPN C) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 28 opportunities, resulting in a medication error rate of 7.14%. The findings include: 1. Review of the rosemontpharma.com article titled, Information For Patients On The Dangers Of Tablet Crushing, dated 9/2023, revealed . The clinical consequences for the patient of crushing tablets or opening capsules can mean that the drug is less effective or more likely to cause side effects. When crushing disrupts a drug's sustained-release properties, the active ingredient is no longer released and absorbed gradually, resulting in overdose. When a gastro-resistant layer is destroyed by crushing, underdosing is likely . Enteric coatings .These stop the drug breaking down in the stomach, to protect either the stomach or the drug, or to enable it to be released further along the digestive process . Modified or prolonged release .These drugs - also known as extended release, slow release or controlled release - are steadily released, which means they don't have to be taken so frequently . Review of the Medlineplus.gov article titled, Sevelamer, dated 7/20/2024, revealed .Sevelamer is in a class of medications call phosphate binders. It binds phosphorus that you get from foods in your diet and prevents it from being absorbed into your blood stream .It is usually taken three times a day with meals. Follow the directions on your prescription .Take sevelamer exactly as directed . Review of the facility's policy titled, Medication Administration- Unit Dose Cart System, dated 1/2025, revealed .Objective .To correctly administer medications as prescribed .Verify right ordered time for administration . Review of the facility's policy titled, Medication Administration-Feeding Tube, dated 5/2024, revealed .Do not crush enteric coated, sustained-released or sublingual medications . 2. Review of medical record revealed Resident #413 was admitted to the facility on [DATE], with diagnoses including Thrombocytopenia, Dementia, Anxiety Disorder, Hypertension, and Heart Failure. Review of Physician Orders dated 3/7/2025, revealed Potassium Chloride 20 MEQ [milliequivalent] tablet, extended release .1 tablet oral twice a day. [Time: 8:00, 16:00] for Acute on chronic diastolic (congestive) heart failure . Review of Physician Orders dated 3/11/2025, revealed .Buspirone 5mg tablet .1 tablet oral twice a day. [Time: 8:00, 16:00] for generalized anxiety disorder, metabolic encephalopathy . Observation during medication administration on 3/11/2025 at 3:43 PM, revealed LPN F removed the following medications from the cart to administer to Resident #413. a. Buspirone 5 mg tablet 1 tablet. b. Furosemide 40 mg tablet 1 tablet. c. Potassium chloride 20 MEQ Extended Release 1 tablet. LPN F crushed the medications including the extended-release potassium, mixed in pudding, entered the room and administered medications to Resident #413, resulting in a medication error for crushing an extended-release medication. During an interview on 3/12/2025 at 11:43 AM, the Director of Nursing (DON) confirmed that extended-release medications should not be crushed. 3. Review of medical record revealed Resident #414 was admitted to the facility on [DATE], with diagnoses including Atrioventricular Block, End Stage Renal Disease, Cardiac Arrhythmia, Anemia, and Diabetes Mellitus. Review of admission MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #414 was cognitively intact. Review of Physician orders dated 3/10/2025, revealed .Sevelamer Carbonate [a phosphate binder used to prevent low levels of calcium for kidney disease] 800 mg [milligram] tablet .3 tabs [tablets] oral with bkfst [breakfast], lun [lunch], and din [dinner] [Time .17:00 [5:00 PM] for chronic kidney disease . Observation during medication administration on 3/11/2025 at 4:05 PM, LPN C removed the following medications from the cart to administer to Resident #414. a. Sevelamer Carbonate 800 mg tablet 3 tablets LPN C removed the medications from the cart, offered medications to Resident #414, resident asked about taking meds with meal, nurse instructed to take before the meal, medication administered, resulting in a medication error for not administering a medication at the scheduled time with the dinner meal. During an interview on 3/12/2025 at 11:43 PM, the DON confirmed that a physician order to administer a medication with meals is for an important reason and should be followed, and that administering a medication that is to be taken with food an hour before a meal is not following the order.

Based on policy review, medical record review, and interview the facility failed to ensure residents' medication regimen was free of unnecessary medications when the facility failed to provide evaluation and rationale for continued orders for (PRN) as needed psychotropic medications for 2 of 6 (Resident #19 and Resident #412) sampled residents reviewed for unnecessary medications. The finding include: 1. Review of the facility policy titled, Psychotropic Medications, revised 11/2022, revealed .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition .PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [that is] 14 days) .If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order . 2.Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Anxiety (excessive worry and fear about everyday situations), Depression, Dementia, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #19 had severe cognitive impairment. Review of the Physician Orders dated 3/2025, revealed .Order Date .11/03/24 [11/3/2024] .Xanax [a controlled substance that is used to treat anxiety disorders] 1 MG TABLET (ALPRAZolam) 1 mg [milligram] Oral PRN BID [twice daily] for . Anxiety disorder . Facility was unable to provide physician documentation to extend the PRN psychotropic medication beyond 14 days or indicate the duration for the PRN psychotropic medication. 3. Review of the medical record Resident # 412 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety Disorder, Dementia, and Depression. Review of the Physician Orders dated 3/2025, revealed .Order Date .3/06/25 [3/6/2025] .LORAZEPAM [a controlled substance that is used to treat anxiety disorders] 0.5 MG TABLET (LORazepam) 1 TAB [Tablet] Oral PRN BID for .Anxiety Disorder . Facility was unable to provide physician documentation to indicate the duration of the PRN psychotropic medication. During an interview on 3/12/2025 at 11:50 AM, Director of Nursing (DON) confirmed that PRN psychotropic medications should be ordered for 14 days and have a stop date.

Based on policy review, medical record review, and interview, the facility failed to ensure a resident's medication regimen was free from unnecessary medications in excessive dosages for 1 of 6 residents (Resident #33) sampled for unnecessary medications. The findings include: 1. Review of the facility's policy titled, .Orders for Services . dated 10/2024, revealed .Products, service, treatment, and care are provided in accordance with the most current physician's order .When a written order is received, appropriate staff will verify it for accuracy, completeness, and appropriateness .Service, treatment and/or care will be provided based on the most current written order . 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Diabetes, Morbid Obesity, Chronic Obstructive Pulmonary Disease, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 has a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #33 was cognitively intact. Review of the Physicians Order dated 11/7/2024, revealed .OZEMPIC [diabetic/weight loss medication] .Subcutaneous [applied under the skin] .Weekly on Thursday .Give 0.25mg [milligrams] x [times] 4 weeks . Review of the Physician Order dated 12/19/2024, revealed .OZEMPIC .Weekly on Saturday . Review of the Medication Administration Record (MAR) dated January 2025, revealed Resident #33 received an Ozempic Injection on 1/2/2025, 1/4/2025, 1/9/2025, 1/16/2025, 1/23/2025. Review of the MAR dated February 2025 revealed Resident #33 received an Ozempic Injection on 2/1/2025, 2/6/2025, 2/13/2025, 2/15/2025, 2/20/2025, 2/27/2025. Review of the MAR dated March 2025 revealed Resident #33 received an Ozempic Injection on 3/6/2025 and 3/8/2025. Resident #33 was receiving the Ozempic injections more than weekly. During an interview on 3/12/2025 at 11:03 AM, Licensed Practical Nurse (LPN) B was shown the January, February, and March 2025 MAR's, and was asked did she sign both Ozempic order injections for Thursday and Saturday in the same week. LPN B stated, If I signed my name, I would have given it, I will look at that order and see if it may be a duplicate order. During an interview on 3/12/2025 at 11:14 AM, the Director of Nurses (DON) was asked how often a Ozempic Injection should be given. The DON stated, Weekly. The DON was asked should the Ozempic physician order on Thursday's been discontinued. The DON stated, Yes. The DON was asked did Resident #33 receive multiple doses of OZEMPIC injections during some weeks. The DON stated, Yes .I will go get this corrected immediately.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders and to monitor the oxygen flow rate for 2 of 2 (Resident #59 and #412) sampled residents reviewed for respiratory therapy. The findings include: 1. Review of the facility policy titled, Oxygen Therapy/Administration, dated 11/2018, revealed .The purpose of this procedure is to facilitate breathing by providing supplemental oxygen to Residents so that oxygen concentrations are increased to enhance tissue perfusion .Turn oxygen on the prescribed amount . 2. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia [inadequate supply of oxygen to the body's tissues], Pulmonary Hypertension, Pneumonia, and Interstitial Pulmonary Disease. Review of the Physician orders dated 2/21/2025, revealed .02 [oxygen] @ [at] 4LPM [liters per minute] by NC [nasal canula]- Every Shift .to decrease the risk for Hypoxia r/t [related to] to dx [diagnosis] of respiratory failure . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #59 was cognitively intact. Resident was assessed for shortness of breath or trouble breathing when lying flat and required oxygen therapy. Review of the Progress Note dated 3/6/2025, revealed .continuous 02 via nasal cannula @4l/m, rhonchi noted, shortness of breath . Observations in Resident #59's room on 3/10/2025 at 9:07 AM, 3:48 PM, and 3/11/2025 at 9:26 AM, revealed oxygen set at 3.5 liters/minute. During an interview on 3/11/2025 at 4:25 PM, the Director of Nursing (DON) confirmed that if the order is for oxygen at 4 liters, the concentrator should be set at 4 liters. The DON confirmed that physician orders should be followed. 3. Review of the medical record revealed Resident #412 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. Review of the Physician's Orders 3/6/2025, revealed .O2 [oxygen] at 2 lt/min[liters/minute] by nc [nasal cannula] every shift .to decrease the risk for hypoxia . Observations in Resident #412's room on 3/11/2025 at 9:19 AM, revealed oxygen was set at 5 liters/minute. During observation and interview on 3/11/2025 at 9:33 AM, Licensed Practical Nurse C confirmed that Resident #412's oxygen was set at 5 liters, and it should have been set at 2 liters as ordered. During an interview on 3/12/2025 at 11:50 AM, the DON confirmed that physician orders should be followed for oxygen flow rates. 51365

Based on policy review, medical record review, and interview the facility failed to timely notify the physician and failed to reassess pain for a resident with a fall that resulted in a fracture for 1 of 4 (Resident #212) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, Fall Prevention Program, dated 2/2025, revealed .The Fall Prevention Program is designed to ensure a safe environment for all Residents .When fall occurs .Conduct a physical assessment .Notify MD [Medical Director] and transfer to ER [emergency room ] for evaluation for obvious injury. Notify nursing supervisor, responsible party, and family . Review of the facility policy titled, Pain Management dated 3/2025, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice .Manage or prevent pain, consistent with comprehensive assessment and plan of care, current professional standards of practice .The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. Based on professional standards of practice, an assessment or evaluation of pain by appropriate members of the interdisciplinary team ( .nurses, practitioner, pharmacists, and anyone else who has direct contact with the resident) may necessitate gathering the following information .Asking the patient to rate the intensity of his/her pain using a numerical scale .Duration of pain, Frequency, Location, Timing, Pattern, Radiation of pain .Obtaining descriptions of the pain (stabbing, aching, pressure, spasms) .Impact of pain on quality of life (sleeping, functioning, appetite and mood) .Physical and psychosocial issues that might be causing or exacerbating the pain .Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences . 2. Review of the medical record revealed Resident #212 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Left femur fracture, Anxiety, and Osteoporosis. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #212 was cognitively intact. Resident required staff assistance with Activities of Daily Living. Review of the Care plan revised on 2/6/2025, revealed .Fractures - I have fractures to the left ankle with ligament injury .Assess for pain level. Administer pain medication as ordered. Observe effectiveness of pain medications . Review of the facility's Incident Case Report documentation dated 2/6/2025 at 12:31 AM, revealed .Type: Fall .Incident location: Resident room .Observations: Alert with Moderately impaired .Foot wear: footwear off .Socks only .Full weight bearing .Uses walker .Bed mobility .Requires assistance .Major injuries: Fracture .Location: Lower extremities/feet .Comments: Resident stated that she was coming back to her bed from the restroom with her rolling walker and her left ankle went out on her and she went down. Resident stated that she did not hit her head but did bend ankle a little. Upon further interview, resident was almost back to the bed, and she went to grab the side rail and her hand slipped, she then was trying to grab onto the bed linens and got tangled and fell .Notified Physician [Nurse Practitioner] on 2/6/2025 at 8:00 AM . Review of the Xray results dated 2/6/2025, revealed .There is fracture involving the medial and lateral malleoli with displacement. The joint is disrupted with medial displaced tibia relative to the talus. There is associated soft tissue swelling. Ankle fractures and ligament injury as described . Review of the Medication Administration Record dated 2/2025, revealed that staff failed to reassess resident's pain after the administration of Hydrocodone/Acetaminophen (used to treat pain) 5/325mg (milligram) at the following times: a. 2/6/2025 at 12:47 AM with resident's pain was 9/10 on pain scale. Resident's pain was not reassessed. b. 2/6/2025 at 12:47 PM with resident's pain 8/10 and reassessed on 2/11/2025 at 10:49 AM as effective decreased pain level 2/10 c. 2/6/2025 at 5:52 PM with resident's pain 7/10 and reassessed on 2/11/2025 at 8:43 AM with medication effective. d. 2/6/2025 at 11:50 PM with resident's pain 10/10 and reassessed on 2/9/2025 at 7:28 PM effective pain 4/10 During an interview on 3/11/2025 at 2:13 PM, the Director of Nursing (DON) confirmed that pain should be reassessed within 1 hour after administration and confirmed that the physician should have been notified immediately of resident's fall.

Based on policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 6 nurses (Licensed Practical Nurse (LPN A) failed to clean reusable equipment before and after use, and failed to wear Personal Protective Equipment (PPE) in an enhanced barrier precautions room, and when LPN C failed to properly dispose of sharps. The findings include: 1.Review of the facility policy titled, Medication Administration: Feeding Tube, dated 5/2024, revealed .put on gloves . Review of the facility policy titled, Cleaning of Equipment, dated 9/2021, revealed .Reusable resident-care equipment will be cleaned and disinfected in accordance with the current CDC recommendations in order to break the chain of infection .Reusable multiple-resident items are items that may be used multiple times for multiple residents .Multiple-resident use equipment shall be cleaned and disinfected after each use . Review of the facility policy titled, Enhanced Barrier Precautions, dated 11/2022, revealed .Initiation of Enhanced Barrier Precaution . feeding tubes .Staff will don gown and gloves immediately prior to entering the room for high contact resident care activities .High-contact resident care activities include .feeding tubes . Review of the facility's policy titled, Sharps, dated 8/2024, revealed .It is the policy of this facility to ensure the safety of staff and proper management of sharps .Contaminated sharps will be placed in appropriate sharps containers at the point of use . 2. Review of the Medical Records revealed Resident #48 was admitted on [DATE], with diagnoses including Dysphagia and Gastrostomy. ?? Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the Resident #48 was cognitively intact.? ?? Observation during medication administration on 3/11/2025 at 4:26 PM, revealed Licensed Practical Nurse (LPN) A administered medications and enteral feeding through a PEG (Percutaneous Endoscopic Gastrostomy a feeding tube placed directly into the stomach through the abdominal wall) without the use of PPE (personal protective equipment), and then removed pulse oximeter from pocket, checked Resident #48's oxygen saturation, and returned pulse oximeter to pocket without cleaning or disinfecting. During an interview on 3/12/2025 at 11:43 AM, revealed the Director of Nursing (DON) confirmed staff should use PPE when administering medications/feedings through a PEG tube, and stated, .that would be an infection control error . The DON confirmed that a pulse oximeter should be cleaned and not be stored in a pocket or returned to a pocket after use. 3. Review of medical record revealed Resident #414 was admitted to the facility on [DATE], with diagnoses including Atrioventricular Block, End Stage Renal Disease, Cardiac Arrhythmia, Anemia, and Diabetes Mellitus. Review of admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #414 was cognitively intact. Observation during medication administration and blood glucose check on 3/11/25 at 4:05 PM, revealed LPN C entered Resident #414's room, obtained blood glucose check, exited room and disposed of used lancet in trash can on medication cart. During an Interview on 3/12/2025 at 11:50 AM the DON was asked where a used lancet should be disposed of, DON replied, In a sharps box. The DON confirmed a trash can is not appropriate for disposal of a used lancet.

Based on policy review, medical record review, observation, and interview the facility failed to ensure medications were properly and securely stored when 2 medications were left unattended in a resident's room for 1 of 1 (Resident #22) sampled residents and when 1 of 4 nurses (License Practical Nurse (LPN) A left medications unsecured and unattended at the bedside of Resident #48 during medication administration. The findings include: 1. Review of the facility policy titled, Medication Administration - Self-Administration by Resident, dated 1/2025, revealed .Self-administered medication must be stored in a safe place, which is not accessible to other Residents .As part of their overall evaluation, the staff and practitioner will assess the Resident's mental and physical abilities, to determine whether the Resident is capable of self-administering medications . 2. Review of the medical record revealed Resident #22, was admitted to the facility on [DATE], with diagnoses including, Fracture Lower End Left Femur, Osteoporosis, and Hypothyroidism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #22 was cognitively intact. During a random observation in Resident #22's room on 3/10/2025 at 8:50 AM,10:35 AM, 11:40 AM, 2:08 PM and 3:50 PM revealed Resident #22 had Tylenol in a basket on the overbed table. During an interview on 3/10/2025 at 4:41 PM, LPN C was taken to resident #22 room and asked if the Tylenol medication should be left unsecured and unattended in the resident's room. LPN C confirmed that medication should not be left in a residents' room unless in a locked boxed, and resident has orders to self-administer medications. 3. Review of the Medical Records revealed Resident #48 was admitted on [DATE], with diagnoses including Dysphagia (difficulty swallowing), Chronic Kidney Disease, Benign Neoplasm (noncancerous mass of abnormal cells), and Malignant Neoplasm (cancerous tumor). Review of the annual MDS assessment dated [DATE], revealed Resident #48 had a BIMS score of 13, which indicated the Resident #48 was cognitively intact. Observation in the hallway during medication administration on 3/11/2025 at 4:33 PM, revealed LPN A prepared the following medications to administer to Resident #48: a. Hydroxyzine hcl (hydrochloride) (used to treat allergies/itching) 25 mg 1 tablet b. Meclizine (a medication to treat motion sickness) 12.5mg 1 tab c. Acetaminophen (a pain reliever) 325 mg 2 tabs LPN A entered the Resident's room, where Resident #48 was up in his wheelchair wheeling himself around in the room. LPN A placed the medications on the bedside table, then entered the bathroom leaving the medications unsecured and unattended, within reach of Resident #48. During an interview on 3/12/2025 at 9:42 AM, the Director of Nursing (DON) confirmed medications should not be in a Resident room unsecured and unattended. The DON stated, .Medication must be kept in a locked box at bedside so other resident cannot access the medication .

Based on policy review, job description review, and interview, the facility Administration failed to provide oversight to ensure all residents were free of abuse, failed to conduct thorough investigations related to abuse incidents, failed to report abuse to appropriate state agencies, and failed to ensure the Quality Assurance Performance Improvement (QAPI) program included ongoing problems with resident safety to prevent, identify, report, and thoroughly investigate, allegations of abuse. The Administration's failure to ensure all residents were free of abuse resulted in Immediate Jeopardy for Residents ##307, #24, #20, and #40. On 7/20/2023, Resident #307, a severely cognitively impaired resident, was observed rubbing the exposed breast of Resident #24; on 7/21/2023, Resident #24, a moderately cognitively impaired resident, was observed with her hand down the front part of Resident #307's pants, and on 8/27/2023, Resident #307 and Resident #24 were observed with their hands in each other's pants and the incident was captured on camera. On 10/25/2023 and 10/30/2023, Resident #40, a severely cognitively impaired resident, was touching staff members inappropriately. The facility failed to implement interventions to prevent sexual abuse of residents and on 11/1/2023 at 9:45 AM and again, at an unknown time, Resident #40 was observed in Resident #20's room with his hand under the Resident's blanket and another time the same day sitting at Resident #20's bedside with the covers pulled off of Resident #20. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director (ED), the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-835 on 12/20/2023 at 12:59 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-835. The facility was cited at F-835 at a scope and severity of J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM and was validated onsite by the surveyors though medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 and continued through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The findings include: 1. Review of the facility's policy titled Administrative Management, dated 11/2023, revealed .The Administrator is accountable to the governing body .The Administrator has been given the authority and responsibility for the management of then nursing home and the implementation of the facility's policies . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must .Provide a safe environment and protect resident from .Resident to Resident Abuse of any type .Prohibit and prevent verbal, mental, sexual, or physical abuse .PREVENTION . Respond to all allegations or questions about abuse from a resident, family member, employee or visitor taking all comments seriously .Take appropriate action when any type of abuse is suspected . IDENTIFICATION .The facility will consider and train staff on identifying factors indicating possible abuse .INVESTIGATION .Initiate an immediate Investigation into the Allegation of Abuse, neglect, or exploitation .Interview the resident involved in the allegation if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses .Interview the resident's family, responsible party, or the individual involved in the resident's care to identify any information they may have related to the allegation .Interview staff members that were on duty during time of the allegation to identify any concerns or unusual actions by the accused .All interviews should be written by the person being interviewed if possible, on the Witness Explanation of Incident Form AD-29A [Witness Explanation of Incident Form] .and signed and dated .Review the resident's medical record for any changes in condition .A summary of the investigation will be documented on form AD-29 [Resident Abuse Investigation Report] to include whether or not the allegation of Abuse is substantiated or unsubstantiated and any corrective action necessary .PROTECTION .The facility will respond immediately to any allegations of abuse, neglect or exploitation of a resident to protect the alleged victim as well as other residents while also protecting the integrity of the investigation . REPORTING AND RESPONSE .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident .The Abuse Coordinator will review any changes with systems to the QAPI [Quality Assurance Performance Improvement] Committee and evaluate for effectiveness . 2. Review of the facility's Executive Director/Chief Operating Officer JOB DESCRIPTION-FACILITY, signed 7/30/2021, revealed .Accepts 7-day/week, 24-hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility .Consistently demonstrates loyalty and commitment to the facility staff as well as establishes standards, goals, policies and procedures .Assure resident safety at all times .Willing to address each resident by his/her preferred name as well as learn and abide by Residents' Rights, rules and regulations .Willingness to accept administrative responsibility for facility operations and chair of various committees .Ensures the delivery of the highest level of health services and quality of care that is responsive to customers' needs .Performs as the PI (Performance Improvement) Coordinator .Performs as the designated Compliance Officer/Risk Manager charged with the responsibility for operating and monitoring the Compliance Program and chairs the Performance Improvement/Risk Management Committee .Consistently promotes a safe environment for Resident .Ensures compliance with all Federal, State, and licensure regulations and laws as measured by annual surveys and complaint visits .Resident preferences are followed when providing care and service .Review Resident complaints and grievances and make written reports of action taken .Review accident/incident reports ( .falls, injuries of an unknown source, abuse .) .Monitor to determine the effectiveness of the facility's risk management program . Review of the facility's Director of Nursing Job Description, signed 9/27/2023 revealed .Duties and Responsibilities .Assure Resident safety at all times .Establishes and implements objectives and standards for the Nursing Department in compliance with the current requirements of regulatory agencies . Fill in as the Executive Director in their absence and as needed .Maintain effective communications interdepartmentally to ensure that Residents' Rights are enforced and included in overall plan of care with input from all disciplines . Understand, comprehend and respond promptly to any deficiencies noted by regulatory agencies .Knows and complies with all applicable federal and state statues, rules and regulations . Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program . 3. The allegations of sexual abuse that occurred on 7/20/2023, 7/21/2023, and 8/27/2023, were not thoroughly investigated per the facility's policy, incident reports were not completed, staff were not interviewed, all staff statements were not obtained, head-to-toe assessments were not completed on Resident #24 and Resident #307, alert and oriented residents were not interviewed, and the incidents were not reported to the State Survey Agency, the Ombudsman, or Adult Protective Services. There was no documentation a thorough investigation was conducted for the 7/20/2023 and the 7/21/2023 incidents. The was no documentation an investigation was conducted for the 8/27/2023 incident and the facility was unable to provide an investigation. 4. On 10/25/2023 and 10/30/2023, documentation revealed that Resident #40 was touching staff members inappropriately. Resident #40's Care Plan was not revised to reflect the behaviors and no interventions were implemented to protect residents at that time. On 11/1/2023 at approximately 9:45 AM, Resident #40 was observed by a staff member in Resident #20's room with his hand on the edge of her bed and under the blanket that was covering the Resident. Resident #40 was removed from the room by the staff member. At an unknown time on the same day of 11/1/2023, Resident #40 was again observed by a Sitter in Resident #20's room sitting by her bedside and the covers were pulled back off the Resident. The Sitter stated Resident #20 yelled out at the time and she reported the incident to a staff member, who removed Resident #40 from Resident #20's room at that time. All staff members working the shift were not interviewed with statements documented, the Sitter (who was a witness) was not asked to write a statement, an incident report was not completed, alert and oriented staff on the same hall were not interviewed, head-to-toe assessments were not performed to identify injuries, and the incidents were not reported to the State Survey Agency, the Ombudsman, and Adult Protective Services (APS) in accordance with the facility policy. 5. The facility Administration failed to ensure an effective Quality Assurance Performance Improvement (QAPI) program that recognized ongoing problems with resident safety to prevent, identify, report, and thoroughly investigate, allegations of abuse for Residents #307 and #24, and Residents #40 and #20. 6. During an interview on 12/12/2023 at 4:43 PM, the Executive Director (ED) was asked, what did the facility complete during the incident with Resident #24 and Resident #307 on 7/21/2023. The ED stated, .Well according to the report we did an investigation . asked [Named Resident #24] to explain what happen .he [Resident #307] did not have the mental compacity to content to anything like that [consensual sex] . The ED was asked if the facility completed an abuse in-service. The ED stated, .I don't recall doing an in-service it was during the huddle . The ED was asked if he had documentation that the Residents were monitored. The ED stated, .there is no documentation of the monitoring . The ED stated, .I don't have an answer . The ED was asked if the facility completed an incident report for both incidents. The ED stated, .No . The ED was asked if he had staff write statements or were there interviews of alert residents. The ED stated, I don't have statements or interviews of other residents . The ED was asked if he reported the incidents to the State. The ED stated, .No . we felt it was somewhat residents right and no harm was done . The ED confirmed he is responsible for the facility. During an interview on 12/20/2023 at 11:25 AM, Regional Client Operation Consultant was asked when she was made aware of the inappropriate sexual behaviors between Resident #24 and Resident #307 and what her guidance to the ED was. The Regional Client Operation Consultant stated, .[Named ED] was just starting the investigation .his findings at that point he did not consider it as a abuse situation .that it was sexual contact in nature .neither party express dissatisfaction or being upset about the interaction or harmed .[named ED] concern was it was in a public area in the day room which is concerning for their privacy and dignity .he did not feel like it escalated to the point of abuse .[Named Resident #307] was difficult to understand he [ED] was his [Resident #307] uncle . Regional Client Operation Consultant was asked if she was aware of Resident #24 and Resident #307's BIMS score. The Regional Client Operation Consultant stated, .Yes . [Named Resident #24] was a [BIMS] 12 . [Named Resident #307] was lower . The Regional Client Operation Consultant was asked if she was aware there were 3 separate incidents of sexual inappropriate behavior. The Regional Client Operation Consultant stated, .I didn't know a third incident had occurred . The Regional Client Operation Consultant was asked if she was aware of the Federal Guidelines of abuse and consensual sex. The Regional Client Operation Consultant stated, .Yes I'm aware of the Federal guidance .I did not look to the policy on consensual sex and assure all the steps were followed and interventions . The Regional Client Operation Consultant stated, .I think we need to follow our policy of consensual relations if that was the findings . The Regional Client Operation Consultant was asked if she was aware the ED brought staff members to his office to review the camera recording of another interaction with Resident #24 and Resident #307 and told them this is what happens when you all were on break. The Regional Client Operation Consultant stated .No I was not aware of that . During an interview on 12/21/2023 at 8:05 AM, the [NAME] President of Client Operation Consulting for Care Center was asked if he was part of the Governing Body. The [NAME] President of Client Operation Consulting for Care Center stated, .I report to the Governing Body .I'm a consultant . [NAME] President of Client Operation Consulting for Care Center was asked what guidance he provided to the facility. The [NAME] President of Client Operation Consulting for Care Center stated, .first of all getting back to what they reported .we had a male and a female resident .[Named Resident #24] cant propel self .[Named Resident #307] did .she [Resident #24] approached him to touch her .he [Resident #307] did in the day room .that was not appropriate .they [Management] were under the impression they [Resident #24 and Resident #307] knew what they were doing .they [the Residents] were separated .later an episode occurred in the day room he [Resident #307] rolled up to her [Resident #24] and she had her hands in his pants .based on the faculty opinion you had two Resident not bothered by it she approached him .the Medical Director stated they knew what they were doing .was it abuse .two Residents not upset and attracted to each other .the facility separated them .we did not see abuse we had two people that did know what they were doing .it's consensual tow Resident touching each other and it did not appear it was abuse .there are technical things in the regulation that the facility did not do .we take it serious .we are taking this very serious and not brushing this off .I feel like the Medical Director's opinion they know what they are doing .just a score [BIMS] don't tell the whole picture .the regulation look at it and that is the trusted part .don't mean the facility did everything right .they did not .it would be helpful to pull the regulation .the steps talk about [in the policy] .it would help all of us for a better picture of the two Residents .looking back they [Management] said they did in-services .I think it would have be better if they would have the records [of the in-service] the DON said she did .as nurses you have to write it down .they missed the mark on that . [NAME] President of Client Operation Consulting for Care Center was asked who did he report the incident to. [NAME] President of Client Operation Consulting for Care Center stated, .[Named Regional Client Operation Consultant] .she reported it to me .we looked at it .if it was abuse or not .the facility said it was consensual sex .that is as far as it went .[Named ED ] has the authority to run this facility and we count on that .did I get the all the details from the [Named ED ] of the events .no I did not .that would have been helpful .I think we would have looked into more details .they failed to follow all the steps [policy] .we are addressing that . During an interview on 12/21/2023 at 8:40 AM, the Regional Client Operation Consultant was asked if the ED had additional information for the complaint investigations, he wanted to give the support the complaints. The Regional Client Operation Consultant stated, .He does not . Refer to F-600, F-609, F-610, and F-867. The following Removal Plan was validated onsite by the surveyors through record review, review of in-service education, assessment review, interviews with the Executive Director, the Director of Nurse Consultant, and other staff on all shifts: 1. The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. 2. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. 3. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. 4. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: 5.Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. 6. Staff will redirect residents engaging in intimacy and/or sexual expression in public. 7. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). 8. Staff should immediately report suspected sexual abuse to immediate supervisor. 9. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. 10. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. 11. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. 12. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. 13. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. 14. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). 15. The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. 16. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. 17. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. 18. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant. Allegations of abuse will be submitted in a timely manner to meet initial reporting regulations. The allegation will be thoroughly investigated by the Executive Director and appropriate management team members. Upon completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will ensure that the Consulting Staff are contacted immediately upon notification of any allegation of abuse so that reporting and investigating regulations will be met and conducted timely. 19. There are no staff currently on leave of absence. 20. Agency staff working on 12/19/23 and 12/20/23 were included in the staff education. 21. Any agency staff that are assigned to work that have not received the education provided on 12/19/23 and 12/20/23 will be provided with education on the abuse policy and consensual sexual contact prior to reporting to the assigned nursing unit. This education will be provided by either the Director of Nursing or Assistant Director of Nursing. 22. Newly hired staff will be educated on the abuse policy and consensual sexual contact policy during the new hire paperwork which is done prior to working in the department they have been hired for. 23. No staff member will be able to work prior to receiving the education on abuse and consensual sexual contact. Further investigation for other potential allegations of abuse: 24. Current Residents with a BIMS score of ?8 were interviewed by the Director of Nursing, Social Services Director and the Nursing Consultant. The interviews were completed by 12/20/23. The results showed that no further incidents of inappropriate sexual contact occurred. 25. Current Residents with a BIMS score of <8 were assessed using an Emotional Change Assessment by the Director of Nursing. The results noted no emotional changes observed. 26. All current staff were interviewed by the Assistant Director of Nursing regarding any observations of residents having inappropriate sexual contact with each other. The results showed there were no new incidents of inappropriate sexual contact. 27. The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. 28. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. 29. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. 30. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: 31. Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. Staff will redirect residents engaging in intimacy and/or sexual expression in public. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). Staff should immediately report suspected sexual abuse to immediate supervisor. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. 31. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. 32. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant. Allegations of abuse will be submitted in a timely manner to meet initial reporting regulations. The allegation will be thoroughly investigated by the Executive Director and appropriate management team members. Upon completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will ensure that the Consulting Staff are contacted immediately upon notification of any allegation of abuse so that reporting and investigating regulations will be met and conducted timely. There are no staff currently on leave of absence. Agency staff working on 12/19/23 and 12/20/23 were included in the staff education. Any agency staff that are assigned to work that have not received the education provided on 12/19/23 and 12/20/23 will be provided with education on the abuse policy and consensual sexual contact prior to reporting to the assigned nursing unit. This education will be provided by either the Director of Nursing or Assistant Director of Nursing. Newly hired staff will be educated on the abuse policy and consensual sexual contact policy during the new hire paperwork which is done prior to working in the department they have been hired for. No staff member will be able to work prior to receiving the education on abuse and consensual sexual contact. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Direc [TRUNCATED]

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to provide evidence that a thorough investigation was conducted related to abuse for 4 of 20 (Resident #24, #307, #40, and #20) sampled residents reviewed for abuse. The facility's failure to thoroughly investigate allegations of abuse resulted in Immediate Jeopardy (IJ) related to Residents #24, #307, #40, and #20. On 7/20/2023, the facility failed to investigate the report by staff that Resident #307, a severely cognitively impaired resident, was observed rubbing the exposed breast of Resident #24, on 7/21/2023, when Resident #24, a moderately cognitively impaired resident, was observed with her hand down in the front part of Resident #307's pants, and on 8/27/2023, when Residents #307 and #24 were observed with their hands in each other's pants with this incident captured on camera. On 10/25/2023 and 10/30/2023, Resident #40, a severely cognitively impaired resident, was touching staff members inappropriately. The facility failed to implement interventions to prevent sexual abuse of residents when on 11/1/2023 at 9:45 AM and again the same day at an unknown time, Resident #40 was observed in Resident #20's room with his hand under Resident #20's blanket and at another time the same day Resident #40 was sitting at the bedside of Resident #20 with the covers pulled off of the resident. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director [ED], the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-610 on 12/19/2023 at 3:48 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM and was validated onsite by the surveyors though medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 and continued through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled Resident Rights, dated 1/2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The facility must have evidence that all alleged violations are thoroughly investigated .The results of all investigations must be reported to .officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .Abuse Coordinator .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must . INVESTIGATION .Initiate an immediate Investigation into the Allegation of Abuse, neglect, or exploitation .Interview the resident involved in the allegation if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses .Interview the resident's family, responsible party, or the individual involved in the resident's care to identify any information they may have related to the allegation .Interview staff members that were on duty during time of the allegation to identify any concerns or unusual actions by the accused .All interviews should be written by the person being interviewed if possible, on the Witness Explanation of Incident Form AD-29A .and signed and dated .Review the resident's medical record for any changes in condition .A summary of the investigation will be documented on form AD-29 [Resident Abuse Investigation Report] to include whether or not the allegation of Abuse is substantiated or unsubstantiated and any corrective action necessary .PROTECTION .The facility will respond immediately to any allegations of abuse, neglect or exploitation of a resident to protect the alleged victim as well as other residents while also protecting the integrity of the investigation .The assigned nurse will examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. The attending physician and behavioral health services will be notified to also assess the alleged victim as necessary .Increased supervision of the alleged victim and residents .REPORTING AND RESPONSE .Staff will need to stay with the residents to ensure they are safe and protected from further incident .The Nurse in charge will complete an Incident Report .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident. Summarizing all findings and any corrective actions needed on form AD-29 . Review of the facility's Executive Director/Chief Operating Officer JOB DESCRIPTION-FACILITY, signed 7/30/2021, revealed .Accepts 7-day/week, 24-hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility .establishes standards, goals, policies and procedures .Assure resident safety at all times .Ensures compliance with all Federal, State, and licensure regulations and laws as measured by annual surveys and complaint visits .Review Resident complaints and grievances and make written reports of action taken .Review accident/incident reports ( .falls, injuries of an unknown source, abuse .) . Review of the facility's Director of Nursing Job Description, signed 9/27/2023, revealed .Duties and Responsibilities .Assure Resident safety at all times .Establishes and implements objectives and standards for the Nursing Department in compliance with the current requirements of regulatory agencies .Maintain effective communications interdepartmentally to ensure that Residents' Rights are enforced and included in overall plan of care with input from all disciplines .Evaluates each prospective Resident prior to admission .Understand, comprehend and respond promptly to any deficiencies noted by regulatory agencies .Knows and complies with all applicable federal and state statues, rules and regulations .Ascertains that documentation of clinical records is orderly, accurate, current, and informative and the Resident's response is consistently noted .Review Resident complaints and grievances and make written reports of action taken .Discuss such actions with Resident and family as appropriate .Review accident/incident reports . 2. Medical record review and interview revealed 3 sexual incidents occurred between Resident #307 and Resident #24 on 7/20/2023, 7/21/2023, and 8/27/2023. Review of the medical record revealed Resident #307 and Resident #24 were cognitively impaired, were not assessed by facility staff to have the capacity to give consent to participate in sexual relations, there was no documentation that the residents were educated on disease processes by Social Services staff, and there was no documentation that consults were performed by the Medical Director and Mental Health Services Provider to determine if Resident #307 and Resident #24 had the capacity to give consent to consensual sex per the facility's policy. (a.) Review of the closed medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Aphasia, Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, Anxiety Disorder, and Extrapyramidal and Movement Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #307 scored a 4 on his Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of a progress note dated 7/21/2023 (for the incident that occurred on 7/20/2023), revealed Resident #307 was observed rubbing Resident #24's breast. There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and resident #24's sexual behaviors in accordance with the facility policy. There was no documentation in Resident #307's medical record of a 7/21/2023 incident where Resident #24 hand her hands down in the front part of Resident #307's pants. Review of the BIMS assessment dated [DATE] revealed Resident #307 scored a 5, which indicated severe cognitive impairment. Review of the annual MDS dated [DATE], revealed Resident #307 scored a 9 on his BIMS assessment, which indicated he was moderately cognitively impaired. Review of the 24 HOURS SHIFT REPORT dated 8/28/2023 (for a behavior that occurred on 8/27/2023), revealed . [Named Resident #307] .Family made aware- [Named Executive Director who was Resident #307's nephew] Inappropriate behavior [Each resident had their hand in the other resident's pants] in common area [Day Room] w [with]/female resident [Resident #24] . There was no documentation of the time this incident occurred. (b.) Review of medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Hypertension, Hemiplegia, and Aphasia. Review of the Care Plan with a revision date of 3/1/2023, revealed Resident #24 experienced cognitive loss and dementia with behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #24 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Review of the BIMS assessment conducted on 7/25/2023, revealed Resident #24 was assessed with a score of 13, which indicated she was cognitively intact. Review of the quarterly MDS dated [DATE], revealed Resident #24 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. There was no documentation in Resident #24's medical record of the 7/20/2023 incident where Resident #307 was rubbing Resident #24's exposed breast. Review of a progress note dated 7/22/2023, revealed .LATE ENTRY FOR 07/21/2023 17:25 [5:25 PM] .Resident [Resident #24] observed putting her hand down in another residents [resident's] pants [Resident #307's pants]. When asked what she was doing, Resident stated, working it Resident was taken to her room to separate her from the other male resident [Resident #307]. Review of the 24 HOURS SHIFT REPORT, dated 8/28/2023, revealed . [Named Resident #24] Inappropriate behavior [Each resident had their hand in the other resident's pants] w/male resident Family aware of resident's behavior . (c.) Review of the facility investigation dated 7/24/2023 (after the 7/20/2023 and 7/21/2023 incidents) included the following: A typed statement from the Executive Director. Progress notes for Resident #307 dated 7/14/2023 through 7/25/2023. A Psychiatric Progress Note for Resident #307 dated 7/28/2023. A Psychiatric Progress Note for Resident #24 dated 7/28/2023. The investigation did not include witness statements, staff interviews, head to toe assessments of Residents #24 and #307, resident interviews, increased monitoring of the residents, staff abuse education, documentation of the investigation on Form AD-29, in accordance with the facility's Abuse Policy, or documentation that the incidents were reported to the State Survey Agency, the Ombudsman, and Adult Protective Services (APS). There was no documentation of an investigation for the 8/27/2023 incident for Resident #307 and Resident #24, the facility was unable to provide an investigation. (d.) During an interview on 12/12/2023 at 3:33 PM, the Director of Social Services was asked about her documentation of the incident in July between Resident #24 and #307 that had occurred in the Day Room. The Director of Social Services stated, .What I remember it was a consensual type thing, but it was public .his [Resident #307] BIMS was actually lower than hers. I think it was 5 .he [NAME] and flows [fluctuates] some and she does too [cognitive status]. I followed them both for probably a week . The Director of Social Services stated, I think it happened on the 21st [7/21/2023] on a Friday evening. I found out about it on the 24th [7/24/2023] and that's when we started dealing with it . Investigation revealed the first sexually appropriate incident between Resident #24 and #307 occurred on Thursday 7/20/2023, and the second incident occurred on Friday 7/21/2023. During a telephone interview on 12/12/2023 at 4:18 PM, Licensed Practical Nurse (LPN) #3 confirmed she observed sexually inappropriate behaviors between Resident #307 and #24. LPN #3 confirmed it was reported to Administration at the time it occurred. LPN #3 stated, .everybody was at the desk [Nurses' Station across from the Day Room where the incident occurred] .the Administrator [ED], the DON [Director of Nursing] at that time . LPN #3 confirmed the incident where she documented Resident #307 rubbed Resident #24's breast occurred on 7/20/2023 and the incident where Resident #24 had her hand down in the front part of Resident #307's pants occurred on 7/21/2023. LPN #3 confirmed the former DON told her to write a Progress Note when the second incident occurred on 7/21/2023, but she wasn't told to do anything following the first incident on 7/20/2023. LPN #3 stated, .I was under the impression they were writing one [a statement], too . LPN #3 was asked did she know if Administration reported the incidents to the State and she stated, I know they didn't. During an interview on 12/12/2023 at 4:43 PM, the Executive Director (ED) confirmed two incidents of sexually inappropriate behaviors (7/20/2023 Thursday and 7/21/2023 Friday) occurred in the Day Room between Resident #307 and #24. The ED denied that he was present when either incident occurred. The ED stated, .I believe that might have occurred on the weekend .I believe I found out Monday morning .we began an investigation .asked [Named Resident #24] and kind of explained to [Named Resident #24] with [Named Resident #307] BIMS being lower than hers he [Resident #307] didn't really have the mental capacity to consent to anything like that .could be some serious consequences . The ED confirmed the facility investigation was not thorough, witness statements were not obtained, and incident reports were not completed. The ED was asked should the incidents have been reported to the State Survey Agency. The ED stated, If I thought it needed to be reported I would have reported it then. During an interview on 12/13/2023 at 8:15 AM, the ED, Clinical Nurse Specialist (CNS), and Director of Social Services presented the former DON's statement and asked to talk to the survey team. The ED stated, We don't feel like you all have the complete picture of the situation [between Resident #24 and Resident #307] .feel like this was a case of attraction to one another . The CNS stated, .These were Residents that did not wander into other rooms .when we asked them do you not feel afraid, or do you feel safe and both replied yes .it appeared more consensual to us .why we didn't report it or send them out . The CNS stated, There should have been an in-service sign in sheet for any kind of education because that is a policy .she [the former DON] was new and she was still learning. During an interview on 12/13/2023 at 3:01 PM, LPN #7 was asked did the facility educate staff to keep Resident #24 and Resident #307 separated and stated, We did a little something like he [Resident #307] wasn't supposed to go in the room [Resident #24's room]. He had been caught trying to go in the room before .there was never a group type meeting but a pass along by word of mouth. During an interview on 12/14/2023 at 9:15 AM, CNA #3 confirmed she observed Resident #307 touching Resident #24's breast in the Day Room. CNA #3 confirmed she told LPN #3, who was present at the Nurses' Station at the time and stated, [Named Executive Director] was coming down the hall and we told him about it . CNA #3 confirmed the Executive Director told staff present to monitor the residents and make sure they were kept separated, but she was not asked to write a statement about the incident. CNA #3 reported she was aware of another incident that was caught on camera on a Sunday (8/27/2023) when they were having a potluck. CNA #3 could not remember the date but confirmed the incident happened shortly before Resident #307 was sent out to an inpatient psychiatric facility. CNA #3 reported that the ED called some staff in the office on the Monday (8/28/2023) following the incident and showed them camera footage from the previous day where Residents #24 and #307 exhibited sexually inappropriate behaviors in the Day Room while staff were eating lunch. During an interview on 12/14/2023 at 10:23 AM, the ED confirmed the facility only kept camera footage for 2 weeks. The ED was asked how long the facility kept camera footage on incidents that occurred and stated, We keep footage of incidents, if it's possible, depending on where the camera is located [in relation to the incident] .it's [camera footage] not cloud based . During a telephone interview on 12/15/2023 at 11:38 PM, CNA #5 confirmed that she witnessed sexually inappropriate behaviors between Resident #24 and Resident #307 when she was training. CNA #5 stated, I think they were in the living room [Day Room] area where the TV was and I can't remember everything that went on . end of August [time it happened] . [CNA #5] started [hired in] around the 22nd [Tuesday 8/22/2023] and it [the incident] would have been that following weekend . CNA #4 was asked was that the only sexually inappropriate incident between Resident #24 and Resident #307 that she was aware of. CNA #4 stated, No . I heard one of the employees say they do it all the time .not the first time .I wasn't educated [to monitor the residents] but I knew that just from history. I wasn't told by no one. During a telephone interview on 12/15/2023 at 1:05 PM, CNA #8 confirmed she walked in on Resident #24 and Resident #307 with their hands in each other's pants. CNA #8 stated, .In the Day Room .other residents [were] around .No [wasn't educated to keep them separate] I didn't know anything about them .until that particular day .they should have had in-services .I would have thought it should have been reported .one of those incidents that we're like Oh my God .thought the nurse would be the one to report . CNA #8 confirmed she could not remember the date the incident happened but the last shift she worked was in August. During an interview on 12/18/2023 at 2:15 PM, the DON was asked would she expect an incident report to be completed by staff following incidents where residents are having sexually inappropriate behaviors. The DON stated, Absolutely unless it's something that's been previously determined that they are consenting, and all the paperwork is present. The current DON was hired 9/27/2023 and was not present when the sexually inappropriate behaviors occurred between Resident #24 and Resident #307. During an interview on 12/19/2023 at 9:11 AM, the ED was asked how many times sexually inappropriate behaviors were observed between Resident #24 and Resident #307. The ED stated, I'm aware of 2 .my understanding is they were on the same day, is that correct . Explained to him that our investigation revealed the first incident occurred on 7/20/2023 and the second incident occurred on 7/21/2023. The ED was asked was he on the hall shortly after the incident had occurred between Resident #24 and Resident #307 on 7/20/2023. The ED stated, I don't believe so, it's been a while, but I don't recall that. The ED confirmed that one of the sexually inappropriate incidents that occurred between Resident #24 and Resident #307 in the Day Room was captured on camera and he had shown it to some staff members, but he could not recall the date of the incident. The ED was asked how he determined the dates of the two incidents of sexually inappropriate behaviors he documented on his typed statement dated 7/24/2023. The ED stated, I'm trying to remember .only thing I can say is my dates may be wrong . The ED confirmed he did not have staff write witness statements. The ED was shown the 24 Hours Shift Report from 8/28/2023 that documented Resident #24 and Resident #307 had inappropriate behaviors and that he was notified. The ED denied he had knowledge of any sexually inappropriate incidents that occurred between Resident #24 and Resident #307 in August. The ED was asked was he aware of the Federal Regulations and the interpretive guidelines in the regulation regarding sexual abuse. The ED stated, Yes . The ED confirmed the facility should have followed State and Federal guidelines when there is an allegation of abuse. During an interview on 12/20/2023 at 7:34 AM, the Director of Nurse Consultant was asked what the facility should do when an allegation of abuse is made. The Director of Nurse Consultant stated, First thing, keep them [residents] safe .resident to resident, separate, then we start investigating. The Director of Clinical Nurse Consultant confirmed the facility did not follow the Federal Regulation guidance for an allegation of abuse. The allegations of sexual abuse that occurred on 7/20/2023, 7/21/2023, and 8/27/2023 were not thoroughly investigated per the facility's policy, incident reports were not completed, staff were not interviewed, staff statements were not obtained, a head-to-toe assessment was not completed on Resident #24 and Resident #307, and alert and oriented residents were not interviewed. 3. Medical record review and interview revealed 2 incidents occurred between Resident #40 and Resident #20 on 11/1/2023. a.) Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Cerebrovascular Disease, Anxiety, Depression, Hypertension, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #40 scored a 4 on his BIMS assessment, which indicated he was severely cognitively impaired, exhibited no behaviors, and independently propelled himself in a wheelchair. Review of the Care Plan with a revision dated 9/19/2023, revealed Resident #40 had cognitive deficits and a BIMS of 5. Review of the medical record revealed staff members reported that Resident #40 touched them inappropriately on 10/25/2023 and 10/30/2023. There was no documentation in the medical record that the facility developed a Care Plan or implemented a plan to monitor Resident #40 to protect residents following his sexually inappropriate behaviors. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 11/1/2023, revealed .CNA and Administrator reported that resident [Resident #40] noted in another residents [resident's] [Resident #20] room with his hand under the covers. Resident was escorted back to his room by CNA. Review of the Care Plan with a revision date of 11/3/2023, revealed Resident #40 exhibited sexually inappropriate and wandering behaviors. There were no interventions documented. Review of the medical record and the 24-Hour Shift Report form revealed Resident #40 continued to exhibit inappropriate behaviors with staff members on 11/3/2023 and 11/4/2023. Documentation revealed he was verbally educated on his inappropriate behaviors. Resident #40 had severe cognitive impairment. (b.) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses of Cerebral Atherosclerosis, Vascular Dementia, Diabetes, and Hypertension. Review of the Care Plan dated 11/1/2023, revealed Resident #24 had limitations in her ability to communicate her daily care needs, was nonverbal, and had dementia. Review of the medical record revealed Resident #20 was a hospice patient, had contractures of both upper extremities and her right lower extremity, and was unable to communicate. Record review revealed on 11/1/2023, Resident #40 was observed in Resident #20's room with his hand under the covers that were on top of her. Interviews with CNA #7 verified the incident occurred. On 11/1/2023, Resident #40 was observed in Resident #20's room, sitting by the Resident's bedside and Resident #20's covers had been pulled off of her. Interviews with the Sitter verified the incident occurred. Review of the admission MDS dated [DATE], revealed Resident #20 was rarely/never understood and could not be assessed for a BIMS score. Staff assessment revealed she was moderately impaired for daily decision-making skills. Resident #20 had impairment on both sides, in her upper and lower extremities and was dependent on staff for all ADLs. (c.) Review of the facility investigation requested on 12/28/2023 and presented to the survey team on 1/2/2024 revealed the following: a. Typed statement from the ED dated 11/1/2023. b. Typed statement from the DON dated 11/3/2023. c. Daily Assignment sheet dated 11/1/2023. d. Undated typed investigation summary. e. Witness statements from LPN #7, CNA #1, and CNA #7. f. 4 undated staff statements written by the ADON. g. 1 statement from the Sitter written by the ADON and dated 12/29/2023. h. 3 staff statements dated 12/29/2023. The facility's investigation did not include Form AD-29, an incident report, statements obtained from all staff at the time of the incident, a head-to-toe assessment of Resident #20, interviews of alert and oriented residents on the same hall, and documentation that the incidents were reported to the State Survey Agency, the Ombudsman, and APS. (d.) During an interview on 1/2/2024 at 8:52 AM, CNA #7 confirmed that Resident #40 was in Resident #20's room and stated, .she's [Resident #20] in Hospice, can't talk, can't really move .once he's [Resident #40] in his wheelchair he's really independent . CNA #7 reported that Resident #40's hand was on the edge of Resident #20's bed under the blanket. CNA #7 stated, .I reported it to cover myself .[reported] to the nurse . During an interview on 1/2/2024 at 2: 08 PM, the ADON stated CNA #7, CNA #1, LPN #7, and the DON all wrote statements in November following the incident where Resident #40 was observed in Resident #20's room. The ADON confirmed that she was asked on 12/29/2023 to get statements from the remainder of the staff who worked on 11/1/2023 and who had not written statements. The ADON also stated that she obtained the Sitter's statement by telephone on 12/29/2023. During an interview on 1/2/2024 at 2:20 PM, the ED confirmed he did not obtain a statement from the Sitter who reported Resident #40 was in Resident #20's room on 11/1/2023, until 12/29/2023. The ED was asked what the facility abuse policy directed staff to do if there is an allegation and stated, Investigation, statements. The ED was asked were all staff working that day asked to write statements and he stated, No . I got a statement from two staff members [CNA #1 and CNA #7]. During an interview on 1/2/2024 at 2:34 PM, CNA #11 confirmed she worked on 11/1/2023 and was not asked to write a statement. CNA #11 was asked was Resident #20 able to yell out or make verbal noise. CNA #11 stated, I've had her once and when we were turning her, she said it hurt. CNA #11 confirmed Resident #20 was not physically able to protect herself from anyone touching her. Continued interview on 1/2/2023 at 2:47 PM, revealed the ED was asked could he definitely determine from the staff statements if Resident #40 had or had not touched Resident #20. The ED stated, I cannot definitely say that. The ED was asked if he had this investigation to do over again what would he do differently. The ED stated, I definitely would dig a little deeper . The ED was asked was an incident report completed following the allegation of Resident #40 in Resident #20's room with his hand under the covers. The ED stated, Probably not, I don't know. The ED confirmed he did not remember who reported the incident to him. The ED was asked did he think that was something that he should keep up with and stated, Yes, you're right. The ED was asked who he reported the incident to. The ED stated, I can't swear to it, but I think we had a call [Corporate] about it. The ED denied that he observed Resident #40 in a female resident's room at any time. The ED was asked when the Sitter who observed Resident #40 pull Resident #20's covers back when should the Sitter have been asked to write her statement. The ED stated, That day [11/1/23], the day of occurrence. The ED was asked did he talk to the Sitter on the day of the occurrence [11/1/2023] or on 12/29/2023. The ED stated, I don't know if I talked to her or not .again I should get me a book [to document in]. The ED was asked who he talked to on 12/28/2023 following the survey teams request for the investigation. The ED stated, I know we talked to the Sitter .we talked to more staff because our policy says statements from all staff, so I finished getting statements from them. The ED was asked did he follow the facility's Abuse policy for his investigation into this allegation. The ED stated, No, we didn't investigate like we should have. The ED was asked was this incident reported to the appropriate agencies per the facility policy and the Federal regulation and stated, Probably not. Refer to F600. The following Removal Plan was validated onsite by the surveyors through record review, review of inservice education, assessments and audit review, and interviews with Administration and Staff. This is the facility Allegation of Compliance for the Immediate Jeopardy for F610 Investigating. The facility is alleging the Immediate Jeopardy removed as of 12/27/23. Specific Actions: Resident: On 7/21/23 Resident #307 had an increase in medroxyprogesterone from 2.5 mg to 5 mg daily. Resident was followed by Mental Health. Mental Health saw the resident following the incident on7/21/23, 7/28/23, 8/4/23, 8/11/23, 8/5/23, and 9/21/23. There were no further changes in this medication during the rest of the residents' stay at the facility. The Resident was started on Paxil on 8/4/23 which was increased from 10 mg to 20 mg on 8/25/23. Resident #307 was discharged from the facility on 10/31/23. On 8/4/23 Resident #24 had an increase in Zoloft from 25 mg to 50 mg. Resident #24 is followed by Mental Health. Resident #24 was seen 7/28/23, 8/4/23, 8/25/23, and 9/8/23 following incident. In all notes the resident is described as engaging well, without agitation or distress. There have been no further changes in this medication. Resident remains stable as to her psychosocial well-being. Staff: The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Con [TRUNCATED]

Based on policy review, job description review, medical record review, and interview, the facility failed to report allegations of abuse to the appropriate agencies for 4 of 20 (Residents #307, #24, #40, and #20) sampled residents reviewed for abuse. The facility's failure to report incidents of abuse to the State Survey Agency resulted in Immediate Jeopardy (IJ) when the facility failed to report allegations of sexual abuse between Resident #24 and Resident #307, and between Resident #20 and Resident #40. Incidents of abuse between Resident #307, who's severely cognitively impaired, and Resident #24, who's moderately cognitively impaired, occurred on 7/20/2023, 7/21/2023 and 8/27/2023. Resident #40, who's severely cognitively impaired, had a history of sexual behaviors towards staff on 10/25/2023 and 10/30/2023. The facility failed to implement effective interventions to prevent abuse of residents following sexual behaviors toward facility staff. On 11/1/2023, Resident #40 was observed in Resident #20's room on 2 different occasions; one incident at 9:45 AM, revealed he had his hand up under resident #20's bed covers, and again at an unknown time Resident #40 had pulled back Resident #20's bed covers and was at the Resident's bedside. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director, the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-609 on 12/19/2023 at 3:48 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM and was validated onsite by the surveyors though medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 and continued through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled Resident Rights, dated 1/2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress .The results of all investigations must be reported to .officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident . Review of the facility policy titled, Consensual Sexual Contact of Residents, dated 9/2022, revealed .It is the policy of this facility to respect the right of residents to express themselves sexually, as long as it does not violate the rights of other residents. This policy applies to individuals who exhibit intact cognitive decision-making capacity . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .Abuse Coordinator .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must .Provide a safe environment and protect resident from .Resident to Resident Abuse of any type .Prohibit and prevent verbal, mental, sexual, or physical abuse .REPORTING AND RESPONSE .Staff will need to stay with the residents to ensure they are safe and protected from further incident .The Nurse in charge will complete an Incident Report .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident . Review of the facility's Executive Director/Chief Operating Officer JOB DESCRIPTION-FACILITY, signed 7/30/2021, revealed .Accepts 7-day/week, 24-hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility .Assure resident safety at all times .Ensures compliance with all Federal, State, and licensure regulations and laws as measured by annual surveys and complaint visits .Review Resident complaints and grievances and make written reports of action taken . 2. On 7/20/2023, Resident #307, a severely cognitively impaired Resident, was observed in the Day Room rubbing Resident #24's exposed breast. On 7/21/2023, Resident #24, a moderately cognitively impaired resident, was observed in the Day Room with her hand down in the front part of Resident #307's pants, and other residents were present. On 8/27/2023, Residents #24 and #307 were observed in the Day Room on camera with their hands in each other's pants. The facility failed to ensure Residents #307 and Resident #24 exhibited intact cognitive decision-making capacity to engage in a sexual relationship. The facility failed to develop and implement effective care plans to monitor the sexual behaviors of Resident #307 and Resident #24, and the facility failed to implement effective interventions to ensure all residents were free of sexual abuse. (a). Review of the closed medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Aphasia, Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, Anxiety Disorder, and Extrapyramidal and Movement Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #307 scored a 4 on his Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of the BIMS assessment dated [DATE] revealed Resident #307 scored a BIMS of 5, which indicated severe cognitive impairment. Review of the annual MDS dated [DATE], revealed Resident #307 scored a 9 on his BIMS assessment, which indicated he was moderately cognitively impaired. Resident #307 was discharged from the facility on 10/31/2023. (b.) Review of medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Hypertension, Hemiplegia, and Aphasia. Review of the Care Plan with a revision date of 3/1/2023, revealed Resident #24 had cognitive loss and dementia with behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored a 12 on the BIMS assessment, which indicated she was moderately cognitively impaired. Review of the PSYCIATRIC PROGRESS NOTE, dated 7/14/2023, revealed Resident #24 exhibited fair insight and judgement and low decision making skills. Review of the BIMS assessment conducted on 7/25/2023, revealed Resident #24 was assessed with a score of 13, which indicated she was cognitively intact. Review of the quarterly MDS dated [DATE] revealed Resident #24 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. (c.) Review of facility records, documentation, and interviews revealed on 7/20/2023, Resident #307 was observed rubbing the exposed breast of Resident #24. The incident occurred in the Day Room. Interviews with Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #3 verified the incident. Review of facility records, documentation, and interviews revealed on 7/21/2023, Resident #24 had her hand down in the front part of Resident #307's pants and when asked by LPN #3 what she was doing Resident #24 stated, Working it. Interviews with LPN #3 verified the incident. Staff and Administrator interviews revealed that a third incident occurred between Resident #24 and Resident #307 in the Day Room on 8/27/2023 and was video recorded on camera. Interviews revealed that both Resident #307 and Resident #24 had their hand in each other's pants. The Executive Director (ED) showed the video footage to staff on 8/28/2023. Review of the medical record revealed there was no documentation that the incident occurred, and there was no documentation that an investigation was completed. The ED verified through interview he did not save the video footage of Resident #307 and Resident #24's incident. The 24-Hour Shift Report Form dated 8/28/2023, documented Resident #307 exhibited inappropriate behaviors with a female resident in the Common Area and the ED was notified. The 24- Hour Shift Report Form dated 8/28/2023, documented Resident #24 exhibited inappropriate behaviors with a male resident and her family was aware of the incident. Interviews with CNA #3 and CAN #8 verified the incident occurred. (d.) During a telephone interview on 12/12/2023 at 4:18 PM, LPN #3 confirmed she observed the sexually inappropriate behaviors between Resident #307 and Resident #24. LPN #3 confirmed the incident when Resident #307 was rubbing Resident #24's breast had occurred on 7/20/2023 and the incident where Resident #24 had her hand in Resident #307's pants had occurred on 7/21/2023. LPN #3 was asked did she know if Administration (ED) reported the incidents to the State and she stated, I know they didn't. During an interview on 12/13/2023 at 8:15 AM, the ED, Clinical Nurse Specialist (CNS), and Director of Social Services presented the former Director of Nursing's (DON) statement and asked to talk to the survey team. The ED stated, We don't feel like you all have the complete picture of the situation [between Resident #24 and Resident #307] .feel like this was a case of attraction to one another . The CNS stated, .These were residents that did not wander into other rooms .it appeared more consensual to us .why we didn't report it or send them out . The CNS stated, There should have been an in-service sign in sheet for any kind of education because that is a policy .she [the former DON] was new and she was still learning. The CNS stated, I didn't feel like it was abuse [reason it was not reported]. The CNS confirmed she was familiar with the federal regulation on abuse and confirmed sexual abuse should be reported to the State Survey Agency. During an interview on 12/14/2023 at 9:15 AM, CNA #3 confirmed she observed Resident #307 touching Resident #24's breast in the Day Room. CNA #3 confirmed she told LPN #3, who was present at the Nurses' Station at the time and stated, [Named Executive Director] was coming down the hall and we told him about it . CNA #3 reported she was aware of another incident that was caught on camera on a Sunday [8/27/2023] when they [staff] were having a potluck. CNA #3 reported that the ED called some staff in the office on the Monday following the day the incident occurred and showed them camera footage from the previous day where Residents #24 and Resident #307 exhibited sexually inappropriate behaviors in the Day Room while staff were eating lunch at the pot luck. (e.) During an interview on 12/12/2023 at 4:43 PM, the ED confirmed the incidents of sexually inappropriate behaviors in the Day Room had occurred between Resident #307 and Resident #24. The ED confirmed the facility investigation was not thorough, witness statements were not obtained, and incident reports were not completed. The ED was asked should the incidents have been reported to the State Survey Agency. The ED stated, If I thought it needed to be reported I would have reported it then. During an interview on 12/19/2023 at 9:11 AM, the ED was asked was he aware of the Federal Regulations and the interpretive guidelines in the regulation regarding sexual abuse. The ED stated, Yes .should be reported . The ED confirmed the facility should have followed State and Federal guidelines for an abuse allegation. The allegations of sexual abuse that occurred on 7/20/2023, 7/21/2023, and 8/27/2023 were not reported to the State Survey Agency, the Ombudsman, or Adult Protective Services (APS). 3. On 10/25/2023 and 10/30/2023, documentation revealed Resident #40, a severely cognitively impaired resident, exhibited sexually inappropriate behaviors towards staff. The facility failed to implement effective interventions to prevent abuse of residents following sexual behaviors toward facility staff. On 11/1/2023, Resident #40 was observed in Resident #20's room on 2 different occasions, once at 9:45 and again at an unknown time, once with his hand under the Resident #20's bed covering and again the same day with Resident #20's bed covers pulled back off of her with him sitting at her bedside. (a.) Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Cerebrovascular Disease, Anxiety, Depression, Hypertension, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #40 scored a 4 on his BIMS assessment, which indicated he was severely cognitively impaired, exhibited no behaviors, and independently propelled himself in a wheelchair. Review of the Care Plan with a revision dated 9/19/2023, revealed Resident #40 had cognitive deficits and a BIMS of 5 which indicated he was severely cognitively impaired. Review of the facility progress notes dated 10/25/2023, and 10/30/2023, revealed Resident #40 had the behaviors of inappropriately touching staff. There was no documentation in the medical record that the facility developed a Care Plan or implemented a plan to monitor Resident #40's behaviors and to protect other residents. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 11/1/2023, revealed .CNA and Administrator reported that resident [Resident #40] noted in another residents [resident's] [Resident #20] room with his hand under the covers. Resident was escorted back to his room by CNA. Review of the medical record and the 24-Hour Shift Report form revealed Resident #40 continued to exhibit inappropriate behaviors with staff members and going in female resident rooms on 11/3/2023 and 11/4/2023. Documentation revealed he was verbally educated on his inappropriate behaviors. Resident #40 had severe cognitive impairment. (b.) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Cerebral Atherosclerosis, Vascular Dementia, Diabetes, and Hypertension. Resident #20 was a hospice patient, had contractures of both upper extremities and her right lower extremity, and was unable to communicate. Review of the Care Plan dated 11/1/2023, revealed Resident #20 had limitations in her ability to communicate her daily care needs, was nonverbal, and had dementia. Record review revealed on 11/1/2023, Resident #40 was observed in Resident #20's room with his hand under the covers that were on top of her. Interviews with CNA #7 verified the incident occurred. On 11/1/2023, Resident #40 was observed in Resident #20's room, sitting by the Resident's bedside and Resident #20's covers had been pulled off of her. Interviews with the Sitter verified the incident occurred. Review of the admission MDS dated [DATE], revealed Resident #20 was rarely/never understood and could not be assessed for a BIMS score. Staff assessment revealed she was moderately impaired for daily decision-making skills. (c.) During an interview on 1/2/2024 at 2:34 PM, CNA #11 confirmed she worked on 11/1/2023, and was not asked to write a statement. CNA #11 was asked was Resident #20 able to yell out or make verbal noise. CNA #11 stated, I've had her once and when we were turning her, she said it hurt. CNA #11 confirmed Resident #20 was not physically able to protect herself from anyone touching her. During an interview on 1/2/2023 at 2:47 PM, the ED was asked could he definitely determine from the staff statements that Resident #40 did not touch Resident #20. The ED stated, I cannot definitely say that. The ED was asked if he had this investigation to do over again what would he do differently. The ED stated, I definitely would dig a little deeper . The ED was asked was an incident report completed following the allegation of Resident #40 in Resident #20's room with his hand under the covers and the ED stated, Probably not, I don't know. The ED confirmed he did not remember who reported the incident to him. The ED was asked did he think that was something that he should keep up with and stated, Yes, you're right. The ED was asked who he reported the incident to. The ED stated, I can't swear to it, but I think we had a call [Corporate] about it. The ED denied that he observed Resident #40 in a female resident's room at any time. The ED was asked when the Sitter who observed Resident #40 pull Resident #20's covers back when should she have been asked to write her statement. The ED stated, That day [11/1/23], the day of occurrence. The ED was asked did he talk to the Sitter on the day of the occurrence [11/1/2023] or on 12/29/2023. The ED stated, I don't know if I talked to her or not .again I should get me a book [to document in]. The ED was asked who he talked to on 12/28/2023 following the survey teams request for the investigation. The ED stated, I know we talked to the Sitter .we talked to more staff because our policy says statements from all staff, so I finished getting statements from them. The ED was asked did he follow the facility's Abuse policy for his investigation into this allegation. The ED stated, No, we didn't investigate like we should have. The ED was asked was this incident reported to the appropriate agencies per the facility policy and the Federal regulation and stated, Probably not. Refer to F600 The following Removal Plan was validated onsite by the surveyors through record review, review of inservice education, assessments and audit review, and interviews with Administration and Staff. This is the facility Allegation of Compliance for the Immediate Jeopardy for F609 Reporting. The facility is alleging the Immediate Jeopardy removed as of 12/27/23. Specific Actions: On 7/21/23 Resident #307 had an increase in medroxyprogesterone from 2.5 mg to 5 mg daily. Resident was followed by Mental Health. Mental Health saw the resident following the incident on7/21/23, 7/28/23, 8/4/23, 8/11/23, 8/5/23, and 9/21/23. There were no further changes in this medication during the rest of the residents' stay at the facility. The Resident was started on Paxil on 8/4/23 which was increased from 10 mg to 20 mg on 8/25/23. Resident #307 was discharged from the facility on 10/31/23. On 8/4/23 Resident #24 had an increase in Zoloft from 25 mg to 50 mg. Resident #24 is followed by Mental Health. Resident #24 was seen 7/28/23, 8/4/23, 8/25/23, and 9/8/23 following incident. In all notes the resident is described as engaging well, without agitation or distress. There have been no further changes in this medication. Resident remains stable as to her psychosocial well-being. Staff: The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. Education emphasized to the Executive Director reporting to the required state and federal agencies to meet the reporting regulations. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. Staff will redirect residents engaging in intimacy and/or sexual expression in public. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). Staff should immediately report suspected sexual abuse to immediate supervisor. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant. Allegations of abuse will be submitted in a timely manner to meet initial reporting regulations. The allegation will be thoroughly investigated by the Executive Director and appropriate management team members. Upon completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will ensure that the Consulting Staff are contacted immediately upon notification of any allegation of abuse so that reporting and investigating regulations will be met and conducted timely. There are no staff currently on leave of absence. Agency staff working on 12/19/23 and 12/20/23 were included in the staff education. Any agency staff that are assigned to work that have not received the education provided on 12/19/23 and 12/20/23 will be provided with education on the abuse policy and consensual sexual contact prior to reporting to the assigned nursing unit. This education will be provided by either the Director of Nursing or Assistant Director of Nursing. Newly hired staff will be educated on the abuse policy and consensual sexual contact policy during the new hire paperwork which is done prior to working in the department they have been hired for. No staff member will be able to work prior to receiving the education on abuse and consensual sexual contact. Further investigation for other potential allegations of abuse: Current Residents with a BIMS score of ?8 were interviewed by the Director of Nursing, Social Services Director and the Nursing Consultant. The interviews were completed by 12/20/23. The results showed that no further incidents of inappropriate sexual contact occurred. Current Residents with a BIMS score of <8 were assessed using an Emotional Change Assessment by the Director of Nursing. The results noted no emotional changes observed. All current staff were interviewed by the Assistant Director of Nursing regarding any observations of residents having inappropriate sexual contact with each other. The results showed there were no new incidents of inappropriate sexual contact. Training: The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. Staff will redirect residents engaging in intimacy and/or sexual expression in public. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). Staff should immediately report suspected sexual abuse to immediate supervisor. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant.

Based on policy review, facility investigation forms, medical record review, and interview, the facility failed to ensure residents' right to be free from abuse for 4 of 20 (Resident #20, #24, #40, and #307) sampled residents reviewed for abuse. The facility's failure to ensure residents' right to be free from abuse resulted in Immediate Jeopardy (IJ) when on 7/20/2023, Resident #307 who's a severely cognitively impaired resident was observed in the Day Room rubbing the exposed breast of Resident #24, on 7/21/2022, when Resident #24 who's a moderately cognitively impaired resident was observed in the Day Room with her hand in the front of Resident #307's pants where other residents were present, and on 8/27/2023, when Residents #307 and #24 were observed with their hands in each other's pants with this incident captured on camera. The facility failed to place either resident on one-on-one monitoring, or document increased monitoring of the residents to ensure no other incidents occurred between the residents, and to ensure other residents were protected from sexual abuse. On 10/25/2023 and 10/30/2023, documentation revealed Resident #40, a severely cognitively impaired resident, was inappropriately touching female staff members. The facility failed to implement interventions for Resident #40 to prevent sexual abuse of residents, after the incidents with staff. On 11/1/2023, Resident #40 was observed in Resident #20's room on 2 different occasions, once at 9:45 AM and again an unknown time, once with his hand under the blanket covering Resident #20 and the other time with Resident #20's covers thrown back. Resident #20 was assessed by facility staff to be moderately cognitively impaired. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director, the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-600 on 12/19/2023 at 3:48 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM, and was validated onsite by the surveyors through medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility policy titled Resident Rights, dated 1/2014, revealed .Resident Rights are not just philosophical, moral, or ethical principles that should guide nursing facility staff in their interactions with Residents. Resident Rights are .rights .that must be afforded a Resident during his/her stay in this facility .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress .The results of all investigations must be reported to .officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident . Review of the facility policy titled, Consensual Sexual Contact of Residents, dated 9/2022, revealed .It is the policy of this facility to respect the right of residents to express themselves sexually, as long as it does not violate the rights of other residents. This policy applies to individuals who exhibit intact cognitive decision-making capacity .social services staff will educate the resident about any disease processes and the residents' rights .Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/or sexual expression .The physician, as well as Mental Health Services Provider, will be notified regarding all residents that desire to participate in sexual activity for a clinical and cognitive evaluation to determine intact cognitive decision-making capacity and capacity to give consent .The decision to conduct a cognitive re-assessment will be made by the interdisciplinary team and based upon noticing a change in a resident's behavior or demeanor .Care Plan meetings with the interdisciplinary team shall be scheduled as soon as possible for initial notification of the social services staff .The interdisciplinary team shall conduct a review of situations and accounts of sexual expression among or between residents .to determine a solution that best meets the needs of and protects those involved .Outcomes of the Interdisciplinary team review will be shared with the residents involved and documented in the plan of care .Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault, and who to contact to report any issues .The facility shall provide initial staff orientation and ongoing staff training regarding abuse, intimacy and/or sexual expression as well as sensitivity awareness about residents' sexual rights and staff documenting and reporting responsibilities .The facility shall obtain consultation regarding intimacy and/or sexual expression in cases that are deemed complex or controversial . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .Abuse Coordinator .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must .Provide a safe environment and protect resident from .Resident to Resident Abuse of any type .Prohibit and prevent verbal, mental, sexual, or physical abuse .PREVENTION .The facility will consider utilization of the following for prevention of abuse .Train staff In appropriate interventions .Observe resident behavior .Observation of resident for any sudden or unexplained change in behavior or attitude .Respond to all allegations or questions about abuse from a resident, family member, employee or visitor taking all comments seriously .Take appropriate action when any type of abuse is suspected .Identify areas of the physical environment that may make abuse or neglect more likely to occur, such as a secluded area for resident care .Assess resident characteristics or needs that might lead to conflict or abuse/neglect, such as residents with history of abusive or aggressive behaviors .inappropriate sexual behavior .Develop appropriate plans of care for residents with these characteristics .IDENTIFICATION .The facility will consider and train staff on identifying factors indicating possible abuse .INVESTIGATION .Initiate an immediate Investigation into the Allegation of Abuse, neglect, or exploitation .Interview the resident involved in the allegation if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses .Interview the resident's family, responsible party, or the individual involved in the resident's care to identify any information they may have related to the allegation .Interview staff members that were on duty during time of the allegation to identify any concerns or unusual actions by the accused .All interviews should be written by the person being interviewed if possible, on the Witness Explanation of Incident Form AD-29A [Witness Explanation of Incident Form] .and signed and dated .Review the resident's medical record for any changes in condition .A summary of the investigation will be documented on form AD-29 [Resident Abuse Investigation Report] to include whether or not the allegation of Abuse is substantiated or unsubstantiated and any corrective action necessary .PROTECTION .The facility will respond immediately to any allegations of abuse, neglect or exploitation of a resident to protect the alleged victim as well as other residents while also protecting the integrity of the investigation .The assigned nurse will examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. The attending physician and behavioral health services will be notified to also assess the alleged victim as necessary .Increased supervision of the alleged victim and residents .REPORTING AND RESPONSE .Staff will need to stay with the residents to ensure they are safe and protected from further incident .The Nurse in charge will complete an Incident Report .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident. Summarizing all findings and any corrective actions needed on form AD-29 .Define how care and services will be changed and /or improved to protect residents .Update resident care plan as appropriate based on any needs or preferences as a result of the allegation .Determine any additional training for staff on any changes made .Determine any system changes necessary and revise policies and procedures accordingly .The Abuse Coordinator will review any changes with systems to the QAPI [Quality Assurance Performance Improvement] Committee and evaluate for effectiveness . Review of a blank Form AD-29 titled, Resident Abuse Investigation Report, revealed .Completed form is to be filed with the Accident/Incident reports and a copy provided to the Administrator [Executive Director] within 24 hours of the incident. The form included a way to thoroughly document the investigation of an allegation of abuse. Review of a blank Form AF-29A titled, Witness Explanation of Incident, revealed .Resident involved .Clearly document, in your own words, your involvement related to the incident. If the incident was not observed by you, or you were not involved in the incident, explain your knowledge of the incident .Include dates, times and exact quotes if available in explanation . 2. Medical record review and interview revealed 3 sexual abuse incidents occurred between Residents #307 and #24 on 7/20/2023, 7/21/2023, and 8/27/2023. On 7/20/2023, Resident #307 (severely cognitively impaired) was observed in the Day Room rubbing the exposed breast of Resident #24 (who's moderately cognitively impaired). On 7/21/2022, Resident #24 was observed in the Day Room with her hand in the front of Resident #307's pants. On 8/27/2023, Residents #307 and #24 had their hands in each other's pants. (a). Review of the closed medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Aphasia, Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, Anxiety Disorder, and Extrapyramidal and Movement Disorder. Review of the referral packet sent to the facility prior to Resident #307's admission revealed a Medication Review Report dated 12/15/2022, .Medroxyprogesterone Acetate [a medication that when administered in males it lowers testosterone levels, lowering sexual drive without causing feminization] .give 2.5 mg [milligrams] by mouth one time a day related to BIPOLAR DISORDER . Review of the PHYSICIAN ORDERS, dated 12/29/2022, revealed .Medroxyprogesterone .2.5 mg .one time daily .Bipolar Disorder . Review of the (Named Clinic) Nurse Practitioner (NP) Progress Note dated 2/23/2023, revealed .History of Present Illness .MEDROXYPROGESTERONE, PRESUMABLY FOR SOME TYPE OF IMPULSE CONTROL ISSUES .POTENTIALLY BEING USED APPARENTLY FOR POSSIBLE SEXUAL ACTING OUT IN THE PAST . Review of the BIMS assessment dated [DATE], revealed Resident #307 scored a BIMS of 02, which indicated he was severely cognitively impaired. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #307 scored a 04 on his Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired, exhibited no behaviors, and was dependent on staff for locomotion on and off the unit. Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/7/2023, revealed .KNOWLEDGE .POOR .JUDGEMENT .POOR .ORIENTATION .PARTIALLY .Self [oriented to self only] .ABNORMAL . Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/17/2023, revealed .KNOWLEDGE .POOR .JUDGEMENT .POOR .MOOD/AFFECT .LABILE .ATTENTION/CONCENTRATION .IMPAIRED . Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/21/2023 (for an incident that occurred on 7/20/2023), revealed .Resident [Resident #307] observed rubbing a female residents' [resident's] breast [resident #24]. Stated she asked him to. Separated resident from female resident and resident was to be under observation . There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and resident #24's sexual behaviors in accordance with the facility policy. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/21/2023, revealed .Resident was seen by Psych today and was prescribed medroxyprogesterone 5mg everyday [every day] for sexual behavior towards others . Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/21/2023, revealed .Patient examined to follow up secondary to recent sexual disinhibitions . Exhibits remote and recent impairment .Will redirect based on neuropsychiatric features, as sexual disinhibitions appear to be increasing .MEDICATION . Medroxyprogesterone .Increase 5 mg q [every] day sexual disinhibitions . Review of the medical record revealed Resident #307 was not assessed by facility staff to have the capacity to give consent to participate in sexual relations with Resident #24, there was no documentation that he was educated on disease processes by Social Services staff, and there was no documentation that consults were performed by the Medical Director and Mental Health Services Provider to determine if Resident #307 had the capacity to give consent to consensual sex per the facility's policy. Review of the PHYSICIAN ORDERS, dated 7/21/2023, revealed .Medroxyprogesterone .5 mg . One time daily .for sexual disinhibitions . There was no documentation in Resident #307's medical record of the 7/21/2023 incident where Resident #24 hand her hands down in the front of Resident #307's pants. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/24/2023, revealed .Sw [Social Worker] notified by staff of sexual encounter resident has had with a female resident. Nursing staff reported to sw this occurred in the day room just off the nurse's station. Mental health services are seeing him and NP with psych services visited resident Friday morning and therapist will be here this week to meet with him to explore this further since his BIMS is a low score. There have been no noted encounters since 7/21/23 . Review of the facility investigation dated 7/24/2023, revealed a typed statement from the Executive Director, progress notes for Resident #307 dated 7/14/2023 through 7/25/2023, a Psychiatric Progress Note for Resident #307 dated 7/28/2023, and a Psychiatric Progress Note for Resident #24 dated 7/28/2023. There was not a Form AD-29, no witness statements, no resident assessments, and no resident interviews included in the facility investigation. Review of the Executive Director's typed statement dated 7/24/2023, revealed . [Named Resident #307 was admitted to our facility on 12/29/2022 .has a BIMS of 2 . [Named Resident #24] was admitted to our facility on 5/17/2022 .has a BIMS of 12 .On 7/21/2023, [Named Resident #307] was observed rubbing [Named Resident #24] breast in the day room, which he stated that [Named Resident #24] asked him to rub her breast. [Named Resident #307] was removed from the day room and was referred to psych for behaviors. His behavior is being monitored by staff .On 7/24/2023, [Named Resident #24] was observed by staff with her hand down [Named Resident #307] pants while they were in the day room. [Named Resident #24] was taken to her room and separated from [Named Resident #307]. I spoke with [Named Resident #24] today and explained to her the consequences that potentially could occur if we allowed this behavior to continue. I explained to her that the other resident involved does not have the mental capacity to consent to inappropriate contact. I explained that if the male resident started to make his way over to her that she is to notify staff. It is confirmed that this behavior has only taken place in the day room and not behind closed doors. Neither resident has made attempts to enter one another's room . [Named Resident #24] demonstrated verbal understanding of the situation . There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and Resident #24's sexual behaviors in accordance with the facility policy. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/25/2023, revealed .Resident has been receiving medroxyprogestrone [medroxyprogesterone] for 4 days for having sexual behaviors with [Named Resident#24]. Tolerated well with no s/s [signs or symptoms] of adverse reactions noted. Resident has not had and [any further] sexual behaviors or interaction with resident [Named Resident #24]. There was no documentation the facility developed and implemented a care plan to monitor Resident #307 for these behaviors. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/25/2023, revealed .Sw [Social Worker] visited resident and he agreed to participate in BIMS assessment and scored a 5. He was in good spirits and sw asked if he recalled the events from last week and he initially reflected a puzzled expression, but soon after gasped, smiled and said, oh yeah. Sw attempted to explore this to determine what he was recalling, and he smiled and said, I don't need to tell all of it. Sw asked if he feels uncomfortable about anything, and he said no and sw asked if he feels safe in this facility and he smiled and said yes. Sw will continue to visit and observe for signs of maladaptive behavior. Review of the Care Plan for Resident #307 with a revision date of 7/26/2023, revealed .Behavior-I am at risk and I have an active behavior Problem: Sexually inappropriate . The Care Plan did not reflect Resident #307 received Medroxyprogesterone daily since admission for sexual acting out that was documented 2/2/2023, or the sexually inappropriate behaviors that occurred between Resident #307 and #24 on 7/20/2023, 7/21/2023, and 8/27/2023, or the intervention to monitor Resident #307 more closely or to keep Resident #307 and #24 separated. Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/28/2023, revealed .Pt [Resident #307] denies any relationship with resident [Resident #24]. Pt unable to comprehend questions .appears to be unaffected by incident . Review of the annual MDS dated [DATE], revealed Resident #307 scored a 9 on his BIMS assessment, which indicated he was moderately cognitively impaired, exhibited no behaviors, and required staff supervision with setup help only for locomotion on and off of the unit. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 8/27/2032 at 2:31 PM, revealed .Resident [Resident #307] at nurses station in w/c [wheelchair]. All of a sudden resident began speaking loud to writer and another nurse seated at nurses station. Yelling with garbled speech about state troopers, FBI [Federal Bureau of Investigation], and that someone had taken his w/c this morning. Started speaking really loud, became very angry, stood up and started walking toward other nurse with fist balled up. Other nurse stood up, started speaking to resident in a really calm, low-toned voice trying to convince resident to not hit her. Nurse placed her hands over resident's hands and asked him to please calm down several times. Resident appeared to calm down after that. Writer and other nurse persuaded resident to sit back down in w/c. other nurse on the phone notifying family and resident began speaking really loudly again and stating that he didn't do what nurse was notifying family of. Family member could hear resident yelling while nurse was on the phone. Resident calmed down after family came to visit. In hallway in w/c talking to other residents . Review of the 24 HOURS SHIFT REPORT, (for a behavior that occurred on 8/27/2023) dated 8/28/2023, revealed . [Named Resident #307] Behaviors today-Family made aware- [Named Executive Director who was Resident #307's nephew] Inappropriate behavior in common area [Day Room] w [with]/female resident [Resident #24] . There was no documentation of the time this incident occurred. Record review revealed there was no documentation in Resident #307's medical record that the sexually inappropriate incident occurred on 8/27/2023. The camera footage for the incident was not saved, and there was no documentation that an investigation was completed. Staff interviews revealed the third incident that occurred between Resident #307 and #24 in the Day Room on 8/27/2023 and was caught on camera. Further interviews revealed that each resident had their hand in the other resident's pants and the Executive Director showed the footage to staff on 8/28/2023. Review of the Time Detail Report, dated 8/27/2023, revealed CNA #3, CNA #8, Licensed Practical Nurse (LPN) #4, and LPN #8 all worked the day the third sexually inappropriate incident was alleged to occur between Resident #24 and #307. Review of the 24 HOURS SHIFT REPORT, dated 8/28/2023, revealed . [Named Resident #307] Going to [Named Geri-psych hospital] tomorrow . There was no documentation the resident's behaviors were monitored prior to being sent out to the psychiatric hospital. Review of the Census Activity Report for Resident #307 revealed he was discharged from the facility on 8/30/2023. Review of the [Named Psychiatric Hospital] Admission Record for Resident #307 dated 8/30/2023, .MEDROXYPROGESTERONE .5 MG ORAL TABLET 1 Tablet Daily .Sexually inappropriate/Hypersexual . (b). Review of the medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Hypertension, Hemiplegia, and Aphasia. Review of the Care Plan with a revision date of 3/1/2023, revealed .I [Resident #24] have cognitive loss due to confusion and forgetfulness. I have dementia with behaviors . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #24 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired, exhibited no behaviors, required staff assistance for all activities of daily living (ADLs), and was always incontinent of bowel and bladder. Review of the PSYCIATRIC PROGRESS NOTE, dated 7/14/2023, revealed Resident #24 exhibited fair insight and judgement and low decision making skills. There was no documentation in Resident #24's medical record of the 7/20/2023 incident where Resident #307 was rubbing Resident #24's exposed breast. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/22/2023, revealed .LATE ENTRY FOR 07/21/2023 17:25 [5:25 PM] .Resident [Resident #24] observed putting her hand down in another residents [resident's] pants [Resident #307's pants]. When asked what she was doing, Resident stated, working it Resident was taken to her room to separate her from the other male resident [Resident #307]. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/24/2023, revealed .Sw [Social Worker] notified by staff of sexual encounter resident [Resident #24] has had with a male resident [Resident #307]. Nursing staff reported to sw this occurred in the day room just off the nurse's station. Mental health services are seeing her and therapist will be here this week to meet with her to explore this .She is not reporting any concerns related to this event. There have been no noted encounters since 7/21/2023 . Review of Resident #24's medical record revealed an incident report was not completed following the incident of inappropriate sexual contact and Resident #24 was not evaluated by psych services until 7/28/2023, which was 8 days following the sexually inappropriate incident on 7/20/2023. Review of the Care Plan with a revision date of 7/24/2023, revealed .I [Resident #24] have an active behavior problem: Sexually inappropriate aeb [as evidenced by] asking male resident to touch her breast and attempting to touch male resident inappropriately . The Care Plan did not include interventions to monitor Resident #24 more closely or to keep Resident #24 and #307 separated. Review of the medical record revealed Resident #24 was not assessed by facility staff to have the capacity to give consent to participate in sexual relations with Resident #307, there was no documentation that she was educated on disease processes by Social Services staff, and there was no documentation that consults were performed by the Medical Director and Mental Health Services Provider to determine if Resident #24 had the capacity to give consent to consensual sex per the facility's policy. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/25/2023 revealed, Sw visited resident [Resident #24] .she agreed to participate in BIMS assessment and scored a 13 . The Resident's BIMS score of 13 indicated the Resident was cognitively intact. Review of the PSYCIATRIC PROGRESS NOTE, dated 7/28/2023, revealed .Pt [patient] [Resident #24] denies relationship with resident [ Resident #307] .didn't express any distress .didn't recall any touching or being touched . KNOWLEDGE .POOR .JUDGEMENT/INSIGHT .FAIR .DECISION MAKING SKILLS/RISK .LOW . Review of the quarterly MDS dated [DATE], revealed Resident #24 scored a 13 on the BIMS assessment, which indicated she was cognitively intact, exhibited no behaviors, required staff assistance for all ADLs, and was always incontinent of bowel and bladder. Review of the Social .Behavioral Health Review, dated 7/31/2023, revealed .Behavior Change .Noted recently with inappropriate sexual behavior toward another resident in a public area .There have been no noted psych med changes since May of this year [2023] .Was a new medication started or medication dosage changed . [box checked] No . Was a new non-medication intervention started . [box checked] No . Review of the PSYCHIATRIC PROGRESS NOTE, dated 8/4/2023, revealed .reported w/potential sexual disinhibitions. Will recommend to titrate SSRI [medication used to treat depression] and redirect based on clinical course . Staff interviews revealed that a third incident occurred between Resident #24 and #307 in the Day Room on 8/27/2023 and was caught on camera. Interviews revealed that each resident had their hand in the other resident's pants and the Executive Director showed the footage to staff on 8/28/2023. Review of Resident #24's medical record revealed there was no documentation that the incident occurred, the camera footage was not saved, and there was no documentation that an investigation was completed. Review of the 24 HOURS SHIFT REPORT, dated 8/28/2023, revealed . [Named Resident #24] Inappropriate behavior w/male resident Family aware of resident's behavior . Review of the annual MDS dated [DATE], revealed Resident #24 had a BIMS score of 12, exhibited no behaviors, was dependent on staff for all ADLs, and was frequently incontinent of bladder and always incontinent of bowel. Observation on 12/11/2023 at 1:44 PM, revealed Resident #24 reclined in a Broda (customizable wheelchair that eliminates slipping and slouching and makes transfers safe for staff and residents) chair in the Day Room in front of the television and was awake and alert. Resident #24 did not respond when spoken to. Observation on 12/12/2023 at 7:26 AM, revealed Resident #24 sat in a Broda chair at her bedside and fed herself breakfast using her right hand. Resident #24 only nodded when spoken to and did not respond verbally. Review of an email from the former Director of Nursing (DON) dated 12/12/2023, revealed Upon learning of the interaction between [Named Resident #307 and Resident #24], the Administrator [Executive Director] .and myself went to the nurse's station and met with nurses and CNAs [certified nursing assistants]. They were instructed to separate residents and to monitor the residents and document any behaviors noted. We also spoke with [Named Resident #307] regarding behaviors and the importance of not putting his hands on other resident. He stated his understanding. Numerous attempts were made to call the former DON, but she did not return the calls. There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and Resident #24's sexual behaviors in accordance with the facility policy. Review of an email signed by the Psychiatric Nurse Practitioner and dated 12/13/2023, revealed .The past occurrence of residents [Named Resident #24 and Resident #307] that took place July 2023 is suggestive of a consensual event. Both parties have medical and mental health diagnoses that can induce sexual inhibitions. Both parties yielded no psychological post event. Residents involved have the ability and capacity to refuse advances, whether sexual or physical, of other parties at a given time. Review of a typewritten statement signed by the Assistant Director of Nursing (ADON) dated 12/13/2023, revealed .I have taken care of [Named Resident #307] and [Named Resident #24]. In my professional opinion the incident that happened on July 20th had to be consensual . Review of an email provided from the facility's Medical Director and dated 12/13/2023, revealed .This email is to respond to a situation between two patients [Resident #24 and Resident #307] in July 2023, at [Named facility]. The first patient was [Named Resident #307], who was a very difficult patient from a medical standpoint and had to be sent to Geripsych units on more than one occasion for behaviors. he [Resident #307] was very difficult to assess because after you've been around him multiple times you understand that he comprehends what is going on around him although he's unable to articulate things correctly . [Named Resident #307] approached [Named Resident #24]. She was not mobile, and he was mobile in his wheelchair. He began to touch her .they were immediately separated . [Named Resident #307] approached her again on his own free will, this is apparently when [Named Resident #24] began touching him back. This is seen in nursing home situations and it's difficult to police. When she began touching him, he did not attempt to get away from her .He had the ability to get away if he wanted to since he's fully mobile in a wheelchair. From both myself, and my nurse practitioner, it was clear that [Named Resident #307] was not upset about the situation and that he even smiled about it and reported 'no' when asked if he felt unc[TRUNCATED]

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of accident hazards when the facility failed to ensure fall intervnetions were implemented for 2 of 4 (Resident #17 and Resident #305) reviewed for falls. The findings include: 1. Review of the facility's, Fall Program Guide revealed, .Note what footwear .wearing .or lack of footwear .environmental contributions .determine root cause .Documentation .assessment findings .interventions in place .Complete incident report .Complete Post-Fall Assessment .Update the care plan with new intervention .Update the Kardex/C.N.A [Certified Nursing Assessment] .with new intervention . Review of the facility's policy titled Fall Prevention Program dated 4/2023, revealed .provide guidelines for fall and repeat fall preventive interventions .Procedure .Update the Fall Risk Assessment with each fall .quarterly review .change in residents status .Be sure bed is in lowest position .teaching should be documented on patient teaching sheet .Document the fall risk measures in the resident care plan .When fall occurs .Conduct a physical assessment .Complete an incident report .Notify .responsible party, and family .Complete the Post Fall Evaluation form .Document in the medical record . 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Major Depressive Disorder, Diabetes, Congestive Heart Failure and History of Falls. Review of the Care Plan dated 7/28/2023, revealed, .I may fall because I have dementia, I require assistance with ADL's [Activities of Daily Living], take psychotropic medications .Interventions .Help me remain safe by providing any necessary items that will help me not to fall and help me understand how to use them .bed in lowest position. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #17 was unable to complete a Brief Interview for Mental Status (BIMS) interview and staff assessed the her to have moderate cognitive impairment. Resident needed maximum assistance for ADLs. Review of the significant change MDS dated [DATE], revealed Resident #17 was unable to complete a BIMS interview and staff assessed her to have moderate cognitive impairment. Resident had a fall in the last month, with fracture in the last 6 months, had major surgery, repair of leg. Review of the Progress Notes dated 9/23/2023, revealed, .upon entering room found Resident on floor at bedside calling for help .Left arm pain reported by Resident. Right knee pain reported by Resident .No injuries noted .Resident given PRN [as needed] pain medication noted .STAT [Immediately] XRay [Radiologic Study] ordered by NP [Nurse Practitioner] this morning as a follow up post fall revealed acute fracture to distal humorous [humerus] with soft tissue swelling and joint effusion. NP notified of results, nurse instructed to send resident to ER [emergency room ] for ortho [orthopedic] consult and acute care. RP [Responsible Party] contacted . Review of the September 2023 Medication Record (MR) revealed there were no as needed (PRN) medications administered for pain as indicated in the progress note. Observations in the resident's room on 12/13/2023 at 8:20 AM, 12/19/2023 at 2:32 PM, and 12/20/2023 at 3:47 PM, revealed the bed was not in the lowest position. During an interview on 12/19/2023 at 2:32 PM, the Director of Nursing (DON) confirmed Resident #17's bed should be in lowest position. Observation and interview in the resident's room on 12/20/2023 at 8:20 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #17's bed was not in the lowest position. During a telephone interview on 12/20/2023 at 12:10 PM, Licensed Practical Nurse (LPN) #11 stated, .the bed was super high . 3. Review of medical record revealed Resident #305 was admitted to the facility on [DATE], with diagnoses of Intrahepatic Bile Duct Carcinoma, Anxiety, Hypothyroidism, Atrial Fibrillation, Hypertension and Depression. Review of Care Plan dated 4/29/2023, revealed, .Problem .I may fall because I am weak .Interventions .help me when I need assistance with standing and moving from one place to the next . Review of the admission MDS dated [DATE], revealed Resident #305 had a BIMS score of 12 which indicated he was moderately cognitively impaired. Review of the Progress Notes dated 5/28/2023, revealed .Resident is showing signs of increased confusion and increased weakness. Resident is trying to get out of bed without assistances. Resident is now full assist with 2+ [plus] person . Review of the medical record revealed on 5/22/2023, Resident #305 weighed 355.8 pounds. Review of the DOCUMENTATION AND PRN RESULTS REPORT, dated 5/30/2023, revealed .Weekly Head to Toe Skin Check-Document current skin .RESULTS .bruising from recent fall . Review of the Hospice Notes dated 6/1/2023, revealed .Pt [patient - Resident #305] has multiple bruising noted to BUE [Bilateral Upper Extremity] from recent fall including skin tear to left forearm with foam dressing D/I [dry/intact] . During a telephone interview on 12/19/2023 at 8:11 AM, Family Member #3 stated, .I was not told about this .until the afternoon [the next day] .I know the CNAs[Certified Nursing Assistant] .told me he had fallen out of bed .the nurse lied .said they were helping him down .have pictures of a glass broken .he was overweight .he was trying to go to the bathroom . During a telephone interview on 12/21/2023 at 11:42 AM, LPN #10 stated, .he was sitting on the side of the bed and he was trying to get up .I'm a 120 pounds .he sat himself in the floor .we tried to assist him back to the bed .[the] CNA said you were supposed to call EMS [Emergency Medical Services] to get them up .I am pretty sure they reported it .I didn't . During a telephone interview on 12/28/2023 at 10:16 AM, LPN #9 stated, .I do remember working that night .he was not my patient and I do remember them calling EMS for him .he was a very large man and too much for them to pick up .he did fall . During an interview on 12/28/2023 at 10:35 AM, CNA #13 stated, .I went in there to help lift him, we weren't able to get him up .that [that's] why we got the nurse and said we are going to need EMS .he was in sitting position in the floor .he was at the foot of the bed . During a telephone interview on 1/2/2024 at 12:14 PM, Registered Nurse (RN) Hospice #1 stated, I do remember him .he was a very big man and he had a lot of edema .I only recall the one fall, he would try to get up by himself .he had a walker .not 100% [percent] sure .what was reported by the daughter .not by the facility . During a telephone interview on 12/28/2023 at 10:50 AM, CNA #12 stated, .I do remember another aide went down there .doing her rounds and she went in and found him hanging off the bed barely and she came and got me to help .we tried to get him in the bed and eventually .he came off into the floor and one of us stood with him to get some help because both of us couldn't do it .went and got nurse . we couldn't get him off the floor and had to call EMS .they came with the sliding board and it took all of us to get him back in the bed .he was kinda [kind of] confused .he was real heavy .don't know if anyone called the family .I was told the nurse was going to do it .there were a lot of shift key [agency staff] in the building . CNA #12 confirmed she didn't write a statement about the incident. During an interview on 1/2/2024 at 1:53 PM, the DON stated, .I never met this person .but by looking at his weight .would have taken outside agencies to come out to help .big fell ow .family called hospice said he fell .I couldn't find any evidence that he fell . The DON confirmed nurses should have charted in the chart if EMS or any outside agencies had come to the facility to get him off the floor and put him back into bed and stated, If they change planes, it's still a fall .should have done incident report .notified the physician .assess the resident .injuries .pain .notified the family . During an interview on 1/2/2024 at 7:03 PM, the Executive Director confirmed falls and all incidents should be reported, investigated, incident report, physician and family notified.

Based on policy review, medical record review, observation and interview, the facility failed to implement comprehensive care plans for 8 of 13 sampled residents (Resident #1, #6, #17, #29, #38, #306, #307, and #354) reviewed for care planning. The findings include: 1. Review of the facility's policy titled, Care Plans dated 8/2022, revealed, .Identify needs .thorough assessment .comprehensive care plan is developed .Resident Assessment (MDS) [Minimum Data Set] . reviewed at least quarterly .significant change .Care Plan .reflect the following .updated as changes occur . Review of the facility's policy titled Resident Responsible Party Notification dated 4/2017, revealed .significant change .major change in . status .requires interdisciplinary .revision of the .care plan . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Congestive heart Failure, Chronic Obstructive Pulmonary Disease, Cerebrovascular Disease, Diabetes, Hypertension, and Seizures. Review of the quarterly MDS dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Review of the Care Plan dated 2/12/2023, revealed Resident #1 was care planned to have relief from pain/discomfort and staff were to administer medications as ordered. Review of the Medication Record (MR) revealed that Resident #1 missed two doses of pain medication on 12/16/2023 and one dose on 12/17/2023. During an interview on 12/28/2023 at 11:28 AM, the Director of Nursing (DON) confirmed care plans should be followed. 3. Closed medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Major Depressive Disorder and Generalized Anxiety Disorder. Review of a quarterly MDS dated [DATE], revealed Resident #6 was unable to complete the BIMS interview and staff assessed her to be moderately impaired for daily decision making skills. Review of the Comprehensive Care Plan dated 4/27/2023, revealed Resident #6 was care planned for behaviors such as disrobing, altered mood, Schizophrenia, and Bipolar Disorder. During further review, the resident was not care planned for being part of the behavior program and monitoring. During an interview on 1/2/2024 at 4:26 PM, the Social Service Director confirmed that behavior monitoring should be on the care plan. 4. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Major Depressive Disorder, Diabetes, Congestive Heart Failure and History of Falls. Review of the significant change MDS dated [DATE], revealed Resident #17 was unable to complete a BIMS assessment and staff assessed her with moderate cognitive impairment. Review of the Care Plan with a revision date of 9/23/2023, revealed Resident #17's bed was to be in the lowest position. Observations in the resident's room on 12/13/2023 at 3:47 PM, 12/19/2023 at 2:15 PM, and 12/20/2023 at 8:20 AM, revealed Resident #17's bed was not in lowest position. During an interview on 12/19/2023 at 2:32 PM, the DON confirmed the bed should be in lowest position if on the care plan. During and observation and interview on 12/20/2023 at 8:20 AM, Licensed Practical Nurse (LPN) #1 was asked if Resident #17's bed was in the lowest position, LPN #1 confirmed the bed was not in the lowest position. 5. Review of medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Chronic Obstructive Pulmonary Disease, Heart Failure, Pain, Dysphagia and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE] revealed Resident #29 was unable to complete a BIMS interview and staff assessed Resident #29 with severe cognitive impairment. Resident #29 had moderate hearing difficulty and used a hearing aid. Review of Resident #29's Comprehensive Care Plan revealed he was not care planned for a hearing aid. During an interview on 12/18/2023 at 3:17 PM, the DON confirmed Resident #29 should have been care planed for hearing aids. 6. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses of Dementia, Hypertension, Transient Ischemic Attack, Hypothyroidism, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #38 had a BIMS score of 3, which indicated she had severe cognitive impairment. Review of the nursing progress note dated 12/19/2023, revealed .Resident [Resident #38] moved to [other room] as roommate was noted to be throwing items in the room .resident said she could not sleep [because of her roommate] . The facility failed to implement a care plan for the 12/19/2023 behavior incident. 7. Review of the medical record review revealed Resident #306 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Diabetes, Dementia, Pleural Effusion, Acute Pulmonary Edema, and Congestive Heart Failure. Review of the quarterly MDS dated [DATE] revealed Resident #306 had a BIMS score of 15, which indicated she was cognitively intact. Review of the Care Plan dated 2/20/2023 revealed, .Problem .risk fluid and electrolyte imbalance r/t [related to] use of diuretics .Interventions .Administer medications as ordered .Problem .risk for pain r/t medical comorbidities .Interventions .Staff to administer me medications as ordered .Problem .risk for complications r/t respiratory diagnoses COPD [Chronic Obstructive Pulmonary Disease], allergies, bronchitis .11/19/22[2022] .Administer medications as ordered . Review of the February 2023 MR, revealed on 2/9/2023 the Lorazepam (treatment of anxiety), Atorvastatin (treatment for high Cholesterol), Morphine (used for pain), Melatonin (sleep aid), Lisinopril (treatment for high blood pressure), Flavoxate (used for urinary incontinence), Colace (used for constipation), Ferrous Sulfate (iron deficiency) were not administered as prescribed. On 2/27/2023 Guaifenesin (cough medication) was not administered as prescribed. Review of the 2023 March MR, revealed on 3/5/2023 the nasal spray and guaifenesin were not administered as prescribed. On 3/7/2023 Guaifenesin was not administered as prescribed. On 3/17/2023 and 3/30/2023 blood glucose was not done as ordered. On 3/18/2023 Fluticasone (allergy medication) was not administered as prescribed. On 3/18/2023 and 3/19/2023 Senna Docusate (stool softener) was not administered as prescribed. Review of the April 2023 MR, revealed on 4/1/2023 the Oxycodone (pain medication) were not administered as prescribed. On 4/11/2023 the Albuterol (used to treat wheezing) was not administered as prescribed. Review of the May 2023 MR, revealed on 5/2/2023 and 5/5/2023 the Oxycodone were not administered as prescribed. On 5/3/2023, 5/4/2023, 5/14/2023 and 5/15/2023 the Morphine was not administered as prescribed. On 5/4/2023 and 5/14/2023 Albuterol Inhaler was not administered as prescribed. On 5/6/2023, 5/7/2023 and 5/9/2023 Furosemide (diuretic) was not administered as prescribed. On 5/7/2023 and 5/8/2023 Omeprazole (used for gastric reflux) was not administered as prescribed. On 5/14/2023 the Blood Glucose was not taken as prescribed due to no lancets. On 5/14/2023 the Klorcon (potassium), Morphine, Lorazepam, Lisinopril, Lasix, Docusate (stool softener), Loratadine (allergy relief), Montelukast (used for asthma), Senna Docusate, Flavoxate, Ferrous Sulfate, and Breo Ellipta Inhaler (asthma). The medications were not administered as ordered in accordance with the care plan. 8. Review of the medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, and Anxiety. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 4, which indicated Resident #307 was severely cognitively impaired no behaviors. Review of the medical record revealed Resident #307 was observed on 7/20/2023, rubbing Resident #24's breast. Review of the annual MDS dated [DATE], revealed a BIMS score of 9, which indicated Resident #307 was moderately cognitively impaired, with no behaviors. Review of the 24 Hour Report Sheet dated 8/28/2023, revealed Resident #307 exhibited inappropriate behaviors with a female resident in the Common Area and the Executive Director was notified. Review of the Care Plan dated 12/12/2023, revealed there was no revision to the care plan for the inappropriate behaviors for the incidents that occurred. Continued review of the care plan revealed the facility did not care plan Resident #307 for hypersexual behaviors and receiving medroxyprogesterone on admission. During an interview on 12/20/2023 at 7:34 AM, the Director of Nursing Consultant confirmed Resident #307 should have been care planned for his sexual behaviors and the Director of Nursing Consultant also confirmed the care plan should have been revised after each sexually inappropriate encounter with Resident #24. 9. Review of the medical record revealed Resident #354 was admitted to the facility on [DATE] with diagnoses Hypertension, Chronic Pain Syndrome, and Anxiety. Review of the Baseline Care Plan dated 12/13/2023, revealed Resident #354 was care planned to receive psychotropic medication for anxiety as ordered. Review of the December 2023 MR, revealed on 12/16/2023 the Simvastatin (medication to lower cholesterol) and Meloxicam (used to treat arthritis) were not administered as prescribed. On 12/17/2023 the Alprazolam (anxiety medication) was not administered as prescribed. During an interview on 12/28/2023 at 11:28 AM, the DON was asked should care plans be followed. The DON stated, Yes, ma'am.

Based on policy review, record review, observation, and interview, the facility failed to ensure proper infection control practices were followed in the laundry room on 2 of 2 (12/18/2023 and 12/19/2023) days observed, failed to ensure infection control practices to prevent the spread of infection when 4 of 6 (Licensed Practical Nurse (LPN) #1, #2, #6 and #7) failed to perform hand hygiene during medication administration and 2 of 8 (Certified Nursing Assistants (CNA) #3, #9 and #16) failed to perform proper hand hygeine during dining. The findings include: 1. Review of the facility's undated policy titled Cleaning Schedule, revealed .Clean laundry room at the end of our shift .Clean lint traps .after every load of laundry . Review of the facility's policy titled Infection Prevention & (and) Control Program, dated 4/2023, revealed .All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures .Linens .Laundry .shall handle, store, process, and transport linens to prevent spread of infection . Review of the facility's policy titled Hand Hygiene, dated 11/2023, revealed .This Facility considers hand hygiene to be the single most important factor in the control of infection .Use an alcohol-based hand rub .or .soap and water for the following .Before and after handling medications .Before and after assisting a resident with meals .Rub hands together for at least 20 seconds . Observation and interview on 12/18/2023 beginning at 7:58 AM, revealed Laundry/Housekeeping Staff Member #1 was asked what is the process for sorting dirty laundry into the washers. Laundry/Housekeeping Staff Member #1 stated, .bring the laundry from the floor to the dirty side .put on the long black glove, gown and goggles . Observation in the washer area of the laundry room revealed a basket truck with a spring lift (To elevate productivity and reduce strain on the back with basket trucks) contained dirty gloves, torn briefs and trash under the spring lift and the hand sink had large amount of lint and a brush. Laundry/Housekeeping Staff Member #1 was asked should there be lint and a brush in the hand sink. Laundry/Housekeeping Staff Member #1 stated, No. Observation in the clean area of the laundry room revealed a basket truck with a spring lift that contained several dirty gloves, a torn brief, and trash filled with personal items, the bathroom had multiple paper towels on the floor, a white wipe next to the trash can, the trash can was over flowing with trash, and the dryers had a large amount of lint in both lint traps. Laundry/Housekeeping Staff Member#1 was asked how often are the basket trucks cleaned. Laundry/Housekeeping Staff Member #1 stated, .every shift .I got here at 6:00 AM .had to clean front bathrooms, the chapel and therapy room .the clothes were in the bin when I got here . Laundry/Housekeeping Staff Member #1 was asked how often are the lint traps cleaned. Laundry/Housekeeping Staff Member #1 stated, .After every cycle . During an interview on 12/18/2023 at 11:00 AM, the Housekeeping/Laundry Supervisor was asked when are the laundry basket trucks cleaned. The Housekeeping/Laundry Supervisor stated, .They are to be cleaned every day .when [the] last person leaves for the day they clean them .when the night shift person leaves they are to be cleaned .I did not have a night shift person this weekend .so the last time they should have been cleaned was at 4:00 PM on yesterday [12/17/2023] . The Housekeeping/Laundry Supervisor was asked how often are the lint traps cleaned. The Housekeeping/Laundry Supervisor stated, .after every cycle .every 30-45 minutes depending on the items . The Housekeeping/Laundry Supervisor was asked should the dryer traps contain a large amount of lint. The Housekeeping/Laundry Supervisor stated, .No .I had a CNA in the laundry room last night . The Housekeeping/Laundry Supervisor was asked had the CNA been trained to work in the laundry. The Housekeeping/Laundry Supervisor stated, .No ma'am .she ask me if she could go in the laundry and wash some pads .they were low .they had about 12 pads last night .the laundry staff left around 4:00 PM on yesterday . The Housekeeping/Laundry Supervisor was asked in reviewing the lint log book can you tell the last time the lint trap was cleaned. The Housekeeping/Laundry Supervisor stated, No ma'am. Review of the Laundry Dyer Lint Trap cleaning list contained the lint trap cleaned, date, and person responsible. The Laundry Dyer Lint Trap did not have a time on the form indicating the times the lint traps were cleaned. Observation and interview on 12/19/2023 at 9:38 AM, revealed 4 isolation carts in the central supply room, the first isolation cart had white stains down the front of the cart, the second isolation cart had a dark brown stain on the top of the cart with purple stains and white stains down the front of the cart, the third isolation cart had a large moderate amount of brown particles on top of the cart, the isolation caddy had black particles on the top and inside the caddy, the third drawer contained loose gloves and paper trash, the top drawer of the fourth isolation cart contained 2 empty glove boxes and a empty box labeled deluxe inflatable bed shampoo kit. The Maintenance Director was asked what is the process for when the isolation cart are stored in the central supply room. The Maintenance Director stated, .They should be wiped down and sanitized .they need to clean the carts before they go to the halls .while on the halls they need to be cleaned as well . Observation and interview on 12/19/2023 at 9:55 AM, Laundry Staff Member #2 was in the washroom sorting clothes with regular gloves. The Laundry Staff member #2 was asked what type of Personnel Protective Equipment (PPE) she should wear when sorting clothes and placing them in the washer. The Laundry Staff member #2 stated, .Apron, gloves, goggles and the long black gloves . Laundry Staff Member #2 was asked if she had on the appropriate PPE. The Laundry Staff Member #2 stated, .No ma'am. Observation in the clean room revealed a basket truck with a spring lift filled with personal clothes, a large amount of trash, torn briefs, socks, gloves, and multiple pieces of trash. During an interview on 12/19/23 at 10:02 AM, the Housekeeping/Laundry Supervisor entered the clean room and was asked should the basket truck with a spring lift have trash, briefs, and gloves under the spring lift. The Housekeeping/Laundry Supervisor stated, No ma'am. The Housekeeping/Laundry Supervisor was asked what type of PPE should the staff members wear when sorting the dirty clothes to put in the washer. The Housekeeping/Laundry Supervisor stated, .gown, gloves, apron and shield . Observation at Medication Cart #1 on 12/12/2023 at 4:08 PM, revealed LPN #1 entered Resident #39's room and failed to perform proper hand hygiene before and after administering medications. Observation at Medication Cart #1 on 12/12/2023, revealed LPN #7 entered Resident #26's room and failed to perform hand hygiene before donning and after doffing gloves, and before and after administering medications. Observation at Medication Cart #2 on 12/12/2023, revealed LPN #2 entered Resident #204's room and failed to perform proper hand hygiene before and after administering medications. Observation at Medication Cart #2 on 12/14/2023 at 11:25 AM, revealed LPN #6 entered Resident #25's room and failed to perform hand hygiene. LPN #6 dropped a glove on the floor, retrieved the glove from the floor, donned it, and cleaned the glucometer. LPN #6 doffed her gloves and failed to perform hand hygiene before donning new gloves to draw up the medications. Observation in the resident's room on 12/11/2023 at 11:45 AM, CNA #9 delivered a tray to Resident #27's room, set the tray on the over bed table, raised the head of bed, adjusted the blankets, and failed to perform hand hygiene before tray set up. Observation in the resident's room on 12/11/2023 at 11:53 AM, CNA #9 delivered a tray to Resident #15's room, set the tray on the over bed table, raised the head of the bed, and failed to perform hand hygiene before tray set up. Observation in Resident #25's room on 12/11/2023 at about 12:10 PM, revealed CNA #16 delivered a meal tray to the Resident and failed to perform hand hygeine before donning gloves. CNA #16 grabbed a chair with gloved hands and assisted Resident #25 with the meal without rewashing hands and donning clean gloves. Observation on 12/12/2023 at 7:31 AM, CNA #3 failed to perform proper hand hygeine after doffing gloves.

Based on policy review, observation, and interview, the facility ensure residents were treated with dignity and respect during dining when 2 of 8 staff members (Certified Nursing Assistant (CNA) #3 and #15) stood to assist 2 of 20 sampled residents (Residents #25 and #32) with meals. The findings include: 1. Review of the facility's policy titled, Resident Rights, dated 1/2014, revealed .primary responsibilities .Resident's rights are protected .enhancement of quality of life .Dignity .enhances each resident's dignity and respect .his or her individuality . 2. Observation in the resident's room on 12/12/2023 at 7:31 AM, revealed CNA #3 stood over Resident #25 while she assisted her with her meal. 3. Observation in the resident's room on 12/13/2023 at 8:50 AM, revealed CNA #15 stood over Resident #32 while she assisted her with her meal. 4. During an interview on 12/12/2023 at 2:09 PM, the Director of Nursing confirmed staff should not stand to assist a resident with meals.

Based on policy review, medical record review, and interview, the facility failed to notify the responsible party (RP) for 2 of 8 (Resident #6 and #305) sampled residents reviewed for behaviors and falls. The findings included: 1. Review of the facility's policy titled, Resident Responsible Party Notification, dated 4/2021, revealed .The facility must immediately inform the Resident .the Resident's representative .If any of the following occur .An accident involving the Resident .A significant change in the Resident's physical, mental, or psychosocial status .A decision to transfer .the Resident from the facility . 2. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Bipolar Disorder, Schizophrenia, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Anxiety Disorder. Review of Nursing Progress Note dated 6/14/2023, revealed .LATE ENTRY FOR 06/14/2023 .Patient with acute status change. Times 3 aides [3 Certified Nursing Assistants (CNAs) in room with patient as she had loose bm [bowel movement] and smeared over everything. She is observed wrapping cords around her body and neck. She is unable to follow any commands. Observed bumping and jumping violently in bed and hitting things on the wall. Patient has been agitated per staff since 2100 [9:00 PM] .Staff at the bedside at this time .0230 [2:00 AM] Patient still agitated and increasing at this time. Staff has gotten her up and dressed in wheelchair to decrease agitation riding her around. Notify [Named County] EMS [emergency medical system] to transport to ER [emergency room ] .0300 [3:00 AM] EMS arrived, and report given. She is transported x[times]2 to [Named Hospital] currently . Review of Behavior, Social Service - Progress Note dated 8/2/2023, revealed .Sw [Social Worker] was notified by staff that Resident wandered last night into the room next door where two ladies reside .staff report resident was naked and ran into room .and tried to step on items that were lying on the floor. She has had medication changes and an attempt was being made to wean her off Clozapine [used to treat certain mental/mood disorders (schizophrenia, schizoaffective disorders) .but she has become more agitated and out of control with her body movements. This behavior noted is an example of her behavior agitation . The facility was unable to provide an incident report or documentation the RP was notified of the change in condition of Resident #6. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #6 was unable to complete the interview for a BIMS score, and staff assessed her to be moderately cognitively impaired. During an interview on 1/2/2024 at 6:23 PM, Family Member #2 was asked if he was notified of the incident on 6/14/2023 when his mother was sent to the emergency room for evaluation. Family Member #2 stated, .No, they did not notify me then . Family Member #2 was asked if the facility notified him on 8/2/2023 when Resident #6 was wandering in other resident rooms. Family member #2 stated, .No . they only notified me of the recent one where they sent her out because she threw a water pitcher .this is the only one I have heard about . 3. Review of the medical record revealed Resident #305 was admitted to the facility on [DATE], with diagnoses of Intrahepatic Carcinoma, Hepatomegaly, Anemia, Agranulocytosis, Anxiety Disorder, Atrial Fibrillation, Depression, and Hypertension. Review of the MDS dated [DATE], revealed Resident #305 had a BIMS score of 12, which indicated he was moderately cognitively impaired, disorganized thinking, altered level of consciousness identified and required partial to moderate assistance with Activity of Daily Living (ADLs). Review of the Hospice notes dated 6/1/2023 revealed, .admitted to hospice services with a terminal dx [diagnoses] of liver cancer .has metastasized to his lymph nodes .Pt [patient] continues to transition .Pt has multiple bruising noted to BUE [Bilateral Upper Extremity] from recent fall including skin tear to left forearm with foam dressing D/I [dry/intact] . Review of the DOCUMENTATION AND PRN RESULTS REPORT dated 5/30/2023 revealed, .Weekly Head to Toe Skin Check - Document current skin .RESULTS .bruising from recent fall . Review of the medical record revealed no documentation that Resident #305 had a fall in the facility. During a telephone interview on 12/19/2023 at 8:11 AM, Family Member #3 stated, .I was not told about this .until the afternoon .I know the CNA's .told me [the next day] he had fallen out of bed .the nurse lied .said they were helping him down .have pictures of a glass broken .he was overweight .he was trying to go to the bathroom . During an interview on 12/28/2023 at 11:28 AM, the Director of Nursing (DON) was asked should family be notified of any falls. The DON confirmed the family should be notified .incident report completed .