Every finding on record at Elliott Nursing and Rehabilitation

Based on interview, record review, review of the facility's policy, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 of 2 residents reviewed for resident assessment requirements, Resident (R) 1 and R2.The findings include:Review of the facility's policy titled, Accurate Assessment, dated 08/01/2025, revealed the purpose was To assure that all residents/patients receive an accurate assessment, reflective of the resident's/patient's status at the time of the assessment, by the Care Team Members qualified to assess relevant care areas. Further review of the policy revealed definitions to include Accuracy of assessment is the appropriate, qualified health professionals correctly document the resident's/patient's medical, functional, and psychosocial problems and identify resident/patient strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. [id est; that is] comprehensive, quarterly, significant change in status). Continued review revealed the policy included C. The appropriate, qualified health professional will correctly document the resident's/patient's characteristics, medical, functional, and psychosocial problems and identifies resident/patient strengths to maintain or improve medical status, functional abilities, and psychosocial status.Review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument user manuals, dated 10/2024 and 10/2025, revealed N0415: High-Risk Drug Classes: Use and Indication Coding Instructions included Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Further review of the manual revealed Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days. Continued review of the manual revealed Column 2: If Column 1 is checked, check if there is an indication noted for all medications in the drug class. Review of the manual revealed N0415E1. Anticoagulant (e.g. [exempli gratia; for example], warfarin, heparin, or low molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Further review of the manual revealed N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days. Continued review of the manual revealed N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). Review of the manual revealed N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). Further review of the manual revealed Coding Tips and Special Populations included Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant.Review of R1's admission Record revealed the facility admitted R1 on 10/07/2024 with diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (the death of brain tissue due to a blockage in blood supply) affecting left-nondominant side.Review of R1's significant change in status MDS, with an Assessment Reference Date (ARD) of 03/11/2026, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment. Further review of the MDS revealed the resident received anticoagulant medication during the seven-day lookback period and the medication was indicated.Review of R1's Care Plan Report included a focus area, initiated 09/05/2024, that revealed the resident was at risk for increased bruising or bleeding due to use of antiplatelet medication. Further review revealed the interventions directed staff to administer medication as ordered. Continued review revealed no indication that the resident received anticoagulant medication.Review of R1's Order Recap [Recapitulation] Report, for the timeframe from 02/01/2026 through 04/30/2026, that included active and discontinued orders, revealed an order dated 03/04/2026 for clopidogrel (an antiplatelet medication) 75 milligrams (mg) one time a day for blood clot prevention. Further review revealed no orders for medications classified as anticoagulants.During an interview with the Registered Nurse Assessment Coordinator (RNAC) on 04/08/2026 at 3:05 PM, she stated R1's significant change in status MDS was inaccurately coded because she thought that clopidogrel was an anticoagulant.2. Review of R50's admission Record revealed the facility admitted R50 on 10/21/2022 with diagnoses to include chronic systolic heart failure.Review of R50's annual MDS, with an ARD of 08/16/2025, revealed R50 had a BIMS score of five out of 15, which indicated the resident had severe cognitive impairment. Further review revealed the resident received anticoagulant medication during the seven-day lookback period and the medication was indicated.Review of R50's quarterly MDS, with an ARD of 11/12/2025, revealed R50 had a BIMS score of five out of 15, which indicated the resident had severe cognitive impairment. Further review revealed the resident received anticoagulant medication during the seven-day lookback period and the medication was indicated.Review of R50's quarterly MDS, with an ARD of 02/05/2026, revealed R50 had a BIMS score of five out of 15, which indicated the resident had severe cognitive impairment. Further review revealed the resident received anticoagulant medication during the seven-day lookback period and the medication was indicated.Review of R50's Care Plan Report revealed no indication that the resident received anticoagulant medication.Review of R50's Order Recap [Recapitulation] Report, for the timeframe from 08/01/2025 through 04/30/2026, which included active and discontinued orders, revealed an active order with an original order date of 05/24/2023 for ticagrelor (an antiplatelet medication) 90 mg two times a day for blood thinner. Further review revealed no orders for medications classified as anticoagulants.During an interview with the RNAC on 04/08/2026 at 3:05 PM, she stated the information for MDS assessments came from the residents' medical records. She stated she reviewed resident orders and MARs [Medical Administration Records] to determine what kinds of medication a resident was on. The RNAC stated R50 was on ticagrelor, which she categorized as an anticoagulant. She stated R50's previous three MDS assessments, including two quarterly assessments and an annual assessment, were inaccurately coded because she thought ticagrelor was an anticoagulant.During an interview with the Director of Nursing (DON) on 04/09/2026 at 1:09 PM, she stated the RNAC was responsible for coding MDS assessments, and she found the medication information from the orders. She stated both ticagrelor and clopidogrel were antiplatelet medications, not anticoagulants, and she stated they should be coded appropriately.During an interview with the Executive Director (ED) on 04/09/2026 at 1:55 PM, she stated the RNAC was responsible for coding MDS assessments. The ED stated staff reviewed the orders to learn what medications residents took and how they were classified. She stated she did not know how ticagrelor and clopidogrel were supposed to be classified.

Based on interview, record review, and review of the facility's policy, the facility failed to keep residents free from significant medication errors for 1 of 1 resident reviewed for psychiatric medication side effects, Resident (R) 50, and 1 of 5 residents reviewed for unnecessary medications, R6.The findings include: Review of the facility's policy titled, Physician Orders, dated [DATE], revealed The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Further review revealed 'Professional Standards of Quality' means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific situation or setting. Review of the facility's policy titled, Medication Administration, dated [DATE], revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Further review revealed the procedure included 11. Compare medication source (bubble pack, vial, etc. [et cetera; and so forth] with MAR [medication administration record] to verify resident name, medication name, form, dose, frequency, route, and time. Continued review revealed a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects, and b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician or if facility has adopted open medication pass times. Review of the policy revealed 14. Administer medication as ordered in accordance with manufacturer specifications. Further review revealed, 21. Medications that are not readily available for administration will be obtained from the Emergency Kit, drop shipped from the pharmacy, or obtained from an alternative pharmacy. Continued review revealed 22. Physicians will be notified timely of medication omissions. Instructions on how to proceed (example: administer medications when it becomes available) will be followed per physician order. 1. Review of R50's admission Record revealed the facility admitted R50 on [DATE] with diagnoses to include generalized anxiety disorder, bipolar disorder, major depressive disorder with psychotic symptoms, and psychotic disorder with hallucinations due to known physiological condition. Review of R50's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R50 had a Brief Interview for Mental Status (BIMS) score of five of 15, which indicated the resident had severe cognitive impairment. Further review revealed the resident had active diagnoses that included bipolar disorder and psychotic disorder. Review of R50's Care Plan Report included a focus statement initiated [DATE], that indicated the resident received psychotropic medications. Interventions directed staff to administer medications as ordered by the physician (initiated [DATE]). Review of R50's Order Recap [Recapitulation] Report, for the timeframe from [DATE] through [DATE], contained the following orders: - Risperidone (an antipsychotic) 25 milligrams (mg) intramuscular (IM) one time a day every 14 days for psychotic disorder, with a start date of [DATE] and end date of [DATE]. - Risperidone 25 mg IM one time only for one day, with a start date of [DATE] and end date of [DATE]. - Risperidone 25 mg IM one time only for one day, with a start date of [DATE] and end date of [DATE] for. - Risperidone 25 mg IM one time only for one day and inject 25 mg IM every 14 days, with a start date of [DATE] and end date of [DATE]. - Risperidone 25 mg IM one time only for one day, with a start date of [DATE] and end date of [DATE]. Review of R50's [DATE] Medication Administration Record (MAR) revealed staff coded 9 on the MAR for risperidone 25 mg IM on [DATE] and [DATE], indicating the medication was not administered and to See Progress Notes. The MAR revealed staff documented the resident received risperidone 25 mg IM on [DATE] (17 days after the previous dose on [DATE]) and [DATE] (13 days following the previous dose). Review of R50's Progress Notes revealed an Administration Note, dated [DATE], that revealed risperidone 25 mg IM was not available. The note was electronically signed by Registered Nurse (RN) 4. Review of R50's [DATE] MAR revealed staff coded 9 on the MAR for risperidone 25 mg IM on [DATE] and [DATE], indicating the medication was not administered and to See Progress Notes. The MAR revealed staff documented the resident received risperidone 25 mg IM on [DATE] (29 days after the previous dose on [DATE]) and [DATE] (eight days following the previous dose). Review of R50's Progress Notes revealed an Administration Note, dated [DATE], that revealed risperidone 25 mg IM was On order and indicated the pharmacy was aware. The note was electronically signed by RN6. Review of R50's Progress Notes revealed an Administration Note, dated [DATE], that revealed risperidone 25 mg IM was On order. The note was electronically signed by Certified Medication Aide (CMA) 7. During an interview with RN4 on [DATE] at 9:16 AM, she stated if a resident's medication was unavailable for administration, staff documented it in the progress notes. She stated that staff were also expected to notify the physician and the family or resident if that happened. She further stated that if staff administered the medication, they documented it in the MAR. Referring to the note she authored on [DATE], RN4 stated she did not know why there was a delay. During an interview with RN6 on [DATE] at 3:47 PM, she stated if a resident's medication was unavailable for administration, it was documented on the MAR and in the progress notes. She stated the medications that were ordered for immediate delivery from the pharmacy could be delivered within three hours. She stated if the medication did not come quickly enough, staff should contact the physician. Regarding the note she authored on [DATE], RN6 stated she ordered the risperidone for immediate delivery from the pharmacy. She further stated that she did not administer it that day and did not know if someone else administered it later. During an interview with Pharmacist 8 on [DATE] at 10:09 AM, she stated risperidone 25 mg IM was scheduled every 14 days due to its pharmacokinetics (how the body absorbs, distributes, metabolizes, and excretes a medication). She stated that staff should document administrations and omissions of a medication in the MAR. When discussing the gaps in R50's risperidone administrations between [DATE] and [DATE] (17 days) and [DATE] and [DATE] (29 days), she stated maintaining therapeutic levels of the medication was a potential concern with the wide gaps. During an interview with Psychiatric Nurse Practitioner 9 on [DATE] at 11:28 AM, she stated if staff did not administer medication due to unavailability, they contacted pharmacy and the physician. She stated staff had never reached out to her regarding the unavailability of risperidone. She stated her specific concern with gaps in R50's risperidone administration was that the medication would become subtherapeutic, and the resident might decompensate quickly if it started to wear off. During an interview with the Director of Nursing (DON) on [DATE] at 1:09 PM, she stated she expected residents to receive their medications promptly. She stated she also expected staff to notify the physician if the resident did not receive their medication. She further stated she believed the delays in R50's risperidone administration was due to the pharmacy. Regarding the gaps in R50's medication administration, the DON stated she was concerned that the medication levels may become subtherapeutic. During an interview with the Executive Director (ED) on [DATE] at 1:55 PM, she stated if staff did not administer a medication due to unavailability, they notified the pharmacist, resident, and physician. She stated medications could be delivered immediately from the pharmacy within four hours. She further stated she expected staff to administer medications as ordered. 2. Review of R6's admission Record revealed the facility admitted R6 on [DATE] with diagnoses to include atrial fibrillation, congestive heart failure, and hypertension (HTN). Review of R6's quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of [DATE], revealed R6 had a Brief Interview of Mental Status (BIMS) score of 4 of 15, which indicated the resident had severe cognitive impairment. Review of R6's Care Plan Report included a focus area initiated on [DATE] and revised on [DATE], that revealed the resident was at risk for impaired cardiac output related to arrythmia, congestive heart failure, HTN, anemia, episodes of orthostatic hypotension, and hypotension. Interventions directed the staff to administer medication as ordered (initiated [DATE]), and to check the resident's vital signs as ordered and to notify the physician of abnormalities (initiated [DATE]). Review of R6's Order Recap [Recapitulation] Report, for the timeframe from [DATE] through [DATE], included the following orders: - Midodrine hydrochloride (HCL) (an alpha-1 agonist) 5 milligrams (mg), one tablet by mouth three times a day for hypotension. The order specified to hold the medication from being administered if the resident's systolic blood pressure (top number; measures the pressure in the arteries when the heart beats) was greater than 115 millimeters of mercury (mmHg). The order revealed a Start Date of [DATE] and an End Date of [DATE]. - Metoprolol tartrate (a cardioselective beta blocker) 25 mg, one tablet by mouth two times a day for HTN. The order specified to hold the medication from being administered if the resident's systolic blood pressure was less than 110 mmHg, or the resident had a pulse less than 50 beats per minute (BPM). The order revealed a Start Date of [DATE] and an End Date of [DATE]. - Metoprolol tartrate 25 mg, one tablet by mouth two times a day for HTN. The order specified to hold the medication from being administered if the resident's systolic blood pressure was less than 110 mmHg, or the resident had a pulse less than 50 BPM. The order revealed a Start Date of [DATE] and an End Date of [DATE]. - Verapamil HCL (a Group IV antiarrhythmic) 40 mg, one tablet by mouth two times a day for HTN. The order specified to hold the medication from being administered if the resident had a heart rate of less than 50 BPM or systolic blood pressure less than or equal to 110 mmHg. The order revealed a Start Date of [DATE] and an End Date of [DATE]. - Verapamil HCL 40 mg, one tablet by mouth two times a day for HTN. The order specified to hold the medication from being administered if the resident's systolic blood pressure was less than 110 mmHg, or the resident had a pulse less than 50 BPM. The order revealed a Start Date of [DATE] and an End Date of [DATE]. Review of R6's Order Summary Report, with active orders as of [DATE] included the following orders: - Metoprolol tartrate 25 mg, half a tablet by mouth two times a day for HTN. The order specified to hold the medication from being administered if the resident's systolic blood pressure was less than 110 mmHg, or the resident had a pulse less than 50 BPM. The order revealed a Start Date of [DATE]. - Verapamil HCL 40 mg, one tablet by mouth two times a day for HTN. The order specified to hold the medication from being administered if the resident's systolic blood pressure was less than 110 mmHg, or the resident had a pulse less than 50 BPM. Review of R6's [DATE] Medication Administration Record [MAR] revealed staff documented administering the following medication on the following dates when the resident's vital signs were outside the established parameters for administration: - Metoprolol Tartrate 25 mg: [DATE]- Staff (Licensed Practical Nurse [LPN] 1) documented the resident's systolic blood pressure was 106 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was documented as 104 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 97 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 90 mmHg - Verapamil HCL 40 mg: [DATE]- Staff documented the resident's systolic blood pressure was 110 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 110 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 106 mmHg. - Midodrine HCL 5mg: [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 119 mmHg. Review of R6's February 2026 MAR revealed staff documented administering the following medication on the following dates when the resident's vital signs were outside the established parameters for administration: - Metoprolol tartrate 25 mg: [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 108 mmHg. [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 97 mmHg. [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 99 mmHg. [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 105 mmHg. [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 105 mmHg. [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 95 mmHg. - Verapamil HCL 40 mg: [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 108 mmHg. Review of R6's [DATE] MAR revealed staff documented administering the following medication on the following dates when the resident's vital signs were outside the established parameters for administration: - Metoprolol Tartrate 25 mg: [DATE]- Staff (LPN1) documented the resident's systolic blood pressure was104 mmHgXXX[DATE]- Staff documented the resident's systolic blood pressure was 105 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 103 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 105 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 103 mmHgXXX[DATE]- Staff (LPN1) documented the resident's systolic blood pressure was 99 mmHg. - Verapamil HCL 40 mg: [DATE]- Staff documented the resident's systolic blood pressure was 97 mmHgXXX[DATE]- Staff documented the resident's systolic blood pressure was 107 mmHgXXX[DATE]- Staff documented the resident's systolic blood pressure was 107 mmHg. Review of R6's [DATE] MAR revealed staff documented administering the following medication on the following dates when the resident's vital signs were outside the established parameters for administration: - Verapamil HCL 40 mg: [DATE]- Staff documented the resident's systolic blood pressure was 104 mmHg. During an interview with LPN1 on [DATE] at 3:38 PM, she stated the process for administering a medication that had parameters established in the order, was to look at the parameters, and if the vital signs were out of range, the nurse should not give the medication; it should be held. LPN1 stated if the nurse was going to hold a medication, they marked the medication as being held in the electronic medical record by choosing a reason the medication was held, which was indicated by a number code. LPN1 stated if a medication documented on the MAR had no number with the nurse's initials, then the medication was given. During the interview, LPN1 reviewed R6's [DATE], February 2026, [DATE], and [DATE] MARs, and stated she was not aware that she had not followed the physician's orders so many times. LPN1 stated she documented that she gave the medications and did not document on the MAR that she had held them from being administered. She stated that the potential effects of giving blood pressure medication when the resident's blood pressure was already low could result in the resident's blood pressure dropping low, causing the resident to pass out, or their heart to stop beating. She stated she was not aware she had not paid attention to the parameters on R6's orders that many times in the previous three months. LPN1 stated if she had not documented that she held the medication and a number code for why the medication was held, then she documented that she gave the medication and had not followed the physician's orders, because the blood pressures were too low to give the medication. During an interview with Registered Nurse (RN) 2 on [DATE] at 2:35PM, she stated if a medication had parameters established in the order, depending on what they were, the nurse held a medication if the vitals were outside the established parameters. She stated there were some orders that even required a physician to be notified if the blood pressure or blood sugar were at certain levels. RN2 stated when there was an order with parameters, staff documented the medication as being held with vitals outside of parameters, which she believed was a #4. She stated if there was not a #4 coded on the MAR, or any other number other than a 0 under the nurses' initials, it meant the medication was given. RN2 stated it would be a medication error to give a medication if the vital signs were outside of the parameters. During an interview with Nurse Practitioner (NP) 3 on [DATE] at 11:17 AM, who was R5's primary care NP, she stated that parameters were set in place for the purpose of potentially having nurses administering medications who were not aware of what appropriate parameters for low/high blood pressures, heart rates, or blood sugars were. She stated it would be a medication error to give medication if the parameters were not met. NP3 stated the nurses were able to document they held a medication from being administered by using a number coding system on the MAR to indicate why it was held. She stated if there was not a number above or below the nurses' initials on the MAR, then the check mark meant they administered the medication. During the interview, NP3 reviewed R6's MARs for the months of [DATE], February 2026, [DATE], and [DATE], and validated there were several days the staff documented the blood pressure medications as administered on the MAR with vital signs outside the ordered parameters and should have been marked as being held from being administered. She stated most of the instances the medication was not marked as held, was by one nurse, LPN1. She stated when blood pressure medications were given with low blood pressures, it could cause the resident's blood pressure to drop extremely low to the point the resident could become unconscious or require interventions such as intravenous fluids in bolus. She stated it could even result in cardiac arrest with a need for cardiopulmonary resuscitation (CPR) and/or to be sent to the emergency room if the resident was a full code. NP3 stated it was even more important to pay attention to the blood pressure parameters when there was more than one blood pressure medication being given, like for R6. NP3 reviewed the documented blood pressures for the days when the blood pressures were outside of parameters, and the medications were documented as given, and she stated there were no patterns in the low blood pressure reading following the administration of the medications outside of the established parameters. NP3 stated she expected the nurses to follow the parameters given by the physicians. During an interview with the Director of Nursing (DON) on [DATE] at 2:40 PM, she stated if the nurses did not document that they held a medication from being administered, and a numeric coded reason why they did not give the medication on the MAR, they must assume the medication was given, even when the vitals were outside of the parameters. She stated her expectation was for the nurses to administer the medications with parameters as they were ordered, and to notify the physician as appropriate. During an interview with the Executive Director (ED) on [DATE] at 1:41 PM, she stated she expected the nurses to follow the physician's orders, and if there were parameters on the orders, the nurses were to follow them. She stated the nurses needed to document accurately if they gave or held medications.

Based observation, interview, record review, and review of the facility's policy, the facility failed to ensure nursing staff completed handwashing and glove changes between wound care tasks to prevent potential infection for 1 of 2 residents observed for wound care, Resident (R) 46.The findings include:Review of the facility's policy titled, Infection Prevention & Control Program, revised 07/17/2025, revealed the purpose of the policy was To provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Review of the facility document titled, Validation Checklist Wound Care, undated, revealed the purpose of the checklist was To determine if the individual performing wound care is doing so in accordance with facility policy. Further review of the checklist revealed a column titled Procedures Observed, which included 12. Removed dressing and placed in appropriate receptacle; 13. Performed hand hygiene and donned clean gloves; and 14. Cleansed wound thoroughly with prescribed cleansing agent, taking care to not contaminate other skin surfaces or other surfaces of the wound.Review of R46's admission Record revealed the facility admitted R46 on 02/04/2022 with diagnoses to include type 2 diabetes with hyperglycemia, heart failure, essential hypertension, and lymphedema.Review of R46's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2026, revealed R46 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident had moderate cognitive impairment. Further review revealed the resident had one unstageable pressure ulcer and received pressure ulcer care.Review of R46's Care Plan Report revealed a focus area initiated 01/14/2026, that indicated the resident had an unstageable pressure area to their right heel. Interventions directed staff to provide wound treatments as ordered (initiated 01/14/2026).Review of R46's Order Summary Report, with active orders as of 04/07/2026, contained the following orders: Clean right heel with wound cleaner, pat dry, apply a silver-impregnated wound dressing to wound bed, cover with non-border dressing, secure with a sterile gauze and tape, to be completed one time a day for 15 days to aide in wound healing. The order had a start date of 04/06/2026; Cleanse left heel with wound cleaner, pat dry, apply a skin barrier product, cover with heel foam and secure with tape, to be completed once a day for skin integrity. The order had a start date of 04/05/2026.Observation of wound care for R46 on 04/08/2026 at 11:18 AM, revealed Registered Nurse (RN) 2, assisted by the Director of Nursing (DON), completed wound care for the resident's bilateral heel wounds. RN2 prepared the bedside table by cleaning it and placing a barrier down. She placed her clean supplies on the barrier and began to open and prepare her dressings, dating and initialing them prior to placement on the resident's feet. While RN2 prepared the dressings, the DON stated she was going to remove the old dressings from both heels at once and offered to cleanse the wounds for RN2 as well. The DON, with gloved hands, removed the dressings from both Resident 46's heel wounds and threw them in the trash. Without removing her gloves and performing hand hygiene, the DON grabbed a small stack of sterile gauze pads and a bottle of wound cleanser from the bedside table. Holding the sterile gauze pads in her hand, she sprayed them with a wound cleanser and washed the resident's right heel. Without removing her gloves and performing hand hygiene between wounds, the DON reached onto the bedside table and grabbed another small stack of gauze in her hand and cleansed the resident's left heel with them. The remainder of the treatment to R46's bilateral heel wounds was completed by RN2.During an interview with RN2 on 04/08/2026 at 2:07 PM, she stated she was unsure if there was a policy on treating more than one wound at a time; however, she would change her gloves and perform hand hygiene before the procedure, after removing the soiled dressings, after cleansing each wound, and at the end of the procedure. She stated she would do this process over again for the second wound. RN2 stated cross-contamination could occur if two wounds were addressed at the same time. She stated she did not see any breaches in infection control practices as she had her back to the DON prepping supplies; however, if the DON did not remove her gloves after taking off the soiled dressings and then cleansed both heel wounds without washing her hands, then there was a breach of infection control due to cross-contamination issues between the wounds, and germs from the dirty dressings on the gloves.During an interview with the Assistant Director of Nursing (ADON), who was also the Infection Preventionist (IP), on 04/09/2026 at 1:56 PM, she stated she expected staff to perform hand hygiene and glove changes between dirty and clean aspects of wound care. She stated the staff should not be addressing more than one wound at a time, and even more so if the wounds were in close proximity to each other.During an interview with the DON on 04/08/2026 at 3:02 PM, she stated she did not change her gloves after taking off the soiled dressing on both of the resident's feet, and she had used the same gloves when she washed both of the resident's heel wounds. She stated she also touched the resident's wound cleanser bottle as well. The DON stated, I know better than that. I was just trying to help [RN #2] out, was going fast and must have gotten nervous myself and messed it all up. The DON stated she expected staff, including herself, to follow the infection control policy for dressing changes and to follow the wound care protocol to prevent infections.During an interview with the Executive Director (ED) on 04/09/2026 at 1:55 PM, she stated her expectation was for staff to follow the infection control policies and the wound care protocol.

Based on observation, interview, and review of the facility's policy, the facility failed to dispose of refuse in a sanitary manner. The deficiency had the potential to affect all residents of the facility.The findings include:Review of the facility's policy titled, Garbage and Refuse, dated 10/01/2025, revealed the purpose was To ensure the safe, sanitary, and compliant handling, storage, and disposal of garbage and refuse in accordance with Federal, State, and Local regulations while maintaining a clean, safe, and healthy environment for residents/patients, Care Team Members, and visitors. Further review revealed the procedure included A. Garbage and refuse containers will be kept clean and covered when not in use/continuous use; and B. Outside dumpsters will be monitored to be kept clean, free of surrounding litter, lid closed, and inaccessible to pests.Observation of the dumpsters with the Dietary Manager (DM) on 04/06/2026 at 9:04 AM, revealed dumpsters inside a wooden fenced area located just outside the kitchen, near the front of the facility, which was not closed or gated. Further observation revealed trash laid scattered around the garbage dumpster that included six gloves, two empty boxes for medical gloves, and a garbage bag sitting in the corner of the fenced dumpster area. Continued observation revealed one of the dumpster lids was open.During immediate interview with the DM on 04/06/2026 at 9:04 AM, she stated the maintenance department was responsible for keeping the dumpster area clean and dumpster lids were supposed to be closed.Further observation of the dumpsters 04/06/2026 at 9:21 AM, the lids to the dumpsters remained open.Further observation of the dumpsters and concurrent interview with the DM on 04/08/2026 at 2:30 PM, the dumpster lids remained open. The DM stated she did not know who kept leaving the dumpster lids open.During an interview with the Maintenance Director on 04/09/2026 at 8:46 AM, he stated he was responsible for the dumpster area. He stated that every time he went to the dumpsters, he made sure they were closed, and he found them open on a regular basis. The Maintenance Director stated he stressed the importance of closing the lids to staff, and explained to staff that raccoons, opossums, and cats were in the area.During an interview with the Director of Nursing (DON) on 04/09/2026 at 1:09 PM, she stated when staff discarded items in the dumpsters, they were expected to close the lids on the dumpsters.During an interview with the Executive Director (ED) on 04/09/2026 at 1:55 PM, she stated that anybody who used the dumpsters was responsible for making sure the lids were closed. She stated that if someone was out there and they saw debris, they were expected to clean up the debris. The ED further stated it was important to keep the lids closed because animals might get into the trash, and the facility wanted to keep it clean and closed to deter vermin.

Based on observation, interview, record review, review of the manufacturer's instructions, review of the Food and Drug Administration (FDA) article, and review of the facility's policy, the failed to ensure appropriate storage of residents' oral, ophthalmic, otic, and injectable medications. Unopened insulin was stored below the recommended temperature range of 36 degrees Fahrenheit (F) to 46 degrees F in 1 of 2 medication refrigerators. Observation of 2 of 5 medication carts on the 100, 200, and 300 Halls revealed Cart 1 was not maintained in a sanitary manner, insulin pens in use were not stored in a sanitary manner, and medications were not labeled and dated correctly. Cart 2 contained medications that were expired. The findings include: Review of the facility's policy, titled Storage of Medications, most recently revised 08/2024, revealed medications and biologicals were stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. Review further revealed orally administered medications were stored separately from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, et cetera. Eye medications were stored separately per facility policy. Continued review revealed, except for those requiring refrigeration or freezing, medications intended for internal use were stored in a medication cart or other designated area. Medications labeled for individual residents were stored separately from floor stock medications when not in the medication cart. Policy review also revealed outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled or without secure closures were immediately removed from inventory, and disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed. Additional review revealed medication storage areas were kept clean, well lit, and free of clutter and extreme temperatures and humidity. Further review revealed medication storage conditions were monitored on a regular basis by the consultant pharmacist and corrective action was taken if problems were identified. Additional review revealed refrigerated medications were kept in closed and labeled containers, with internal and external medications separated from each other and from fruit juices, applesauce and other foods used in administering medications. Review of the policy also revealed all medications were maintained within the temperature ranges recommended in the United States Pharmacopoeia (USP) and by the Centers for Disease Control and Prevention (CDC). Further review revealed for refrigerated medications, the temperature range was 36 degrees F to 46 degrees F, using the thermometer to allow temperature monitoring. Medications requiring storage in a cool place were refrigerated, unless otherwise directed on the label, and controlled substances that required refrigeration were stored within a locked box within the refrigerator that was attached to the inside of the refrigerator or in accordance with state regulations and facility policy. Additional review revealed the facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. Further review revealed the facility should check the refrigerator or freezer in which vaccines were stored at least two times a day, per CDC guidelines. Additional review revealed expiration dates or beyond use dates of dispensed medication shall be determined by the pharmacist at the time of dispensing. Further review revealed certain medications or package types, such as injectable vials and ophthalmics required an expiration date shorter than the manufacturer's expiration date, once opened to ensure medication purity and potency. Subsequent review revealed no expired medications would be administered to a resident, and all expired medications would be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. Review of the Food and Drug Administration (FDA) article Pharmaceutical Quality Resources, Expiration Dates - Questions and Answers, dated 01/21/2025, Expiration Dates - Questions and Answers | FDA revealed drug expiration dates reflected the period of time in which the medication was known to remain stable. Further review revealed the stability meant the medication retained strength, quality, and purity when it was stored according to its labeled storage conditions. Continued review revealed there were potential harms that could occur if expired medications were taken, including the medication not providing the intended benefit because it had less strength than intended. Additional review revealed when a drug degraded, it could yield toxic compounds that could cause unintended side effects. Review of bisacodyl rectal suppositories package insert revealed they should be stored at room temperature, between 59 degrees F and 86 degrees F, not exceeding 86 degrees F. Review of the manufacturer's package insert, for insulin lispro (Humalog 100 unit (u)/milliliter (ml), dated 07/21/2023, and insulin lispro (Admelog 100 u/ml), undated, revealed the necessity to store all unopened (unused) pens or vials in the original carton in a refrigerator at 36 degrees F to 46 degrees F. Further review revealed insulin lispro instruction to not freeze and to not use if it had been frozen. Continued review revealed to keep unopened insulin in the refrigerator or at room temperature below 86 degrees F for up to 28 days and to discard an opened vial after 28 days of use, even if there was insulin left in the vial. Further review revealed unopened vials could be used until the expiration date on the carton and label, if the medicine had been stored in a refrigerator. Continued review revealed for cartridge and prefilled pens, to keep at room temperature below 86 degrees F for up to 28 days, and to not store a cartridge or prefilled pen that was in use in the refrigerator. The insert stated to throw away a used cartridge or prefilled pen after 28 days, even if there was insulin left in the cartridge or the pen. Review of the manufacturers' package inserts for insulin glargine (300 u/ml), Lantus (insulin glargine 100 u/ml), dated 2023, the package insert for Basaglar (insulin glargine 100u/ml), dated 08/2022, revealed unused insulin should be stored in a refrigerator between 36 degrees F and 46 degrees F. Further review revealed instructions not to freeze insulin and to discard if frozen. Continued review revealed, once opened, to store up to 28 days at room temperature, up to 86 degrees F. Review of insulin glargine (Toujeo Solostar 300 u/ml pen) package insert, dated 8/29/2024, revealed storage was the same except could be stored after opening, up to 86 degrees F, for 56 days. Review of the manufacturer's instructions for insulin aspart 100 u/ml), revealed it should not be frozen, nor used if having been frozen. Further review revealed an instruction to store unused insulin in a refrigerator between 36 degrees F and 46 degrees F. Review of the manufacturer's instructions for insulin degludec (Tresiba 100 u/ml FlexTouch pen), copyrighted and revised 07/2022, revealed guidance to store unused pens in the refrigerator at 36 degrees F to 46 degrees F and to not freeze the pens nor use them if having been frozen. Review of the semaglutide Wegovy 2.5 milligram (mg)/0.5 ml pen package insert revealed it must be stored in the refrigerator between 36 degrees F to 46 degrees F and should not be frozen. Further review revealed, if frozen, or if out of the refrigerator for 28 days or longer, the pens must be discarded. Review of the dulaglutide Trulicity 0.75 mg/0.5 ml and 1.5 mg/0.5 ml pens package insert revealed the pens should be stored in the refrigerator between 36 degrees F and 46 degrees F and could be stored at room temperature for up to a total of 14 days. Further review revealed if a pen was frozen, it must be discarded. Review of insulin isophane human (Humulin 100 u/ml 10 ml vial or KwikPen) package insert revealed the vials and KwikPens should not be frozen and, if frozen, should be discarded. Further review revealed an unopened vial could be stored from 36 degrees F to 46 degrees F until expiration date or at room temperature, up to 86 degrees F, for 31 days. Continued review revealed after opening, the vial could be stored refrigerated or at room temperature for 31 days. Additional review revealed unopened pens could be stored refrigerated from 36 degrees F to 46 degrees F until expiration date or at room temperature for up to 14 days and should not be refrigerated after in use. Review of Xalatan (latanoprost 0.005% 50 nanograms/ml) eye drops package insert revealed unopened bottles should be refrigerated from 36 degrees F to 46 degrees F and at room temperature up to 77 degrees F after opening for six weeks. Review of Tuberculin Purified Protein Derivative (PPD) (Aplisol 5 Tuberculin Units (TU)/0.1 ml injection) package insert revealed it should be stored at 36 degrees F to 46 degrees F and protected from light and should not be in use for more than 30 days due to possible oxidation and degradation which may affect potency. 1. Observation of the main medication storage room Main Unit refrigerator on 04/08/2025 at 2:38 PM revealed the temperature at that time, per the thermometer, was 50 degrees F. During interview at the time of the observation, Licensed Practical Nurse (LPN) 1 stated she was not aware of anyone being in the refrigerator prior to beginning observation and review that would have caused warming. In further interview, LPN1 could not state the correct temperature range of 36 degrees F to 46 degrees F. Review of the Temperature Log, for April 2025, revealed documented temperatures of 30 degrees F, 32 degrees F and 34 degrees F from 4/01/2025 through 4/07/2025. Further review of the log revealed neither the correct parameters nor the actions to take for temperatures out of range were referenced. Observation of the top shelf of the Main Unit refrigerator on 04/08/2025 at 2:38 PM revealed the Emergency Box which included insulin lispro, two pens, 100 u/ml; insulin glargine, two pens, 100 u/ml; and insulin aspart, two pens, 100 u/ml. Further observation revealed Bisacodyl, 609 suppositories, including 21 for Resident 73 (R73), who was discharged on [DATE], and 28 for R24, which expired on 03/12/2025. Observation of the bottom shelf of the Main Unit refrigerator on 04/08/2025 at 3:05 PM revealed the following: Insulin lispro pen 100 u/ml x1 Insulin lispro pen 100 u/ml x5 Insulin lispro pen (Humalog Kwik pen) 100 u/ml x10 Insulin lispro pen (Humalog Kwik pen) 100 u/ml x4 Insulin lispro pen (Humalog Kwik pen) 100 u/ml x2 Insulin lispro pen (Humalog Kwik pen) 100 u/ml x2 Insulin lispro pen (Humalog Kwik pen) 100 u/ml x1 Insulin lispro pen (Lyumjev Kwikpen) 100 u/ml x2 Insulin lispro pen (Lyumjev Kwikpen) 100 u/ml x2 Insulin lispro pen (Admelog Solostar) 100 u/ml x2 Insulin lispro vial, 100 u/ml vial x1 Insulin lispro vial (Humalog)100 u/ml x1 Insulin lispro vial (Humalog)100 u/ml x1, contained in small plastic bag that was soaking wet Insulin glargine pen, 100 u/ml x1 Insulin glargine pen, 100 u/ml x3 Insulin glargine pen, 300 u/ml x2 Insulin glargine pen (Toujeo Solostar pen) 100 u/ml x1 Insulin glargine pen (Toujeo Solostar) 300 u/ml x1 Insulin glargine pen (Toujeo Solostar) 300 u/ml x1 Insulin glargine pen (Lantus Solostar) 100 u/ml x8 Insulin glargine pen (Lantus Solostar) 100 u/ml x2 Insulin glargine pen (Lantus Solostar) 100 u/ml x7 Insulin glargine pen (Lantus Solostar) 100 u/ml x2 Insulin glargine pen (Lantus Solostar) 100 u/ml x2 Insulin glargine pen (Basaglar Kwik Pen) 100 u/ml x4 Insulin glargine vial (Lantus) 100 u/ml x2 Insulin degludec pen (Tresiba Flextouch) 100 u/ml x1 Insulin degludec pen (Tresiba Flextouch) 100 u/ml x4 Humulin NPH Kwikpen 100 u/ml x1 Humulin insulin vial 100 u/ml x1 Wegovy insulin pen 0.25mg/0.5 ml x2 Trulicity insulin pen 0.75 mg/0.5 ml pen x3 Trulicity insulin pen 1.5 mg/0.5ml pen x1 Levemir insulin pen 100 u/ml x5 Insulin aspart flex pen 100 u/ml x1 Observation of the Main Unit refrigerator door storage on 04/08/2025 at 3:31 PM revealed the following: Insulin glargine (Lantus vial) 100 u/ml x1 Latanoprost vials 0.005% ophthalmic solution x9 Tuberculin (PPD) (Aplisol ) labeled as facility house stock x 4 days, dated 02/28/2025 During telephone interview with LPN3 on 04/09/2025 at 7:48 PM, she stated the night shift was responsible to check the medication refrigerator temperature but could not state with certainty about the expected temperature range. During interview with Registered Nurse (RN) 2 on 04/09/2025 at 7:18 PM, she stated they did the refrigerator temperature log on night shift. However, she could not state the appropriate temperature range with certainty. 2. Observation on 04/08/2025 at 3:40 PM of Medication Cart 1 revealed its drawers were visibly dirty with trash and spilled liquids. Further observation revealed medications were not separated from equipment such as glucometers, blood pressure (BP) cuff, scissors, and clippers. Additional observation of Cart 1 revealed one loose loperamide tablet with no resident label and one each opened Systane Ultra solution vial and prednisone 1% ophthalmic solution without recorded open dates. Observation also revealed an ofloxacin otic solution 0.3% package labeled for a different resident than the bag in which it was stored. Continued observation revealed ketorolac 0.4% ophthalmic solution was stored with otic solutions. Additional observation revealed Systane Ophthalmic drops with an expiration date of 11/30/2024. Additionally, 12 insulin pens were not stored in a sanitary manner. The pens were stored lying together in a single section of the drawer with other pens and a glucometer and were not stored in individual bags. Those included: Humalog Kwik Pen, 100u/ml x3, two with handwritten name on the cartridge and no original pharmacy label. Lantus pens, 100u/ml x3 Lyumjev Kwik Pen, 100u/ml x2 Insulin glargine pen, 300u/ml x1 Basaglar insulin pen,100u/ml x1 Admelog Solstar pen, 100u/ml x1 Tresiba FlexTouch pen, 100u/ml x1 Observation of Cart 2 revealed one bottle of nitroglycerin sublingual tablets 0.4 mg, with expiration date of 09/2023 and one bottle of acetaminophen 500 mg tablets, with expiration date of 12/12/2024. During interview with LPN 1 on 04/08/2025 at 3:50 PM, he stated there were two medication carts each for 100 Hall and 200 Hall and one for 300 Hall. He stated he was not certain about the proper temperature range for refrigerated medications. He also stated expired medications should be discarded as they might not be as effective, and the nurse on duty was responsible to audit for expired medications. He stated he was not familiar with appropriately storing insulin pens in separate bags, nor separating ophthalmic and otic medications. He stated Cart 1 and Cart 2 served the 100 Hall, Cart 3 and Cart 4 served the 200 Hall and Cart 5 was for the 300 Hall. He further stated Cart 2 contained overflow medications. During interview with the Infection Preventionist (IP) Nurse on 04/09/2025 at 3:55 PM, she stated they took pride in keeping the carts clean, neat, and up-to-date and audited them regularly. She was not able to state the appropriate temperature range with confidence nor the need to store insulin pens separately from other items and in individual bags. She stated expired medications should be discarded by the expiration dates, and this was to ensure the medications were effective. She also stated otic and ophthalmic medications should be stored separately, and all medications should be labeled and dated. During interview with the Director of Nursing (DON) on 04/08/2025 at 4:00 PM, she stated she was not confident to state the correct temperature range for medication storage, but night shift nurses were responsible to check the refrigerator temperatures. She also was not able to state the necessity to store insulin pens in separate bags. She stated expired medications should be discarded and otic and ophthalmic medications should be stored separately. She stated medications past the expiration date might not be as effective and separating otic and ophthalmic medications could prevent errors in using a solution by the incorrect route. She stated medications should always be labeled and have use by or expiration dates During telephone interview with the Consultant Pharmacist on 04/09/2025 at 3:23 PM, she stated the typical accepted range of temperatures for refrigerated medications was 36 degrees F to 46 degrees F for most medications, and one could consult the package inserts for clarification. She further stated that range was generally accepted. She stated she believed if a medication required a different temperature, it would be marked, but she was not certain about that. She stated insulin was not kept at freezing temperatures. She stated she would have to assume that it would not work after being frozen. She stated she would go with recommended ranges. She also stated she would not use an insulin that had been frozen, and she would go by manufacturer's guidelines. She stated she had seen medication items stored in the refrigerator door but did not have the answer for whether that was unacceptable. The Consultant Pharmacist stated she audited floor carts, during monthly visits to the facility, for expiration dates and ensured the cards were with the correct resident's section in the cart. She also stated she reviewed for opened dates on inhalers, storage for drugs sensitive to light, and whether anything was in the cart that should be in cart. During followup telephone interview with the Pharmacist Consultant on 04/10/2025 at 8:47 AM, she stated insulins were supposed to be stored at 36 degrees F to 46 degrees F. She stated according to the insulin pen manufacturer's package insert, the pens should not be used if frozen. She stated all medications in the main medication room refrigerator were returned, and there would be no penalty to the resident. During subsequent interview with the DON on 04/10/2025 at 4:17 PM, she stated she believed the nurses all understood about the use-by-date, and now all have been labeled with it. She stated each insulin pen was in a zip bag with a label. She stated her expectation was that staff followed the facility's policy for labeling and storage. She further stated it was important for all the nurses to know the right temperature because they all gave medications. She stated both day and night shift nurses must check the refrigerator temperatures, and it was important to manage the temperature range so the medications remained effective. During interview with the Executive Director on 04/10/2025 at 3:53 PM, she stated her expectation was that staff followed the facility's policy and manufacturer's guidelines for safe medication storage. She stated this was important so medication was effective and worked the way it was supposed to.

Based on observation, interview, record review, and review of the facility's documents and policy, the facility failed to honor resident food preferences for 2 of 10 sampled residents, Resident (R) 6 and R61. In an interview with R6, who had diabetes mellitus and was on a special diet, she stated she had requested no bread, pasta, or desserts because these foods raised her blood sugar levels, but still received them on her trays. In an interview with R61, she voiced concern she was still receiving broccoli and cauliflower on her meal trays. The findings include: Review of the facility's policy titled, Dining and Food Preferences, dated 10/2022, revealed individual dining food and beverage preferences were identified for all residents. The registered dietitian or other clinically qualified nutrition professional would review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that did not consume certain food or food groups. Per the policy, the individual tray assembly ticket would identify all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. The policy stated, upon meal service, any resident with expressed or observed refusal of food and or beverage would be offered an alternate selection of comparable nutritional value. 1. Observation of the posted dining room menu on 04/07/2024 at 12:15 PM, revealed cornflake crusted tilapia fillet, tomatoes [NAME], rice pilaf, dinner roll, and carrot cake with cream cheese frosting were served at lunch. Review of the facility's form Resource: Menu Substitution Form, dated 04/07/2025, the cornflake crusted tilapia substituted with breaded fish; the [NAME] tomatoes substituted with peas; and the rice pilaf substituted with white rice. 2. Observation of the posted dining room menu, on 04/09/2025 at 12:00 PM, revealed roast turkey, honey roasted carrots, cornbread dressing, dinner roll/bread brown sugar, and glazed angel food cake. Observation of the resident tray line on 04/09/2025 at 12:05 PM, revealed the honey roasted carrots were cooked carrots. In an interview with Resident Council members on 04/08/2025 at 11:00 AM, they stated the food sucks. They stated the posted menu for lunch on 04/07/2025 was not followed as residents received fish squares and not the cornflake crusted tilapia. They stated the food on the meal tray was always a surprise because the posted menu in the dining room was not always followed. They stated residents were not given a choice; however, a substitution list was available. They stated it had been a year or more since residents were asked about their food preferences. They stated they were served the same breakfast every day and were served a lot of fish and chicken. They stated residents were given snacks of cookies, vanilla wafers, chips, and popcorn, which they did not consider healthy. 3. Review of R6's Admission Record revealed the facility admitted the resident 03/05/2021 with diagnoses including major depression, diabetes mellitus type 2, and anxiety. Review of R6's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/27/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated intact cognition. Review of R6's Menu Ticket, dated 04/10/2025, did not list food dislikes. The morning breakfast food items included toast; the lunch menu included thin crust cheese pizza and garlic bread; and dinner included macaroni and cheese and a dinner roll. Review of the facility's computer printout Resident Dislikes Report, dated 04/10/2025 at 1:23 PM, revealed R6 was on a carbohydrate-controlled diet, with no salt packet and an allergy to strawberries. The food preference list included bread items. In an interview with R6 on 04/07/2025 at 10:57 AM, she stated she had concerns with the food served at meals. She stated she was trying to control her blood sugar levels by taking oral medication and did not want to take insulin. She stated when her blood sugar was elevated, she had a headache, and her stomach became upset. She stated she had talked with the Registered Dietitian and other staff about her food preferences. She stated she preferred no bread, rolls, pasta, cheese, and desserts, unless sugar free. 4. Review of R61's Admission Record revealed the facility admitted the resident on 02/21/2024 with diagnoses including major depression and anxiety. Review of R61's quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of 13 out of 15, which indicated intact cognition. Review of R61's Menu Ticket, dated 04/10/2025, listed an allergy to strawberries. The dinner meal listed winter vegetable blend which included broccoli and cauliflower. Review of the facility's computer printout Resident Dislikes Report, dated 04/10/2025 at 1:23 PM, revealed R61 was on a carbohydrate-controlled diet, with no salt packet and no dislike list. The food preference list included broccoli, cauliflower, and many other types of vegetables. In an interview with R61 on 04/08/2025 at 11:15 AM, she voiced concern she was still receiving broccoli and cauliflower on her meal trays. She stated she had expressed her food preferences to staff. In an interview with [NAME] 1 on 04/09/2025 at 9:15 AM, she stated she did not have the tilapia available and substituted with the fish square; did not have the tomatoes [NAME] and substituted with peas; and did not have the rice pilaf and substituted with white rice. She stated she always asked the Account Manager before she made a substitution. She stated what was she to do since she did not have the ingredients for the tomatoes [NAME] or the rice pilaf. She stated soup, sandwiches, and baked potatoes were always available to residents. In an interview with the Account Manager on 04/09/20205 at 9:47 AM, she stated many residents did not like the tilapia and wanted the fish squares. She stated she met with the food committee once a month to discuss the menus with the residents. She stated residents did not like the shrimp alfredo, so she removed the shrimp alfredo from the menu with approval from the Registered Dietitian (RD). She stated many of the residents did not like tomatoes [NAME] or tomato products and green peppers. She stated residents preferred biscuits and gravy, fried or scrambled eggs, and hot cereal for breakfast. She stated residents' food preferences were on-going, with changes by the RD or Account Manager. She stated any diet changes went through the clinical morning meeting and then passed onto her. She stated she entered the diet changes into the computer. In an interview with the RD on 04/09/2025 at 10:43, 04/10/2025 at 11:30 AM, and 04/10/2025 at 2:00 PM, she stated she signed and reviewed the menus. She stated the residents did not like shrimp and seafood and preferred beans, cornbread, ham, the breaded fish squares, and for the summer menu, hot dogs. She stated she did not visit residents for food preferences. She stated the Account Manager visited residents quarterly and at the Resident Council meeting. She stated she would communicate any food preferences she was made aware of to the Account Manager, who entered the food preferences into the system. She stated the meal tracker program replaced food items residents did not like on the menu. She stated she provided education to the resident concerning food that would elevate the blood sugar. However, she stated she did not remember talking with R6 about her food preferences. In an interview with the Food Service District Manager (FSDM) on 04/10/2025 at 11:05 AM, the FSDM stated resident food preferences were taken upon admission, quarterly, and as needed. The FSDM stated nursing staff was mainly responsible to communicate food preferences to the kitchen, and family members provided the food preferences for residents who could not communicate. The FSDM stated the menu needed to be updated with changes, if possible. The FSDM stated staff tried different ways of preparing fish, and the residents did not like the cornflake crusted tilapia. The FSDM stated food always available included sandwiches, soup, salad, and baked potatoes. The FSDM stated side items available were a fruit cup, yogurt, and the chef's dessert of choice. The FSDM stated the meal tracker program would not recognize broccoli or cauliflower in mixed vegetables, and staff needed to enter the specific mixed vegetables to avoid. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 04/10/2025 at 4:02 PM, she stated her expectation was that residents' food preferences were met. She stated she expected the RD to follow facility policy for resident preferences. She stated clinical staff should share with Dietary any food preferences voiced by residents; however, the Account Manager and RD were responsible to talk with residents about food preferences. In an interview with the Executive Director on 04/10/2025 at 4:45 PM, she stated the RD consulted for food preferences concerning weight loss. She stated clinical nursing staff should report any resident food preferences to the Account Manager. However, she stated clinical nursing staff were not solely responsible to visit residents for food preferences. She stated she expected staff to follow the facility's policy concerning resident food preferences.

Based on observation, interview, record review, review of the facility's policy, review of manufacturer's guidelines, and review of the Environmental Protection Agency (EPA) disinfectant registry, the facility failed to ensure staff cleaned and disinfected the blood glucose monitor (glucometer) after obtaining a blood glucose reading on 1 of 7 residents who shared the glucometer on the 100 hall, to include Resident (R57) and R24. On 04/18/2024 at 6:05 PM, the survey team provided a copy of the Immediate Jeopardy (IJ) Template to the Executive Director and notified her that staff failure to disinfect the glucometer after obtaining Resident 57's blood glucose measurement constituted IJ at 42 CFR S483.80 F880 Infection Prevention & Control. The survey team determined the IJ first existed on 04/18/2024, when surveyors observed Licensed Practical Nurse (LPN) 3 failed to disinfect the glucometer on the 100 Hall, where six residents shared the glucometer with one resident (R24) diagnosed with viral hepatitis (a bloodborne illness). This failure created the potential for the shared glucometer, which had not been properly disinfected, to transmit a bloodborne illness to the six uninfected residents. The facility provided an acceptable IJ removal plan on 04/20/2024 at 10:35 AM. The survey team validated through observations, interviews, and record reviews that the facility removed the IJ on 04/19/2024, following the facility's implementation of the IJ removal plan. The deficient practice remained at a D (no actual harm, with the potential for more than minimal harm) scope and severity following removal of the IJ. The findings include: Review of the facility's policy titled, Blood Glucose Monitoring, dated 2023, revealed facility staff members were to disinfect shared glucometers per manufacturer's recommendation after each use. Review of the manufacturer's guidelines for the glucometer EvenCare ProView Blood Glucose Monitoring System, dated 2018, revealed facility staff members were to use an EPA registered disinfectant to sanitize the glucometer. Further, it stated disinfection should occur after use on each patient (resident). Review of the EPA registry of disinfectants from https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-bloodborne#products, as of 04/18/2024, revealed the list did not include Medline alcohol swabs. Review of the facility's Census, dated 04/16/2024, revealed seven residents on the 100 Hall received blood glucose checks (which would have used the shared glucometer), including R57 and R24. Review of the facility's list of Residents with Bloodborne Illnesses, dated 04/18/2024, revealed R24, residing on the 100 Hall, had viral hepatitis. 1. Review of R24's Admission Record revealed the facility admitted the resident on 03/09/2020 with diagnoses including viral hepatitis C, viral hepatitis B, and type 2 diabetes. Further review revealed R24 lived on the 100 Hall. 2. Review of R57's Admission Record revealed the facility admitted the resident on 03/29/2024 with diagnoses including type 2 diabetes, chronic kidney disease, and unspecified dementia. Further review revealed R57 lived on the 100 Hall. Observations of LPN3 on 04/18/2024 at 12:47 PM, revealed LPN3 placed the glucometer on R57's bedside table without a barrier. Further observation revealed LPN3 used the glucometer on R57. The LPN took the glucometer from R57's room and placed it back in the medication cart drawer with the second glucometer and testing supplies without disinfecting the soiled glucometer. In an immediate interview, on 04/18/2024 at 12:50 PM, LPN3 stated she had not thought about it until asked, but she should have cleaned the glucometer prior to placing it back in the medication cart drawer after use. She proceeded to wipe the glucometer down with a Medline alcohol swab and replaced it in the same drawer without a barrier. LPN3 stated she received training during orientation to disinfect the glucometer after every use, but she forgot to do so in this instance. In further interview, LPN3 was unable to state which wipes the facility management trained her to use to disinfect the glucometer. Per interview, LPN3 stated disinfection was important to prevent cross contamination. In an interview on 04/18/2024 at 12:55 PM, Registered Nurse (RN) 1 stated she typically used the Micro-Kill wipes to disinfect the glucometer after use, but she believed the Medline alcohol swabs were also acceptable to use for disinfection. In an interview on 04/18/2024 at 1:59 PM, the Infection Preventionist/Assistant Director of Nursing Services (IP/ADNS) stated she expected staff to clean the glucometers with one Micro-Kill wipe and then wrap the glucometer in a second Micro-Kill wipe for one (1) minute, which was the disinfection time listed by the manufacturer. In continued interview, the IP/ADNS stated the facility did not have an auditing process to ensure compliance with the glucometer cleaning policy after nursing staff completed orientation. In an interview on 04/20/2024 at 11:48 AM, the Director of Nursing Services (DNS) stated she expected staff to clean the glucometers after each use according to policy and the glucometer's manufacturer's guidelines. In an interview on 04/20/2024 at 12:18 PM, the Executive Director (ED) stated she expected staff to follow the facility's policy on glucometer cleaning and disinfection. In further interview, the ED stated the facility investigation into LPN3's actions after measuring R57's blood glucose found that LPN3 failed to disinfect the glucometer according to the facility's policy.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to develop and implement comprehensive, person-centered care plans for 2 of 31 sampled residents, Resident (R) 9 and 65. R9 developed a facility acquired stage 3 pressure ulcer. Observation and documentation revealed R9 was not repositioned routinely as per the intervention on the care plan. R65 expressed a preference for taking her blood pressure medication at 8:00 AM. However, the resident stated she often did not receive it until two to three hours later. The facility failed to develop the resident's care plan to include this preference. (Cross Reference F561 and F686) The findings include: In an interview on 04/18/2024 at 8:37 AM, the Executive Director (ED) stated the facility did not have a care planning policy; they followed the Resident Assessment Instrument (RAI) manual in lieu of a policy. Review of the RAI manual, dated 10/2023, revealed the resident care plan must include measurable objectives and time frames to describe the services the facility provided for the resident. Further review revealed the facility was to assess the resident for the resident's preferences and care plan interventions to accommodate those preferences. Continued review revealed the facility was to assess the resident for pressure ulcer risk factors and develop and implement interventions based directly on the resident's individual risks, including monitoring for effectiveness of the interventions. 1. Review of R9's Admission Record revealed the facility admitted the resident on 02/17/2020 with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke), type 2 diabetes, and cognitive communication disorder. Review of R9's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/15/2023, revealed the facility assessed the resident as dependent on staff to roll from side to side and back to a supine position. Further review revealed the facility assessed the resident as at risk for the development of pressure ulcers. During this assessement, the facility documented R9 was free of pressure ulcers. Review of R9's Care Plan, revised 02/01/2024, revealed the facility identified the resident as at risk for altered skin integrity and included the intervention for staff to assist with bed mobility to turn and reposition routinely, which was added to the care plan on 02/17/2020. Further review of the care plan revealed R9 required extensive assistance of two staff members for bed mobility. Review of the facility's document Pressure Ulcer-Weekly Observation-V2, dated 01/17/2024 revealed that date was the first time the facility identified the stage 3 pressure ulcer on R9's lower back. Review of the Tasks tab documentation in the electronic medical record, under Monitor-Turn and Reposition, dated 01/01/2024 through 01/17/2024, revealed no documented evidence facility staff turned R9 according to the care plan. Further review revealed facility staff charted turning R9 fewer than eight times per day on 11 of 17 sampled days with no documented refusals. Review of R9's quarterly MDS, with an ARD of 03/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as dependent on staff to roll from side to side and back to a supine position. Continued review revealed the facility assessed the resident as having a stage 3 pressure ulcer that was not present on admission/reentry to the facility. Observations on 04/19/2024 from 8:35 AM through 11:48 AM, revealed facility staff failed to reposition R9 during those three hours and 13 minutes. During the observation time frame, the State Survey Agency (SSA) Surveyor observed the resident lying in a supine position, placing her weight on the pressure wound. Continued observation at 11:48 AM revealed R9 complained of pain on her sacrum when staff repositioned her. In an interview on 04/19/2024 at 2:32 PM, State Registered Nurse Aide (SRNA) 6 stated she was assigned to care for R9 that day. SRNA6 stated she failed to turn R9 every two hours as she should have that morning because she was very busy. She stated that repositioning a dependent resident according to the care plan was important to prevent development or worsening of pressure ulcers. In an interview on 04/19/2024 at 2:46 PM, Registered Nurse (RN) 2 stated repositioning should have been completed every two hours to promote tissue perfusion and prevent breakdown. In an interview on 04/19/2024 at 3:58 PM, the Registered Nurse Assessment Coordinator (RNAC) stated the care planned intervention for turning and repositioning R9 was vague because residents' care needs were different. She further stated routinely did not inform staff what frequency R9 needed to be repositioned based on her over all condition. In an interview on 04/19/2024 at 5:44 PM, the Director of Nursing Services (DNS) stated the care plan intervention to reposition a resident routinely meant staff were to turn a resident at risk for a pressure ulcer every two hours. 2. Review of R65's Admission Record revealed the facility admitted the resident on 01/29/2024 with diagnoses including congestive heart failure, atrial fibrillation, and primary hypertension. Review of R65's admission MDS, with an ARD of 02/06/2024, revealed the facility assessed the resident to have a BIMS score of eight of 15, indicating the resident was moderately cognitively impaired. Review of R65's Care Plan, dated 01/31/2024, revealed the facility assessed the resident as at risk for cardiac dysfunction and included the intervention to administer medications as ordered. Further review revealed no interventions that mentioned honoring R65's preference to receive her blood pressure medicine at 8:00 AM. Review of R65's Medication Administration Record (MAR) for 04/2024, revealed no information specifying the time the resident received blood pressure medication each day. Review of R65's Blood Pressure Summary from the electronic medical record, dated 04/16/2024 through 04/19/2024, revealed facility staff measured R65's blood pressure between 9:00 AM and 10:45 AM each morning. In an interview on 04/16/2024 at 11:17 AM, R65 stated she wanted her blood pressure medication at 8:00 AM but often had to wait until 10:00 AM and 11:00 AM. She further stated she had expressed this preference to a couple of staff members who administered medications; however, R65 did not recall the names of the staff members. In an interview on 04/18/2024 at 4:40 PM, Kentucky Medication Aide (KMA) 5 stated she did not believe the resident had a care plan intervention to specify when staff should complete R65's medication administration. In further interview, KMA5 stated resident preferences should be included in the care plan and followed by staff. Per interview, KMA5 stated she could modify her routine for medication administration to give R65 her medication earlier, since the resident appeared to want her medications earlier than she had been getting them. In an interview on 04/19/2024 at 3:58 PM, the RNAC stated any nurses in the facility could add interventions, including resident preferences, to the resident's care plan. Per interview, the RNAC preferred staff to tell her about their added intervention so she could review it to make sure the new intervention was appropriate. In further interview, the RNAC stated she was not aware of R65 expressing preferences regarding medication administration times. In an interview on 04/20/2024 at 11:48 AM, the DNS stated the process for accommodating resident preferences for medication administration was for facility staff to ask the resident if they had any preferences on timing of medications. She further stated most residents were fine with flexible medication administration times and did not express a desire for staff to administer medications at specific times. Per interview, the DNS was not aware of R65 expressing a preference for administration of her morning medications. In an interview on 04/20/2024 at 12:18 PM, the Executive Director (ED) stated facility staff asked residents and families during the admission process if they had any preferences with medication administration changes. She further stated if residents were confused upon admission but later expressed to staff they wanted their medication earlier or later, the staff member should ensure that preference was documented on the care plan. The ED stated she was not aware of R65 expressing a preference for medication administration times. The ED stated she expected the facility to develop and implement individualized care plans because each resident had specific needs.

Based on observation, interview, record review, and review of the American Nurse Journal, the facility failed to ensure residents received care consistent with professional standards for 1 of 4 sampled residents (Resident (R) 9) who were at risk for developing pressure ulcers. R9 developed a stage 3 pressure ulcer, and staff failed to turn and repostion the resident every two hours to prevent the pressure ulcer. (Cross Reference F656) The findings include: In an interview on 04/19/2024 at 5:44 PM, the Executive Director stated the facility did not have a policy on skin care and pressure ulcer prevention. Review of the American Nurse Journal, volume 16, number 7, as published by the American Nurse's Association, dated 07/2021, revealed nursing staff were to turn residents every two hours when the resident was in bed to prevent pressure injury to the skin. Review of R9's Admission Record revealed the facility admitted the resident on 02/17/2020 with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke), type 2 diabetes, and cognitive communication disorder. Review of R9's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/15/2023, revealed the facility assessed the resident as dependent on staff to roll from side to side and back to a supine (laying on the back) position while in bed. Further review revealed the facility assessed the resident as at risk for the development of pressure ulcers. Continued review revealed the facility assessed R9 as free from pressure ulcers at the time of assessment. Review of R9's Care Plan, revised 02/01/2024, revealed the facility identified the resident as at risk for altered skin integrity and included the intervention for staff to assist with bed mobility to turn and reposition routinely, which was added to the care plan on 02/17/2020. Further review of the care plan revealed R9 required extensive assistance of two staff members for bed mobility. Review of the Tasks tab documentation in the electronic medical record, under Monitor-Turn and Reposition, dated 01/01/2024 through 01/17/2024 (17 sampled days), revealed no documented evidence the facility staff turned R9 according to the care plan. Further review revealed facility staff charted turning R9 fewer than eight times per day, ranging from one hour to seven hours between documented turns, on 11 of 17 sampled days with no documented refusals. Review of the facility's document Pressure Ulcer-Weekly Observation-V2, dated 01/17/2024, revealed that date was the first time the facility identified the stage 3 pressure ulcer on R9's sacrum (lower part of the back). Review of the facility's document IDT [interdisciplinary team] Risk Review-v 10, dated 01/25/2024, revealed the facility assessed contributing factors to the development of R9's wound, including incontinence and decreased food intake. Further review revealed no documented evidence the facility discussed or investigated staff compliance with care planned interventions, including repositioning the resident. Review of R9's quarterly MDS, with an ARD of 03/08/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as dependent on staff to roll from side to side and back to a supine position in bed. Continued review revealed the facility assessed the resident as having a stage 3 pressure ulcer that was not present on admission/reentry to the facility. Review of the Physicia's Wound Care Orders, dated 04/11/2024, revealed cleanse area to sacrum with wound cleaner, pat dry, apply calcium alginate and cover with foam dressing one time per day for wound healing. Continuous observation of R9 on 04/19/2024 from 8:35 AM through 11:48 AM revealed facility staff failed to reposition R9 during those three hours and 13 minutes. During the observation time frame, the surveyor observed the resident laying in a supine position, placing her weight on the pressure wound. Continued observation at 11:48 AM revealed State Registered Nurse Aide (SRNA) 7 and SRNA8 came to change R9 and R9 complained of pain on her backside (location of the pressure ulcer) when staff repositioned her. Observation on 04/19/2024 at 12:02 PM revealed Registered Nurse (RN) 2 completed a dressing change for R9. The wound had tissue loss, appeared to be a stage 3 pressure ulcer with no redness or signs of infection. In an interview on 04/19/2024 at 2:32 PM, SRNA6 stated she was assigned to care for R9 that day. In further interview, SRNA6 stated she failed to turn R9 every two hours as she should have that morning because she was very busy. She continued to state that repositioning a dependent resident according to the care plan was important to prevent development or worsening of pressure ulcers. In interview on 04/19/2024 at 2:46 PM, RN2 stated she was R9's nurse that day. In further interview, RN2 stated the nurse's role in pressure ulcer treatment and prevention was to change the dressings and administer supplements as ordered. She continued to state SRNAs were responsible for turning and repositioning. Additionally, RN2 stated repositioning should have been completed every two hours to promote tissue perfusion and prevent breakdown. In an interview on 04/19/2024 at 5:44 PM, the Director of Nursing Services (DNS) stated she expected staff to turn a resident at risk for a pressure ulcer every two hours. Per interview, the DNS stated she believed staff turned the residents in a timely fashion most of the time because if they did not everyone would have pressure ulcers. The DNS further stated turning and repositioning was not the only way to prevent a pressure ulcer. The DNS stated the facility did not perform audits of resident repositioning as part of a root cause analysis into development of a facility acquired pressure ulcer. Per interview, the DNS trusted staff members to comply with turning and repositioning standards of care because they knew her expectations. In an interview on 04/19/2024 at 7:32 PM, the Medical Director stated she defined an unavoidable wound as one that developed despite appropriate offloading, repositioning, and nutrition interventions. Per interview, the Medical Director stated she did not consider R9's pressure wound to be unavoidable because the resident had not significantly declined from her baseline. The Medical Director stated she had not identified a particular root cause of R9's wound but had noted the resident was in her wheelchair for long periods of time, and the IDT (members included the Activities Director, Dietary Manager, Infection Preventionist/Assistant Director of Nursing Services (IP/ADNS), DNS, and Executive Director (ED)) needed to evaluate encouraging the resident to take breaks from the wheelchair, even with a pressure redistribution cushion. In an interview on 04/19/2024 at 5:44 PM, the Executive Director (ED) stated she expected staff to follow a resident's care planned interventions to prevent pressure ulcers. She further stated routine repositioning meant every two hours. Per interview, the ED stated the facility's process to evaluate a resident who developed a pressure ulcer was to look at all the aspects of the resident's care, including nutrition and psychosocial needs, to determine what interventions would best help the resident. She further stated the IDT met once per week to discuss residents with pressure ulcers, and they had not identified any staff noncompliance with repositioning interventions. The ED stated the IDT did not determine if a wound was unavoidable; that was the role of the Medical Director.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to accommodate the resident's right to set her own daily schedule with respect to medication administration for 1 out of 31 sampled residents, Resident (R) 65. The findings include: Review of the facility's policy titled, Home-Like Medication Regimen, dated 03/01/2009, revealed facility staff members were to honor the residents' right to set their own daily schedule with respect to medication administration. Further review revealed the facility expected staff to administer morning medications when the resident got out of bed in the morning. Review of R65's Admission Record revealed the facility admitted the resident on 01/29/2024 with diagnoses including congestive heart failure, atrial fibrillation, and primary hypertension. Review of R65's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/06/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight of 15, indicating the resident was moderately cognitively impaired. Review of R65's Medication Administration Record (MAR) for 04/2024, revealed no information specifying the time the resident received blood pressure medication each day. Review of R65's Blood Pressure Summary from the electronic medical record, dated 04/16/2024 through 04/19/2024, revealed facility staff measured R65's blood pressure taken between 9:00 AM and 10:45 AM each morning. In an interview on 04/16/2024 at 11:17 AM, R65 stated she wanted her blood pressure medication at 8:00 AM but often had to wait between 10:00 AM and 11:00 AM. She further stated she had expressed this preference to a couple of staff members who administered medications. However, R65 did not recall the names of the staff members. Observation on 04/18/2024 at 9:49 AM revealed R65 standing in the doorway to her room, dressed and groomed for the day, looking back and forth in the hallway. Continued observation revealed R65 pacing in her room and coming back to the doorway to look in the hall. Further observation at 9:58 AM revealed R65 asked State Registered Nurse Aide (SRNA) 4 where the nurse was because she was waiting for her medicine. Per observation, R65 told SRNA4 that she asked for her medication when the Kentucky Medication Aide (KMA) measured her blood pressure earlier that morning, but the KMA had not returned yet. Additional observation at 10:01 AM revealed KMA5 administered R65's morning medication. In an interview on 04/18/2024 at 4:40 PM, KMA 5 stated she was assigned to administer medications for the 300 and 400 Halls. She further stated R65 often stood in the doorway waiting on her medication because the resident was anxious to get her medications. Per interview, KMA5's process was to administer medications to the residents in the 400 Hall first because they had more disruptive behaviors than residents on the 300 Hall. KMA5 further stated it was her process to take blood pressures on all residents on the 300 Hall who received blood pressure medication and then go down the hall and administer the medication. In continued interview, KMA5 stated she preferred that process because she had to document the blood pressure reading before administering the medication, and she did not feel it was efficient to go back and forth to the medication cart between taking blood pressure measurements and preparing medications for administration for each resident. In an interview on 04/20/2024 at 11:48 AM, the Director of Nursing Services (DNS) stated she expected residents to receive medications when they wanted them, as long as it was medically safe to do so. In further interview, the DNS stated R65 was confused on admission and did not express preferences during the admission process. The DNS further stated R65 was more alert and aware after acclimating to life in the facility, but the DNS was not aware of the resident expressing a desire to receive medications at a specific time. In an interview on 04/20/2024 at 12:18 PM, the Executive Director (ED) stated she expected staff to follow the home-like medication policy and administer medications according to the resident's preference. Per interview, the ED was not aware of R65 expressing a preference for medication administration times.

Based on interview, record review, review of the facility's incident report, and review of the facility's policy, the facility failed to ensure residents were free from abuse for 2 of 31 sampled residents (Residents (R) 48 and 64a). On 02/17/2024, R48 reported that R64a hit him in the chest area and punched him in the nose, causing his nose to bleed. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation Policy, undated, revealed the facility was to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as .willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . and instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Review of the facility's Incident Report, dated 02/17/2024, revealed on 02/17/2024 at 6:30 PM, R48 reported that R64a hit him in the nose. Per the report, R48 reported that he heard R64a in his bathroom and stated he told R64a that it was not the resident's bathroom. R48 stated R64a hit him in the nose and stomach. R48 suffered a bloody nose and was sent to the hospital emergency room for evaluation and treatment. The report stated his nose was not broken per the hospital record and both residents were eventually returned to the facility. Psychiatric consultations were initiated for R48 and R64a. 1. Review of R64a's closed record Face Sheet revealed the facility admitted the resident on 01/19/2024 with diagnoses that included severe dementia with other behavioral disturbances, anxiety disorder, and a history of alcohol abuse. Review of R64a's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/26/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15. This score indicated severe cognitive impairment. Review of R64a's admission Care Plan, dated 01/20/2024, revealed the resident rejected care and made inappropriate comments, exhibited delusional thoughts, and had auditory hallucinations. Further review revealed R64a startled easily. Review of R64a's Incident Note, dated 02/17/2024 at 8:30 PM, revealed R64a .hit another resident in the nose and kicked him in the chest. Further review of the Note revealed the resident was unable to recall the event. He was put on 1:1 supervision immediately. Skin assessment complete. Interview with R64a was not obtained as the resident was not in the facility during the time of the State Survey Agency (SSA) survey. 2. Review of R48's Face Sheet revealed the facility admitted the resident on 02/04/2022 with diagnoses of altered mental status, moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Review of R48's quarterly MDS, with an ARD of 02/05/2024, revealed the facility assessed the resident as having a BIMS score of 12 out of 15. This score indicated the resident was cognitively intact. Review of R48's Incident Note, dated 02/18/2024, revealed R48 stated, I was kicked in the stomach and punched in the nose. R48 reported when he told R64a that it was not his bathroom, R64a then became agitated and proceeded to kick him in the chest, and punch him in the nose. During an interview with R48 on 04/16/2024 at 10:30 AM, he stated R64a used to wander all the time. From the day of the incident, R48 recalled hearing the door handle to his room wiggle and he opened the door. R48 stated R64a was standing there so he said Boo and closed it back. R48 stated the next thing he knew R64a was in his bathroom and he told R64a he was in the wrong room. R48 stated R64a told him that he (R48) was not going to tell him (R64a) what to do, and then R64a started kicking R48. R48 stated, I was in the wheelchair so he [R64a] kicked me in the chest. I grabbed the door handle to help me from rolling back. He [R64a] lost his balance and couldn't use his feet anymore and punched me in the nose. R48 stated he got a bloody nose, the facility sent him to the hospital emergency room to make sure it was not broken, and it was not. During an interview with State Registered Nurse Aide (SRNA) 7 on 04/18/2024 at 12:00 PM, she stated she was the first to observe the incident. She stated she had been in another room and came out to see R48 covered in blood from a nosebleed and reported that R64a had kicked him in the chest area and then punched him in the nose. She stated she requested the help of Kentucky Medication Aide (KMA) 8. She further stated R48 and R64a were immediately separated, and Licensed Practical Nurse (LPN) 3 was notified. During a telephone interview with LPN3 on 04/17/2024 at 7:40 PM, she stated she was at the facility on the day of the incident. She stated she did not see what happened but came back to help after she was notified. During an interview with the Executive Director on 04/20/2024 at 8:25 AM, she stated she spoke to the staff that responded first, SRNA7, and confirmed R64a was on one-to-one supervision. She stated that per her interview with R48, the resident (R64a) had been wandering around as if in a cloud, or someone who was lost. She stated both R48 and R64a were sent to the hospital for evaluation, and no residual injuries were noted. She stated she expected that abuse would be reported immediately and the safety of the residents would be ensured.

Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were protected from sexual abuse and failed to develop policies, procedures, and protocols that identified when, how, and by whom determinations of capacity to consent to sexual contact would be made and where this determination would be recorded for three (3) of nineteen (19) sampled residents (Residents #68, #13, and #63). Review of the Facility's Allegation Report and Investigation, dated 01/08/2022, revealed Licensed Practical Nurse (LPN) #2 heard Resident #13 making pleasurable noises in the community room near the nursing station. LPN #2 went to investigate and observed Resident #68 with his/her hand down Resident #13's pajama pants and Resident #13 had his/her arm around Resident #68. Review of the Facility's Allegation Report and Investigation, Final Report, dated 03/05/2022, revealed LPN # 6 observed Resident #68 in the room of Resident #63. Resident #63 was in the bed with the covers on, behind the privacy curtain. Resident #68's hands were moving back and forth over Resident #63 under the covers. Resident #63 stated Resident #68 had his/her hands in his/her (Resident #63) brief while in bed. Resident #62 stated he/she told Resident #68 to stop, and it made him/her feel uncomfortable. The facility's failure to have an effective system in place to ensure each resident remained free from abuse and to ensure the facility developed policies, procedures, and protocols that identified when, how, and by whom determinations of capacity to consent to a sexual contact would be made has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/22/2022 and was determined to exist on 01/08/2022, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a J along with Substandard Quality of Care; and at 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 04/22/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, alleging removal of the IJ on 04/26/2022. The State Survey Agency determined the IJ had been removed on 04/26/2022, as alleged, prior to exit on 05/04/2022 with remaining noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a D and 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Resident Abuse Prevention, dated 2019, revealed every resident might be at risk for abuse and/or neglect due to the potential for diminished capacity, and would have care planned interventions designed to reduce the threat of abuse or neglect. The facility's policy stated that all residents had the right to be free from willful physical and/or emotional injury, punishment, intimidation, or unreasonable confinement. The facility defined sexual abuse as including but not limited to: sexual harassment, sexual coercion, or sexual assault. Interview with the Director of Social Services (SS), who was identified as the primary person for initiating and updating behavioral care plans, on 04/20/2022 at 9:04 AM, revealed there was no policy specific to residents and capacity to consent to sexual activity. Review of Resident #68's clinical record revealed the facility admitted the resident, on 04/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed on 09/29/2021, Resident #68 received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/07/2022, revealed the facility assessed Resident #68 with a score of thirteen (13) of fifteen (15) on the Brief Interview for Mental Status (BIMS) examination. This score indicated the resident's cognition was intact. Review of Resident #68's CCP (Comprehensive Care Plan), revealed a behavioral care plan, initiated on 11/02/2021, for sexually inappropriate and disruptive behaviors. Interventions included: removing the resident from the situation; psychiatric services as ordered; and, medication as ordered. 1. Review of Resident #13's clinical record revealed the facility admitted the resident, on 02/03/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #13, in a Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/2021, with a score of five (5) of fifteen (15) on the Brief Interview for Mental Status examination (BIMS), indicating severe cognitive impairment. Record review revealed the facility assessed Resident #13 to exhibit behaviors. Review of Resident #13's Comprehensive Care Plan (CCP), revealed a behavioral care plan, initiated on 12/14/2021, which identified the problem: sexually inappropriate behaviors that included flashing other residents and shaking his/her breasts at others. Interventions included maintaining a safe environment for the resident, redirection as needed, and encourage resident to wear pants. Review of the Facility's Allegation Report and Investigation, dated 01/08/2022, revealed Licensed Practical Nurse (LPN) #2 heard Resident #13 making pleasurable noises in the community room near the nursing station. LPN #2 observed Resident #68 with his/her hand down Resident #13's pajama pants. Resident #13 had his/her arm around Resident #68. Interview with Resident #68, on 04/20/2022 at 9:11 AM, revealed he/she remembered the incident involving Resident #13. Resident #68 stated that he/she and Resident #13 never kissed or hugged, and nothing happened. Interview with Resident #13, on 04/20/2022 at 10:30 AM, revealed he/she remembered the incident involving Resident #68. Resident #13 stated that Resident #68 put his/her hands down his/her (Resident #13's) pants, and Resident #68 grabbed Resident #13's breast (pointed to breast). Resident #13 stated this had never occurred before. Also, Resident #13 stated this did not make him/her feel uncomfortable, and he/she felt safe in the facility. Interview with LPN #2, on 04/19/2022 at 12:56 PM, revealed she remembered the incident with Resident #68 and Resident #13. She stated she had been observing Resident #13 closely because the resident had been sitting in the family room in a chair with his/her legs spread and was wearing a nightgown with pants on underneath. LPN #2 stated she had been sitting at the nurses' station for four (4) to five (5) minutes, when she heard Resident #13 making a commotion in the family room. She stated she responded and observed Resident #13 sitting in a chair making pleasurable noises. LPN #2 stated Resident #68 had his/her hands down Resident 13's pants. The LPN explained that by the time she got to the residents, they had separated; both denied anything had happened, and neither resident was in distress. She stated she did a BIMS assessment on both residents and recalled Resident #13's score was five (5) of fifteen, indicating severe cognitive impairment. LPN #2 stated she did another BIMS assessment a few minutes later, and the score was eight (8) of fifteen, indicating moderately impaired cognition. LPN #2 stated the family room was a community or common room. She stated she was not sure how long Resident #68 had been in the family room. Interview with LPN #2, on 04/19/2022 at 12:56 PM, revealed Resident #13 could make some of his/her own choices, such what to wear, when to shower, and where he/she wanted to go. LPN #2 stated Resident #13 could remember names and faces very well and could tell a staff member if someone hurt him/her. The LPN stated that after this incident, there had been no change in Resident #13's demeanor or behavior. LPN #2 stated Resident #13 and Resident #68 would talk for three (3) or four (4) minutes at the most when Resident #68 walked past the nurses' station. She stated Resident #13 wanted to know where Resident #68 was, and Resident #13 was always looking for Resident #68. LPN #2 explained that Resident #13 would get fixated on a person of the opposite sex and want to talk to or be close to him/her. She stated she could not recall any other incidents with Resident #13 and Resident #68. Interview with the Director of Social Services (SS), on 04/20/2022 at 9:11 AM, revealed Resident #13 was his/her own responsible party and could make his/her own choices, which included being competent to consent to sexual activity. Also, she stated Resident #68 was his/her own person and was capable of consenting to sexual activity. Interview with the Executive Director (ED), on 04/19/2022 at 11:56 PM, revealed the facility did not have a policy on sexual relations or consenting. She stated the facility consulted an outside psychiatric agency to make the determination on consent, if facility staff had questions about whether someone was able to give consent. She stated, since the incident with Resident #13 and Resident #68, the facility would get this assessment with a resident's increased sexual behaviors or if an interest was shown. The ED stated Resident #13 was assessed by the outside psychiatric agency, on 01/11/2022, and the assessment determined Resident #13 was capable of making choices about sexual behavior. The ED explained she had tried to get Resident #13 a state guardian last week. The ED stated Resident #13's parent was in the hospital recently and coded (heart and respirations stopped and resuscitative procedures were begun), which was successful, but that was why she was exploring Resident #13's legal status. She stated during the process, Adult Protective Services, the Ombudsman, and the Guardianship office were called, and they all said Resident #13 was his/her own person. Interview with the Advanced Practice Nurse Practitioner (APRN), on 04/20/2022 at 1:18 PM, revealed she worked for the contracted psychiatric services provided at the facility. She stated she was scheduled to be at the facility, on 01/11/2022. She stated she contacted Social Services (SS), who mentioned the incident that the Facility had reported between Resident #13 and Resident #68. The APRN stated SS requested that she speak with Resident #13 regarding his/her understanding and consent. She stated she met privately with Resident #13. She stated Resident #13 identified Resident #68 as his/her boyfriend, and that they were making out on the couch. The APRN stated that Resident #13 told her that Resident #68 touched him/her and that was what the resident wanted. The APRN stated Resident #13 verbalized understanding of the incident with Resident #68, and the resident told the APRN that he/she had experienced sexual engagement before the incident. The APRN stated she felt Resident #13 was a high functioning individual with Down Syndrome and was able to give consent to sexual behavior. She stated Resident #13 was able to tell her what he/she would do if he/she did not consent, such as alert a nurse immediately. Interview with the APRN, on 04/20/2022 at 1:18 PM, revealed she had received training through her master's degree in determining competency. She stated to determine competency, the BIMS score and the interview were reviewed. The APRN stated she felt confidently that Resident #13 was capable of giving consent. Also, she stated the facility did not request her to speak with Resident #68 about this incident. She stated she did see Resident #68, on 01/11/2022, to talk about anger issues because he/she had experienced combativeness with another resident. Further interview revealed she was never made aware of any prior sexual behaviors, sexual assault, or anything like that. The APRN stated Resident #68 was high functioning, and she did not see the need to assess him/her for capacity to consent. 2. Review of the Facility's Allegation Report and Investigation, Final Report, dated 03/05/2022, revealed LPN # 6 observed Resident #68 in Resident #63's room. Resident #63 was behind the privacy curtain lying in the bed with covers on, and Resident #68's hands were moving back and forth over Resident #63 under the covers. In an interview with Resident #63, the resident stated Resident #68 had his/her hands in Resident #63's brief while in bed. Resident #63 stated he/she told Resident #68 to stop, as it made him/her feel uncomfortable. Continued review of the Facility's Allegation Report and Investigation, Final Report, dated 03/05/2022, revealed Resident #68 consistently denied touching Resident #63 other than to awaken him/her. Per the report, statements by Resident #63 were inconsistent with what was observed by LPN #6, as Resident #63 indicated Resident #68 had removed the covers as well as his/her brief. The report stated both Resident #63 and Resident #68 were seen by in-house psychiatric services, with no psychosocial distress noted. Review of a Kentucky Incident Based Reporting System (KYIBRS) Report, dated 03/06/2022, revealed police responded to the incident reported at 10:45 PM on 03/05/2022. The report revealed in the interview with police, Resident #63 alleged Resident #68 had touched his/her private area, and Resident #63 asked Resident #68 to stop and he/she did not. Per the report, Resident #68 denied touching Resident #63 and stated he/she did not know why Resident #63 would make the accusation. Included as part of the police report were written interviews conducted by LPN #6 with Resident #63, which corroborated what he/she had told the officers. Resident #68's interview also remained consistent regarding no touching and just talking. Review of Resident #63's clinical record revealed the facility admitted the resident, on 01/15/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #63 in an Annual MDS Assessment, dated 01/12/2022 as a twelve (12) of fifteen (15) on the BIMS assessment, indicating moderate cognitive impairment. Review of Resident #63's Comprehensive Care Plan revealed a behavioral care plan for sexually inappropriate and disruptive behaviors, dated 02/05/2021, which was updated following the 03/05/2022 incident to include fifteen (15) minute checks, Physician visits as needed, and visit by the Licensed Clinical Social Worker (LCSW) from psychiatric services. Interview with Resident #68, on 04/20/2022 at 9:20 AM, revealed Resident #68 remembered the incident involving resident #63. Resident #68 stated he did not do anything, and Resident 63 had invited him/her to look at pictures. Interview with Resident #63, on 04/21/2022 at 1:02 PM, revealed Resident #68 touched Resident #63 down there (pointed to his/her perineal area), and Resident #68 would not stop when asked. Resident #63 stated the Nurse put Resident #68 in another room. Also, Resident #63 stated that this made him/her feel uncomfortable. Interview with LPN #6, on 04/20/2022 at 1:43 PM, revealed she was administering medications, and Resident #68 was in Resident #63's room. She stated Resident #63 was lying on his/her side facing the bathroom; Resident #68 was facing the door. LPN #6 stated the privacy curtain was pulled, and she could not see where Resident #68's hand was, but it was moving. She stated Resident #68 said they were just talking. She stated she removed Resident #68 from the room and reported the incident to the Director of Nursing Services (DON). LPN #6 stated Resident #63 told her Resident #68 was trying to finger me out. LPN #6 stated Resident #63 was not crying and did not seem upset. Interview with the Advanced Practice Nurse Practitioner (APRN), on 04/20/2022 at 1:18 PM, revealed she was aware of the incident with Resident #63 and stated she heard family members had been made aware and did not want to pursue the matter. She stated she was not aware of who the other resident was. The APRN stated she did see Resident #63, 03/16/2022, as they made a report. She stated she knew a nurse saw a resident at Resident #63's bedside, and the nurse noticed a scratch on Resident #63's abdomen. The APRN stated a Psychologist recently saw Resident #63, and the resident was happy and overall calm when speaking about the incident. Interview with the Director of Nursing Services (DON), on 04/22/2022 at 5:36 PM, revealed she did not feel the situation with Resident #68 and Resident #13 was sexual abuse. She stated she expected that anyone that suspected abuse would report it to her or the ED (Executive Director) immediately and would intervene immediately to protect residents. She stated she felt the nurses that observed the incidents did the appropriate interventions as soon as they were witnessed. The DON stated she thought the resident would typically be treated as competent until the resident was deemed incompetent. She stated the incident with Resident #13 and #68 was reported because of Resident #13's low BIMS score. Regarding Resident #68 and Resident #63, the DON stated when she interviewed Resident #63, she felt like it was sexual abuse, and that was why she called law enforcement and took additional steps. The DON stated she did not think Resident #63 should have been assessed for competency, as he/she was not voluntarily participating. In addition, she stated she was not sure whether or not Resident #68 was or should have assessed for capacity to consent. Interview with the Executive Director (ED), on 04/21/2022 at 1:56 PM, revealed she did not agree that the incidents, with Residents #68, #13, and #63, were sexual abuse. The ED stated she felt Resident #13 was cognitive enough to give consent; he/she was his/her own person. She stated she reported the incident due to Resident #13's low BIMS' score. She stated her only concern was it took place in the community/family room, but there were no other residents in the area. The ED stated, as an intervention for the incident with Resident #63, Resident #68 was placed on a secure unit, without members of the opposite sex. Additional interview with the ED, on 04/22/2022 at 5:18 PM, revealed Resident #13 had been care planned for sexual tendencies, but he/she did not show any interest in having a sexual relationship prior to this incident. She stated her expectation was that residents would be kept safe from abuse and neglect, and if something happened, staff would protect them. Regarding Resident #68 and Resident #63, the ED stated, if that truly happened it was sexual abuse, but the facility could not substantiate that. She stated the nurse did not see any of that because the residents were blocked from view behind the privacy curtain; therefore, the facility could only substantiate that Resident #68 was in Resident #63's room. The ED stated she did not feel there was a question of consent for Resident #63 because if it did happen, he/she was not a voluntary participant, as se/he said no. The ED stated facility staff did follow Resident #68's behavioral care plan, initiated on 11/02/2021, for sexually inappropriate and disruptive behaviors. She stated the facility's staff did behavior meetings, talked to the physician, and talked to the nurse practitioner every day; and, the staff did put interventions in place. The ED explained that the health care provider determined whether residents were competent, and that was why staff reported the incident with Resident #13. In addition, she stated staff did not make the determination of capacity to consent on admission because a resident would not be asked about consent if he/she had never shown any interest in a sexual relationship. Regarding Resident #68, she stated, staff went by the BIMS score, which showed intact cognition, and the resident did not have a POA or guardian. The ED stated there was no question that Resident #68 was competent. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, that alleged removal of the Immediate Jeopardy (IJ) on 04/26/2022. The facility implemented the following: 1. Resident #13 was immediately placed on fifteen (15) minute checks after the incident, on 01/08/2022, with Resident #68. Once the determination of capacity to consent was made regarding Resident #13, the fifteen (15) minute checks were discontinued. 2. Resident #13 was assessed by the contracted behavioral Advanced Practice Registered Nurse (APRN) on 01/11/2022 to determine if the resident had capacity and could give consent in regard to sexual activity. 3. On 03/06/2022, Resident #68 was placed on one-to-one (1:1) observation following the incident with Resident #63, and it was not discontinued until Resident #68 was moved to a same gender secured unit that evening. 4. On 04/22/2022, an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director (ED), Director of Nursing Services (DON), and Vice-President (VP) of Operations. This meeting reviewed the alleged deficiency, IJ Removal Plan, and education for all care team members to review the facility's policy on Resident Abuse Prevention. This training would include definitions of sexual abuse and reporting abuse and neglect and would be conducted by the ED, DON, and ADON. In addition, this education, with all care team members was initiated on 04/22/2022. 5. The entire Comprehensive Care Plans (CCP) for Resident #13, Resident #63, and Resident #68 were reviewed by the Regional Registered Nurse (RN)/MDS Specialist, on 04/22/2022, to ensure current interventions were up-to-date. 6. A new policy titled, Resident Sexual Expression, related to determination of capacity to consent to sexual contact, was developed and reviewed and implemented on 04/25/2022. Education regarding this new policy was conducted by a Director of Social Services of a contracted consulting company, with the ED, DON, Director of Social Services, VP of Operations, VP of Clinical Services, and outside legal counsel on 04/25/2022. Additional members of the IDT, consisting of the ADON, MDS Coordinator, Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records also received this education on 04/25/2022. This education included review of the occurrence, the documentation required after the review, and that all required documentation was present and completed. In addition, education was provided on the types of abuse, action(s) to be taken immediately, and the consent process. 7. On 04/25/2022, all residents with a BIMS score of eight (8) or greater were interviewed by the facility's Director of Social Services or the ED regarding if any resident entered their rooms without permission or attempted to bother them/touch them in any way that made them uncomfortable. All residents responded NO to the question, denying anyone had bothered them in any way. 8. On 04/25/2022, all residents with a BIMS score less than eight (8) had skin assessments completed by the Wound Care Nurse. Any injuries not documented, prior to 04/25/2022, were documented in the Electronic Medical Record (EMR) and the causative factor was identified. Any injuries where the causative factor could not be determined were reported, as required, to the Office of Inspector General (OIG)/(State Survey Agency) and investigated. 9. On 04/25/2022, all allegations of abuse, neglect, and exploitation, occurring since 01/01/2022, were reviewed by the VP of Operations or the Clinical Consultant to ensure the interventions enacted by the facility were appropriate for the allegation. This review produced no negative findings as all were thoroughly investigated. 10. On 04/25/2022, all nursing and ancillary staff were educated by the DON, ADON, and/or ED on the Resident Sexual Expression policy related to the process of reporting to the Nurse Supervisor, DON, or ED if it was unclear that sexual expression that was observed, witnessed, or heard involving residents was between consenting adults. The training instructed staff that residents should be separated immediately until determination of their capacity to consent was verified. This determination was made by the residents' physicians regarding the residents' capacity to make decisions related to sexual participation. This education was completed for seventy-eight (78) of seventy-nine (79) of the facility's care team members. Any staff not educated on 04/26/2022 will not be allowed to perform direct resident care until they have received this education. 11. On 04/25/2022, an AdHoc QAPI meeting was held with the ED, DON, Medical Director, and Director of Social Services. This meeting reviewed the actions, education and audit tools that would be performed by the facility after 04/25/2022 regarding the alleged deficiencies. The Medical Director reviewed and approved the education and audit tools. A weekly AdHoc QAPI meeting will be held for the next four (4) weeks or until removal of the IJ has been validated by the State Survey Agency. 12. On 04/25/2022, education was provided by the Regional Clinical Reimbursement Specialist (by a contracted company) on reviewing and updating residents' Comprehensive Care Plans, per the RAI manual, to the IDT, which included the ED, DON, Care Plan Nurse, the MDS Coordinator, SS, Dietary Manager, and Director of Activities. Then, on 04/25/2022, all residents' Comprehensive Care Plans were reviewed by the IDT to identify any determination of sexual behavior. If identified, the IDT reviewed and updated the resident's Comprehensive Care Plan. 13. By 04/25/2022, the Comprehensive Care Plans of Resident #68, Resident #13, and Resident #63 were updated to reflect a comprehensive resident centered plan of care for each resident including determination of capacity to consent by the physician and subsequent care plan interventions. For Resident #68, the care plan was updated to include to offer privacy as needed or desired and a care plan for sexual expression was added. For Resident #13, the care plan was updated to include to offer privacy as needed. Also disrobing and self-pleasuring were added to the behavior care plan. For Resident #63, the care plan was updated to include the resident seeks attention of others and enjoys being helpful to staff. 14. On 04/25/2022, Resident #68 was assessed by the behavioral APRN and by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #68 had the capacity to consent to all sexual expressions, except sexual intercourse. 15. On 04/25/2022, Resident #63 was assessed by the behavioral APRN and, on 04/26/2022 by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #63 had the capacity to consent to all sexual expressions, except sexual intercourse. 16. On 04/26/2022, Resident #13 was assessed by a PhD Psychologist; a post evaluation case review was completed on 04/26/2022. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #13 had the capacity to consent to all sexual expressions, except sexual intercourse. 17. The seven (7) residents that had some mention of sexual expression in their Comprehensive Care Plans were reviewed and updated on 04/25/2022 by the IDT. They were also assessed by the behavioral APRN, on 04/25/2022, and by a PhD Psychologist on 04/26/2022. Some examples of personalized care plans included: offer privacy as needed or desired and/or sexual expressions such as exhibits self-pleasuring and/or provide positive feedback for good behavior and/or emphasize the positive aspects of appropriate behavior. 18. On 04/26/2022, education was provided to all nursing staff and ancillary staff by the DON, ADON, and/or ED on reviewing, updating, and revising the residents' comprehensive care plans. This education also included accessing the Kardex, which is the electronic care guide for direct care nursing team members. 19. On 04/26/2022, an AdHoc QAPI meeting was held with the ED, DON, Regional Nurse Consultant, and VP of Operations which determined that the actions, education, and audit tools were effective and that they removed the immediacy of the alleged deficiencies. 20. All new hire staff and agency staff will be educated by the DON or ADON on the above items (Resident Abuse Prevention and Resident Sexual Expression policies) before providing care to the residents. Newly hired staff will be educated by the DON or ADON during the orientation process. 21. Audits will be completed to ensure that the education provided was effective via a series of questions related to the education. Five (5) questionnaires will be completed daily until the IJ removal has been validated by the State Survey Agency. These audits will be completed by the DON, ADON, ED, or the Senior Clinical Consultant to ensure understanding of reporting suspected sexual abuse without appropriate consent. 22. Members of the IDT to include the ED, DON, ADON, MDS Coordinator, Care Plan Nurse, SS, Director of Dietary Services, and Director of Activities will review one-hundred percent (100%) of the Nurse's Progress Notes daily during the Clinical Meeting until IJ removal has been validated by the State Survey Agency. The review will include the documentation for any residents for signs and/or symptoms of new, worsening and/or increased behavior and follow up for any form of sexual expression that might have occurred and not have been immediately reported. The IDT will discuss any notes with behavior documentation, decide upon an action or actions needed related to the behavior including update care plans timely, referral to the contracted behavioral/psychiatric services for new onset sexual behaviors or notification of the contracted services related to any resident on caseload for worsening or increased sexual behaviors. Any incidents will be discussed by the IDT, and if necessary, an investigation will be conducted by the DON and/or ADON. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of the facility's investigation into the 01/08/2022 incident confirmed Resident #13 was placed on fifteen (15) minute checks immediately following the incident, and Resident #13 was seen by the facility's nurse practitioner on 01/12/2022. Review of Resident #13's Comprehensive Care Plan revealed these interventions were not added until 04/25/2022. 2. Review of Resident #13's Comprehensive Care Plan revealed the resident was seen by the behavioral APRN, on 01/11/2022, who determined the resident was mentally capable to consent to sexual activity at that time. 3. Review of the facility's investigation into the 03/05/2022 incident confirmed Resident #68 was placed on one-to-one (1:1) observation following the incident. Review of Resident #68's Comprehensive Care Plan revealed a behavioral care plan for sexual behaviors was updated on 03/08/2022, which included the one-to-one (1:1) observation, which was discontinued on 03/06/2022, and a room change to a secure unit, was care planned as occurring on 03/06/2022. Interview with State Registered

Based on interview, record review, and review of the Centers for Medicare and Medicaid's (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to have an effective system in place to ensure care plans were reviewed and revised for two (2) of nineteen (19) sampled residents (Resident #13, Resident #63 and Resident #68). Residents #13 and #68 had a sexual encounter in the facility's family room, on 01/08/2022, which was witnessed by Licensed Practical Nurse (LPN) #2. Resident #13 was overheard making pleasurable sounds in the family room, and LPN #2 observed Resident #68 quickly removing his/her hand from Resident #13's pajama pants. The residents were separated, and the facility initiated an investigation. Resident #13 was placed on fifteen (15) minute monitoring pending a psychiatric evaluation. Review of Resident #68's care plan revealed Resident #68 had been previously care planned for sexually inappropriate/disruptive behaviors at times, with interventions to maintain a safe environment for the resident, and to redirect the resident as needed. However, Resident #68's care plan was not updated to include increased supervision for safety of the resident and others following the incident on 01/08/2022. Resident #68's care plan was not revised regarding capacity to consent following this increase in sexual behaviors. Review of Resident #13's care plan revealed it addressed inappropriate sexual behaviors. However, after the incident, on 01/08/2022, there was no documented evidence the facility revised the care plan with interventions to address the increase in sexual behavior; the resident's capacity to consent, or monitoring of the behaviors. On 03/05/2022, LPN #6 observed Resident #68 in Resident #63's room. Resident #63 was in the bed behind the privacy curtain, and Resident #68's hands were under the covers, moving back and forth over Resident #63's body. In interview with Resident #63, the resident stated Resident #68 had his/her hands in his/her brief while he/she was in bed. Per the interview, Resident #63 stated Resident #68 made him/her feel uncomfortable. Resident #63 stated he/she told Resident #68 to stop. The facility's failure to have an effective system in place to ensure residents' care plans were updated to prevent resident-to-resident sexual abuse has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/22/2022 and was determined to exist on 01/08/2022, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a J along with Substandard Quality of Care; and at 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 04/22/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, alleging removal of the IJ on 04/26/2022. The State Survey Agency determined the IJ had been removed on 04/26/2022, as alleged, prior to exit on 05/04/2022 with remaining noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a D and 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Interview with the facility's Regional Clinical Reimbursement Specialist RAI (Resident Assessment Instrument), on 04/22/2022 at 4:14 PM, revealed the facility did not have a policy regarding care plans and followed the RAI manual regarding care planning. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.16, dated October 2018, revealed the comprehensive care plan was an interdisciplinary communication tool that should be revised on an ongoing basis to reflect changes in the resident and the care that the resident was receiving. The manual revealed the overall care plan should be oriented toward individualized interventions that honored the resident's preferences, and managed risk factors to the extent possible or indicated the limits of such interventions. Review of the Facility's Five Day Allegation Report and Investigation, dated 01/14/2022, revealed on 01/08/2022, LPN (Licensed Practical Nurse) #2 observed Resident #68 in the family room with his/her hand in Resident #13's pajama pants. LPN #2 was at the nurses station across from the family room when she overheard Resident #13 making pleasurable noises from the family room. LPN #2 observed Resident #68 quickly pull his/her hands out of Resident #13's pajama pants when he/she saw LPN #2 entering the area. The LPN observed that Resident #13 had his/her arm around Resident #68's neck with his/her head resting on Resident #68's shoulder. The residents were immediately separated, and both denied any nonconsensual behavior. Review of Resident #13's clinical record revealed the facility admitted the resident, on 02/03/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #13, in a Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/2021, with a score of five (5) of fifteen (15) on the Brief Interview for Mental Status (BIMS) examination, indicating severe cognitive impairment. Review of Resident #13's Comprehensive Care Plan (CCP), revealed a behavioral care plan, initiated on 12/14/2021, identifying the resident as having Down Syndrome and exhibiting child-like tendencies which included playing with baby dolls, [NAME] dolls, and watching cartoons. The behavioral care plan stated as a problem: inappropriate verbalizations toward other residents to include telling others to shut up and that they were ugly; and sexually inappropriate behaviors that included flashing other residents and shaking his/her breasts at others. Interventions included maintaining a safe environment for the resident, redirection as needed, and encourage resident to wear pants. Further review of Resident #13's behavioral care plan, dated 12/14/2021, revealed there was no evidence it was revised following the 01/08/2022 incident to include fifteen (15) minute monitoring or an evaluation by psychiatric services as indicated in the facility's investigation. There was also no assessment regarding the resident's ability to consent to sexual activity. Review of Resident #68's clinical record revealed the facility admitted the resident, on 04/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] with Behavioral Disturbance was added on 06/23/2021. The facility assessed Resident #68, in a Quarterly MDS Assessment, dated 01/07/2022, with a score of thirteen (13) of fifteen (15) on the BIMS, indicating intact cognition. Review of this MDS Assessment revealed Resident #68 had verbal and other behaviors directed towards others, as well as rejection of care, one (1) to three (3) days of the seven (7) day look-back period. Review of Resident #68's CCP, revealed a behavioral care plan, initiated on 11/02/2021, for sexually inappropriate and disruptive behaviors. Interventions included removing the resident from the situation, psychiatric services as ordered, and medication as ordered. Further review of Resident #68's behavioral care plan, dated 11/02/2021, revealed there was no evidence this care plan was revised following the 01/08/2022 incident, to include any assessment regarding the resident's ability to consent to sexual activity. Review of the Facility's Five Day Allegation Report and Investigation, Final Report, dated 03/11/2022, revealed on 03/05/2022, LPN #6 entered Resident #63's room and found Resident #68 in Resident #63's room partially obscured by the privacy curtain. Resident #68's arm was beneath the bed covers where Resident #63 was lying. The report stated Resident #68's right hand was moving back and forth over Resident #63's lower body. Upon LPN #6 entering Resident #63's room, Resident #68 pulled his/her arm away. The report stated Resident #68 told LPN #6 that he/she and Resident #63 were not doing anything but talking. The report stated LPN #6 directed Resident #68 back to his/her room, placed Resident #68 on one-to-one (1:1) supervision, and placed Resident #63 on fifteen (15) minute supervision. The report stated an investigation was started and law enforcement was contacted. The facility determined Resident #68 had been trying to awaken Resident #63 when LPN #6 entered and was unable to substantiate any sexual abuse. Interview with the Director of Social Services (SS), who was identified as the primary person for initiating and updating behavioral care plans, on 04/20/2022 at 9:04 AM, revealed she did not recall very much about the 01/08/2022 situation between Resident #13 and Resident #68. However, she stated in such situations she would ensure the residents were safe and update the residents' care plans, as needed, to include observing for any psychosocial needs. Interview with the Care Plan Nurse, on 04/22/2022 at 4:20 PM, revealed she was responsible for writing and updating residents' care plans. She explained she followed residents throughout their stay at the facility, with any behaviors, wounds, or anything out of the ordinary that was reviewed in the morning meeting with the Interdisciplinary Team (IDT), which could prompt a care plan change. She stated all members of the IDT, (members included the Executive Director (ED), Director of Nursing Services (DON), Assistant Director of Nursing Services (ADON), Minimum Data Set (MDS) Coordinator, Director of Social Services (SS), Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records) could update care plans. Further interview regarding resident behaviors, revealed the SS usually updated those; but, resident behaviors were discussed with all members of the IDT. She stated, unless there were other interventions already in place, care plans for Resident #13 and Resident #68 should have been updated following the incident on 01/08/2022. She stated she thought psychiatric services were involved in that situation, and the residents were observed more closely afterwards to see if there were any psychosocial issues. Additional interview with the SS, on 04/22/2022 at 4:34 PM, revealed she updated care plans specific to resident behaviors; however, as the incident between Resident #13 and Resident #68 was consensual, she did not feel there needed to be any care plan updates. Regarding the public location of the encounter between Resident #68 and Resident #13, she stated the family room was a common area that all residents had the right to use, and Resident #68 and Resident #13 might have considered that to be a private place. Interview with the Executive Director (ED), on 04/22/2022 at 5:49 PM, revealed Resident #13 had not shown any interest in having a sexual relationship, prior to 01/08/2022, and had been care planned for sexual tendencies prior to the incident. She stated the residents might have felt they were in a private place. The ED explained the determination regarding capacity to consent was not made on admission and was only considered after a resident had shown an interest in a sexual relationship. She stated the health care provider made the determination whether residents were capable of consenting or not. The ED stated her expectation was that residents would be kept safe from abuse and neglect, and if something happened, staff protected them. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, that alleged removal of the Immediate Jeopardy (IJ) on 04/26/2022. The facility implemented the following: 1. Resident #13 was immediately placed on fifteen (15) minute checks after the incident, on 01/08/2022, with Resident #68. Once the determination of capacity to consent was made regarding Resident #13, the fifteen (15) minute checks were discontinued. 2. Resident #13 was assessed by the contracted behavioral Advanced Practice Registered Nurse (APRN) on 01/11/2022 to determine if the resident had capacity and could give consent in regard to sexual activity. 3. On 03/06/2022, Resident #68 was placed on one-to-one (1:1) observation following the incident with Resident #63, and it was not discontinued until Resident #68 was moved to a same gender secured unit that evening. 4. On 04/22/2022, an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director (ED), Director of Nursing Services (DON), and Vice-President (VP) of Operations. This meeting reviewed the alleged deficiency, IJ Removal Plan, and education for all care team members to review the facility's policy on Resident Abuse Prevention. This training would include definitions of sexual abuse and reporting abuse and neglect and would be conducted by the ED, DON, and ADON. In addition, this education, with all care team members was initiated on 04/22/2022. 5. The entire Comprehensive Care Plans (CCP) for Resident #13, Resident #63, and Resident #68 were reviewed by the Regional Registered Nurse (RN)/MDS Specialist, on 04/22/2022, to ensure current interventions were up-to-date. 6. A new policy titled, Resident Sexual Expression, related to determination of capacity to consent to sexual contact, was developed and reviewed and implemented on 04/25/2022. Education regarding this new policy was conducted by a Director of Social Services of a contracted consulting company, with the ED, DON, Director of Social Services, VP of Operations, VP of Clinical Services, and outside legal counsel on 04/25/2022. Additional members of the IDT, consisting of the ADON, MDS Coordinator, Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records also received this education on 04/25/2022. This education included review of the occurrence, the documentation required after the review, and that all required documentation was present and completed. In addition, education was provided on the types of abuse, action(s) to be taken immediately, and the consent process. 7. On 04/25/2022, all residents with a BIMS score of eight (8) or greater were interviewed by the facility's Director of Social Services or the ED regarding if any resident entered their rooms without permission or attempted to bother them/touch them in any way that made them uncomfortable. All residents responded NO to the question, denying anyone had bothered them in any way. 8. On 04/25/2022, all residents with a BIMS score less than eight (8) had skin assessments completed by the Wound Care Nurse. Any injuries not documented, prior to 04/25/2022, were documented in the Electronic Medical Record (EMR) and the causative factor was identified. Any injuries where the causative factor could not be determined were reported, as required, to the Office of Inspector General (OIG)/(State Survey Agency) and investigated. 9. On 04/25/2022, all allegations of abuse, neglect, and exploitation, occurring since 01/01/2022, were reviewed by the VP of Operations or the Clinical Consultant to ensure the interventions enacted by the facility were appropriate for the allegation. This review produced no negative findings as all were thoroughly investigated. 10. On 04/25/2022, all nursing and ancillary staff were educated by the DON, ADON, and/or ED on the Resident Sexual Expression policy related to the process of reporting to the Nurse Supervisor, DON, or ED if it was unclear that sexual expression that was observed, witnessed, or heard involving residents was between consenting adults. The training instructed staff that residents should be separated immediately until determination of their capacity to consent was verified. This determination was made by the residents' physicians regarding the residents' capacity to make decisions related to sexual participation. This education was completed for seventy-eight (78) of seventy-nine (79) of the facility's care team members. Any staff not educated on 04/26/2022 will not be allowed to perform direct resident care until they have received this education. 11. On 04/25/2022, an AdHoc QAPI meeting was held with the ED, DON, Medical Director, and Director of Social Services. This meeting reviewed the actions, education and audit tools that would be performed by the facility after 04/25/2022 regarding the alleged deficiencies. The Medical Director reviewed and approved the education and audit tools. A weekly AdHoc QAPI meeting will be held for the next four (4) weeks or until removal of the IJ has been validated by the State Survey Agency. 12. On 04/25/2022, education was provided by the Regional Clinical Reimbursement Specialist (by a contracted company) on reviewing and updating residents' Comprehensive Care Plans, per the RAI manual, to the IDT, which included the ED, DON, Care Plan Nurse, the MDS Coordinator, SS, Dietary Manager, and Director of Activities. Then, on 04/25/2022, all residents' Comprehensive Care Plans were reviewed by the IDT to identify any determination of sexual behavior. If identified, the IDT reviewed and updated the resident's Comprehensive Care Plan. 13. By 04/25/2022, the Comprehensive Care Plans of Resident #68, Resident #13, and Resident #63 were updated to reflect a comprehensive resident centered plan of care for each resident including determination of capacity to consent by the physician and subsequent care plan interventions. For Resident #68, the care plan was updated to include to offer privacy as needed or desired and a care plan for sexual expression was added. For Resident #13, the care plan was updated to include to offer privacy as needed. Also disrobing and self-pleasuring were added to the behavior care plan. For Resident #63, the care plan was updated to include the resident seeks attention of others and enjoys being helpful to staff. 14. On 04/25/2022, Resident #68 was assessed by the behavioral APRN and by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #68 had the capacity to consent to all sexual expressions, except sexual intercourse. 15. On 04/25/2022, Resident #63 was assessed by the behavioral APRN and, on 04/26/2022 by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #63 had the capacity to consent to all sexual expressions, except sexual intercourse. 16. On 04/26/2022, Resident #13 was assessed by a PhD Psychologist; a post evaluation case review was completed on 04/26/2022. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #13 had the capacity to consent to all sexual expressions, except sexual intercourse. 17. The seven (7) residents that had some mention of sexual expression in their Comprehensive Care Plans were reviewed and updated on 04/25/2022 by the IDT. They were also assessed by the behavioral APRN, on 04/25/2022, and by a PhD Psychologist on 04/26/2022. Some examples of personalized care plans included: offer privacy as needed or desired and/or sexual expressions such as exhibits self-pleasuring and/or provide positive feedback for good behavior and/or emphasize the positive aspects of appropriate behavior. 18. On 04/26/2022, education was provided to all nursing staff and ancillary staff by the DON, ADON, and/or ED on reviewing, updating, and revising the residents' comprehensive care plans. This education also included accessing the Kardex, which is the electronic care guide for direct care nursing team members. 19. On 04/26/2022, an AdHoc QAPI meeting was held with the ED, DON, Regional Nurse Consultant, and VP of Operations which determined that the actions, education, and audit tools were effective and that they removed the immediacy of the alleged deficiencies. 20. All new hire staff and agency staff will be educated by the DON or ADON on the above items (Resident Abuse Prevention and Resident Sexual Expression policies) before providing care to the residents. Newly hired staff will be educated by the DON or ADON during the orientation process. 21. Audits will be completed to ensure that the education provided was effective via a series of questions related to the education. Five (5) questionnaires will be completed daily until the IJ removal has been validated by the State Survey Agency. These audits will be completed by the DON, ADON, ED, or the Senior Clinical Consultant to ensure understanding of reporting suspected sexual abuse without appropriate consent. 22. Members of the IDT to include the ED, DON, ADON, MDS Coordinator, Care Plan Nurse, SS, Director of Dietary Services, and Director of Activities will review one-hundred percent (100%) of the Nurse's Progress Notes daily during the Clinical Meeting until IJ removal has been validated by the State Survey Agency. The review will include the documentation for any residents for signs and/or symptoms of new, worsening and/or increased behavior and follow up for any form of sexual expression that might have occurred and not have been immediately reported. The IDT will discuss any notes with behavior documentation, decide upon an action or actions needed related to the behavior including update care plans timely, referral to the contracted behavioral/psychiatric services for new onset sexual behaviors or notification of the contracted services related to any resident on caseload for worsening or increased sexual behaviors. Any incidents will be discussed by the IDT, and if necessary, an investigation will be conducted by the DON and/or ADON. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of the facility's investigation into the 01/08/2022 incident confirmed Resident #13 was placed on fifteen (15) minute checks immediately following the incident, and Resident #13 was seen by the facility's nurse practitioner on 01/12/2022. Review of Resident #13's Comprehensive Care Plan revealed these interventions were not added until 04/25/2022. 2. Review of Resident #13's Comprehensive Care Plan revealed the resident was seen by the behavioral APRN, on 01/11/2022, who determined the resident was mentally capable to consent to sexual activity at that time. 3. Review of the facility's investigation into the 03/05/2022 incident confirmed Resident #68 was placed on one-to-one (1:1) observation following the incident. Review of Resident #68's Comprehensive Care Plan revealed a behavioral care plan for sexual behaviors was updated on 03/08/2022, which included the one-to-one (1:1) observation, which was discontinued on 03/06/2022, and a room change to a secure unit, was care planned as occurring on 03/06/2022. Interview with State Registered Nurse Aide (SRNA) #10, on 04/21/2022 at 5:20 PM, revealed Resident #68 had been moved to the secure unit more than a month ago following an incident with another resident. The SRNA stated Resident #68 had not exhibited any sexual behaviors or said anything inappropriate to her since placement on the unit. 4. Review of the AdHoc Quality Assessment and Performance Improvement (QAPI) Meeting Minutes Note Form, dated 04/22/2022, confirmed the ED, DON, and VP of Operations attended the meeting, with topics which included Capacity to Consent, Resident Rights, and Resident Abuse. Interview with the ADON, on 05/04/2022 at 2:16 PM, revealed staff were educated on sexual abuse on 04/22/2022. She revealed staff education continued, and included education on the new policy titled, Resident Sexual Expression, once it was finalized on the evening of 04/25/2022. Interview with the DON, on 05/04/2022 at 3:17 PM, revealed education was initiated with nursing staff on the evening of 04/22/2022 regarding the facility's abuse policy with a focus on sexual abuse. Interview with the ED, on 05/04/2022 at 3:32 PM, revealed that she, the DON, and the ADON initiated training on sexual abuse on the evening of 04/22/2022 and continued education with staff throughout the weekend. 5. Interview with the Clinical Reimbursement Consultant, on 05/04/2022 at 3:13 PM, revealed she assisted the IDT team in reviewing and updating as necessary the care plans for every resident in the building. Review of a statement signed by the Clinical Reimbursement Consultant, revealed she had reviewed care plans for Resident #68, Resident #13, and Resident #63 to ensure the current care plan interventions were up to date. Review of Resident #63's CCP revealed the resident's behavioral care plan was updated on 04/22/2022, to include interventions detailing previous visits that had been conducted by the Medical Director on 03/10/2022; the behavioral APRN on 03/16/2022; and the Doctor of Philosophy (PhD) of Psychology on 03/18/2022. 6. Review of the AdHoc QAPI Meeting Minutes Note Form, dated 04/25/2022 confirmed the new Resident Sexual Expression policy was reviewed by the ED, DON, Director of Social Services, the VP of Operations, the VP of Clinical Services, the Medical Director, and outside legal counsel. Review of Inservice Documentation & Sign In Sheet, dated 04/25/2022, revealed the Director of Social Services conducted an in-service on the Resident Sexual Expression policy for the IDT, with all members signing in attendance which included the ED, DON, ADON, MDS Coordinator, Director of Social Services, Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records. Interview with the MDS Coordinator, on 05/04/2022 at 1:43 PM, revealed she had received training as a member of the IDT on the Resident Sexual Expression Policy. She stated staff discussed what sexual expression was, and what to do if staff saw two (2) residents showing sexual expression. Interview with the DON, on 05/04/2022 at 3:17 PM, confirmed she had received education on the Resident Sexual Expression policy, on 04/25/2022, which covered determining the resident's capacity to consent. She stated, after management staff received education, they began the process of educating the rest of the facility staff. Interview with the Director of Social Services for contracted Consulting Group, on 05/04/2022 at 2:51 PM, revealed a new policy was developed, the Resident Sexual Expression policy. She stated her consulting group wanted to be sure leadership understood the policy and how to follow up. She revealed she presented the policy, and as a team, spoke with the Medical Director a few times over the week to ensure the policy aligned with the Medical Director's understanding. She revealed the procedure to determine someone's capacity to consent was clarified, as was the definition of sexual expression and what it would look like for someone cognitively intact as well as someone cognitively impaired. Finally, she stated she presented the policy to the resident council, as she felt it was important to ensure the rights of residents were recognized and respected in a safe and healthy manner. 7. Review of the resident interview sheets revealed residents had been interviewed regarding the question, Has any resident entered your room without permission or attempted to bother/touch you in anyway that made you feel uncomfortable? Review of residents' responses revealed no response indicative of any sexual abuse. Interview with the Director of Social Services (SS), on 05/04/2022 at 2:05 PM, revealed she conducted some resident interviews, asking if they felt safe, if anyone ever touched them inappropriately, and if they felt safe reporting. She revealed no residents expressed any concerns to her on the interviews she conducted. 8. Review of resident Shower Sheets, dated 04/25/2022, revealed residents were assessed by the Wound Care Nurse, with no injuries identified consistent with physical or sexual abuse. Interview with RN #4, the Wound Care Nurse, on 05/03/2022 at 4:14 PM, revealed she assessed all residents with BIMS' scores less than eight (8), on 04/25/2022, with only one (1) concern identified, which was ecchymosis (bruising) to the arm of one (unsampled) resident, who was on blood thinners that previously had not been identified. She stated, regarding sexual abuse, she would expect to possibly find signs of irritation or injury, to include scratches and/or bruises. 9. Review of a typed note, dated 04/25/2022 and signed by the Clinical Nurse Consultant revealed she had reviewed all allegations of abuse, neglect, and exploitation reported by the facility since 01/01/2022 to ensure interventions were appropriate for the allegation. She reported all allegations had been investigated thoroughly, with no investigations identified related to resident capacity to consent. 10. Review of Inservice Documentation & Sign In Sheet, dated 04/25/2022 and continued through 04/26/2022, revealed direct care nursing staff and ancillary staff were educated on the Resident Sexual Expression and Resident Abuse Prevention policies related to the process of reporting any observed, witnessed, or heard sexual expression. Education included the importance of separating residents for safety, which included cases of sexual behaviors until determination of the residents' competency to consent. Review of sign in sheets and facility employee listing revealed seventy-eight (78) of seventy-nine (79) employees had been educated, with the only exception being one (1) employee on family medical leave. Interview with Activities #1 (also a KMA), on 05/03/2022 at 2:55 PM, revealed if she observed any resident touching another resident or saying anything inappropriate, she would make sure both were safe, separate them, then report it to the nurse. Interview with RN #2, on 05/04/2022 at 12:56 PM, revealed the Medical Director and the IDT were responsible for making the determination regarding residents' ability to consent to sexual activity, and this information was documented in residents' care plans. She revealed she received education on where information was in the chart, if consenting, and steps to take, as well as when not consenting. She stated Resident Sexual Expression policies had been printed off and were available throughout the facility for staff to read and familiarize themselves with them. Interview with Dietary Aide #1, on 05/04/2022 at 1:23 PM, revealed she had received education recently on the facility's sexual abuse policy. She stated if she was to observe intimate contact - to include hugging, kissing, or other things - she would report it immediately to her supervisor, a nurse on the floor, or the ED, whoever was closest. Interview with Cook #1, on 05/04/2022 at 1:35 PM, revealed if she observed any residents engaged in any intimate contact, she would alert the ED. She stated the ED educated her on the facility's resident sexual abuse policy. Interview with SRNA #3, on 05/04/2022 at 8:54 AM; SRNA #2, on 05/04/2022 at 9:18 AM; and SRNA #17, on 05/04/2022 at 11:00 AM revealed they all had recent education on the Resident Sexual Expression and Resident Abuse Prevention policies, which included written inservices and testing. They stated they would separate residents and report to their immediate supervisor if they observed sexual behavior and were uncertain if it was between residents that could [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from resident-to-resident physical abuse as determined by direct observation by staff of physical abuse between two (2) of five (5) sampled residents, Resident #1 and #2. On 04/01/2021, Resident #1 wandered into Resident #2's room. Resident #1 was in a wheelchair and rolled to Resident #2's bedside, and Resident #2 was in the bed. Resident #2 fondled Resident #1's left breast, which Licensed Practical Nurse (LPN) #1 observed. The findings include: Review of the facility's policy titled, Resident Abuse Prevention, dated 2019, revealed abuse included physical, mental, verbal, psychological, sexual, corporal punishment, unreasonable seclusion and intimidation. In addition, physical abuse included hitting, slapping, pinching, and kicking. Per the policy, abuse also included controlling behavior through corporal punishment. Review of the facility's Long-Term Care Facility Initial Report, dated 04/07/2021, revealed, on 04/01/2021, LPN #1 witnessed Resident #2 touching Resident #1's breast, and the nurse immediately removed Resident #1 from the situation. The report stated Resident #2 told LPN #1 he/she did touch Resident #1's breast, but only after Resident #1 entered Resident #2's room, came to the bed, and raised his/her blouse which exposed his/her breast. The report revealed Resident #1 received a head-to-toe skin assessment, which revealed no injury, and the resident did not show any signs of distress. In addition, the report stated Resident #1 was placed on one-to-one (1:1) care and moved to a secure unit, and Resident #2 was placed on every fifteen (15) minute checks. Per report, from interviews of staff and residents, this appeared to be an isolated incident. Observation of Resident #1, on 05/19/2021 at 1:47 PM, revealed the resident was sitting near the nurse's station in a wheelchair, on Unit 200, holding two (2) baby dolls. Further observation, on 05/20/2021 at 12:25 PM, was of Resident #1 being redirected by staff out of other residents' rooms. Observation of the Lighthouse Unit, on 05/19/2021 at 1:50 PM, revealed the lobby was in the middle of the unit, and to the left were female resident rooms, with male resident rooms to the right. The nurse's station was located between both halls with a clear view of all resident rooms. Observation of Resident #2, on 05/19/2021 at 1:55 PM, revealed the resident was sitting in a wheelchair, in the lobby of the Lighthouse Unit, eating a root beer float. The resident appeared very pleasant. Observation of Unit 200, on 05/19/2021 at 2:10 PM, revealed Stop signs in place over the residents' doorways. Additional observation of the Lighthouse Unit, on 05/20/2021 at 10:45 AM, revealed Resident #2 was in his/her room with the door shut. Additional observation of Resident #1, on 05/20/2021 at 11:05 AM, revealed the resident was in a wheelchair rolling about Unit 200 holding a baby doll in one arm and opening doors to the Main Lobby with the other arm. Review of Resident #1's medical record revealed the facility admitted the resident, on 10/07/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/26/2021, revealed a Brief Interview for Mental Status (BIMS) score under C 1000, as Severely Impaired. Review of Resident #2's medical record revealed the facility admitted the resident, on 12/30/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission MDS Assessment, dated 01/06/2021, revealed a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Interview with LPN #1, on 05/20/2021 at 1:15 PM, revealed Resident #2's call light was on, and she went to the room to answer the call light. She stated she checked the resident in Bed A, who appeared to be asleep and went to check on Resident #2, who was in Bed B. LPN #1 stated she saw Resident #1 sitting in a wheelchair in front of Bed B, with Resident #2 sitting on the side of the bed. Per interview, she stated she saw Resident #2's hands on Resident #1's left breast; and when Resident #2 saw LPN #1, the resident removed his/her hands from Resident #1's breast. LPN #1 stated Resident #2 told her he/she had touched Resident #1's boobies. In addition, LPN #1 stated she separated the residents and told the Registered Nurse (RN). Then, she stated they called the Director of Nursing (DON) and Administrator, placed Resident #2 on every fifteen (15) minute checks, and monitored Resident #1 to ensure he/she did not return to Resident #2's room. Interview with RN #1, on 05/20/2021 at 1:30 PM, revealed she was working with LPN #1, on 04/01/2021. She stated LPN #1 reported to her what was observed between Resident #1 and Resident #2 and that she had separated the residents. RN #1 stated she immediately went to the room to make sure the residents were separated and called the DON. RN #1 further stated Resident #2 told her that Resident #1 had pulled up his/her own shirt, and Resident #2 put his/her hands on Resident #1's breast. Per interview, RN #1 stated the skin assessment on Resident #1 was completed with no concerns, and Resident #2 was placed on fifteen (15) minute checks and moved to the Lighthouse Unit. RN #1 stated Resident #1 liked to roam with his/her wheelchair, and staff redirected him/her to stay in the general public areas, away from other residents' rooms and personal belongings. She stated Stop signs on the units were working to redirect Resident #1, and there had been no further incidents between these residents. Interview with Social Services Staff (SSS), on 05/20/2021 at 1:00 PM, revealed the Administrator told her about the incident between Resident #1 and Resident #2 and that the staff had moved the residents apart immediately, then moving Resident #2 to the Lighthouse Unit. She stated she visited both residents and assisted the Assistant Director of Nursing (ADON) to provide counseling to Resident #2; Resident #1 was not able to communicate and was only able to laugh in response to questions or comments. SSS stated Resident #2 appeared happier and liked residing in the Lighthouse Unit. Also, she stated Resident #1 continued to wander on the Main Unit and opened doors; however, staff redirected him/her as needed. Per interview, SSS stated this was the first time the facility had resident-to-resident abuse of this type, and there were no further concerns with Resident #2 and sexual behavior. Interview with the DON, also an RN, on 05/20/2021 at 1:30 PM, revealed RN #1, a nursing supervisor, notified her that resident-to-resident abuse had occurred. In addition, she stated Resident #2 was placed on fifteen (15) minute checks, and Resident #1 was immediately placed in the DON office for safety. Per interview, the DON stated a complete head-to-toe skin assessment was completed on Resident #1, and Resident #2 was moved to the Lighthouse Unit, where he/she was counseled by the ADON and SSS. The DON stated no further incidents had occurred with either resident, and Resident #1 continued to wander the unit, but staff redirected the resident and found activities for Resident #1 to do. Interview with the Administrator, on 05/19/2021 at 4:45 PM, revealed she had been notified of the resident-to-resident abuse. She stated Resident #1 liked to wander and open all doors and had been assessed for exit-seeking behavior. The Administrator stated Resident #1 had a short attention span, but was easy to redirect. In addition, she stated, in response to Resident #1's behaviors, Stop signs had been placed over the residents' doors to redirect him/her. The Administrator stated Resident #2 had been moved to the Lighthouse Unit and appeared happier and more involved with activities. Per interview, she stated no other incidents had occurred with either Resident #1 or Resident #2.

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. This affected Residents #2, #3, #4, and #5, and had the potential to affect confused or wandering residents in the facility. Observation of Resident #2's room on [DATE], revealed a tube of [MEDICATION NAME] cream (antifungal medication) prescribed for Resident #2, in a box with candy, on the resident's bedside table in front of the resident's bed. Record review revealed the medication had been discontinued in (MONTH) 2019. In addition, there was no documented evidence the resident was assessed as able to self administer medications. In addition, observation of Resident #3's room, on [DATE], revealed a bottle of prescription Men Phor lotion ([MEDICATION NAME] and menthol topical medication) was observed in an open cart at the resident's bedside and the label on the lotion stated, apply to back twice daily, steroid free formula, and for external use only. Also, a bottle of [MEDICATION NAME] powder, (antifungal medication) which was prescribed for Resident #6 was observed in the same open cart at Resident #3's bedside. There was no documented evidence the resident was assessed as able to self administer medications. Furthermore, observation of Resident #4's room, on [DATE] at 4:37 PM, revealed a small individual packet of expired [MEDICATION NAME] gel (topical anti-[MEDICAL CONDITION] drug), documented as Rx (prescription) only, with no label and no date, on the resident's bedside table. However, there was no documented evidence the resident was assessed as able to self administer medications. Moreover, observation on [DATE], from 4:53 PM until 5:29 PM, revealed a tube of Santyl 250 U/Gm (units per gram) was observed on the top of the Medication/Treatment Cart for the 300 Hall, and five (5) residents were observed in the area near the cart. Further observation revealed the Medication/Treatment Cart was unsupervised by nursing staff. In addition, the medication was labeled as prescribed to Resident #5; and review of Resident #5's current (MONTH) 2019 Physician's Orders, revealed a Physician's Verbal Order, dated [DATE] to discontinue the Santyl. The findings include: Review of the facility Policy titled Storage of Medications, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Per Policy, the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the Policy, revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility Policy titled Discontinued Medications, undated, revealed when medications are discontinued by the prescriber the medications are stored in a secure and separate area from the active medications. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Review of a document provided by the facility at the time of the survey titled List of Residents that Wander, revealed there were four (4) residents who wander in the facility. 1. Review of Resident #2's clinical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #2 as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Observation during the initial tour, which began on [DATE] at 4:37 PM, revealed a tube of [MEDICATION NAME] cream (antifungal medication) prescribed for Resident #2, in a box with candy, on the resident's bedside table in front of the resident's bed. Interview with Resident #2 during this observation, revealed staff left the medication in his/her room. Interview with Registered Nurse (RN) #2, on [DATE] at 5:29 PM, revealed the [MEDICATION NAME] should not be in Resident #2's room. Subsequent interview with Resident #2, on [DATE] at 2:05 PM, revealed Nurses applied [MEDICATION NAME] cream under his/her left breast and arm, and then forgot to take the medication after they had applied the treatment. Review of Resident #2's Physician's Orders revealed orders with a start date of [DATE], for [MEDICATION NAME] 100,000 unit/gram cream, apply under left breast twice daily until resolved. The [MEDICATION NAME] was documented D/C (discontinued) on the (MONTH) 2019 Physician's Orders. Review of Resident #2's medical record revealed no documented evidence the resident had been assessed to self administer medications and review of the Comprehensive Care Plan revealed no documented evidence of a Plan of Care related to self administration of medications. Review of Resident #2's Physician Orders dated (MONTH) 2019, revealed there was no documented evidence of an active Physician's Order for the [MEDICATION NAME]. 2. Review of Resident #3's clinical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Assessment MDS Assessment, dated [DATE], revealed the facility assessed Resident #3 as having a BIMS score of ten (10) of fifteen (15), indicating moderate cognitive impairment. Observation of Resident #3's room, on [DATE] at 4:20 PM, revealed a bottle of prescription Men Phor lotion ([MEDICATION NAME] and menthol topical medication) was observed in an open cart at the resident's bedside and the label on the lotion stated, apply to back twice daily, steroid free formula, and for external use only. In addition, a bottle of [MEDICATION NAME] powder, (antifungal medication) which was prescribed for Resident #6 was observed in the same open cart at Resident #3's bedside. Observation on [DATE] at 5:29 PM, revealed the Men Phor lotion remained in the cart at Resident #3's bedside. Further observation revealed the the [MEDICATION NAME] Powder prescribed for Resident #6 remained in the cart at Resident #3's bedside. Interview with RN #2 during this observation, revealed the Men Phor lotion was not to be left in the resident's room and the [MEDICATION NAME] Powder was not prescribed for Resident #3. RN #2 stated use of another resident's medication could result in cross-contamination and she would have to dispose of the medication. Continued interview with RN #2, revealed she was not sure why Resident #6's [MEDICATION NAME] was in Resident #3's room. Interview with Resident #3, on [DATE] at 3:29 PM, revealed the resident did not know if he/she had used the bottle of [MEDICATION NAME] powder. Further interview revealed the nurses applied the Men Phor lotion to his/her back and sometimes left it on the tray by the bed in the room. Continued interview revealed the resident was unsure if any other residents wandered into his/her room and stated, If they do, I don't pay any attention to them. Review of Resident #3's Physician's Orders, dated (MONTH) 2019, revealed an order for [REDACTED]. Review of Resident #3's current Physician's Orders dated (MONTH) 2019, revealed no documented evidence of a current order for [MEDICATION NAME] ([MEDICATION NAME]) Powder. Further review revealed an order dated [DATE], for [MEDICATION NAME]-Menthol 0.5%-0.5% lotion (Men Phor), with instructions to apply to back topically two (2) times a day for itching. Review of Resident #3's medical record revealed no documented evidence the resident had been assessed to self administer medications and review of the Comprehensive Care Plan revealed no documented evidence of a Plan of Care to self administer medications. 3. Review of Resident #4's clinical record revealed the facility admitted the resident on [DATE] and readmitted the resident [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #4 as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Observation of Resident #4's room, on [DATE] at 4:37 PM, revealed a small individual packet of [MEDICATION NAME] gel (topical anti-[MEDICAL CONDITION] drug), documented as Rx (prescription) only, with no label and no date, on the resident's bedside table. Interview with the resident during this observation, revealed he/she was using the medication for an itchy rash on his/her face and a worker gave it to him/her. Observation on [DATE] at 5:29 PM, revealed the [MEDICATION NAME] gel remained in Resident #4's room. Further observation revealed the packet of medication was labeled [MEDICATION NAME] (40 % [MEDICATION NAME] Sodium and 2 GM solution) and the packet had an expiration date of ,[DATE]. Interview with RN #2 during this observation revealed the individual packet of medication was not something the facility stocked. Further interview with RN #2, revealed the resident was not allowed to have the medication in his/her room. Interview with the Administrator, on [DATE] at 12:30 PM, revealed she was told Resident #4's relative gave the packet of medication to the resident. Further interview with Resident #4 on [DATE] at 2:15 PM, revealed he/she could not remember who gave him/her the packet of medication he/she was rubbing on his/her face, but again stated it was someone who worked at the facility. Record review revealed (MONTH) 2019 Physician's Orders for Resident #4, did not include orders for (40 % [MEDICATION NAME] Sodium and 2 GM solution). However, Resident #4 did have a current order for [MEDICATION NAME] Sodium 1% gel, with an order date of [DATE], with instructions to apply to bilateral shoulders topically three (3) times a day related to unspecified [MEDICAL CONDITION], unspecified site. Review of Resident #4's medical record revealed no documented evidence the resident had been assessed to self administer medications and review of the Comprehensive Care Plan revealed no documented evidence the Plan of Care addressed self administration of medications. 4. Review of Resident #5's clinical record revealed the facility admitted the resident on [DATE] and readmitted the resident [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. On [DATE] at 4:53 PM, a tube of Santyl 250 U/Gm (units per gram) was observed on the top of the Medication/Treatment Cart for the 300 Hall, and five (5) residents were observed in the area near the cart. Further observation revealed the Santyl was labeled with Resident #5's name. Observation on [DATE] at 5:29 PM, revealed the tube of Santyl 250 U/Gm (units per gram) remained on top of the Medication/Treatment Cart for the 300 Hall. Interview with RN #2 during this observation, revealed the Santyl should not be left on top of the cart, because the medication was accessible to other residents. Review of Resident #5's current (MONTH) 2019 Physician's Orders, revealed a Physician's Verbal Order, dated [DATE] to discontinue the Santyl. Interview with RN #1/Wound Nurse, on [DATE] at 11:30 AM, revealed she did not use Santyl for Resident #5 when she completed his/her treatment on [DATE]. Further interview revealed Resident #5's treatment was changed the prior week. Per interview, residents were not allowed to have creams or ointments in their rooms and the facility did not have any residents who self administered medications. Interview with RN #2, on [DATE] at 5:29 PM, revealed residents were not allowed to have medications or prescriptions for topical use in their rooms unless the resident had been assessed to administer his or her own medications. Continued interview with RN #2, revealed the facility did not currently have any residents who had been assessed as able to self administer medications. Interview with State Registered Nurse Aide (SRNA) #4, on [DATE] at 5:28 PM, revealed medications should not be on top of the Medication/Treatment Cart or where a resident could get the medication. Further interview revealed if a confused resident had access to prescription topical medication, the resident could put it in his or her eyes or mouth. Continued interview revealed if a resident had access to another resident's medication, this could cause an allergic reaction. Interview with SRNA #3 on [DATE] at 5:55 PM revealed residents were not allowed to have any prescription medications in their rooms. Continued interview revealed the facility had a few residents who wandered and they could pick up the medication. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 5:19 PM, revealed residents were not allowed to have prescription medications in their rooms. Continued interview revealed the facility had a few residents who were confused and wandered, and could possibly pick up medication that was left in a resident's room. Additional interview with LPN #2, revealed discontinued prescription topical medications were supposed to be discarded. Interview with LPN #3, on [DATE] at 6:03 PM, revealed residents were not allowed to keep medications, creams or topicals at the bedside without an order. Continued interview revealed if a topical medication was discontinued, it should be discarded. Per interview if topical medications were left out where residents could access them, they could be misused or another resident could wander in and pick up the medication. Interview with the Director of Nursing (DON), on [DATE] at 6:10 PM, revealed medications should be locked up in the Medication/Treatment Cart and were not to be left on top of the Cart accessible to residents. Further, medications should not be left in resident rooms. The DON stated if a confused resident had access to topical prescription medications which were left unsupervised on top of the Medication/Treatment Cart or left in resident rooms, the confused resident could eat or drink the medication. Further interview with the DON, revealed when medications were discontinued, she expected the nurse to remove the medication and bag the medication for pharmacy to take back. Continued interview revealed it was her expectation that all medications, including topical medications, be kept locked up in the Medication/Treatment Carts. Interview with the Administrator, on [DATE] at 3:15 PM, revealed there were no residents a the facility who self administered medications. Subsequent interview with the Administrator, on [DATE] at 5:27 PM, revealed there should be no topical prescriptions in resident rooms and all topical prescriptions should be locked in the Medication/Treatment Carts, as per the facility policy. Further interview revealed if medications were discontinued, they were to be removed from the Medication/Treatment Carts, and disposed of or returned to pharmacy. Continued interview with the Administrator revealed it was her expectation staff keep facility residents safe.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for one (1) of eight (8) sampled residents (Resident #3). Observation during the initial tour on 09/24/19, revealed two (2) pair of bandage scissors on the top of the 300 Hall Medication/Treatment cart, and there were residents observed near the cart. On 09/25/19, scissors were observed in Resident #3's room on the resident's bedside table. The findings include: The State Agency (SA) Representative requested facility policy regarding accident hazards and supervision of residents; however, the facility did not have a policy to address accident hazards except related to falls. Review of the facility Resident Rights Policy, effective 05/01/12, revealed the resident has a right to receive services in a facility environment that is safe, clean, and comfortable. Review of the facility List of Residents that Wander, revealed there were four (4) residents who wander the facility. 1. Observation during the initial tour on 09/24/19 at 4:53 PM and 5:09 PM, revealed two (2) pair of bandage scissors in a container sitting on top of the Medication/Treatment Cart on the 300 Hall. There were five (5) residents observed in the area near the cart, and there was no staff observed supervising the cart. Observation on 09/24/19 at 5:23 PM, revealed the two (2) pair of bandage scissors remained in a container sitting on top of the Medication/Treatment Cart on the 300 Hall, and at this time, Licensed Practical Nurse (LPN) #2 obtained the cart and began pushing the cart to a resident's room. Interview with LPN #2 during this observation, revealed the two (2) pair of scissors should not be on top of the Medication/Treatment Cart. Further interview with LPN #2, on 09/25/19 at 5:19 PM, revealed scissors should be locked in the cart because a resident could fall on them, cut themselves or someone else, or use them in a harmful way. Interview with State Registered Nurse Aide (SRNA) #4, on 09/25/19 at 5:28 PM, revealed medications and scissors should not be on the Medication/Treatment Cart and nothing that could pose a hazard to a resident should be in eyesight or in hand reach of a resident. Continued interview revealed a resident could hurt someone with scissors or hurt himself/herself. Interview with LPN #3, on 09/25/19 at 3:35 PM, revealed scissors should not be on top of the Medication/Treatment Cart as this could be a hazard for residents. Interview with Registered Nurse (RN) #2, on 9/24/19 at 5:29 PM, revealed scissors should not be on top of the Medication/Treatment Cart because the residents may use them to harm someone. 2. Review of Resident #3's clinical record revealed the facility admitted the resident on 07/02/15 and readmitted the resident on 05/03/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) Assessment, dated 07/03/19, revealed the facility assessed Resident #3 as having a BIMS (Brief Interview for Mental Status) score of ten (10) out of fifteen (15), indicating moderate cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility, dressing, toilet use, and personal hygiene. Review of Resident #3's Progress Note, dated 09/21/19, revealed the resident's daughter came to Nursing Station requesting scissors that were removed from resident's room on night shift due to cutting fingernails into the skin. Daughter states Daddy has always cut {his/her} nails this way, and {he/she} is allowed to have these in {his/her} room where {he/she} is able to reach them anytime {he/she} wants. Further review of the Note, revealed Scissors were given to the daughter, and the daughter gave the scissors back to the resident. Will pass information on to next shift. Further review of Resident #3 medical record revealed there was no Care Plan to address the resident using scissors to cut his/her nails. In addition, there was no documented evidence a safety assessment or the risks versus benefits were assessed and explained to the resident/ responsible party. In addition, there was no documented evidence the facility provided Resident #3 or family/responsible party with safety education regarding scissors. Observation on 09/25/19 at 3:29 PM, revealed a pair of scissors with a green handle was observed on Resident #3's bedside table. Interview with Resident #3, during this observation, revealed the resident was unsure if any other residents wandered into his/her room and stated if they did, I don't pay any attention to them. Observation on 09/25/19 at 5:00 PM, revealed the pair of scissors with a green handle was again observed on Resident #3's bedside table. Interview with SRNA #1, on 09/25/19 at 5:10 PM, revealed residents were not supposed to have scissors unless the resident was alert and oriented and staff was aware, but scissors were not to be in resident rooms at all. Further interview revealed if residents were allowed to have scissors in their rooms, the residents could hurt themselves or someone else. Interview with SRNA #4, on 09/25/19 at 5:28 PM, revealed residents were not allowed to have scissors in their rooms because if the resident could walk, they might fall on them. Continued interview revealed a resident could hurt someone with scissors or hurt themselves. Interview with SRNA #2, on 09/25/19 at 5:50 PM, revealed residents shouldn't have scissors in their rooms because this was a safety issue. Interview with SRNA #3, on 09/25/19 at 5:55 AM, revealed residents did not typically have access to scissors in their rooms because residents may get cut by the scissors. Further interview revealed scissors should not be left on top of medication carts Interview with LPN #2 on 09/25/19 at 5:19 PM revealed scissors should be locked in the treatment cart and not kept in resident rooms. Further interview revealed if a resident had scissors in their room, they could possibly fall on them, cut themselves or someone else, or use them in a harmful way. Continued interview revealed Resident #3's daughter brings scissors to the resident and wants the resident to have them. Interview with LPN #3 on 09/25/19 at 3:35 PM revealed facility staff removed the scissors from the resident's room, but then the resident's daughter said to give them back. LPN #3 stated the resident cuts his/her nails with the scissors. Continued interview revealed the scissors in Resident #3's room could be dangerous, but stated no one goes in there. Further interview revealed the facility had a resident that wandered into other residents' rooms if he/she sees pop ([MEDICATION NAME] beverage) and this behavior usually occurred at night. She stated Resident #3's roommate was alert and oriented. Interview with the Director of Nursing (DON), on 09/25/19 at 6:10 PM, revealed scissors on a resident's bedside table was not good because a confused resident could enter the room and obtain the scissors. The DON stated Resident #3 and the resident's roommate were alert and oriented to person, place and time. Continued interview revealed she would not expect to see scissors on a Medication/Treatment Cart because a resident could possibly injure self or another resident if they had access to scissors. Further interview revealed the scissors should be kept locked inside the Carts and not on top of the Carts accessible to residents. Interview with the Administrator, on 09/25/19 at 5:27 PM, revealed she was unable to find documentation related to Resident #3 being assessed as safe with scissors nor was there documented evidence of education related to the potential for injury related to scissors discussed with the resident or family. Subsequent interview with the Administrator on 09/25/19 at 6:48 PM, revealed she did not think Resident #3's scissors in his/her room would be a danger and she did not think Resident #3 would let anyone take the scissors from him/her. Per interview, the facility staff gave Resident #3's daughter his/her scissors and the resident's daughter gave the scissors to the resident. Continued interview revealed it was not okay to have scissors on the Medication/Treatment Cart and staff should make sure scissors were out of the reach of residents. Additional interview with the Administrator, revealed it was her expectation staff keep facility residents safe.

Based on interview, record review and review of facility Policy, it was determined the facility failed to ensure food safety. Record review during initial kitchen tour on 05/21/19, revealed food temperatures were not documented for all meals during the months of (MONTH) and (MONTH) 2019. The findings include: Review of the facility Food Holding Temperatures on Food Service Line Policy, dated 01/01/17, revealed all foods were to be served at appropriate temperatures to ensure resident/patient acceptance while reducing the risk of food borne illness. Temperatures were to be recorded on the Food Temperatures by Meal form which would be reviewed by the Dietary Manager. Review of the facility form titled Daily Food Temperature Control Log by Meal, dated (MONTH) 2019, revealed food temperatures on the Food Service Line were not recorded for 04/12/19, 04/25/19 and, and 04/28/19 for lunch and supper meals. Review of the facility form titled, Daily Food Temperature Control Log by Meal, dated (MONTH) 2019, revealed food temperatures on the Food Service Line were not recorded for 05/02/19, 05/03/19, 05/08/19 and 05/11/19 for the lunch and supper meals. In addition, food temperatures were not recorded on the Food Service Line for 05/10/19 for the supper meal or 05/14/19 for the breakfast meal. Interview on 05/23/19 at 8:43 AM, with Dietary Assistant #1, revealed food temperatures on the Food Service Line, were to be obtained and recorded on the Log prior to meals being served. Per interview, cold foods should be kept at a temperature of 40 degrees Fahrenheit (F) and below, to promote food safety and prevent bacteria growth. Further interview revealed the Dietary Manager was responsible to check the food temperature logs to ensure food temperatures were obtained and recorded. Interview on 05/23/19 at 8:50 AM, with Dietary Assistant/Cook #1, revealed Hot food temperatures should be between 180-190 degrees F prior to meals being served in order to ensure the food was cooked thoroughly and to prevent germs and bacteria from contaminating the food. Interview on 05/23/19 at 8:58 AM, with the Dietary Manager (DM), revealed staff were responsible to document food temperatures on the food service line prior to meal service. Per interview, foods should be cooked to temperature to prevent the growth of bacteria, and Hot foods temperatures below 160 degrees F needed to be reheated to 165-185 degrees F to prevent bacterial growth. The DM further stated Cold foods should be below 40 degrees F, and if they were above 40 degrees F, they were to be discarded. Further interview revealed she was responsible to ensure the food temperatures were recorded daily for food safety and to prevent food borne illnesses as the unsafe food temperature range was 40 degrees F to 165 degrees F. Interview on 05/23/19 at 1:57 PM, with the Director of Nursing (DON), revealed the dietary food temperatures should be recorded on the dietary logs prior to food being served to ensure food was served at the appropriate temperatures. Per interview, food served at incorrect temperatures could lead to resident illness, spoilage of food, and bacteria growth. Interview on 05/23/19 at 2:26 PM, with the Administrator, revealed if food temperatures were not taken before plating food, the kitchen could not prove the food temperatures were served to residents within safe temperature ranges. Further interview revealed it was important food was served at the correct temperatures to ensure the food was cooked properly, and to prevent food borne illness. Additional interview revealed food should also be served at proper temperatures to ensure the food was palatable.

Based on observation, interview, record review, review of the facility's Policy and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to have an effective system to ensure services were implemented in accordance with the resident's written plan of care for two (2) of eighteen (18) sampled residents (Resident #44 and Resident #68). Resident #44's Comprehensive Care Plan included interventions including: right hand and lower extremities to be elevated; heel lift boots to be applied; and keep resident clean and groomed daily. However, observation of Resident #44 on 06/19/18, 06/20/18 and 06/21/18, revealed the resident's Comprehensive Plan of Care was not implemented as the resident did not have the right hand and lower extremities elevated, and did not have the heel boots in place. Also, the resident had long, unkempt fingernails with thick, brown substance underneath the fingernails and a foul smell coming from the hands. Additionally, Resident #68 received [MEDICATION NAME] 0.5 milligrams (mg) PRN (as needed) when the resident was exhibiting behaviors on 05/12/18 at 9:45 AM for screaming; and on 05/14/18 at 9:18 AM; 05/15/18 at 6:19 AM; and 05/19/18 at 8:51 AM for making disruptive sounds. However, there was no documented evidence Resident #68's Comprehensive Care plan was implemented related to non-pharmalogical interventions for anxiety and behaviors prior to the administration of the PRN [MEDICATION NAME]. The findings include: Review of the facility's Care Planning-Interdisciplinary Team, Policy, dated 11/2017, revealed the facility's interdisciplinary team (IDT) was responsible for the implementation of the resident's comprehensive care plan. Further review of the Policy revealed the facility's IDT team was comprised of the following staff members: Nursing Department; to include both the licensed nurses and nursing assistants, the resident's attending physician, the dietary manager/dietitian or food services designee, social services worker, the activity director/coordinator, therapists; to include speech, physical and occupational as applicable and any consultants as required and appropriate. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written plan of care. Review of Resident #44's clinical record revealed the facility admitted the resident on 11/22/16 with [DIAGNOSES REDACTED]. Review of Resident #44's Comprehensive Plan of Care (CCP), dated 11/22/16, revealed Resident #44 was dependent for all activities of daily living (ADLS) with a goal stating the resident would be clean and well groomed daily with resident's care needs being met through the next review date (08/24/18). Continued review of the CCP, revealed the resident was at an increased risk for skin breakdown with actual skin breakdown present to right middle finger, right ring finger, right index finger, right hip, coccyx and third right toe with a goal stating the resident would not experience any unidentified complications to skin and would not experience any infections related to pressure ulcers through next review date (08/24/18). There were several Care Plan interventions including staff to provide protective and preventative equipment and devices as ordered; keep resident clean and groomed daily; right hand elevated on pillow with hand hanging over edge of pillow; and bilateral lower extremities in heel lift boots and elevated on pillows at all times due to skin breakdown. Review of the Significant Change MDS dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a ninety-nine (99) out of fifteen (15) indicating the resident was unable to participate in the interview. Further review revealed the facility assessed the resident as dependent on the assistance of two (2) staff members for all areas of self-care including grooming/bathing and personal hygiene and totally dependent on the assistance of two (2) staff for bed mobility. Observation on 06/19/18 at 12:10 PM, revealed Resident #44 was lying in bed awake, alert and responsive to verbal stimuli. Resident #44's heel lift boot was observed to his/her left lower extremity. The right lower extremity heel lift boot was in the chair in the corner of the resident's room. The resident's bilateral lower extremities were not elevated, but were lying flat on the mattress of the bed. Observation on 06/19/18 at 4:20 PM, revealed Resident #44 was lying in bed with eyes closed. Heel lift boots were in a chair in the corner of the room. An intact [MEDICATION NAME] dressing was noted to the resident's right hand and his/her left hand was covered under the blanket. The resident's right hand was not elevated on a pillow. The resident's bilateral lower extremities were not elevated, but were lying flat on the mattress of the bed. Observation on 06/20/18 at 8:25 AM; 06/20/18 at 3:22 PM; and 06/21/18 at 8:15 AM; revealed Resident #44 was lying in bed with eyes closed. The resident's heel lift boots were in a chair in the corner of the room. The resident's right hand was not elevated on a pillow, and the resident's bilateral lower extremities were not elevated, but were lying flat on the mattress of the bed. Observation of wound care to Resident #44's right middle finger provided by Registered Nurse (RN) #1, on 06/21/18 at 3:00 PM, revealed the resident had long, unkempt fingernails with thick, brown substance underneath fingernails and hanging off of fingernails on both hands. Further observation revealed the resident's hands emanated a strong sour, foul-smelling odor. The resident's right and left hand contracted firmly together in a fist-like state with fingernails noted to be gouging into the palms of each hand. Continued observation revealed RN #1 proceeded with application of ordered treatment to Resident #44's right middle finger without addressing the length or condition of the resident's fingernails. Interview with Registered Nurse (RN) #1, who identified herself as the facility's wound care nurse, on 06/21/18 at 3:03 PM, revealed she did not wash or soak Resident #44's hand with each dressing change. RN #1 stated she only cleansed the wound with Normal Saline, patted the area dry and applied [MEDICATION NAME] dressing to the finger wound as per the physician's orders [REDACTED].#1 revealed the nursing assistants did not soak Resident #44's hands, but washed the resident's hands during scheduled baths (twice weekly). Continued interview revealed Resident #44's hands should be washed with each dressing change and the resident's fingernails should have been trimmed. RN #1 stated she had witnessed the resident's family members visiting him/her and trimming/cleaning the resident's nails on occasion and was unsure whether or not the families were permitted to do this. Interview with Licensed Practical Nurse (LPN) #1/MDS Assessment Coordinator, on 06/21/18 at 4:49 PM, revealed a resident that was unable to independently carry out ADLs should receive the care and services he/she required to maintain his/her level of well-being including grooming and nail care. LPN #1 revealed she expected staff to ensure Resident #44's fingernails were cleaned and trimmed daily and as needed. Continued interview revealed she expected staff to ensure Resident #44 was wearing the bilateral lower extremity boots while elevating both feet and right hand on pillows at all times as outlined in the resident's plan of care. In addition, LPN #1 stated it should be priority to provide care to a resident dependent for all ADLS because those residents were the most vulnerable. 2. Review of Resident #68's Clinical Record revealed the facility admitted the resident on 02/28/17 and readmitted the resident on 05/24/18 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated 04/17/18, revealed the facility assessed Resident #68 as having a Brief Interview for Mental Status (BIMS) of a two (2) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility did not assess the resident as exhibiting physical or verbal behaviors directed toward others, as rejecting care, or as having wandering behaviors. Additional review of the MDS, revealed the facility assessed the resident as not having received antianxiety medication for the past seven (7) days. Review of Resident #68's Comprehensive Care Plan (CCP), with onset date of 03/17/17, revealed the resident felt isolated from family at times and thought family should visit daily; had attention seeking behaviors at times including comes up with things to keep caregiver in room; and hollers out in hallway when people pass by the door. The goal revealed the resident would maintain relationships with family and friends. There were several interventions including: help resident visit with friends and family in a private location; schedule treatments and therapies around visits; and allow resident time to talk about his/her feelings. Further review of Resident #68's CCP, with onset date of 03/19/17, revealed the resident preferred to do self initiated activities in his/her room. The goal revealed the resident would be able to participate in an acceptable daily routine. There were several interventions including: sit on the front porch when weather permitted, and reminisce with staff and other resident. Continued review of Resident #68's CCP, with onset date of 05/08/18, revealed the resident was at risk for side effects from anti-anxiety medication use and was exhibiting episodes of agitation. The goal revealed the resident would not have unidentified complications related to medication use/side effects through 09/07/18. There were several interventions including: administer medications as ordered; observe for adverse side effects; notify Physician as needed; observe effectiveness of medication; and observe and record behaviors. Review of Resident #68's Departmental Note, dated 05/08/18 at 11:51 AM, revealed the resident was very confused and very agitated, wanting to go home. The Note stated the resident was assisted to the bathroom, and helped with breakfast and was unable to be re-directed. Additional review of the Note, revealed the resident's son came to visit and the resident continued to be agitated, the Physician was notified of the resident's behavior and waiting on Physician to respond. Review of Resident #68's Telephone Orders dated 05/08/18, revealed an order for [REDACTED]. Review of Resident #68's Medication Administration Record (MAR) dated 05/08/18 through revealed the resident received [MEDICATION NAME] 0.5 mg as needed (PRN) for anxiety on 05/08/18 at 1:17 PM. Further review of Resident #68's Medication Administration Record (MAR) dated 05/09/18 through 05/19/18, revealed the resident received [MEDICATION NAME] 0.5 mg as needed (PRN) for anxiety on 05/12/18 at 9:45 AM for screaming; on 05/14/18 at 9:18 AM for making disruptive sounds; on 05/15/18 at 6:19 AM for making disruptive sounds; and on 05/19/18 at 8:51 AM for making disruptive sounds. However, continued review of the (MONTH) (YEAR) MAR and Departmental Notes, dated 05/09/18 through 05/19/18, revealed there was no documented evidence of non-pharmacological interventions initiated prior to administering the PRN [MEDICATION NAME] on 05/12/18 at 9:45 AM; 05/14/18 at 9:18 AM; 05/15/18 at 6:19 AM; and 05/19/18 at 8:51 AM. Interview on 06/21/18 at 4:30 PM with Registered Nurse (RN) #1, revealed the nurses should have implemented non-pharmacological interventions prior to the administration of [MEDICATION NAME] PRN and documented these interventions in the Departmental Notes. Further interview revealed it would have been important to try non-pharmacological interventions and to assess the reasons for behaviors before the administration of PRN [MEDICATION NAME]. Interview on 06/21/18 at 4:49 PM Licensed Practical Nurse (LPN) #1/MDS Nurse, revealed non-pharmacological interventions were to be implemented prior to the administration of anti-anxiety medication. Phone interview on 06/21/18 at 5:23 PM with the Consulting Pharmacist, revealed non-pharmacological interventions were to be in used prior to administering any PRN antianxiety medication for symptoms of agitation, anxiety. Per interview, there should be documentation showing the need for scheduled antianxiety medication when non-pharmacological interventions were not successful. Interview on 06/21/18 at 5:40 PM, and 5:47 PM, with the Assistant Director of Nursing (ADON), revealed the Comprehensive Care Plan reflected the care the residents were to receive from the facility staff. The ADON stated the Care Plan should be implemented related to non-pharmacological approaches for treating behaviors prior to the administration of PRN anti-anxiety medications. Further interview revealed staff should implement the care plan when providing ADL care to dependent residents to ensure the resident receives the proper care, treatment and services he/she requires. Additional interview with the ADON, revealed she had identified no concerns with staff not implementing the Comprehensive Care Plan until this survey. Interview on 06/21/18 at 5:19 PM with Director of Nursing (DON), revealed the Care Plan was a communication tool utilized throughout all disciplines to assist staff in providing care to the residents and reflected the care and services to be provided by staff. Further interview revealed she would expect the Comprehensive Care Plan to be implemented for each resident. The DON stated Resident #68's Comprehensive Care Plan should have been implemented related to non-pharmacological interventions for treating anxiety prior to administering PRN anti-anxiety medications and those interventions should have been documented. Additional interview revealed staff should have ensured Resident #44 was wearing the protective boots to bilateral feet with lower extremities elevated and right hand elevated on pillows; and staff should have ensured the resident was groomed and fingernails were cleaned and trimmed as per the resident's plan of care. Interview with the Administrator on 06/21/18 at 6:54 PM, revealed it was her expectation every staff member implement the Care Plan for every resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (1) of eighteen (18) sampled residents. (Resident #44). Observation of Resident #44 on 06/21/18, revealed the resident had long, unkempt fingernails with a foul smell emanating from the hands and thick brown substance underneath of and hanging from the fingernails. The findings include: Review of the facility's policy, titled, Resident Rights, dated 11/2016, revealed the resident had the right to be treated with dignity and respect including: the right to reside and receive services in the facility with reasonable accommodation of the resident's needs and preferences and the resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Interview on 06/21/18 at 06:54 PM with the Administrator, revealed the facility had no specific policy related to care of a resident who was dependent for Activities of Daily Living (ADLs); however, per interview, it was the expectation of the Administrator that staff ensured the residents of the facility were clean and well groomed. Review of Resident #44's medical record revealed the facility admitted the resident on 11/22/16 with [DIAGNOSES REDACTED]. Review of Resident #44's Comprehensive Plan of Care (CCP), dated 11/22/16, revealed Resident #44 was dependent for all Activities of Daily Living (ADLs). The goal stated the resident would be clean and well groomed daily with resident's care needs being met through the next review date (08/24/18). There were several Care Plan interventions including staff to keep resident clean and groomed daily. Review of the Significant Change MDS dated [DATE], revealed the facility assessed Resident #44 as having a Brief Interview for Mental Status (BIMS) of a ninety-nine (99) out of fifteen (15) indicating the resident was unable to participate in the interview. Further review revealed the facility assessed the resident as dependent on the assistance of two (2) staff members for all areas of self-care including grooming/bathing and personal hygiene. Observation of wound care to Resident #44's right middle finger provided by Registered Nurse (RN) #1, on 06/21/18 at 3:00 PM, revealed the resident had long, unkempt fingernails with thick, brown substance underneath the fingernails and hanging off the fingernails on both hands. Continued observation revealed the resident's hands emanated a strong sour, foul-smelling odor. The resident's right and left hand contracted firmly together in a fist-like state with his/her fingernails noted to be gouging into the palms of each hand. Further observation revealed RN #1 proceeded with application of ordered treatment to Resident #44's right middle finger without addressing the length or condition of the resident's fingernails. Interview with RN #1/wound care nurse, on 06/21/18 at 3:03 PM, revealed Resident #44 was dependent for all Activities of Daily Living (ADLs), but she did not wash or soak Resident #44's hand with each dressing change. RN #1 revealed she only cleansed the resident's finger wound with Normal Saline, patted the area dry and applied [MEDICATION NAME] dressing to the area as per the physician's orders [REDACTED].#44's hands, but washed the resident's hands during scheduled baths (twice weekly). Continued interview revealed Resident #44's hands should be washed with each dressing change with the resident's fingernails being trimmed when required. RN #1 stated she had witnessed the resident's family members visiting him/her and trimming/cleaning the resident's nails on occasion, but was unsure whether or not the families were permitted to do this. Interview with Licensed Practical Nurse (LPN) #1/MDS Assessment Coordinator, on 06/21/18 at 4:49 PM, revealed a resident who was unable to independently carry out ADLs should receive the care and services he/she required to maintain his/her level of well-being. In addition, LPN #1 stated she expected staff to ensure Resident #44's fingernails were cleaned and trimmed as required and to wash his/her hands due to contractures as the resident was unable to perform self-care. LPN #1 revealed it should be priority to provide care to a resident dependent for ADLs because those residents were the most vulnerable. Interview on 06/21/18 at 5:40 PM, with the Assistant Director of Nursing (ADON), revealed staff should ensure those residents dependent on ADLs were clean and groomed appropriately with nails clean and trimmed. Further interview with the ADON, revealed there had been no concerns identified with staff providing care to residents dependent for ADLs until this survey. Interview on 06/21/18 at 5:19 PM, with the Director of Nursing (DON), revealed it was her expectation for staff caring for residents who were dependent on ADLs to ensure they were clean and well groomed and their fingernails were clean and trimmed for the well-being of the resident. Interview with the Administrator, on 06/21/18 at 6:54 PM, revealed it was her expectation for staff to ensure resident's were clean and well groomed and nail care was provided as needed Per interview, staff should have ensured Resident #44's hands were clean and odor free and his/her fingernails were cleaned and trimmed.

Based on interview, record review, and review of the facility's policy, it was determined facility failed to ensure each resident's medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being; and non-pharmacological interventions, unless contraindicated, were used prior to initiating or instead of continuing [MEDICAL CONDITION] medication for one (1) of eighteen (18) sampled residents (Resident #68). Resident #68 had a physician's orders [REDACTED]. However, continued record review of the (MONTH) (YEAR) MAR and Departmental Notes, dated 05/09/18 through 05/19/18, revealed there was no documented evidence of non-pharmacological interventions initiated prior to administering the PRN [MEDICATION NAME]. In addition, Resident #68 was admitted to the hospital on [DATE], and per the Hospital Discharge Summary, dated 05/24/18, the resident presented with a Urinary Tract Infection [MEDICAL CONDITION] with decrease in mentation and responded well to antibiotics. Upon return to the facility on [DATE], orders were received for [MEDICATION NAME] 0.5 mg twice a day routinely. However, the resident's Medical Record did not reflect non-pharmacological interventions had been initiated or implemented to prevent the unnecessary use of the scheduled [MEDICATION NAME] medication. (Refer to F-656) The findings include: Review of the facility's Medication Monitoring and Management Policy, undated, revealed in order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consulting pharmacist would perform ongoing monitoring for appropriate effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the Interdisciplinary Team (IDT) would participate in the care process to identify, assess, address, advocate for, monitor, and communicate the residents needs and changes in condition. Continued review revealed, whenever possible, non-pharmacological interventions would be considered before initiating a new medication. Further review revealed, the resident would be evaluated before initiating, withdrawing, or withholding medications, or using non-pharmacological interventions. An appropriate detailed evaluation should include mental, physical, psychosocial, and functional status, including comorbid conditions and pertinent psychiatric symptoms and diagnoses, and a description of resident complaints, symptoms, and signs including the onset, scope, frequency, intensity, precipitating factors, and other important features. Information gathered during the initial and ongoing evaluation were to be incorporated into a comprehensive care plan that reflected appropriate medication related goals and parameters for monitoring the residents condition and ongoing need for the medication including but not limited to, what is monitored, who will be responsible for monitoring, and how often and when re-evaluation is necessary. Review of Resident #68's Medical Record revealed the facility admitted the resident on 02/28/17, and readmitted the resident on 05/24/18, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, with onset date of 03/17/17, revealed the resident felt isolated from family at times and thought family should visit daily; had attention seeking behaviors at times including comes up with things to keep caregiver in room; and hollers out in hallway when people pass by door. The goal stated the resident would maintain relationships with family and friends. Interventions included: help resident visit with friends and family in a private location; schedule treatments and therapies around visits; and allow resident time to talk about his/her feelings. Further review of Resident #68's Comprehensive Care Plan, with onset date of 05/08/18, revealed the resident was at risk for side effects from anti-anxiety medication use and was exhibiting episodes of agitation. The goal stated the resident would not have unidentified complications related to medication use/side effects through 09/07/18. Interventions included: administer medications as ordered; observe for adverse side effects; observe and record behaviors; notify Physician as needed; and observe effectiveness of medication. However, there was no documented evidence of non-pharmacological interventions to be used prior to the administration of [MEDICATION NAME]. Review of the Departmental Notes, dated 05/08/18 at 11:51 AM, revealed the resident was very confused and very agitated, wanting to go home. Per the Note, the resident was assisted to the bathroom, and helped with breakfast and was unable to be re-directed. Further review of the Note, revealed the resident's son came to visit and the resident continued to be agitated, the Physician was notified of the resident's behavior and waiting on Physician to respond. Review of Resident #68's Telephone Order dated 05/08/18, and signed by the physician, revealed an order for [REDACTED]. Review of Resident #68's Medication Administration Record (MAR) dated 05/08/18 through 05/19/18, revealed the resident received [MEDICATION NAME] 0.5 mg as needed (PRN) for anxiety on 05/08/18 at 1:17 PM for stating he/she wanted to go home to see mommy and slapping himself/herself on the head twice; on 05/12/18 at 9:45 AM for screaming; on 05/14/18 at 9:18 AM for making disruptive sounds; on 05/15/18 at 6:19 AM for making disruptive sounds; and on 05/19/18 at 8:51 AM for making disruptive sounds; for a total of five (5) PRN doses administered in twelve (12) days. However, continued record review of the (MONTH) (YEAR) MAR and Departmental Notes, dated 05/09/18 through 05/19/18, revealed there was no documented evidence of non-pharmacological interventions initiated prior to administering the PRN [MEDICATION NAME]. Review of Resident #68's Hospital Discharge Summary, dated 05/24/18, revealed the resident was admitted to the hospital on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Per the Hospital Course, the resident presented with a UTI with decrease in mentation and responded well to antibiotics which were based on cultures and being transferred back to nursing home today. Review of Resident #68's Re-admission orders [REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #68's Departmental Notes, dated 05/24/18 through 06/19/18, revealed no documented evidence the resident had been having signs and symptoms of anxiety, [MEDICAL CONDITION] or had exhibited adverse behaviors toward self or others. Review of Resident #68's Behavioral and Mood Monitoring Report, dated 05/25/18 through 06/19/18, revealed no documented evidence the resident exhibited adverse moods or behaviors. Review of Resident #68's Quarterly Minimum Data Set (MDS) Assessment, dated 06/19/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility did not assess the resident as exhibiting physical or verbal behaviors directed toward others, as rejecting care, or as having wandering behaviors. Ongoing review of the MDS, revealed the facility assessed the resident as having received antianxiety medication for seven (7) out of seven (7) days. Interview on 06/21/18 at 4:30 PM with Registered Nurse (RN) #1, revealed the nurse's administering medications should have tried non-pharmacological interventions prior to administration of PRN [MEDICATION NAME] from 05/09/18 through 05/19/18, such as assisting the resident to the bathroom, offering an activity, or some type of diversion to correct whatever behavior the resident was exhibiting. Per interview, the nurse should have documented the non-pharmacological interventions in the Departmental Notes. Further interview revealed someone should have looked at how many times the resident had received the PRN [MEDICATION NAME] and the reason for the behaviors before the [MEDICATION NAME] was ordered routinely after the resident's hospitalization . Phone interview on 06/21/18 at 5:23 PM, with the Consulting Pharmacist, revealed she was responsible for reviewing each resident's chart to make sure the appropriate [DIAGNOSES REDACTED]. Per interview, she also reviewed behavioral monitoring, and conducted monthly medication review of all antipsychotics for indication, dose, need for continuation, and adverse side effects. Continued interview revealed she would expect non-pharmacological interventions to be in used prior to administering an anti-anxiety medication for symptoms of agitation, anxiety. Further interview revealed there should be documentation showing the need for scheduled anti-anxiety medication. She stated she was not part of the interdisciplinary team (IDT), but if she identified any medication related concerns she would bring them to the attention of the Primary Care Physician (PCP) or the Director of Nurse's (DON). Per interview, she could not recall Resident #68 and could not address questions related to the [MEDICATION NAME] without reviewing the record. Interview on 06/21/18 at 5:47 PM, with the Assistant Director of Nursing (ADON), revealed staff should implement non-pharmacological approaches to treating behaviors prior to administering PRN antianxiety medications or prior to the ordering of scheduled anti-anxiety medications. The ADON stated non-pharmacological intervention examples could include providing one-to-one staff-to-resident interaction; offering the resident a snack; providing a calm and quiet environment for the resident; or contacting family for assistance related to calming the resident. Continued interview revealed behaviors were to be assessed to determine root cause, which was discussed with the physician at weekly meetings, or by telephone immediately as necessary. Interview on 06/21/18 at 5:19 PM, with the Director of Nursing (DON), revealed she expected non-pharmacological approaches to treating behaviors to be attempted prior to administering PRN anti-anxiety medications and prior to the ordering of scheduled anti-anxiety mediations . She stated these interventions should be individualized to meet the needs of each resident and documented in the medical record. Per interview, non-pharmacological interventions could include consolation; one-to-one interaction; offering a snack; taking the resident outside; and contacting family for a visit or to speak with the resident on the phone. The DON stated nurses were to monitor, document, and report resident behaviors, and reactions to interventions, including medications, and report findings to physician either verbally or telephonically for dosage changes, or discontinuance. Further interview with the DON, revealed the clinical indication for [MEDICATION NAME] was [DIAGNOSES REDACTED]. Per interview, the efficacy of [MEDICATION NAME] was to be documented on the MAR, as well as on the Behavior Record, where specific behaviors were documented, along with non-pharmacological interventions and their effect. The DON also stated a Twenty-Four Hour (24) Report Sheet was to be used by nurses to document care and interventions provided and their effect, and was to be used by clinical staff to communicate up-to-date information between shifts. Per interview, a review of physician orders [REDACTED]. Per interview, during the Morning Meeting all behaviors were evaluated to determine root cause, and findings were discussed with the physician at least weekly. Additional interview revealed she expected the facility to follow the Medication Monitoring and Management Policy related to ensuring non-pharmacological interventions were tried prior to anti-anxiety medication administration. Interview on 06/21/18 at 6:54 PM with the Administrator, revealed it was her expectation the the facility's policies and procedures be followed regarding utilizing non-pharmacological interventions prior to the administration of PRN anti-anxiety medications and also non-pharmacological interventions should be considered before initiating a new anti-anxiety medication regimen.