Every finding on record at Downs Care and Rehab

Based on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen. The facility failed to label, seal, and date food stored in the refrigerator/freezer and dry storage area. The facility also failed to consistently log freezer/refrigerator temperatures. Findings included:- On 04/13/26 at 08:10 AM, observation in the kitchen revealed the following:A white upright freezer had approximately 1/4 inch (in) ice buildup along the inside of the freezer and the shelves.The refrigerator located in the kitchen had a plastic bag with unlabeled, undated sliced yellow cheese.The March Freezer/refrigerator temperature logs lacked documentation of the readings for the following freezers and refrigerators in the morning and evening:1. Chest freezer located in dry storage on 05,06,10,11,14,15,17,19,21, and 23-31/262. A white stand-up freezer on 7,8,14, 15,18, 21, 253. A double door refrigerator on 7,8,15, 18, 21, 224. A single door refrigerator on 6, 7, 8, 21The April freezer/refrigerator temperature logs lacked documentation of the readings for the following freezers and refrigerators in the morning and evening:A double door freezer on 4, 5The ice machine located in the area between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it.Eight (15.5-pound (lb.) plastic jugs of used cooking grease with numerous different sizes of grayish-black substances on their top. The dry storage area had the following:An approximately 1/4 full (5 lb. package of undated pasta Labello egg noodles.An approximately 1/4 full (4.5 lb.) package of unlabeled, undated, unsealed [NAME] noodles. Approximately 3/4 package of undated strawberry gelatin.An approximately 3/4 bag of unsealed buttermilk pancake. On 04/13/26 at 08:20 AM, Dietary Staff (DS) CC verified the above findings and stated she would ask the dietary manager what to do with the findings when she arrived at the facility for her shift. On 04/14/26 at 01:30 PM, the Dietary Manager (DM) stated staff should label and date all food placed in dry storage, refrigerator, or freezer when received, and if open, make sure they are sealed, labeled, and dated with the open date. The facility's Dietary Purchases, Receipt and Storage Policy, revised 01/21/26, documented all products would be labeled with the date received in the facility. Frozen foods stored in the freezer, and the temperature would be maintained at 0 to -10 degrees Fahrenheit (F). Produce is stored in the refrigerator, and the temperature would be maintained at 38-44 degrees F. Dairy products would be stored in the refrigerator, and the temperature would be maintained at 35 to 40 degrees F. The facility's Monitoring of Refrigerators and Freezers Policy, revised 01/21/26, documented all refrigerators/freezers would be cleaned on a weekly basis and as necessary for spills. Refrigerators that are accessible to elders and used by multiple elders and/ or families would contain only food that is sealed in an airtight container that had not been inside an elder's room. All food items would be labeled with the contents of the container and the date it was placed in the refrigerator. A temperature log would be completed. The Certified Dietary Manager/designee is responsible for monitoring temperatures and appropriate logging of temperatures, and appropriate discarding from refrigerators/freezers containing food items. All temperature logs will be maintained in the environmental services office for two weeks.

Based on observation, record review, and interview, the facility failed to implement adequate infection control practices when staff failed to change gloves during incontinent care for Resident (R) 26. Staff also failed to place Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) signage for R11 and R44's and failed to ensure personal protective equipment (PPE- gowns and gloves) was readily available for use for R11 and R44, who shared a room, cares. Staff also failed to provide appropriate complete urinary catheter care for R44. Additionally, the facility failed to have a complete water management plan to prevent the spread of Legionella and other waterborne bacteria. Findings included:1. On 06/23/2026 at 12:05 PM, observation revealed R26 sat in a wheelchair in the hall. Certified Nurse Aide (CNA) N asked R26 if she needed to use the restroom, and she stated Yes. CNA M propelled R26 into R26's bathroom, and CNA N followed. Both applied gloves, CNA N cued R26 to stand using the grab bar on the wall, both assisted R26 in pivoting to the toilet, and CNA N pulled down the resident's pants and incontinent brief. R26 reported she was done, CNA M cued R26 to stand using the bars on the wall, while she assisted her by holding onto a gait belt. CNA N provided perineal (private area) care to the resident, then, with the same soiled gloves, pulled up R26's pants, pulled down her blouse, and touched her gait belt when assisting R26 to pivot turn into a wheelchair, then removed and discarded her gloves.On 06/23/2026 at 12:15 PM, CNA N verified she had not changed her gloves after providing R2 perineal care and stated she should have.2. On 06/22/2026 at 09:30 AM, observation revealed a lack of EBP signage for R11 and R44's and lacked the necessary PPE supplies. Observation revealed a lack of PPE supplies in the 100 hall, on the back of the room door, or in their closets.On 06/23/2026 at 03:30 PM, observation revealed CNA N brought PPE supplies down the hall from the other side of the facility to R44's room door entrance and CNA N and donned a gown, applied gloves, and entered R44's room. R44 sat in a wheelchair facing his bed. CNA N asked R44 if it was ok if she provided urinary catheter care, and he replied, Sure. Observation revealed R44 transferred himself to his bed, pulled down his pants and incontinent brief, CNA N took a washcloth, which hung on a metal bar by the sink, and applied soap on the washcloth. Further observation revealed CNA N used the soaped washcloth and wiped the catheter tubing from the connection site on the urinary catheter bag upwards to the insertion site. CNA N, with the same washcloth, wiped R44's groin area on both sides, then stated she was not going to finish the care because R44 had a bath that morning.On 06/23/2026 at 03:30 PM, CNA N said she knew R44 had EBP because she knew he had a urinary catheter and all residents with one were to be on EBP. CNA N verified there was no signage on the door or PPE supplies available by the door, in the closet, or behind the door, and stated that is why she brought them from the other side of the facility.On 06/23/2026, at 03:45 PM, CNA O stated she was unaware R11 or R44 were on EBP until CNA N brought her a gown and gloves to put on before providing catheter care. She said she had only recently become a CNA.On 06/24/2026, Administrative Nurse D verified R11 and R44's room lacked EBP signage and stated it should have EBP signage on the door, and PPE should be on the backside of the room door, in their closet, or at the aide charting desk in the middle of the hall. Administrative Nurse D stated staff should change gloves between dirty and clean and should provide urinary catheter care starting at the insertion site of the tubing down to the connection site and use a clean wipe or wash cloth for each perineal area cleansed.3. On 06/23/2026 at 08:30 AM, a review of the facility's water management plan revealed a lack of a complete plan, which included the building's water systems' use text or flow-diagrams for identification and control measures. The plan lacked documentation regarding flushing of stagnant areas of the facility's water system.On 06/23/2026 at 8:59 AM, Administrative Staff A and Maintenance Staff (MS) U verified the facility lacked a complete water management plan. Administrative Staff A stated that the prior maintenance staff took the information with them when they left, and MS U was working on it.The facility's Perineal Care Policy, revised 10/2023, instructed staff when providing perineal care to wash and dry hands thoroughly, put on gloves, wash and rinse the urethral area, thoroughly dry the perineum, discard disposable items into designated containers, and remove and discard gloves, then wash and dry hands thoroughly.The facility's Indwelling Urinary Catheters Policy, revised 06/22, instructed staff to use PPE when performing urinary catheter care. The policy instructed staff to follow the following steps when providing catheter care: For a male, use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return the foreskin to its normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward.The facility's EBP Policy, revised 04/2025, documented that appropriate precautions would be taken when caring for individuals known or suspected to have an infection or colonization with a multidrug-resistant organism and requires EBP. The use of PPE refers to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, as well as for residents with MDRO infection or colonization.The facility's Water Management, Legionella Testing Policy, revised 10/2022, documented that the facility would handle and maintain its water supply in accordance with recommendations of the CDC, the Healthcare Infection Control Practices Advisory Committee, and the FDA. The facility would demonstrate its measures to minimize its risk of Legionella and other opportunistic pathogens in the building water system through a documented water management program.

Based on observation, record review, and interview, the facility staff failed to treat Resident (R) 11 with dignity when staff ambulated beside R11 down the hall to the dining room with wet pants. Findings included:- On 06/23/2026 at 12:00 PM, R11 self-propelled in a wheelchair out of his room and started down the hall. Certified Nurse Aide (CNA) O stopped the resident and asked if he wanted to walk the rest of the way to the dining room, and R11 replied, Yes, no one came and got me for lunch. CNA O instructed the resident to wait while she went to get his walker from his room. CNA O returned with the walker and gait belt, applied the gait belt around R11's waist, assisted him to stand, and took hold of the walker. Observation revealed R11's pants were wet from the buttocks to the top of his waist. CNA O continued assisting R11 towards the dining room when the staff asked her if R11's pants were wet. CNA O touched R11's buttock area and stated yes, then asked R11 if he wanted to change his pants before going to the dining room, and he replied: I'd better. Observation revealed R11 turned around with his walker, and the front area from the waist down to the groin area was wet.On 06/23/2026 at 12:10 PM, CNA O verified R11 was incontinent of urine.On 6/23/2026 at 12:20 PM, Administrative Nurse D stated that staff should change the residents' clothing when wet.Upon request, the facility did not provide a dignity policy

Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)7's and R39's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. Findings included:1.R7's Electronic Medical Record (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering and hoarding), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin,) and atherosclerotic heart disease (narrowing or blockage of the arteries that supply blood to the heart muscle). R7's Annual Minimum Data Set (MDS), dated [DATE], recorded R7 had severely impaired cognition. The MDS recorded R7 required staff supervision with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 03/27/2026, recorded R7 received antipsychotic medication and had diagnosis of depression and dementia with behavioral disturbance. R7's Care Plan, dated 06/23/2026, recorded the nurse would administer medications as prescribed and monitor for side effects and effectiveness. The care plan documented Seroquel (antipsychotic) had a Black Box Warning that stated it was not approved for dementia-related psychosis, and there could be increased mortality in the elderly on antipsychotic treatment for dementia. The Physician's Order, order dated 03/11/2026, directed the staff to administer Seroquel XR oral tablet extended release 50 milligrams (mg), one tablet at bedtime for a diagnosis of dementia with other behavioral disturbance. R7's EMR lacked documentation of nonpharmacological approaches that were attempted but unsuccessful for behavioral management and lacked evidence of a physician's rationale including risk versus benefits for the Seroquel. On 06/23/2026 at 08:10 AM, observation revealed R7 sat at the dining room table and License Nurse (LN)G, administered the residents' morning medication. 2. R39's Electronic Medical Record recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder, and hallucinations. R39's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R39 had moderately impaired cognition. The MDS recorded R39 was dependent with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The MDS documented that the R39 did not have hallucinations. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/03/2025, recorded R39 received antipsychotic medication and had a diagnosis of hallucinations. R39's Care Plan, dated 05/12/2026, recorded the nurse would administer medications as prescribed and monitor for side effects and effectiveness. The care plan documented R39 received Seroquel (antipsychotic) for Alzheimer's disease and had a Black Box Warning that stated -not approved for dementia-related psychosis, and there could be increase mortality in the elderly on antipsychotic treatment for dementia. The Physician's Order, order dated 02/19/2026, directed the staff to administer Seroquel 25 milligrams (mg), one tablet at bedtime for diagnosis of Alzheimer's disease with hallucinations. R39's's EMR lacked documentation of nonpharmacological approaches that were attempted but unsuccessful for behavioral management and lacked evidence of a physician's rationale including risk versus benefits for the Seroquel. On 06/23/26 at 07:30 AM, observation revealed R39 in a wheelchair in her room and License Nurse (LN)G, administered the residents' morning medication On 06/24/2026 at 08:30 AM, Administrative Nurse D verified R7 and R39 received Seroquel and stated the facility would contact the physician for appropriate documentation for the residents on antipsychotic medications. The facility's Psychoactive Medications policy dated 04/2025 recorded the resident would only receive psychoactive medications or other approved medications that have an effect on the brain activity when necessary to treat conditions for which they are indicated and effective and would not be used for discipline or for convenience of the staff. The policy recorded psychoactive medication ordered would have behavioral symptoms that present a danger to the resident or others and the expression or indication of distress that are significant distresses to the resident. The policy documented what were the goals of the therapy, the attempted behavioral interventions attempted prior to starting the medication that did not relieve the medical symptom which were presenting a danger or significant distress and a description of why alternative non-pharmacological treatments are not clinically contraindicated, including the rationale for how this conclusion was reached.

Based on observations, interviews, and record review, the facility failed to ensure the Consult Pharmacist identified and reported the lack of appropriate indication or required physician documentation for Resident (R)'7 and R39's use of an antipsychotic (a class of medication used to treat any major mental disorder characterized by a gross impairment testing) medication. Findings included:1. R7's Electronic Medical Record (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering and hoarding), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin,) and atherosclerotic heart disease (narrowing or blockage of the arteries that supply blood to the heart muscle). R7's Annual Minimum Data Set (MDS), dated [DATE], recorded R7 had severely impaired cognition. The MDS recorded R7 required staff supervision with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 03/27/2026, recorded R7 received antipsychotic medication and had diagnosis of depression and dementia with behavioral disturbance. R7's Care Plan, dated 06/23/2026, recorded the nurse would administer medications as prescribed and monitor for side effects and effectiveness. The care plan documented Seroquel (antipsychotic) had a Black Box Warning that stated it was not approved for dementia-related psychosis, and there could be increased mortality in the elderly on antipsychotic treatment for dementia. The Physician's Order, order dated 03/11/2026, directed the staff to administer Seroquel XR oral tablet extended release 50 milligrams (mg), one tablet at bedtime for a diagnosis of dementia with other behavioral disturbance. R7's EMR lacked documentation of nonpharmacological approaches that were attempted but unsuccessful for behavioral management and lacked evidence of a physician's rationale including risk versus benefits for the Seroquel. Pharmacist Consultant reviews on 3/03/26, 04/08/26, and 05/07/26 did not request an approved diagnosis or indication for the use of R7's Seroquel. On 06/23/2026 at 08:10 AM, observation revealed R7 sat at the dining room table and License Nurse (LN)G, administered the residents' morning medication. 2. R39's Electronic Medical Record recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder, and hallucinations. R39's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R39 had moderately impaired cognition. The MDS recorded R39 was dependent with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The MDS documented that the R39 did not have hallucinations. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/03/2025, recorded R39 received antipsychotic medication and had a diagnosis of hallucinations. R39's Care Plan, dated 05/12/2026, recorded the nurse would administer medications as prescribed and monitor for side effects and effectiveness. The care plan documented R39 received Seroquel (antipsychotic) for Alzheimer's disease and had a Black Box Warning that stated -not approved for dementia-related psychosis, and there could be increased mortality in the elderly on antipsychotic treatment for dementia. The Physician's Order, order dated 02/19/2026, directed the staff to administer Seroquel 25 milligrams (mg), one tablet at bedtime for diagnosis of Alzheimer's disease with hallucinations. R39's's EMR lacked documentation of nonpharmacological approaches that were attempted but unsuccessful for behavioral management and lacked evidence of a physician's rationale, including risk versus benefits for the Seroquel. Pharmacist Consultant reviews on 3/03/26, 04/08/26, and 05/07/26 did not request an approved diagnosis or indication for the use of 39's Seroquel. On 06/23/26 at 07:30 AM, observation revealed R39 in a wheelchair in her room and License Nurse (LN)G, administered the residents' morning medication On 06/24/2026 at 08:30 AM, Administrative Nurse D verified R7 and R39 received Seroquel and stated the facility would contact the physician for appropriate documentation for the residents on antipsychotic medications. The facility's Psychoactive Medications policy dated 04/2025, recorded the resident would only receive psychoactive medications or other approved medications that have an effect on the brain activity when necessary to treat conditions for which they are indicated and effective and would not be used for discipline or for convenience of the staff. The policy recorded psychoactive medication ordered would have behavioral symptoms that present a danger to the resident or others and the expression or indication of distress that are significant distresses to the resident. The policy documented what were the goals of the therapy, the attempted behavioral interventions attempted prior to starting the medication that did not relieve the medical symptom which were presenting a danger or significant distress and a description of why alternative non-pharmacological treatments are not clinically contraindicated, including the rationale for how this conclusion was reach

Based on observation, record review, and interview, the facility failed to ensure a medication error rate not greater than five percent (%) when errors were observed for Resident (R) 7, resulting in an error rate of 5.13 percent (%). Findings included: - R7's Physician order, dated 03/11/2026, instructed staff to administer aspirin delayed release 81 milligrams (mg); one tablet a day for atherosclerotic heart disease. R7's Physician order, dated 03/12/2026, instructed staff to administer Glipizide (oral medication used to lower blood sugar) XL- extended release (ER), 2.5 mg, one tablet a day for diabetes mellitus. R7's Electronic Medical Record lacked an order to crush the delayed/extended-release medications. On 06/23/2026 at 08:10 AM, observation revealed Licensed Nurse (LN) G crushed R7's pills, including the delayed/extended-release aspirin and Glipizide, and mixed the medication with pudding. LN G administered one spoonful of the medication, and the resident ingested all the medications. On 06/23/2026 at 08:15 AM, LN G stated R7 liked to take her medications with pudding, and staff crushed them, so she was able to take them easier. On 06/24/2026 at 08:30 AM, Administrative Nurse D verified the delayed or extended-release medication should not be crushed and said they should be administered whole due to the extended release of the medication over time. Administrative Nurse D stated she had administered medication to R7 in the past and had never crushed her medication before administration. The facility's Medication Administration policy, dated June 2025, recorded during medication administration, facility staff should take all measures required by the facility policy and applicable law, including, but not limited to the following: Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Resource: Oral dosage Forms that Should Not Be Crushed, and/or facility policy. Exceptions to Should Not Crush medications may occur when physician orders are documented in the medical record including a statement explaining why crushing the medication will not adversely affect the resident.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 40 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 07/29/24 at 08:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 07/29/24 at 09:40 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had seven residents with mechanical soft diets and one with a pureed diet. On 07/31/24 at 02:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The facility's Food Service Staffing dated 10/2024, documented the community will employ sufficient staff with the appropriate competencies and skills to carry out the function of the food and nutrition services. The qualified Dietician would help oversee clinical nutrition and dietary services in the facility. The policy documented that if the Dietician is not full time the community would employee another qualified nutritional professional, to serve as the Dietary Manager. The person a minimum must meet one of the following qualifications: a) A certified Dietary Manager, b) A certified food service manager, c) Have similar certification in food service management and safety from a national certifying body, d) Has an associate or higher degree in food services management or in hospitality, if the course study includes food service or restaurant management from an accredited institution or higher degree, e) Has two or more years of experience in the position of dietary manager in a nursing facility setting and has completed a course of study in food safety management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illnesses, sanitization procedures, and food purchasing/receiving; and f) meets the state-established standards if applicable. The Dietary Manager would receive frequently scheduled consultations from a qualified dietician. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 40 residents in the facility. This placed the residents at risk for inadequate nutrition.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide a clean, homelike environment when staff failed to clean the dining chairs in the dining room. This placed the residents who ate meals in the dining room at risk for impaired comfort and decreased quality of life. Findings included: - On 07/29/24 at 11:30 AM, the dining observation of the lunch meal in the main dining room included nine dining tables with 14 maroon cloth chairs, and the second dining room had two round tables and three square tables with nine maroon cloth chairs. Further observation revealed all of the chairs in both dining rooms had numerous areas of what appeared to be a liquid blackish-brown stain on the seats. They appeared unclean and dirty. On 07/31/24 at 10:30 AM, Housekeeper U verified he used a shampooer every other week to clean and deodorize the chairs but stated it did not remove the stains due to the age of the chairs. On 07/31/24 at 02:00 PM, Administrative Staff A verified housekeeping staff were to clean the dining room chairs and verified the chairs were stained and appeared unclean. Administrative Staff A stated the facility was aware of the stains and dirty-looking chair seats and said staff had tried to clean them. Administrative Staff A stated the facility was looking into getting the chairs reupholstered, but staff had not done so at that time and did not have a date to have the work completed. The facility's Safe, Clean, Comfortable, Homelike Environment, policy, dated, 09/2024, documented the residents have the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. The facility failed to provide a homelike dining experience for residents who ate meals in the dining room, by having unclean and soiled dining room chairs. This placed the residents who ate meals in the dining room at risk for impaired comfort and decreased quality of life.

The facility had a census of 40 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment in the facility kitchen. This deficient practice placed the facility residents and staff at risk for impaired safety. Findings Included: - On 07/30/24 at 12:15 PM, during kitchen follow up tour, observation revealed the following: Four 2-foot x 4 -foot fluorescent lights, located between the food preparation area and the stove area that lacked a plastic light diffuser (cover). Each fixture had two fluorescent tube glass light bulbs per fixture. Five 2-foot x 4 -foot fluorescent light, located above the dishwasher area lacked a plastic light cover. Each fixture had two fluorescent tube glass light bulbs per fixture. On 07/30/24 at 12:20 PM, Maintenance Staff U verified the overhead fluorescent light fixtures lacked a diffuser/cover and said he thought the facility had some in storage and would replace the covers as soon as he could locate them. The facility's Sanitization policy, dated 10/2024, documented the food service area shall be maintained in a clean and sanitary manner. The kitchen area would be kept clean, maintained in good repair and free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. The facility failed to provide a safe environment for the facility kitchen, placing the residents and staff at risk.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise one sampled resident's care plan to include guidance to staff regarding Resident (R) 25 exiting the building without staff supervision. This placed R25 at risk for impaired care due to uncommunicated care needs. Findings included: - R25's Electronic Medical Record (EMR) documented that R25 had diagnoses of attention-deficit hyperactivity disorder (ADHD-ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development) and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R25's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R25 was independent with most activities of daily living (ADLs). He required staff supervision with ambulation 50 feet (ft) with two turns or 50 ft. once standing. R25's Care Plan, revised 06/25/24, documented R25 required set-up or supervision with ADLs and directed R25 was up ad lib throughout the facility and his room without an assistive device. The care plan lacked guidance to staff on what to do if R25 exited the building unsupervised. On 07/29/24 at 03:15 PM, observation revealed R25 ambulated down the hall, from the nurse's station using a walker with a fast steady gait to his room. Once he was inside the entrance door, he left his walker by the entrance door and ambulated into the bathroom. Further observation revealed R25 ambulated out of his room using a walker with a fast steady gait down the hall to the south exit door. He opened the door and went outside (without staff supervision) and no alarm was heard at the exit door. Further observation revealed R25 ambulated through an open gate and sat on a bench outside the facility. On 07/29/24 at 01:37 PM, Certified Medication Aide (CMA) M stated all of the facility doors were unlocked but did alarm at the nurse's station whenever someone went out without putting in the code. CMA M stated when R25 exited the facility through the south exit door, it alarmed the nurse's station; staff could see him exit from the nurse's station and tried to keep an eye on him when he exited. CMA M stated staff knew R25 was allowed to exit the building unsupervised. On 07/31/24 at 12:00 PM, Administrative Nurse D verified that R25's Care Plan lacked instructions to staff regarding what to do when R25 exited the building unsupervised. Administrative Nurse D stated she discussed with the administrative team whether the facility should include instructions on the care plan related to R25 exiting the building unsupervised. Administrative Nurse D stated the facility had a few other residents who were allowed to exit the building without staff supervision. if R25 was updated, the other care plans would require updating as well so the facility determined it was not necessary. The facility's Comprehensive Assessment Policy, revised 09/2023, documented resident's assessment would be completed within the last 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive care plan. The facility failed to revise R25's care plan to include guidance to staff regarding R25 exiting the building unsupervised. This placed the resident at risk of impaired care due to uncommunicated care needs.

The facility had a census of 40 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R)42. This placed the resident at risk of receiving inadequate care. Findings included: - R42's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R42's Admission Minimum Data Set (MDS), dated [DATE], documented R42 required limited staff assistance with activities of daily living (ADLs). The MDS documented the resident was expected to stay at the facility for three or fewer months. The Care Area Assessment (CAA, dated 04/26/24), documented the resident planned to return to the community, and the social service director would work with the family for possible home health. R42's Admission Care Plan, dated 04/17/24, documented the resident was admitted to the facility for skilled therapy including physical therapy and occupational therapy and he would have a short-term stay at the facility. The Nurse's Note, dated 05/06/24 at 10:42 AM, documented R42 was discharged from the facility to home. A review of R42's EMR lacked a discharge summary which included a complete recapitulation of her stay. On 07/31/24 at 02:30 PM, Administrative Staff A verified R42's discharge summary had an incomplete recapitulation of her stay and stated social service staff and nursing were responsible for completing the discharge summary. The facility's Discharge Summary and Plan, policy, revised 09/2023, documented that staff should complete a discharge summary when the resident is discharged that would include a recapitulation of the resident's stay at the facility and a final summary of the resident status at the time of discharge in accordance with established regulations governing the release of resident information and as permitted by the resident. The recapitulation would include, but not be limited to: diagnoses, course of the illness, treatment or therapy; pertinent lab, radiology, and consultation results; reconciliation of all pre-discharge medications with the residents post-discharge medications, for prescribed and over the counter; and a final summary paragraph that may be released to any provider with the consent of the resident or representative. The facility failed to develop a discharge summary that included a complete recapitulation of R42's stay and post-discharge plan. This placed the resident at risk of receiving inadequate care.

The facility had a census of 40 residents. The sample included 12 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing, for Resident (R)37. This placed the resident at risk for poor personal hygiene and impaired dignity. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnoses of adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals,) dementia (a progressive mental disorder characterized by failing memory, confusion, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R37's Admission Minimum Data Set (MDS), dated [DATE], recorded R37 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS recorded R37 required set-up and clean-up assistance from staff for most ADLs including bathing. R37's Care Plan, dated 06/21/24 indicated that R37 required limited staff assistance and supervision with ADL care. R37's Bathing/Shower Task documentation revealed the resident was scheduled to have a shower/bath once a week. The April 2024 bathing report documented the resident received a bath on the following days: 04/07/24 04/14/24 The May 2024 bathing report documented the resident received a shower on the following days: 05/15/24 (30 days with no shower). The June 2024 bathing report documented the resident received a shower on the following days: 06/05/24 (19 days with no shower) The July 2024 bathing report documented the resident received a shower on the following days: 07/10/23 resident refused to have her hair washed (13 days with no shower) 07/17/24 resident refused to have her hair washed (6 days) 07/24/24 -resident refused to have her hair washed (6 days) The bathing report lacked documentation the resident refused her showers. On 07/29/24 at 10:45 AM, observation revealed R37 sitting in a wheelchair in her room dressed in street clothes. Her hair was uncombed and appeared greasy. On 07/30/24 at 10:00 AM, Administrative Nurse D verified the residents had scheduled shower days and the aides documented in the electronic medical record and on shower sheets. Administrative Nurse D verified the R37's EMR noted the dates she received a shower and verified the resident did not receive her shower once a week. Administrative Nurse D stated the resident did not like to get her ears wet and she would refuse showers but confirmed the facility staff were unsure of her apprehensions or why she did not want to get her ears wet and had not followed up on that. The facility's Activities of Daily Living policy, dated 09/2024, documented the facility would ensure a resident would be provided appropriate care and services including hygiene, mobility, elimination, dining, and communication. The policy documented residents who were unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene and if the resident refuses care and treatment which may contribute to a decline the staff would attempt to find the underlying cause of the refusal if related to depression, behavioral or dementia care. The facility failed to provide the necessary care and bathing services for R37, placing the resident at risk for poor hygiene and impaired dignity.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for the use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) or the required physician documentation for two of five residents, Resident (R) 31 and 38, reviewed for unnecessary medications. This placed the residents at risk for unnecessary psychotropic (alters mood or thought) medications. Findings included: - R31's Electronic Medical Record (EMR) documented R31 had diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R31's Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R31 required partial to moderate staff assistance with toileting, dressing, and bed mobility. R31 required maximal staff assistance with showering and was dependent on staff for putting on and taking off footwear. The MDS documented R31 received an antidepressant (class of medications used to treat mood disorders) medication during the look-back period. R31's Care Plan, revised 06/24/24, instructed staff to monitor R31 for drug-related complications from his Seroquel (antipsychotic medication). R31 used Seroquel related to behavior management. The care plan instructed staff to administer R31's psychotropic medications as ordered by the physician and consult with the pharmacy and physician to consider a dosage reduction of the Seroquel when clinically appropriate, at least quarterly. The Physician Order, dated 02/10/23, instructed staff to administer Seroquel, 25 milligrams (mg), at bedtime related to depression. R31's EMR lacked evidence of nondrug behavioral interventions that were tried and failed before starting the antipsychotic medication and lacked a physician-documented rationale including risk versus benefits for the continued use of Seroquel. On 07/2/24 at 1:00 PM, observation revealed R31 sat in a wheelchair in his room visiting in a polite voice with a family member. On 07/31/24 at 11:22 AM, Administrative Nurse D verified the resident's Seroquel had an inappropriate indication and stated the facility staff tried to get the physicians on board with proper documentation for antipsychotic medications. The facility's Unnecessary Drugs Policy, revised 09/23, documented that residents would receive antipsychotic and psychotropic medications when necessary to treat specific conditions for which they are indicated. The facility failed to ensure an appropriate indication for use, or the required physician documentation for R31's Seroquel. This placed the resident at risk for unnecessary psychotropic medications. 26768 - R38's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) with agitation and heart failure lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. The MDS documented R38 had hallucinations (sensing things while awake that appear to be real, but the mind created) and verbal and wandering behaviors. The MDS documented R38 received antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and opioid (narcotic) drugs. The Dementia Care Area Assessment (CAA), dated 05/09/24, documented R38 would not answer questions, or her answers made no sense, and the interview was completed showing severe dementia. R38 was noted to be alert and oriented to self only and wandered and paced throughout the facility. R38 displayed constant confusion with a scattered thought process, clear speech with frequent rambling, and did not always answer questions appropriately. The physician adjusted her medications which were becoming effective with less agitation noted. Risk factors of her medications included social isolation and behaviors. The Behavior CAA documented R38 wandered nearly daily and had at least one behavioral symptom. No physical aggression was noted, but she had increased verbal rambling, and some foul word use; she paced continuously while talking to herself. One evening she was in a constant state of agitation, restlessness, and irritability as evidenced by her wandering the halls, attempting to leave the facility, entering other resident's rooms, and yelling at them causing other residents to become agitated. R38 spit her crushed medications on staff, verbalized constant cursing at staff, called staff names, and yelled at staff. She scratched a Certified Nurse Aide (CNA). Staff offered drinks, snacks, activities, and television which were refused by the resident. Staff were unable to redirect or distract her. The Quarterly MDS, dated [DATE], documented R38 received antipsychotic, antianxiety, and antidepressant (class of medications used to treat mood disorders) drugs. R38's Care Plan, dated 07/26/24, stated R38 had impaired cognitive function or impaired thought processes related to severe dementia with agitation. The care plan directed staff to perform behavior monitoring each shift due to the dementia diagnosis and document in detail behaviors and chart effective interventions if any. Administer medications as ordered, and monitor for effectiveness and possible adverse reactions. The care plan stated R38 used antipsychotic medications for behavior management and included the Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for Seroquel (antipsychotic medication) which stated, not approved for dementia-related psychosis and mortality risk in elderly people on antipsychotic treatment for dementia-related psychosis. The Physician Note, dated 06/21/24, documented R38's agitation was markedly improved and R38 was calm. The note documented R38's generalized anxiety disorder improved with clonazepam. The Physician Order, dated 06/28/24, directed staff to administer clonazepam (antianxiety medication) 0.5 milligrams (mg) in the afternoon for dementia with agitation. The Physician Order, dated 06/28/24, directed staff to administer Seroquel 75 mg two times a day related to severe dementia with agitation. The Physician Order, dated 06/29/24, directed staff to administer Seroquel 50 mg in the morning for dementia with agitation. The Physician Order, dated 07/21/24, directed staff to administer clonazepam 1 mg in the morning for dementia with agitation. R38's EMR lacked physician documentation of the interventions that were attempted and failed prior to starting an antipsychotic and lacked physician documentation of the risks versus benefits for continued use of Seroquel. On 07/30/24 at 10:06 AM, observation revealed R38 wandered into the room next door to hers. She wore glasses, non-skid socks, and a Wander Guard bracelet. She was very confused. Observation revealed Licensed Nurse (LN) G administered medications crushed and in applesauce to R38 in the hallway. On 07/31/24 at 1058 AM, Administrative Nurse D verified dementia with agitation was not an approved indication for the use of the antipsychotics and the facility did not have the physician's rationale for the continued use of Seroquel and clonazepam for R38. The facility's Unnecessary Medication policy, dated 09/2023, stated residents would only receive antipsychotic and psychotropic medications when necessary to treat specific conditions for which they are indicated and effective and would not be used for discipline or convenience of the staff. The policy directed staff to record and document an individual's target symptoms including if the behavior was observed or identified by shift in the clinical record for antipsychotics and medications used off label to affect the target symptom. The presence or absence of side effects of antipsychotics would be recorded in the clinical record every shift. The facility failed to ensure an appropriate indication for use or the required physician documentation for the ongoing use of antipsychotic medications for R38. This placed the resident at risk for unnecessary psychotropic medications.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to record the open or discard date on residents' insulin (a hormone that lowers the level of glucose in the blood) vials when they opened a new, multi-use insulin vial. This deficient practice placed Residents (R)13 and R30 at risk for ineffective insulin medication. Findings included: - On [DATE] at 08:53 AM, observation of the west medication cart medications with Licensed Nurse (LN) G revealed one opened and partially used insulin glargine (long-acting insulin) vial for R30 was not dated and one insulin glargine vial for R13 had been opened and was not dated. On [DATE] at 08:53 AM, LN G verified staff were to date the insulin vial when opened so they would know when the insulin was expired. On [DATE] at 01:45 PM, Administrative Nurse D verified staff were to date all insulins when opened. Medlineplus.gov, on [DATE] documented that urefrigerated vials of insulin glargine can be used within 28 days; after that time they must be discarded. Opened vials of insulin glargine can be stored for 28 days at room temperature or in the refrigerator. The facility's Insulin Administration policy, dated ,d+[DATE], directed staff to record the expiration date and time on the vial when opening a new insulin vial. The facility failed to date R13 and R30's multi-use insulin vials when opened, placing the residents at risk for ineffective insulin.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to appropriately maintain the chest freezer in the store room to ensure proper function and sanitary food storage. This placed the 38 residents who reside in the facility at risk for food borne illness. Findings included: - On 08/15/22 at 9:10 AM, observation revealed a large chest freezer in the kitchen storeroom. Further observation revealed the chest freezer with packaged food in the freezer had three to four inches of ice build up on the walls of the freezer. The facility's Kitchen Cleaning Checklist documented refrigerators and freezers were to be cleaned and defrosted on a monthly basis and as needed. On 08/16/22 at 12:10PM Dietary Staff BB verified the chest freezer in the storeroom had ice buildup and needed to be defrosted. On 08/17/22 at 3:45PM Administrative Staff A stated the expectation was dietary staff were to defrost the freezers as needed and to maintain the freezers in the kitchen. The facility's Refrigerators and Freezers policy, dated 7/2022, documented freezers are to be kept clean, and free of frost and ice buildup. The facility failed to defrost the storeroom chest freezer to ensure proper function and sanitary food storage. This placed the 38 residents who received meals from the facility kitchen at risk for food borne illness.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review and interview the facility staff failed to assess and record washing machine temperatures in one of one laundry room to ensure adequate temperatures to prevent the spread of infection. This placed the 38 residents at risk for a communicable disease or infection. Findings included: - On 08/17/22 at 11:08 AM observation in the facility laundry room revealed TMA laundry suds, laundry softener, and chlorine de-stainer, hooked to the commercial washing machine. The Monthly Washing Machine Hot Water Temperature Daily Logs lacked documentation for June, July, and August 2022. On 08/17/22 at 11:10 AM Housekeeping Supervisor (HS) U verified she had not checked daily washing machine hot water temperatures for the above months. HS U stated she thought maintenance was checking and recording them. On 08/17/22 at 11:17 AM Maintenance Supervisor (MS) V verified he had not checked hot water washing machine temperatures. MS V stated laundry staff were responsible for checking and recording the daily hot water washing machine temperatures. On 08/18/22 at 09:10 AM, Administrative Nurse E stated she expected laundry staff to check the hot water temperature of the washing machine daily. The facility's Laundry and Bedding Policy, revised 05/2022, documented recommendation for laundry cycles are per manufacturer guidelines and the following : hot water is 160 degrees Fahrenheit (F) for 25 minutes. The facility failed to assess and record a daily hot water temperature for June, July, and August 2022. This placed the 38 residents at risk for a communicable disease or infection.

The facility had a census of 38 residents. The sample included 12 residents with one reviewed for [CONDITION(S)] (a treatment to filter wastes and water from your blood, by the use of a [CONDITION(S)] machine). Based on observation, record review and interview, the facility failed to provide ongoing assessment of Resident (R) 37's condition and failed to monitor for complications before and after [CONDITION(S)] treatments. The facility further failed to adhere to a 1500 milliliter (ml) fluid restriction. This deficient practice placed R37 at risk for complications related to [CONDITION(S)]. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR documented R37 admitted to the facility on [DATE] and transported out of facility three times a week on Monday, Wednesday and Friday to a [CONDITION(S)] center. The Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition. R37 required staff assistance with transfers to the wheelchair, and the resident was independently mobile in a wheelchair. The Activities of Daily Living (ADL) Care Area Assessment Summary (CAA), dated 08/05/22, recorded the resident received hemodialysis at a [CONDITION(S)] center three times a week. The [CONDITION(S)] care plan dated 08/05/22 directed the staff to check and change the dressing at the access site daily. The care plan directed staff to assess the [CONDITION(S)] access site every shift and monitor vital signs and weight before and after [CONDITION(S)]. R37 was to only consume 1500 ml of fluid in a 24-hour period. R37's Physician Order, dated 07/29/22, instructed staff the resident was on a fluid restriction of 1500 ml in a 24-hour period. The registered dietician admission assessment note dated 07/30/22, documented the resident was on a 1500 ml fluid restriction. The Nurses Note dated 08/06/22 at 01:19PM, documented a fistula (an abnormal connection between an artery and a vein) was present in right forearm, and bruit (blowing or swishing sound heard which reflects the blood flow with a [CONDITION(S)] resident's shunt) and thrill (a fine vibration felt which reflects the blood flow by a [CONDITION(S)] resident's shunt ) heard without complications. Review of R37's clinical record lacked documentation of assessment of the [CONDITION(S)] site, assessment before and after [CONDITION(S)], and lacked monitoring of R37's fluid intake. On 08/16/22 at 01:10PM, R37 sat in his wheelchair in his room. Further observation revealed a metal thermos and a water pitcher at the bedside. On 08/16/22 at 12:30PM, Dietary Staff (DS) BB stated dietary staff gave the resident 120 ml of fluid with each meal; nursing staff were to monitor R37's intake. On 08/16/22 at 01:10PM, R37 stated he goes to [CONDITION(S)] three times a week, on Monday, Wednesday and Friday. R37 stated his [CONDITION(S)] access site is in the left [MEDICATION(S)] (an artery or vein in the upper side of the neck) artery and not in either of his arms. R37 stated no one at the facility checked his access site or assess him before or after [CONDITION(S)] treatments. R37 stated he drinks what he wants and stated the facility does not monitor how much he drinks. R37 stated he keeps pop in his room and fills his thermos. On 08/16/22 at 01:35PM, Certified Nurse Aide (CNA) M stated, I am not sure if he is on a fluid restriction. On 08/16/22 at 02:20PM, Licensed Nurse (LN) G stated staff document on R37 every shift since he was on skilled services. LN G confirmed staff did not do an assessment of R37's [CONDITION(S)] site. R37 left about 07:00 AM and returned around 05:00 PM from [CONDITION(S)] Monday, Wednesday and Friday. R37 did not have a daily dressing that staff changed. He was in on a fluid restriction of 1500 ml. On 08/16/22 at 2:50PM, Administrative Nurse D verified the resident was on a fluid restriction and the facility was not compliant with keeping track the amount of fluid the resident was consuming. Administrative Nurse D also verified the facility was not assessing or documenting R37's [CONDITION(S)] before and after treatments. The facility's [CONDITION(S)] Care for a Resident policy, dated 05/2021, stated an ongoing assessment of a resident on [CONDITION(S)] should be done before and after each [CONDITION(S)] session. This includes assessment of [CONDITION(S)] site, weight, vital signs any changes are to be reported to the resident's physician. The facility failed to assess, and monitor for [CONDITION(S)] related conditions and failed to adhere to a fluid restriction for R37 who received [CONDITION(S)] three times a week. This placed R 37 at risk for complications from [CONDITION(S)] and potential fluid overload.

The facility had a census of 38 residents. The sample included 12 residents with one reviewed for [CONDITION(S)] (a treatment to filter wastes and water from your blood, by the use of a [CONDITION(S)] machine). Based on observation, record review and interview, the facility failed to ensure staff possessed the knowledge and skills necessary to provide care to the standards of practice for residents who received [CONDITION(S)] when facility staff failed to assess Resident (R) 37 for complications before and after [CONDITION(S)] treatments and failed to correctly identify a [CONDITION(S)] access site and monitor for complications. This deficient practice placed R37 at increased risk for adverse effects and negative outcomes. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR documented R37 admitted to the facility on [DATE] and transported out of facility three times a week on Monday, Wednesday and Friday to a [CONDITION(S)] center. The Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition. R37 required staff assistance with transfers to the wheelchair, and the resident was independently mobile in a wheelchair. The Activities of Daily Living (ADL) Care Area Assessment Summary (CAA), dated 08/05/22, recorded the resident received hemodialysis at a [CONDITION(S)] center three times a week. The [CONDITION(S)] care plan dated 08/05/22 directed the staff to check and change dressing at access site daily. Assess [CONDITION(S)] access site every shift and monitor vital signs and weight before and after [CONDITION(S)]. R37 was to only consume 1500 ml of fluid in a 24-hour period. R37's Physician Order, dated 07/29/22, instructed staff the resident was on a fluid restriction of 1500 ml in a 24-hour period. The registered dietician admission assessment note dated 07/30/22, documented the resident was on a 1500 ml fluid restriction. Review of the EMR lacked documentation of assessment of the [CONDITION(S)] site, assessment before and after [CONDITION(S)], and lacked monitoring of R37's fluid intake. The Nurses Note dated 08/06/22 at 01:19PM, documented a fistula (an abnormal connection between an artery and a vein) was present in right forearm, and bruit (blowing or swishing sound heard which reflects the blood flow with a [CONDITION(S)] resident's shunt) and thrill (a fine vibration felt which reflects the blood flow by a [CONDITION(S)] resident's shunt ) heard without complications. On 08/16/22 at 01:10PM, R37 observed seated in his wheelchair in his room. Further observation revealed a metal thermos and a water pitcher at the bedside. On 08/16/22 at 01:10PM, R37 stated he goes to [CONDITION(S)] three times a week, on Monday, Wednesday and Friday. R37 stated his [CONDITION(S)] access site is in the left [MEDICATION(S)] (an artery or vein in the upper side of the neck) artery and not in either of his arms. R37 stated no one at the facility checks his access site or assess him before or after [CONDITION(S)] treatments. On 08/16/22 at 02:20PM, Licensed Nurse (LN) G stated staff document on R37 every shift since he was on skilled services. Staff did not do an assessment of his [CONDITION(S)] site. R37 left about 07:00 AM and returned around 05:00 PM from [CONDITION(S)] Monday, Wednesday and Friday. R37 did not have a daily dressing that staff changed. On 08/16/22 at 02:30PM, LN H stated they did the documentation on 08/06/22, and did document the access site in the right forearm. LN H stated he/she was thinking of a different resident. On 08/16/22 at 2:50PM, Administrative Nurse D verified the facility was not assessing or documenting R37's [CONDITION(S)] before and after treatments; Administrative Nurse D was unsure why LN H documented the resident had an access site in the right forearm. The facility's [CONDITION(S)] Care for a Resident policy, dated 05/2021, stated an ongoing assessment of a resident on [CONDITION(S)] should be done before and after each [CONDITION(S)] session. This includes assessment of [CONDITION(S)] site, weight, vital signs any changes are to be reported to the resident's physician. The facility failed to ensure staff possessed the knowledge and skills necessary to provide care to the standards of practice for residents who received [CONDITION(S)] when facility staff failed to assess R37 for complications before and after [CONDITION(S)] treatments and failed to correctly identify a [CONDITION(S)] access site and monitor for complications. This deficient practice placed R37 at increased risk for adverse effects and negative outcomes.

The facility had a census of 38 residents. The sample included three residents reviewed for indwelling catheter care (a closed urinary drainage system inserted into the bladder). Based on observation, interview and record review, the facility failed to provide appropriate catheter care to prevent the risks of urinary tract infections (infection that occurs when bacteria enters into any part of the urinary tract) for one sampled resident, Resident (R)1 placing him at risk for urinary tract infections. - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1's Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further documented R1 required extensive assistance of two staff to total dependence of two staff for all activities of daily living. The MDS documented R1 was admitted with an indwelling catheter. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 11/24/21, documented R1 was admitted to the facility with a catheter to dependent drainage due to [CONDITION(S)] bladder secondary to [CONDITION(S)]. R1 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's catheter was noted to have increased sediment in his catheter tubing and a urine specimen showed that he had a [CONDITION(S)] urinary tract infection was treated with [MEDICATION(S)] (antibiotic) starting on 11/29/21. The Catheter Care Plan, revised on 12/10/21, directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, use contact precautions when working the catheter, monitor and document output, and to change the catheter once a month on the fifth of each month. On 02/07/22 at 10:00 AM, observation revealed R1's catheter bag hanging on the trashcan in his room with the urine collection bag inside of the trashcan. Urine was observed leaking into the trashcan. The urine catheter bag was dated 02/01/22. On 02/07/22 at 01:00 PM, observation revealed, Physical Therapy Assistant/Certified Nurse's Aide (PTA/CNA) M had gloves on and took the catheter bag out of the trash can to change the catheter bag. On02/27/21 at 10:00 AM, R1 stated that his catheter bag had started leaking the night before and the staff had cleaned up the urine on the floor but then had put his catheter bag into the trash can instead of changing the catheter bag. R1 pointed to his catheter bag in the trashcan and stated, That is wrong I'm sure I'm going to get another infection from this. On 02/07/22 at 01:00 PM, PTA/CNA M verified that the catheter bag was leaking into the trashcan and that is why she was changing the catheter bag. On 02/07/22 at 01:00 PM, CNA N stated that she had put the catheter bag on the trash can this morning, but the catheter bag was not inside the trashcan. CNA N stated she knew the catheter bag should not be hung on the trashcan and should be on the zip ties on R1's electric wheelchair. On 02/07/22 at 02:00 PM, Administrative Nurse D, stated that it was absolutely wrong for the catheter bag to be hanging on a trash can and if it had been leaking then the catheter bag should have been changed immediately and she would expect all of her staff to know that and follow the facility protocols regarding catheter care. The facility's Catheter Care policy, dated May 2021, documented the purpose of the procedure was to prevent infection in the resident's urinary tract. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly report it to your supervisor. Should the resident indicate that his or her bladder is full or that he or she needs to void, report it immediately to your supervisor. Check the urine for unusual appearance. The urinary drainage bag must always be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the bladder. Check the resident frequently to be sure the tubing is free of kinks. The facility failed to provide appropriate catheter care to R1, placing him at risk for urinary tract infections.

The facility had a census of 35 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician regarding pulses out of parameters for one of five sampled residents, Resident (R) 28. Findings included: - R28's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS, dated 06/17/21, directed staff to notify R28's primary care physician (PCP) if blood pressure (BP) greater than 180/90 millimeters of mercury (mmHg) or less than 90/60 mmHg and/or if pulse greater than 110 beats per minute (bpm) or less than 60 bpm. Review of R28's Electronic Medical Record (EMAR) -Vital Signs, dated 01/20/21, documented a pulse of 111 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. The Nurse's Note, dated 01/24/21 at 07:24 PM, documented a pulse of 120 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. Review of R28's EMR-Vital Signs, dated 02/13/21, documented a pulse of 113 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. The Nurse's Note, dated 02/14/21 at 01:23 PM, documented a pulse of 124 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. The Nurse's Note, dated 03/06/21 at 11:09 AM, documented a pulse of 116 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. The Nurse's Note, dated 03/09/21 at 08:10 PM, documented a pulse of 120 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. The Nurse's Note, dated 03/09/21 at 08:49 PM, documented a pulse of 118 bpm. The EMR lacked documentation staff notified the resident's PCP of the out of parameter pulse. On 07/14/21 at 10:00 AM, observation revealed R28 sat in the hallway and visited with staff as they passed by. Resident smiling and pleasant with staff. On 07/15/21 at 10:16 AM, Licensed Nurse (LN) G stated the nurses obtained vital signs for any skilled residents and the Certified Nurse Aides (CNAs) obtained vital signs on the rest of the residents. LN G stated she expected the CNAs to report any abnormal vital signs to her or another nurse. The nurses are to review the vital signs before they document them and report any abnormal vital signs to the resident's PCP immediately. On 07/15/21 at 10:37 AM, CNA M stated she obtained vital signs, and if there were any abnormally high vital sign she would check it again. If the vital signs were still high she would notify the nurse. On 07/15/21 at 10:45 AM, CNA N stated she was assigned to obtain vital signs. If there were a vital signs that were out of range she immediately let the nurse know what the vital signs were and then the nurse checked the vital signs herself. On 07/15/21 at 10:52 AM, LN H stated she would notify the PCP of any vital signs that were out of parameters and wait for their direction. On 07/15/21 at 11:20 AM Administrative Nurse D stated she expected the nurses to notify the doctor with any vital signs that were out of parameters. The facility's revised Change in Resident's Condition or Status policy, dated November 2017, documented the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician of changes in the resident's medical/mental condition and /or status. A significant change in the resident's physical, mental, or psychosocial status including deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. Nursing will follow instructions to notify the physician of changes in the resident's condition. The facility failed to notify R28's physician about abnormally high pulses, placing the resident at risk for health complications.

The facility had a census of 36 residents. The sample included six residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure four of six sampled residents were free from inappropriate touching by Resident (R) 1, who made sexual actions toward women on multiple different occasions. This deficient practice placed all 23 female residents in immediate jeopardy. Findings included: - R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of five. R1 required limited assistance of one staff for transfers, walking in his room, and locomotion on the unit. He did not have behaviors. The Quarterly MDS, dated [DATE], documented R1 had had severely impaired cognition with a BIMS score of five. R1 required extensive assistance of one staff for transfers, walking, and locomotion on and off the unit. He did not have behaviors. The Cognitive Patterns/Dementia Care Area Assessment (CAA), dated 10/26/20, recorded the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was alert and oriented to self, town, and aware he was in a nursing facility, but did not know the name of the facility, date, month, or year. R1 knew he could not care for himself at home due to miscommunication, behaviors, elopement, and falls. The Activity of Daily Living (ADL) CAA, dated 10/26/20, recorded the resident required supervision of one staff with bed mobility, limited assistance of one staff with transfers, walking in room, locomotion on the unit, dressing, and personal hygiene, and extensive assistance of one staff with toilet use. During the seven day lookback period, R1 got up when he wanted and ambulated about the facility independently with his walker. The Inappropriate Sexual Behavior Care Plan, initiated 10/21/20, instructed staff to remind R1 sexual comments were inappropriate and to safely walk away if possible. The update, dated 12/17/20, instructed staff to administer [MEDICATION(S)] (medication used to lower sexual behaviors) and monitor effectiveness. R1's Telepsych (live video meeting over the internet) appointment scheduled for s12/28/20 (the first Telepsych visit was on 01/23/21) directed staff to follow the clinician's recommendations and continue with monthly video visits. The revised ADL Care Plan, dated 11/06/20, recorded the resident ambulated with a front wheeled walker and generally transferred independently. The care plan directed staff to provide supervision and/or cueing at times. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychiatric Patient Referral, dated 01/23/21, documented Consultant GG saw R1 for sexual disinhibition with symptoms (inappropriate sexual impulses that were once controlled by intact judgment or moral values) for four months with gradual onset. Symptoms were currently worse, and he had a decline in recent memory. The resident had inappropriate behaviors with female residents like, holding hands at night at the female resident's bedside and attempts to kiss females. The clinician recommended follow up in one month. If R1 continued to have issues, then consideration of additions to implement medications for management of these behaviors with involvement of family. The Psychiatric Patient Referral, dated 02/22/21, documented during R1's one-month follow-up appointment, Consultant GG recommended continued evaluation in one month due to cognitive impairments and recent behavioral impairments of an inappropriate nature. The note directed facility staff to continue observation of mood and behaviors with focus on prevention of re-initiation of impulsive/sexually disinhibited behaviors with continued primary focus on use of redirected/reorienting behaviors by staff to limit behavioral disturbances due to dementia diagnosis. If reoccurrence, again consider medication options. The Psychiatric Patient Referral, dated 03/29/21, documented at R1's one-month follow-up appointment Consultant GG recommended follow up in one month due to cognitive impairments and improved behaviors- tolerating medications. Staff utilized behavioral redirection with success. The Psychiatric Patient Referral, dated 03/29/21, documented during R1's one-month follow-up appointment the clinician recommended follow up in two months due to cognitive impairments and improved behaviors- tolerating medications. Staff utilized behavioral redirection with success. The note directed staff to continue observation of mood and behaviors with focus on prevention of re-initiation of impulsive/sexually disinhibited behaviors with continued primary focus on use of redirection/reorienting behaviors by staff to limit behavioral disturbances due to dementia diagnosis. The Progress Note, dated 10/21/20 at 02:00 AM, documented R1 asked the Certified Nurse Aide (CNA) doing one-to-one care to get in bed with him. R1 told her she could lay on top of him and she would enjoy it and he wanted to see all of the CNA. Staff told him it was inappropriate, and he needed to stop, R1 then went back to bed. The Progress Note, dated 10/23/20 at 01:58 AM, documented staff found R1 in the room of female residents, R4 and R7. R7 yelled for a nurse. When the unidentified staff arrived in the room, R1 sat on his walker's seat touched R4's legs and asked her if she was his wife. Staff redirected R1 out of the female resident's room and back to his own room. The Progress Note, dated 12/15/20 at 02:06 AM, documented R7 turned on her call light, came out into the hallway, and reported R1 was in her room. Staff found R1 naked sitting on R4's bed and was kissing her. R7 stated you guys need to (explicit) do something about him, this is (explicit). Staff assisted R1 back to his bed and closed R4 and R7's door per their request. The Progress Note, dated 12/15/20 at 09:40 AM, documented staff notified R1's physician regarding R1's hypersexual behaviors and wandering into female residents' rooms at night which made the women afraid. The note documented R1 was not violent, but often had very little clothing on. The Progress Note, dated 12/16/20 at 09:40 AM, documented LN J contacted R1's family member to update them on R1's increased sexual behaviors especially in the middle of the night, which frightened some of the women in the facility. The family member stated R1 would come in her room at night when he lived with her. LN J assured the family member R1 did not make any attempt to hurt the female residents, but did scare them when he was standing there in the middle of the night. On one incident, R1 did try to kiss a female resident. LN J discussed Telepsych services for R1 and the family member agreed to start Telepsych services. LN J sent a message to R1's primary care physician (PCP) and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Progress Note, dated 12/19/20 at 05:30 AM, documented CNA staff were in a different resident's room and LN H was dictating report in the quite room. CNA staff found R1 in a female resident, R6's, room standing at her bedside. CNA staff redirected R1 to his room and reminded him that was not appropriate for him to go into other resident's room. R1 stated, I thought that was my wife. The Progress Note, dated 12/19/20 at 03:20 PM, documented LN K observed R1 approacha female resident, R5, sitting in a chair in the hallway. R1 bent over and started rubbing R5's shoulder and back. His face was very close to the female resident and LN K and LN G were nervous about R1's physical closeness to R5. LN G went down the hall and was behind R1 and heard R5 state, You're not supposed to touch me, and R5 was obviously uncomfortable. LN G told R1 he made the female resident uncomfortable and he needed to stop touching her and move away. R1 stated, Oh it's OK, we're just friends. R1 walked down the hall. R5 told LN G thank you and held her hand. The Progress Note, dated 03/19/21 at 10:41 PM, documented R1 wandered up and down the hallway this evening with his walker looking for his wife. Staff redirected him back to his room. The Progress Note, in R2's Electronic Medical Record (EMR), dated 04/21/21 at 10:09 AM, documented at approximately 01:10 AM CNA N answered R2's call light. R2 stated, I had a visitor. That man was in my room . He had tried to get on top of me. LN G assessed R2 from head to toe with no bruising, scrapes, cuts or abrasion noted. While R2 laid in bed LN G asked her to show were R1 touched her. R2 pointed to her left breast area to mid-sternum. LN G notified the administrator, Director of Nursing, the PCP, and R2's son. Staff place R1 on 1:1 status until further notice. The Progress Note, in R1's EMR, dated 04/21/21 at 09:17 PM, documented CNA M did 1:1 care with R1 until he went to bed. (R1's EMR lacked documentation for a reason why R1 was on 1:1 status) On 04/22/21 at 01:01 PM, R2 stated on 04/21/21 around 12:30 AM or 01:30 AM she was sound asleep and woke up in a fright. A man was feeling all over her chest, he was feeling my breast and he said, You are no fun anymore. I kept trying to push his hands back. R2 stated she could not get ahold of the call light to push the button. She said she was mad. He went out the door as the nurse was coming in the door. Staff gave her a night light and closed the room door. R2 stated it took a little while to fall back asleep. R2 talked to the sheriff the next morning and did not want to press charges, she just wanted to forget it ever happened. On 04/26/21 at 12:05 PM, R4 stated about four months ago a male (R1) came in her room while she was asleep. She woke up when he was touching me down below and pointed to her groin area. She stated she was afraid and asked him who he was. The nurse came in and ordered him out of her room. On 04/26/21 at 12:08 PM R7 stated several months ago she woke up and saw a man (R1) touching R4. That had happened a few nights before this too. The man only had on underwear and it was scary, and she was afraid. The staff knew that resident wandered and should have done something to stop him the first time he came in their room. On 04/22/12 at 01:41 PM, Temporary Nurse Aide (TNA) O stated on 04/21/21 R2 said a man was in her room on top of her trying to touch her breast. TNA O assisted R2 to the bathroom and upon returning to her bed, R2 asked TNA O if the man was going to be back. TNA O told her, No, and R1 was back in his own room. TNA O stated she thought R2 wanted her to do more than just take R1 to his room. TNA O told R2 she could tell the nurse on duty so it would be investigated, but R2 said, Never mind, don't worry about it. TNA O told LN G about the incident. TNA O stated R1 got up multiple times a night and walked to the nurse's station. This was the first time he had gone into another resident's room that she knew of. She did not know if he was care planned for any behaviors. R1 had been up a couple of times that night and staff took him to the bathroom and got him a snack. It was a typical night with him. On 04/22/21 at 01:48 PM CNA N stated on 04/21/21 at 01:10 AM she answered R2's call light. R2 said she had a visitor. A man was in here. He was trying to . touch my breast. CNA N told R2 staff would make sure R1 did not come back into her room. R2 told her she would be up all night since she was awakened. CNA N stated while she was in R2's room she heard the toilet flush across the hall and found R1 coming out of the bathroom in another resident's room. R1 told CNA N he was looking for his bed, he did not have his walker, and only had on one gripper sock, so CNA N used another resident's walker and assisted R1 back to bed. On 04/22/21 at 03:01 PM, LN G stated on 04/21/21 around 01:10 AM, R2 reported a man was in her room and touched her breast. R2 said she was frightened by having a man standing by her bed when she woke up. LN G assessed R2 with no injury found. On 04/26/21 at 01:22 PM, Administrative Nurse D identified the female residents R1 had incidents with on 12/15/20 as R4 and R7, on 12/19/20 as R5 and R6. She stated she expected staff to follow the policy and interventions were not put in place to prevent R1's sexual behaviors and wandering into other resident's rooms. On 04/26/21 at 02:33 PM, Administrative Staff A stated she expected staff to have interventions put in place to prevent R1's sexual behavior. She confirmed R1's care plan was not updated after he went into R4's room on 10/23/21 and touched R4's leg. Administrative Staff A stated staff should follow the facility's abuse policy. The revised Facility Abuse Prevention Program policy, dated November 2017, documented residents have the right to be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain or mental anguish. Comprehensive policies and procedures have been developed to aid the facility administration in preventing abuse, neglect, or mistreatment. The abuse prevention program provides policies and procedures that govern, as a minimum the implementation of changes to prevent future occurrences of abuse. The facility failed to ensure female residents remained free from inappropriate sexual touching and behavior from R1 on five different occasions. This deficient practice placed the female residents in the facility in immediate jeopardy. The facility provided an acceptable removal plan on 04/27/21 when the facility placed R1 on 1:1 supervision until admitted to a Geri-psychiatric unit on 04/27/21, moved R1 to a private room and will be supervised within arm's reach of staff when outside of his room, held mandatory staff education/training on abuse, neglect, and exploitation policy, reporting abuse, the use of motion alarms in R1's room. The administrator will monitor daily until lesser frequency is determined during Quality Assurance Meetings, review behavior alerts documented in plan of correction and Point Click Care, review any incident report with 24 hours of incident, and hold daily clinical meeting for daily nurses' notes related any behavior changes that need investigated. This deficient practice remained at a scope and severity of an H.

The facility had a census of 36 residents. The sample included six residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to protect the 23 female residents that resided in the facility when R1 exhibited inappropriate touching and sexual actions on multiple different occasions. This deficient practice placed all 23 female residents in immediate jeopardy. Findings included: - R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of five. R1 required limited assistance of one staff for transfers, walking in his room, and locomotion on the unit. He did not have behaviors recorded on the assessment. The Quarterly MDS, dated [DATE], documented R1 had had severely impaired cognition with a BIMS score of five. R1 required extensive assistance of one staff for transfers, walking, and locomotion on and off the unit. He did not have behaviors recorded on the assessment. The Cognitive Patterns/Dementia Care Area Assessment (CAA), dated 10/26/20, recorded the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was alert and oriented to self, town, and aware he was in a nursing facility, but did not know the name of the facility, date, month, or year. R1 knew he could not care for himself at home due to miscommunication, behaviors, elopement, and falls. The Activity of Daily Living (ADL) CAA, dated 10/26/20, recorded the resident required supervision of one staff with bed mobility, limited assistance of one staff with transfers, walking in room, locomotion on the unit, dressing, and personal hygiene, and extensive assistance of one staff with toilet use. During the seven-day lookback period, R1 got up when he wanted and ambulated about the facility independently with his walker. The Inappropriate Sexual Behavior Care Plan, initiated 10/21/20, instructed staff to remind R1 that sexual comments were inappropriate and to safely walk away if possible. The update, dated 12/17/20, instructed staff to administer [MEDICATION(S)] (medication used to lower sexual behaviors) and monitor effectiveness. R1's Telepsych (live video meeting over the internet) appointment scheduled for 12/28/20 (the first Telepsych visit was on 01/23/21) directed staff to follow the clinician's recommendations and continue with monthly video visits. The revised ADL Care Plan, dated 11/06/20, recorded the resident ambulated with a front wheeled walker and generally transferred independently. The care plan directed staff to provide supervision and/or cueing at times. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychiatric Patient Referral, dated 01/23/21, documented Consultant GG saw R1 for sexual disinhibition with symptoms (inappropriate sexual impulses that were once controlled by intact judgment or moral values) for four months with gradual onset. Symptoms were currently worse, and he had a decline in recent memory. The resident had inappropriate behaviors with female residents like, holding hands at night at the female resident's bedside and attempts to kiss females. The clinician recommended follow up in one month. If R1 continued to have issues, then consideration of additions to implement medications for management of these behaviors with involvement of family. The Psychiatric Patient Referral, dated 02/22/21, documented during R1's one-month follow-up appointment, Consultant GG recommended continued evaluation in one month due to cognitive impairments and recent behavioral impairments of an inappropriate nature. The note directed facility staff to continue observation of mood and behaviors with focus on prevention of re-initiation of impulsive/sexually disinhibited behaviors with continued primary focus on use of redirected/reorienting behaviors by staff to limit behavioral disturbances due to dementia diagnosis. If reoccurrence, again consider medication options. The Psychiatric Patient Referral, dated 03/29/21, documented at R1's one-month follow-up appointment Consultant GG recommended follow up in one month due to cognitive impairments and improved behaviors- tolerating medications. Staff utilized behavioral redirection with success. The Psychiatric Patient Referral, dated 03/29/21, documented during R1's one-month follow-up appointment the clinician recommended follow up in two months due to cognitive impairments and improved behaviors- tolerating medications. Staff utilized behavioral redirection with success. The note directed staff to continue observation of mood and behaviors with focus on prevention of re-initiation of impulsive/sexually disinhibited behaviors with continued primary focus on use of redirection/reorienting behaviors by staff to limit behavioral disturbances due to dementia diagnosis. The Progress Note, dated 10/21/20 at 02:00 AM, documented R1 asked the Certified Nurse Aide (CNA) doing one-to-one care to get in bed with him. R1 told her she could lay on top of him and she would enjoy it and he wanted to see all of the CNA. Staff told him it was inappropriate, and he needed to stop, R1 then went back to bed. The Progress Note, dated 10/23/20 at 01:58 AM, documented staff found R1 in the room of female residents, R4 and R7. R7 yelled for a nurse. When the unidentified staff arrived in the room, R1 sat on his walker's seat touched R4's legs and asked her if she was his wife. Staff redirected R1 out of the female resident's room and back to his own room. The Progress Note, dated 12/15/20 at 02:06 AM, documented R7 turned on her call light, came out into the hallway, and reported R1 was in her room. Staff found R1 naked sitting on R4's bed and was kissing her. R7 stated you guys need to (explicit) do something about him, this is (explicit). Staff assisted R1 back to his bed and closed R4 and R7's door per their request. The Progress Note, dated 12/15/20 at 09:40 AM, documented staff notified R1's physician regarding R1's hypersexual behaviors and wandering into female residents' rooms at night which made the women afraid. The note documented R1 was not violent, but often had very little clothing on. The Progress Note, dated 12/16/20 at 09:40 AM, documented LN J contacted R1's family member to update them on R1's increased sexual behaviors especially in the middle of the night, which frightened some of the women in the facility. The family member stated R1 would come in her room at night when he lived with her. LN J assured the family member R1 did not make any attempt to hurt the female residents but did scare them when he was standing there in the middle of the night. On one incident, R1 did try to kiss a female resident. LN J discussed Telepsych services for R1 and the family member agreed to start Telepsych services. LN J sent a message to R1's primary care physician (PCP) and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Progress Note, dated 12/19/20 at 05:30 AM, documented CNA staff were in a different resident's room and LN H was dictating report in the quite room. CNA staff found R1 in a female resident, R6's, room standing at her bedside. CNA staff redirected R1 to his room and reminded him that was not appropriate for him to go into other resident's room. R1 stated, I thought that was my wife. The Progress Note, dated 12/19/20 at 03:20 PM, documented LN K observed R1 approach a female resident, R5, sitting in a chair in the hallway. R1 bent over and started rubbing R5's shoulder and back. His face was very close to the female resident and LN K and LN G were nervous about R1's physical closeness to R5. LN G went down the hall and was behind R1 and heard R5 state, You're not supposed to touch me, and R5 was obviously uncomfortable. LN G told R1 he made the female resident uncomfortable and he needed to stop touching her and move away. R1 stated, Oh it's OK, we're just friends. R1 walked down the hall. R5 told LN G thank you and held her hand. The Progress Note, dated 03/19/21 at 10:41 PM, documented R1 wandered up and down the hallway this evening with his walker looking for his wife. Staff redirected him back to his room. The Progress Note, in R2's Electronic Medical Record (EMR), dated 04/21/21 at 10:09 AM, documented at approximately 01:10 AM CNA N answered R2's call light. R2 stated, I had a visitor. That man was in my room . He had tried to get on top of me. LN G assessed R2 from head to toe with no bruising, scrapes, cuts or abrasion noted. While R2 laid in bed LN G asked her to show were R1 touched her. R2 pointed to her left breast area to mid-sternum. LN G notified the administrator, Director of Nursing, the PCP, and R2's son. Staff place R1 on 1:1 status until further notice. The Progress Note, in R1's EMR, dated 04/21/21 at 09:17 PM, documented CNA M did 1:1 care with R1 until he went to bed. (R1's EMR lacked documentation for a reason why R1 was on 1:1 status) On 04/22/21 at 01:01 PM, R2 stated on 04/21/21 around 12:30 AM or 01:30 AM she was sound asleep and woke up in a fright. A man was feeling all over her chest, he was feeling my breast and he said, You are no fun anymore. I kept trying to push his hands back. R2 stated she could not get ahold of the call light to push the button. She said she was mad. He went out the door as the nurse was coming in the door. Staff gave her a night light and closed the room door. R2 stated it took a little while to fall back asleep. R2 talked to the sheriff the next morning and did not want to press charges, she just wanted to forget it ever happened. On 04/26/21 at 12:05 PM, R4 stated about four months ago a male (R1) came in her room while she was asleep. She woke up when he was touching me down below and pointed to her groin area. She stated she was afraid and asked him who he was. The nurse came in and ordered him out of her room. On 04/26/21 at 12:08 PM R7 stated several months ago she woke up and saw a man (R1) touching R4. That had happened a few nights before this too. The man only had on underwear and it was scary, and she was afraid. The staff knew that resident wandered and should have done something to stop him the first time he came in their room. On 04/22/12 at 01:41 PM, Temporary Nurse Aide (TNA) O stated on 04/21/21 R2 said a man was in her room on top of her trying to touch her breast. TNA O assisted R2 to the bathroom and upon returning to her bed, R2 asked TNA O if the man was going to be back. TNA O told her, No, and R1 was back in his own room. TNA O stated she thought R2 wanted her to do more than just take R1 to his room. TNA O told R2 she could tell the nurse on duty so it would be investigated, but R2 said, Never mind, don't worry about it. TNA O told LN G about the incident. TNA O stated R1 got up multiple times a night and walked to the nurse's station. This was the first time he had gone into another resident's room that she knew of. She did not know if he was care planned for any behaviors. R1 had been up a couple of times that night and staff took him to the bathroom and got him a snack. It was a typical night with him. On 04/22/21 at 01:48 PM CNA N stated on 04/21/21 at 01:10 AM she answered R2's call light. R2 said she had a visitor. A man was in here. He was trying to . touch my breast. CNA N told R2 staff would make sure R1 did not come back into her room. R2 told her she would be up all night since she was awakened. CNA N stated while she was in R2's room she heard the toilet flush across the hall and found R1 coming out of the bathroom in another resident's room. R1 told CNA N he was looking for his bed, he did not have his walker, and only had on one gripper sock, so CNA N used another resident's walker and assisted R1 back to bed. On 04/22/21 at 03:01 PM, LN G stated on 04/21/21 around 01:10 AM, R2 reported a man was in her room and touched her breast. R2 said she was frightened by having a man standing by her bed when she woke up. LN G assessed R2 with no injury found. On 04/26/21 at 01:22 PM, Administrative Nurse D identified the female residents R1 had incidents with on 12/15/20 as R4 and R7, on 12/19/20 as R5 and R6. She stated she expected staff to follow the policy and interventions were not put in place to prevent R1's sexual behaviors and wandering into other resident's rooms. On 04/26/21 at 02:33 PM, Administrative Staff A stated she expected staff to have interventions put in place to prevent R1's sexual behavior. She confirmed R1's care plan was not updated after he went into R4's room on 10/23/21 and touched R4's leg. Administrative Staff A stated staff should follow the facility's abuse policy. The revised Facility Abuse Investigations policy, dated November 2017, documented reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Residents will (be) protected from further abuse, neglect, exploitation or mistreatment while the investigation is in process. The facility failed to protect the 23 female resident that resided in the facility from R 1's inappropriate touching and sexual actions on multiple different occasions. This deficient practice placed all 23 female residents in immediate jeopardy. The facility provided an acceptable removal plan on 04/27/21 when the facility placed R1 on 1:1 supervision until admitted to a Geri-psychiatric unit on 04/27/21, moved R1 to a private room and will be supervised within arm's reach of staff when outside of his room, held mandatory staff education/training on abuse, neglect, and exploitation policy, reporting abuse, the use of motion alarms in R1's room. The administrator will monitor daily until lesser frequency is determined during Quality Assurance Meetings, review behavior alerts documented in plan of correction and Point Click Care, review any incident report with 24 hours of incident, and hold daily clinical meeting for daily nurses' notes related any behavior changes that need investigated. This deficient practice remained at a scope and severity of a F.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infection for the 36 residents who resided in the facility. Staff failed to follow contact isolation guidelines for Resident (R) 13, who had a [DIAGNOSES REDACTED]. Diff) (a contagious bacteria characterized by foul smelling, frequent, bowel movements), and [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) (a bacteria that is normally present in the human intestines that had developed resistance to the antibiotic [MEDICATION NAME]). The facility also failed to place R24 in isolation after he was diagnosed with [REDACTED]. This deficient practice had the potential to affect the other 34 residents who resided in the facility, placing the other 34 residents in immediate jeopardy. Findings included: - R13's Physician order [REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 05/30/19, documented the resident had intact cognition, required supervision with eating, extensive staff assistance with most Activities of Daily Living (ADLs), and total staff assistance with transfers. The MDS recorded the resident had occasional bowel incontinence, had an open lesion, was not on isolation precautions, did not indicate wound infection, and the resident did not receive antibiotics. The quarterly MDS, dated [DATE], documented the resident had intact cognition, required supervision with eating and extensive assistance of two staff for all other ADLs. The 05/30/19 Care Area Assessment (CAA) for pressure ulcers documented the resident required assistance with bed mobility and was frequently incontinent of bowel. The MDS recorded the resident entered with three fistula sites with purulent (producing or containing pus) drainage, a large amount of thick pungent (strong, unpleasant smell) drainage, and the areas were very red and moist. These fistula areas measured 3.9 centimeters (cm) x 1.8 cm, 1.0 cm x 0.5 cm, and 4.0 cm x 1.1 cm. The 06/12/19 care plan documented the resident had VRE colonization to the wound fistulas. The care plan directed staff to bag and transport soiled trash and wound supply linens in a tied bag and place in the appropriate biohazard receptacle preventing skin exposure or contamination. The care plan directed staff to wear a gown when there was a chance of coming into contact with feces or body fluids from the fistula site and when changing contaminated linens or wound dressings. The care plan directed staff to place soiled linens in bags marked biohazard, bag linens and close the bag tightly before taking to the laundry. The care plan directed staff to instruct family, visitors, and caregivers to wear a disposable gown and gloves during physical contact with the resident, discard in the appropriate receptacle, and wash hands before leaving the room. The care plan directed staff to keep appropriate Personal Protective Equipment (PPE) in a clean linen closet by the resident's door so staff had it easily accessible when needed and observe standard precautions for infection control when there was no risk of coming into contact with infected material. The care plan documented staff were provided VRE education on the resident's admission. The 06/20/19 Physician order [REDACTED]. The 06/23/19 Micro lab detected C.Diff infection and the physician ordered [MEDICATION NAME] (antibiotic) 125 milligrams (mg), by mouth, every six hours until 07/09/19, then 125 mg every 12 hours until 07/16/19, then 125 mg daily until 07/23/19, then 125 mg every two days until 08/08/19. The 07/05/19 physician's orders [REDACTED]. The 07/16/19 physician's orders [REDACTED]. (Already in place per 06/06/19 care plan) The 08/05/19 at 02:49 PM, nurse's note documented the resident continued [MEDICATION NAME] antibiotic therapy for [MEDICAL CONDITION]., continued to have loose, frequent stools, and the fistula areas to the left hip improved. The resident's 07/25/19-08/06/19 Bowel Record recorded no formed stools, majority were loose/diarrhea with six occasional stools recorded as putty like. On 08/06/19 at 10:27 AM, observation revealed Housekeeping Staff (HS) V and W entered room [ROOM NUMBER], washed their hands, and applied gowns and gloves found inside the resident's room. HS W exited the room with trash and placed in a trash bag on the housekeeping cart, wearing her gown and gloves, and reentered the room with the Virasept (powerful disinfectant), set the spray bottle down on the dresser, without a barrier, and tied HS V's gown. Observation revealed HS W sprayed the surfaces of the bedside table, over the bed table, and top of dresser. HS W let the cleaner set for 2 minutes then wiped with a rag. HS W exited the room with gown and gloves in place and retrieved a mop and cloth mop head from the housekeeping cart. HS V cleaned the toilet with Virasept cleaner and flushed. HS W sprayed the floor with Virasept as HS V exited the room with trash liner and placed it into the housekeeping cart parked outside the resident's doorway. Observation revealed at 10:45 AM, Certified Medication Aide (CMA) M, wearing gloves but no gown, entered the room, applied [MEDICATION NAME] gel on the resident, from the tube she carried in with her, then removed her gloves and exited the room with the [MEDICATION NAME] gel, without cleaning the tube, and returned the gel to the medication cart. HS V and W finished mopping the floor, removed gowns and gloves, washed their hands and exited the room. Observation revealed no PPE outside the resident's room, but a sign posted on the resident's door directing visitors to check with the nurse before entering. On 08/06/19 at 03:20 PM, observation revealed Licensed Nurse (LN) H assessed and changed R13's wound dressings. LN H and CMA M washed their hands, applied gloves and gowns from inside the resident's room. LN H used wax paper for a clean surface (barrier) on the bedside table and placed the wound care supplies on it. LN H uncovered two small fistulas on the resident's left hip, which oozed [MEDICAL CONDITION] (mixture of blood and pus), tan drainage. The soiled dressing had a large amount of brownish colored drainage, the nurse (wearing the same soiled gloves) used gauze and wound wash to cleanse the fistulas and applied a thick layer of Zinc/[MEDICATION NAME] ointment. After finishing the wound care, LN H and CMA M removed their soiled gloves and gowns. The resident then requested a turn sheet placed under her, so LN H and CMA M applied new gloves, no isolation gowns, turned and placed the resident on a turn sheet while their unprotected uniforms touched the bed. On 08/06/19 at 10:27 AM, HS W stated she did not know why the gowns were inside R13's room, she just knew that nursing placed them in there. On 08/06/19 at 10:27 AM, HS V stated staff were not aware of the wet time for the Virasept spray cleaner, they need to look at the bottle. On 08/06/19 at 11:12 AM, Housekeeping/Laundry Supervisor U stated she did not understand contact isolation, was not aware that staff had set the Virasept spray bottle down in the isolation room and was not aware staff exited the room several times wearing PPE. HS U stated staff should not have exited the room with the Virasept spray bottle, and housekeeping needed some way to indicate the mop head from that room was designated as an isolation issue. On 08/07/19 at 03:06 PM, Administrative Nurse D verified the physician had not ordered the contact isolation discontinued. Administrative Nurse D stated staff need not apply gowns or gloves unless touching contaminated things or the person and verified staff should have worn isolation gowns when repositioning the resident in bed. On 08/07/19 at 3:20 PM, HS U stated she was unaware of the wet time for the Virasept but would read the label. The facility's Pressure Ulcer Infection Control policy, dated 05/01/10, directed staff to protect dressing supplies from inadvertent contamination by keeping the dressing in the original package or plastic packaging, storing them in a clean dry place, wash hands before contact with clean dressings or dressing supplies, and prior to the dressing change, remove only the number of dressings necessary for each dressing change. The policy directed staff once hands are soiled with wound secretions, remove and discard the gloves properly, and wash hands before touching the remaining clean dressings or other supplies. The facility's Infection Control-[MEDICAL CONDITION] policy, dated 05/01/2010, documented to use standard precautions except for residents with diarrhea associated with [MEDICAL CONDITION]. In this case, use contact precautions. The Virasept Manufacturer Guidelines direct users to apply Virasept to the surface, soaking the surface thoroughly. Virasept is effective against [MEDICAL CONDITION] spores after a 10-minute exposure time. The facility failed to implement thorough contact isolation infection control practices when providing care for R13, who had serious infections which were transmissible by contact. Staff failed to apply PPE prior to entering R13's room, failed to let the Virasept remain on contaminated surface the required disinfectant time, exited and re-entered the isolation room wearing soiled gown and gloves, placing staff, visitors, and other resident's at risk for infection. - Resident (R) 24's Physician order [REDACTED]. to think, feel, and behave clearly). The significant change Minimum Data Set (MDS) assessment, dated 06/20/19, documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating impaired cognition. The MDS documented the resident required extensive assistance of one staff for bed mobility, dressing, toilet use, personal hygiene, limited assistance for transfers, and supervision with eating. The MDS documented no skin issues. The care plan, dated 07/08/19, instructed staff to administer the physician ordered treatment to the resident's right ear and monitor for possible adverse reactions. The 07/31/19 update directed staff to apply [MEDICATION NAME] (antibiotic) ointment to area on inside of resident's right ear two times a day until healed, monitor the area on inside of right ear for signs and symptoms of infection such as swelling, redness, warmth, discharge, odor, and notify the physician of significant findings until healed. The pressure ulcer Care Area Assessment (CAA), dated 06/20/19, documented the resident had a history of [REDACTED]. The 06/14/19 at 01:40 PM, nurse's note recorded the resident picked on his ear at some time that morning and had a small amount of dried blood on it. The 07/24/19 at 11:39 AM, nurse's note recorded a nurse from [MEDICAL CONDITION] hospital returned a call to the facility regarding the resident's ear oozing. The note documented the nurse stated the resident must first be seen by his primary care physician. Appointment scheduled for 07/24/19 at 10:00 AM. The 07/30/19 at 09:30 AM, nurse's note recorded the resident was seen by his primary care physician, right ear wound culture obtained, and new orders received to apply [MEDICATION NAME] ointment to the resident's right ear twice a day. The 08/02/19 at 04:15 PM, nurse's note recorded staff received a new order to administer [MEDICATION NAME] (antibiotic) 100 milligrams (mg) twice a day for 10 days, for [MEDICAL CONDITION] (MRSA) (a type of bacteria resistant to many antibiotics) in the resident's right ear drainage. The 08/02/19 Skin Infection Assessment recorded the results of the 08/02/19 right ear culture [MEDICAL CONDITION] in the resident's right ear drainage. On 08/07/19 at 10:44 AM, observation revealed Licensed Nurse (LN) G entered the resident's semi private room, washed her hands, and applied gloves from the box at the sink. LN G placed a tube of [MEDICATION NAME] ointment on the sink counter (without a protective barrier), removed the lid, and removed two cotton swabs from the package. Observation revealed the nurse removed a dressing from the resident's right ear, containing a moderate amount of red/bloody drainage, and placed it on the overbed table next to the resident (without a protective barrier). Observation of the resident's right ear revealed the top front of the ear missing with red drainage visible in the inner ear canal. LN G applied [MEDICATION NAME] ointment to both cotton swabs, used the swabs and applied the ointment to the resident's right ear canal, then placed the two swabs in a lined trash can. LN G, wearing the same soiled gloves, placed a clean cotton ball in the resident's ear and covered with a dressing. The resident indicated with his finger, and garbled speech, It (his ear) itches, and I scratch it with my finger. The resident indicated with his hand that he wiped his hands on his pant legs. LN G removed her gloves and exited the resident's room without washing her hands and carried the container of ointment. LN G placed the ointment on top of her treatment cart located outside the resident's room and pushed the cart away from the resident's room. Observation revealed no Personal Protective Equipment (PPE) or notification to alert staff and visitors of the resident's infectious status outside of his room. On 08/07/19 at 11:51 AM, observation revealed the resident sat in the dining room with reddish brown material under every fingernail on his right hand. On 08/06/19 at 10:10 AM, Certified Medication Aide (CMA) M stated the resident removed his dressing, and occasionally picked at his ear. On 08/07/19 at 10:44 AM, LN G confirmed the resident [MEDICAL CONDITION] in the right ear drainage. LN G stated she was unable to locate the red biohazard bags that should be used for waste from the resident's room. LN G stated no special considerations for laundry had been used and the resident should be in contact isolation (precautions used for infections that are spread by touching the resident or items in the room (examples:[MEDICAL CONDITION], VRE, diarrheal illnesses). Visitors are to wear a gown and gloves while in the resident's room). On 08/06/19 at 11:10 AM, HS V stated she had been cleaning room [ROOM NUMBER] with Virasept since 08/02/19 because the resident [MEDICAL CONDITION]. On 08/07/19 at 01:45 PM, Administrative Nurse A stated the resident was on contact precautions and produced an Infection Control log which indicated the resident'[MEDICAL CONDITION] and antibiotic use. The log documented the physician ordered [MEDICATION NAME] 100 mg twice a day x 10 days for R24 on 8/2/19. On 08/08/19 at 09:45 AM, Administrator A stated nobody informed Administrative Nurse D that R24 [MEDICAL CONDITION]. The resident's condition was discussed during morning huddles (nursing staff meeting). Administrative Nurse D read the nurse's notes for information. Nursing staff was made aware R24 [MEDICAL CONDITION] during morning huddle on 08/02/19. The facility's Infection Prevention and Control Program policy, dated (MONTH) (YEAR), documented the facility would establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment, and prevent development and transmission of communicable diseases and infections. The facility's [MEDICAL CONDITION]-Resistant-Staphylococcus aureus policy, dated (MONTH) 2010, documented the resident would be placed on contact isolation in addition to following standard precautions. The facility failed to follow their infection control policies to prevent the potential transmission of R24'[MEDICAL CONDITION] to staff, visitors, and the other 34 residents who resided in the facility. This deficient practice placed the other 34 residents who resided in the facility in immediate jeopardy. The facility removed the immediate jeopardy on 08/07/19 at 08:28 PM, when the facility moved R24 to a private room and placed him on total isolation precautions, placed a dressing on R24's right ear, deep cleaned R24's previous room and community's environment, re-educated all staff on infection control and when to initiate isolation precautions. Administrative staff conducted daily rounds to verify that infection control and prevention policies were being followed, and audits on infection control were completed. The deficient practice remained at a F scope and severity following the removal of the immediate jeopardy.