Every finding on record at Glendora Health Care Center

Based on review of the medical record, interview with the staff, and review of facility policy, the facility failed to ensure the mail was delivered daily to Resident #1. This affected one resident (#1) out of three residents reviewed for resident rights; however it had the potential to affect all the residents in the facility. The facility census was 41.Findings Include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included borderline personality disorder, schizoaffective disorder bipolar type, asthma, obstructive sleep apnea, hypertension, obsessive compulsive disorder, insomnia, and anxiety disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had intact cognition and no behaviors.On 05/07/26 at 10:15 A.M, an interview with the Administrator verified the mail was passed out to the residents by the activity department. She stated Business Office Manager (BOM) #62 worked Monday, Wednesday and Friday at the other building and Tuesday and Thursday at this building. On 05/07/26 at 1:25 P.M. an interview with the BOM #62 revealed Resident #1 had been in her office daily looking for her mail. She stated she was waiting on a couple items from the bank, but they had not received anything like that for her, and they gave her all her mail when it came.On 05/11/26 at 8:45 A.M. an interview with Activity Aide #72 revealed she only passed out the mail when BOM #62 gave it to her and BOM #62 only worked on Tuesdays and Thursdays. She stated she did not pass it out every day just when there was a pile of it on her desk, but she could start doing that if that was what was required.On 05/11/26 at 10:45 A.M, an interview with Resident #1 revealed the facility did not pass the mail out every day. She stated she had to ask for her mail, and she still did not always get it when she asked for it. She stated she was waiting on her new bank card she applied for on 04/27/26. Review of the undated facility policy titled, Resident Right to Privacy in Communication, revealed it was the policy of the facility to support and facilitate a resident's right to privacy in communication with individuals and entities within and external to the facility. Promptly delivery mail or other material to the resident within 24 hours of delivery by the postal service and delivery of outgoing mail to the postal service within 24 hours, except when there was no regular scheduled postal delivery and pick-up service.This deficiency represents non-compliance investigated under Complaint Number 2998394.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of the medical record, review of the Self-Reported Incident, review of facility policy, and interview with staff, the facility failed to protect Resident #27 from abuse and video recording by an agency staff member. This affected one resident (#27) of three reviewed for abuse.Findings Include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included diabetes, hypertension, depression, heart failure, mild dementia, neuropathy, major depressive disorder, anxiety disorder, and hyperlipidemia. The resident resided on the [NAME] Hall. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #27 had intact cognition and had physical and verbal behaviors towards others.Review of the plan of care dated 08/08/25 with a revision date of 03/18/26 revealed Resident #27 had a behavior problem, chooses to use racial slurs toward staff members, chooses to be physically aggressive with staff, make sexual comments to staff, become verbally aggressive with staff, disrupts the care environment at times and loudly expresses concerns. Interventions included administer medications as ordered, anticipate and meet the residents needs, caregivers to provide opportunities for positive interactions and attention, stop and talk with him when passing by, explain all procedures to the resident before starting and allow him to adjust to the changes, if reasonable discuss his behavior, explain and reinforce why the behavior was inappropriate, monitor behavior episodes and attempt to determine underlying causes, and praise any indication of the residence progress or improvement in behavior.Review of the Progress notes from 09/13/25 to 09/14/25 revealed no documentation of an incident between Resident #27 and Agency CNA #100 in the progress notes.Review of the statement from Resident #27 from an interview by the Director of Nursing dated 09/14/25 revealed the Director of Nursing met with Resident #27 to discuss the incident from the night before. Resident #27 stated he could not remember all the events that happened but stated Agency CNA #100 was behind the nurse's station when he wheeled himself up to the nurse's station. He stated they were yelling back and forth and at one point the Agency CNA had made a comment about his mother, but he did not remember what it was exactly. Resident #27 stated he was so upset about the comment that he stood up, knocked a basket off the nurse's station, and that was when the Agency CNA #100 stood up, swung at him, hit him in the face, and knocked his glasses off his face. Resident #27 stated he did not remember much after that because the nurse assisted him to his room shortly after, assessed him and he went to bed. Resident #27 was noted to have two scratches down his forehead and one on the bridge of his nose that the resident stated was from the Agency CNA hitting him.Review of the facility's Self-Reported Incident dated 09/14/25 revealed the Former Administrator received a call from the charge nurse at midnight with concerns that a resident was unable to be redirected and a nursing assistant was behind the nurse's station, preparing to leave the facility. Upon answering the call, the resident was yelling at the nursing assistant [Agency CNA #100] from in front of the nurse's station. The nurse was able to get another nursing assistant to come to the nurse's station to sit with the resident while Former Administrator and the nurse spoke with the Agency CNA. The nurse immediately separated Agency CNA #100 and the resident prior to the phone call to the Former Administrator. The Agency CNA was on the phone with nine-one-one (911) dispatch as the nurse tried to interview her regarding what happened. As the nurse was attempting to interview, the resident yelled she hit me!, pointing at Agency CNA #100. The Agency CNA stated that she did not hit him, and wanted to wait until the police arrived, stating that she had captured the entire event on camera. The Former Administrator directed the Agency CNA to remove herself from facility and wait for police arrival. The police arrived and collected statements from Agency CNA #100, the resident, the nurse, and the Former Administrator. A police report was made regarding the incident. The resident was interviewed immediately, the day following, and twice more by the Former Administrator, Director of Nursing, and Social Services Director. The resident stated in the immediate interview that Agency CNA #100 was taunting him by sticking her tongue out, and that was when she allegedly kicked him, then he went after her. The resident stated when he got to the nurse's station, that was when the Agency CNA swatted at him. The resident denied at this time being aggressive towards her. Resident #27 had two scratch-like marks down the left side of his forehead and nose. In the following interview on 09/14/25 in the afternoon, the resident forgot what happened during the event and could not recall the series of events and how they unfolded. During the interview on 09/15/25, resident stated that the Agency CNA had not kicked him, but did smack him across the forehead, the opposite direction of the marks on resident's face. The resident was unsure of how these marks appeared but then stated they were not from her. The resident also had glasses on during this event, but they were now unable to be located. The Agency CNA was interviewed immediately by the Former Administrator on 09/14/25 and stated that she did not kick the resident, but rather created distance from him by holding her leg out, as he was in the wheelchair. She denied hitting the resident in any capacity and stated the resident was very aggressive towards her, trying to hit and kick her, following her down the hallway to nurses' station while calling racial slurs at her. She stated she then began recording [on her phone] for her safety and then called 911 from behind the nurse's station. She stated she wished to say nothing more as she would discuss it with the officer and her lawyer but denied any contact with resident on her behalf. The nurse was interviewed during the incident and stated she witnessed most of the occurrence and did not see the Agency CNA #100 hit the resident, but witnessed the resident being aggressive towards Agency CNA #100. Other staff were interviewed immediately that were on-site and stated they did not witness the event, or anyone being hit. Other staff were interviewed during the following days regarding the incident, and no other findings were noted. Other residents were interviewed at time of event and there was no witness to the event. Residents were interviewed during the following days and stated no concerns about safety, care, abuse, or regarding this nursing assistant.Review of the skin assessment dated [DATE] at 2:51 A.M. revealed Resident #27 had two four-centimeter scratches to the face and one one-centimeter skin tear to the nose.Review of the handwritten, signed, witness statement by Registered Nurse #102 from the police report dated 09/14/25 revealed she was in the doorway of a neighboring resident's room when she heard Resident #27 start yelling about the noise. The nursing assistant let him know that they were working and trying to get things finished. Resident #27 said something under his breath and then she heard a loud, [expletive] you. She tried to de-escalate the resident by telling him they were almost finished with majority of the work, and she got back to her tasks. She heard loud voices again and when she came out in the hallway Resident #27 was getting up out of his wheelchair and walking towards the nursing assistant [Agency CNA #100] trying to kick at her. She stated she sat him down in the wheelchair and told the nursing assistant to leave the area. She indicated Resident #27 kept trying to get up and the nursing assistant would not stop verbally replying to Resident #27's racial slurs/language. The nursing assistant went behind the nurse's station and called the police and Resident #27 threw a cup and the cigarette tote at her. She called the administrator.Review of the handwritten, signed, witness statement by Agency CNA #100 from the police report dated 09/14/25 revealed she encountered Resident #27 on the [NAME] Wing Hallway complaining about the noise that staff were making so she closed the door to his room. She indicated Resident #27 open the door back up and started calling her racial slurs and continued taunting her as she retreated to the nurse's station, at that time he began swinging at her and slapped her. He threw a box of cigarettes and lighters at her face and that was when she got her telephone slapped out of her hand, but she was still able to get video of the altercation. She stated she was asked to leave the property by the administration in defense of the resident. When asked if she made contact with Resident #27 at any time she indicated she was able to create distance by using her foot before walking behind the nurse's station for her safety.Review of the police report by Officer #200 on 09/14/25 at 8:37 P.M. revealed Officer #200 was dispatched to the facility for a threat complaint. The caller was identified as Agency CNA #100 who stated she worked for an agency and a resident had become violate with her. She stated Resident #27 had slapped her in the face and slapped away her telephone. Agency CNA #100 told dispatch that Resident #27 had been calling her racial slurs and making several comments towards her. Prior to the officer's arrival Agency CNA #100 advised that she was now separated from Resident #27 and would be waiting in the parking lot in her vehicle. Officer #200 made contact with Agency CNA #100 in the parking lot outside the nursing home. Agency CNA #100 explained to the officer that Resident #27 became angry because the staff were being too loud in the hallways. Due to his complaint of the noise in the hallway, she decided to shut the door to his room which caused Resident #27 to become very angry. She stated he opened the door and came towards her calling her racial slurs. Agency CNA #100 stated the resident stood up from his wheelchair and came towards her as she backed towards the nurses station which was located across the hall from his room however, before making it behind the nurses station Resident #27 had attempted to swing at her several times and she had pushed Resident #27 back from her by using her foot to push against him to create distance. She stated Resident #27 continued to advance towards her and began reaching over the nurse's station continuing to swing at her. She stated Resident #27 was able to slap her on the left side of her face on her cheek, threw a box of cigarettes and lighters at her and smacked her telephone out of her hand while she was attempting to videotape his behavior. Agency CNA #100 allowed Officer #200 to view the video of Resident #27 coming towards her and attempting to swing and smack at her during the video. Officer #200 indicated viewing the video revealed that no injuries were observed on Resident #27's face however, scratch marks were observed on Resident #27 face that had occurred sometime after the video had ended. Officer #200 then went inside the facility to attempt to speak to Resident #27. He observed Resident #27 sitting calmly in front of the nurse's station across from his room. When the officer was speaking to Resident #27, he was able to observe scratch marks on his forehead and his nose. The resident was calm throughout the time the officer was speaking to him. He indicated Resident #27 stated he had become angry that Agency CNA #100 was out in the hallway acting like a [expletive], sticking her tongue out of him, taunting him, and being loud and obnoxious. He stated he became angry, went after her, calling her racial slurs and said that he began swinging at her. Resident #27 stated when he was trying to swing at her he was attempting to smack her with his hand and he would have been okay with smacking her. However, he stated he had not touched her at any time. Officer #200 indicated it should be noted Agency CNA #100 stated Resident #27 had smacked her, but the officer was unable to observe any injuries to her person. Resident #27 also stated Agency CNA #100 had kicked at him and pushed him back by kicking towards his right hip with her foot. Resident #27 stated he had not smacked her telephone out of her hand and had not touched her at any time. Resident #27 explained he was advancing towards Agency CNA #100, she went behind the nurse's station, and he continued to attempt to smack at her, he eventually grabbed a basket of cigarettes and lighters and threw it at her. Resident #27 stated that after he had thrown the basket of items at her she had scratched him across the face causing the visible injuries on his forehead and nose. The officer indicated he had checked her nails to see if there was any blood under her nails however he was unable to observe any. There also were no visible cameras in the area where the altercation had occurred. An interview on 05/11/26 at 9:55 A.M. with the Director of Nursing (DON) confirmed the details of the incident related to the altercation with Resident #27 and Agency CNA #100, and that Resident #27 was videotaped by the CNA. She stated she remembered seeing the scratches on the resident's face. An interview on 05/11/26 at 10:20 A.M. with Resident #27 revealed the night of the incident, the aides were being loud, and he told them to be quiet. He stated the aide [Agency CNA #100] got mouthy with him and he got mouthy back and she did not like it. He stated he got up out of the wheelchair and went after her, but he never touched her because he would never hit a woman. He stated she swung at him and scratched his face and knocked his new glasses off his face and shattered them. He stated he did throw the cigarette case at her. He stated she kicked him in the right hip when he got up out of his wheelchair. Resident #27 stated he felt safe at the facility but in general he wanted to leave.A second interview on 05/11/26 at 10:29 A.M. with the DON revealed she verified the glasses Resident #27 had on in the video screen shot prior to the incident, were not the same glasses he had on now. She stated she did not know what had happened to them that night.Review of the undated facility policy titled, Abuse, Neglect, and Exploitation, revealed it was the facility policy to provide protections for the health welfare and rights of each residents by developing and implementing written policies and procedure that prohibits and prevents abuse neglect exploitation and misappropriation of resident property.The deficiency was corrected on 09/15/25 after the facility implemented the following corrective actions: -On 09/14/25 at 12:00 A.M. Registered Nurse #102 notified the Former Administrator.-On 09/14/25 at 12:05 A.M. the Former Administrator advised Agency CNA #100 that she was released for the remainder of shift.-On 09/14/25 at 1:21 A.M. the Former Administrator notified the Director of Nursing and Former Social Services Director #104 of the incident.-On 09/14/25 from 12:20 A.M. to 1:00 A.M. the Former Administrator and Former Social Services Director #104 interviewed all staff working via telephone.-On 09/14/25 from 1:00 A.M, to 4:00 A.M. Registered Nurse #102 interviewed all residents on the [NAME] Hall who had a Brief Interview for Mental Status greater than 12 on abuse and performed skin and pain assessments on all residents located on [NAME] Hall.-On 09/14/25 at 10:00 A.M. the Director of Nursing was at the facility and educated all staff on the Abuse policy, and updated the power of attorney, medical director and psychiatric services of the incident. The Director of Nursing also notified Clipboard Health of the incident that involved their staff member and requested Agency CNA #100 be placed on the Do Not Return list.-On 09/14/25 at 11:00 A.M. the Director of Nursing reviewed the incident and statements. Resident #27's orders and care plan were updated as needed.-On 09/14/25 at 12:00 P.M. the Director of Nursing interviewed Resident #27.-On 09/14/25, a Root Cause Analysis was completed to determine the potential cause of the incidentOn 09/15/25, a Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the incident. -On 09/15/25 at 1:00 P.M. Former Social Service Director #104 met with Resident #27 to follow up and discuss the weekend incident.-From 09/15/25 through 09/18/25, Resident #27's pain medications and psychiatric medications were adjusted per a psychiatric evaluation and the psychiatric nurse practitioners orders. -On 09/19/25, Agency CNA #100 was reported to the nurse aide registry. This deficiency represents non-compliance investigated under Complaint Number 2998394.

Based on observation, interview and record review, the facility failed ensure the resident's received the proper portion size on the diet tickets. This affected Resident #20 and had the potential to affect eight other residents who were to receive ground chicken salad for the meal. The facility census was 38.Findings include: Review of the medical record for Resident #20 revealed an admission date of 5/28/25. Diagnoses included Alzheimer's disease and diabetes mellitus.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired and required set up assistance from staff for eating.Review of the physician's orders for March 2026 revealed Resident #20 was ordered a regular diet with dysphasia advanced texture and thin consistency liquids.Observation of lunch tray line service on 03/19/26 at 12:15 P.M. revealed Resident #20's meal ticket stated she was supposed to get ground chicken salad utilizing #10 scoop (3.75 ounce). [NAME] #107 plated Resident #20's ground chicken salad using one scoop with #16 scoop (two ounces), placed the other food items on the tray, and the put the lid on top of the plate and put into the food cart. Dietary Aide (DA) #109 pulled Resident #20's tray out of food cart and [NAME] #107 verified the scoop that he was portioning the ground chicken salad out was a #16 scoop (two ounces) instead of a #10 scoop (3.75 ounce).Observation and interview on 03/19/26 at 12:17 P.M. with [NAME] #107 revealed the serving size should be three ounces and went to the scoop chart in the kitchen, which showed the #16 scoop was only two ounces. [NAME] #107 then changed out the scoop to a #10 scoop to serve ground chicken salad from the tray line.Interview on 03/19/26 at 1:30 P.M. with Dietary Manager (DM) #108 revealed she thinks [NAME] #107 was nervous and that was why he got the wrong scoop out. DM #108 stated she should have checked the serving utensils prior to tray service.Review of the undated recipe for chicken salad revealed that a #10 scoop of chicken salad should be placed between two slices of bread.This deficiency represents non-compliance investigated under Complaint Number 2786863.

Based on observation, interview and facility policy review the facility failed to properly label and store frozen food items in the facility kitchen. This deficient practice had the potential of affecting all residents residing in the facility. The facility census was 36. Findings Include: An observation during the initial kitchen tour on 02/10/25 from 12:40 P.M. to 12:55 P.M. revealed a plastic bag with 10 frozen pork fritters sitting on top of a cardboard box on the second shelf of the freezer. The plastic bag had no date when it had been opened and/or placed in the freezer. The bag was not sealed but loosely wrapped. An interview on 02/10/25 at 12:50 P.M. with [NAME] #218 confirmed the wrapped up open plastic bag with 10 frozen pork fritters was not dated when it had been opened and/or placed in the freezer. [NAME] #218 removed the opened bag of pork fritters and discarded them in the garbage pail. [NAME] #218 stated the bag should have been closed securely and a date should have been placed on the bag to reflect when the bag had been opened. A review of the facility's policy titled, Date Marking for Food Safety dated 02/11/25 revealed The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. This deficiency represents non-compliance investigated under Master Complaint Number OH00162261.

Based on medical record review, observation, interview and facility policy review the facility failed to properly maintain breathing treatment (nebulizer) tubing and medication delivery device (mask) by not changing, cleaning and securing in a bag prior to and following administration of medication. This deficient practice affected two residents (Residents #22 and #23) of two residents reviewed for respiratory care. The facility census was 36. Findings Include: 1. A review of Resident #22's medical record revealed the initial admitted [DATE] and a re-admitted [DATE] with diagnoses including but not limited to opioid abuse, acute respiratory infection, anxiety and shortness of breath. Resident #22 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15 dated 12/18/24. Resident #22 required staff assistance with activities of daily living (ADL) tasks including medication administration. A review of Resident #22's at risk for respiratory status/difficulty breathing care plan dated 08/16/24 revealed an intervention for administering medications as ordered. A review of Resident #22's signed physician orders revealed an order dated 12/28/24 for breathing treatment medication DuoNeb solution 0.5 milligrams (MG) per 2.5 milliliters (ML) (Ipratropium-Albuterol) 1 vial inhale orally via nebulizer every 4 hours as needed for shortness of breath, and an order dated 01/30/25 to clean/disinfect nebulizer machine. Change tubing (initial and date) and replace bag (initial and date) every night shift every Sunday. A review of Resident #22's Medication Administration Record (MAR) dated 02/01/25 to 02/12/25 revealed Resident #22 received a breathing treatment of DuoNeb solution on 02/01/25, 02/02/25, 02/03/25, and 02/06/23 lasting 15 minutes each. Further review of Resident #22's Treatment Administration Record (TAR) dated 02/01/25 to 02/12/25 revealed nebulizer cleaning and changing of nebulizer tubing and mask were completed on 02/03/25 and 02/10/25. An observation on 02/12/25 at 9:15 A.M. revealed in Resident #22's room, a nebulizer laying in the high backed chair on top of several items of clothing and papers. The medication delivery device was dated 02/03/25 and both the medication delivery device and the nebulizer tubing were also laying on top of the clothing items and papers and were not secured in a bag. 2. A review of Resident #23's medical record revealed an admitted d of 06/24/22 with diagnoses including but not limited to congestive heart failure (CHF), high blood pressure (HTN), and shortness of breath. Resident #23 had impaired cognition with a BIMS score of 11 out of a possible 15 dated 12/31/24. Resident #23 required staff assistance with activities of daily living (ADL) tasks including medication administration and was receiving hospice services. A review of Resident #23's signed physician orders revealed an order dated 01/28/25 for breathing treatment medication DuoNeb Solution 0.5-2.5 MG/ML one vial inhale via nebulizer every four hours for shortness of breath, an order dated 01/22/25 to clean/disinfect nebulizer, change tubing (initial and date) and replace bag (initial and date) every night shift every three days and as needed, an order for Oxygen continuous at 2-5 liters (L) via nasal cannula (NC) to maintain oxygen saturation equal to or greater than 90% every shift and as needed, and an order dated 11/26/24 to change oxygen (02) tubing (initial and date), place a new bag (initial and date) every shift every Sunday. A review of Resident #23's MAR dated 02/01/25 to 02/12/25 revealed the breathing treatment DuoNeb Solution was administered daily every four hours, and 02 use was marked daily for every shift. Further review of Resident #23's TAR revealed nebulizer cleaning and tubing change was completed on 02/03/25 and 02/10/25 and 02 tubing change was completed on 02/03/25 and 02/20/25. An observation on 02/11/25 at 2:15 P.M. revealed Resident #23 receiving a breathing treatment via nebulizer and medication delivery device (mask). An observation on 02/12/25 at 7:15 A.M. revealed in Resident #23's room a nebulizer was sitting on top of the three drawer dresser beside Resident #23's bed with the tubing and medication delivery device laying on top of the of the dresser with a date of 02/10/25 but was not secured in a bag. An interview on 02/12/25 at 11:05 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #22's nebulizer, nebulizer tubing and medication delivery device was sitting in the high-backed chair not secured in a bag and was dated 02/03/25. LPN #313 also confirmed Resident #23's nebulizer, nebulizer tubing and medication delivery device was sitting on top of the three drawer dresser and the tubing was not secured in a bag. This deficiency represents non-compliance investigated under Master Complaint Number OH00162261.

Based on observation, interview, and review of the facility policy, the facility failed to store and monitor medications in a safe manner. This had the potential to affect all residents residing in the facility. The facility census was 36. Findings include: 1. Observation on [DATE] at 3:43 P.M. with the Director of Nursing (DON) of the west medication storage room revealed two boxes (100 per box) of bisacodyl (10 milligram) suppositories. Each partially used box had an expiration date of ,d+[DATE]. The DON confirmed the suppositories were a stock medication for residents as needed and they were expired. Observation of the refrigerator revealed multiple boxes of influenza vaccines (stock), six tuberculin vials (stock) 28 haldol injections vials and multiple resident insulin pens. 2. Record review of the refrigerator temperature log for [DATE] for the [NAME] medication room revealed the refrigerator temperature were not monitored for the A.M. or P.M. on [DATE] or [DATE]. The temperature was also not monitored for the P.M. on [DATE], the A.M. on [DATE], or the P.M. on [DATE]. The temperature log also revealed on [DATE] the refrigerator temperature was 48 degrees Fahrenheit. The temperature was signed by Licensed Practical Nurse (LPN) #137. The DON confirmed the temperature logs were not completed daily. The temperature logs were used to ensure the refrigerator temperature was held within the required safe temperature for medication storage. The DON confirmed she was not made aware when the refrigerator temperature was out of range on [DATE] at 48 degrees Fahrenheit. Interview on [DATE] at 8:34 A.M. with LPN #137 confirmed on [DATE] the refrigerator temperature in the [NAME] medication room was 48 degrees. LPN #137 revealed she did not report the temperature to the DON or Maintenance Personnel. 3. Observation on [DATE] at 4:00 P.M. with the DON of the medication storage refrigerator located in the Alixa medication storage room revealed the freezer (located in the upper portion inside the refrigerator) was greater than 50 % solid ice. The ice also built up four to six inches under the freezer base (located directly above residents stored medications). Inside the refrigerator was intravenous medications including vancomycin and ampicillin, 14 insulin pens, and three boxes of apisol injections (used for stock). Observation of the refrigerator temperature logs revealed the last log completed for the medication storage refrigerator was [DATE]. The log for [DATE] revealed nine days that had no temperature documented for either shift. The DON revealed if the refrigerator temperature were monitored, they would be documented on the refrigerator temperature log. The DON confirmed there was no documentation of the temperature being monitored for the Alixa medication storage refrigerator since [DATE]. Review of the facility policy titled, Medication Storage undated revealed it was the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biological's will be stored in locked compartments (i.e. , medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Temperatures are maintained within 36 to 46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee. In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such findings to maintenance department for emergency repair. 22653 4. On [DATE] at 11:22 A.M., Licensed Practical Nurse (LPN) #113 was observed administering medication to Resident #138. An insulin lispro 100 units per milliliter pen was used while preparing the drug. The insulin pen was undated as to when it was opened. This was verified by LPN #113 at that time. Review of the facility's Insulin Pen policy (implementation date not documented) revealed insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. Review of manufacturer information revealed insulin lispro kwik pens should be used within 28 days or discarded.

Based on observation, interview, review of the temperature logs, and review of facility policy, the facility failed to ensure food items were stored and labeled appropriately, refrigerator temperatures were monitored and recorded, and spoiled foods were discarded appropriately. This had the potential to affect all 36 residents in the facility. Findings include: 1. On 09/15/24 at 9:41 A.M., during the initial tour of the kitchen, the following were observed in the dry storage room: one opened bag of raspberry gelatin mix with no label indicating the open date, one open bag of dry pasta unsealed and with no label indicating the open date, one open bag of dry pasta with a paperclip holding it closed and no label indicating the open date, two plastic storage containers labeled bread crumbs with no label indicating the open date, and one unopened bag of rolls on the bread rack with visible green mold. These observations were verified by [NAME] #127 at the time of observation. 2. On 09/16/24 at 10:40 A.M., an observation of the refrigerator in the nurse's station on the [NAME] unit revealed both staff and resident foods were stored in the refrigerator, there was significant ice crystalization in the freezer, and there was a brown substance spilled on the bottom of the freezer and in the freezer door. These observations were verified by Registered Nurse (RN) #109 at the time of observation. 3. On 09/16/24 at 10:56 A.M., an observation of the refrigerator in the servery on the South unit revealed both staff and resident foods were stored in the refrigerator, there was a plastic container of food with no label or date, there was an open popsicle covered in ice crystals in the freezer, and the temperature log on the freezer for September 2024 only had temperatures recorded for 09/15/24, there were no temperatures documented for 09/01/24 through 09/14/24. On 09/16/24 between 11:03 A.M. and 11:06 A.M., interviews with [NAME] #111, Licensed Practical Nurse (LPN) #151, and State tested Nurse Aide (STNA) #155 verified the observations of the South unit refrigerator. [NAME] #111 stated he did not even know there was a refrigerator on that unit and he thought [NAME] #146 was responsible for monitoring and recording refrigerator temperatures. LPN #151 stated she thought it was the responsibility of nursing staff to record refrigerator temperatures. On 09/16/24 at 11:46 A.M., an interview with the Administrator stated staff food was supposed to be stored in the break room refrigerator and not in the refrigerators on the units. On 09/16/24 at 3:05 P.M., an interview with Registered Dietitian (RD) #162 said staff have specific refrigerators designated for storage of staff food and staff should not store food in the refrigerators on the units. RD #162 confirmed the policy on storage of foods brought in from the outside indicated that common use refrigerators on the units would have temperatures monitored and recorded by dietary staff daily, which RD #162 stated was inaccurate and further stated it was actually housekeeping staff's responsibility to monitor and record those temperatures. Review of the facility's policy titled Food Brought in from Outside the Community, not dated, indicated the facility would designate a single refrigerator for residents and families to use for storage of foods brought in from outside the facility. If a common use refrigerator is used, a thermometer will be placed inside the refrigerator and the temperature would be recorded daily by the dietary staff on a temperature log. In addition, dietary staff would check common use refrigerators weekly to wipe up any spills and discard any foods that were not dated or that were seven days old.

Based on observation, interview, record review, and review of the facility policy, the facility failed to maintain infection control practices to include Enhanced Barrier Precautions (EBP) for six residents, Resident #5, #8, #9, #12, #27, and #187 of six residents reviewed for EBP and the facility failed to ensure infection control practices were maintained during laundry services which had the potential to affect all 36 residents residing at the facility and the facility failed to disinfect the glucometer used to assess Resident #138's blood sugar prior to and after use. This affected one resident, Resident #138 of one resident reviewed for blood sugar assessments. The facility census was 36. Findings include: 1. Record review for Resident #12 revealed an admitted [DATE]. Diagnosis included colostomy status, personal history of malignant neoplasm of large intestine, and need for assistants with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact. Resident had an ostomy, used a walker for mobility, required partial/moderate assistants for toileting, bathing and set up or clean up assistants for personal hygiene. Review of the care plan for Resident #12 dated 08/20/24 revealed the resident had an alteration in gastro-intestinal status related to presence of colostomy. Interventions included to change the colostomy bag/wafer as ordered and colostomy care as ordered. The care plan did not include an intervention for use of Personal Protective Equipment (PPE) related to stoma care. Review of the physician orders dated 08/07/24 to empty and clean colostomy bag every shift and as needed. Gentle cleanse stoma site with mild soap and water, pat dry. The physician orders revealed no orders for Enhanced Barrier Precautions (EBP) related to the stoma/care. Interview on 09/15/24 at 2:57 P.M. with the Director of Nursing (DON) revealed the facility had three residents on Enhanced Barrier Precautions (EBP), Resident #12, #27 and #187. The DON confirmed she was also the Infection Preventionist. Observation on 09/15/24 at 3:00 P.M. with the DON verified Resident #12 did not have an isolation bin or any PPE in his room or outside his entrance doorway. The DON verified there was no trash can in Resident #12's room for disposing of used PPE and there was no sign inside or outside identifying Resident #12 was on EBP. 2. Record review for Resident #27 revealed an admitted [DATE]. Diagnosis included benign prostate hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of the bladder and unspecified dementia, severe. Review of the Annual MDS dated [DATE] revealed Resident #27 had an indwelling catheter and was dependent for personal hygiene. Review of the care plan revealed Resident #27 had impaired immunity related to indwelling foley catheter and history of multi-drug resistant organisms (MRDO's). Interventions included to provide care separately from the roommate. Perform foley catheter care. The care plan did not include an intervention for use of PPE related to the indwelling catheter care. Review of the physician orders for Resident #27 revealed an order dated 08/19/24 EBP, staff to use appropriate PPE when assisting resident with high contact care activities such as dressing, hygiene, bathing/showering, transferring, linen changes, bowel/bladder care, device care/use or wound care every shift for history of methicillin resistant staphylococcus aureus (MRSA) in urine with indwelling foley catheter. Perform foley catheter care every shift dated 09/25/23 and monitor and record urine output every shift dated 02/27/24. Observation on 09/15/24 at 3:03 P.M. with the DON verified Resident #27 did not have a sign inside or outside identifying Resident #12 was on EBP. Observation on 09/16/24 at 6:30 A.M. of catheter care provided by STNA #157 for Resident #27 revealed STNA #157 did not donn any isolation gown prior to or during catheter care. STNA #157 provided catheter care without an isolation gown, picked up the soiled washcloths then left the room with the soiled gloves still on carrying the soiled washcloths. Interview on 09/16/24 at 6:43 A.M. with STNA #157 revealed she never had to gown while providing catheter care unless the resident had an infection and Resident #27 did not have an infection. STNA #157 confirmed she did not remove her gloves or wash her hands prior to leaving Resident #27's room after providing care. 3. Record review for Resident #187 revealed a readmitted [DATE]. Diagnosis included orthopedic aftercare following surgical amputation, acquired absence of other right toes, osteomyelitis right ankle and foot, peripheral vascular angioplasty status with implants and grafts, muscle weakness and need for assistants with personal care. Review of the Medicare five-day MDS dated [DATE] revealed Resident #187 was cognitively intact. Resident #187 had a surgical wound and an infection of the foot. Resident #187 received surgical wound care. Review of the care plan for Resident #187 revealed the resident has infection of the right lower extremity related to osteomyelitis. Interventions included to maintain universal precautions when providing resident care. Resident is at risk potential for skin impairment related to muscle weakness impaired mobility development history of toe amputation and osteomyelitis. Interventions included to administer treatments as ordered and monitor for effectiveness. Record review of the physician orders for Resident #187 revealed monitor peripherally inserted central catheter (PICC) line insertion site for signs and symptoms infection, bleeding and dislocation. Change needleless connector every night shift every seven days dated 08/16/24, Gently cleanse right foot wound with normal saline, pat dry, apply dakins soaked gauze, cover with four by four, secure with kerlix and apply post splint and secure with ACE wrap until healed every night shift dated 09/13/24. Additional orders included EBP staff to use appropriate PPE when assisting resident with high contact care activities such as dressing, hygiene, bathing/showering, transferring, linen changes, bowel/bladder care, device care/use or wound care every shift for increased risk of MDRO acquisition related to PICC line dated 08/19/24. Observation on 09/15/24 at 3:06 P.M. with the DON verified Resident #187 did not have an isolation bin or any PPE in his room or outside his entrance doorway. The DON verified there was no trash can in Resident #187's room for disposing of used PPE and there was no sign inside or outside identifying Resident #187 was on EBP. Interview on 09/15/24 at 3:10 P.M. with State tested Nursing Assistant (STNA) #107 revealed Resident #187 did not require EBP during personal/incontinent care. Interview on 09/15/24 at 3:18 P.M. with Registered Nurse (RN) #109 confirmed she was Resident #187's charge nurse. Resident #187 had a surgical wound, osteomyliyis and gangrene and he had intravenous (IV) antibiotics. RN #109 revealed Resident #187 did not require isolation including EBP during wound care or IV administration. RN #109 revealed night shift usually provided the wound care for Resident #109. Interview on 09/16/24 at 5:56 A.M. with Licensed Practical Nurse (LPN) #159 (night shift nurse for Resident #187) revealed she had already completed the wound care for Resident #187 to his foot. LPN #159 revealed she provided wound care/dressing changes to Resident #187's foot on several nights that she worked and she never wore or was required (prior to 09/15/24) to wear an isolation gown during his wound care. 4. Record review for Resident #5 revealed an admitted [DATE]. Diagnosis included neuromuscular dysfunction of the bladder. Review of the quarterly MDS for Resident #5 dated 07/01/24 revealed Resident #5 was cognitively intact. Resident #5 had an indwelling catheter and was dependent with personal hygiene. Review of the care plan dated 04/16/23 for Resident #5 revealed the resident had a suprapubic catheter. Interventions included to change the urinary catheter drainage bag every week and as needed, gently cleanse around suprapubic catheter site with normal saline, apply drain sponge and secure with paper tape as ordered. The care plan did not include an intervention for use of PPE related to the catheter. Review of the physician orders dated 01/17/24 for Resident #5 revealed gently cleanse area around suprapubic catheter site with normal saline, pat dry, apply drain sponge and secure with paper tape every night shift for catheter care and as needed. Urinary output every shift. Review of the physician orders revealed no orders for enhanced barrier precautions. Interview on 09/15/24 at 306 P.M. with DON confirmed Resident #5 was not on EBP and had no PPE for staff use in or near her room. The DON confirmed there was also no trash container for soiled PPE in or near the residents rooms including their bathrooms. Observation on 09/15/24 at 3:53 P.M. revealed STNA #107 placed gloves on and emptied Resident #5' catheter drainage bag. STNA #107 did not donn an isolation gown prior to emptying the urine from the catheter bag and did not wash his hands after emptying the urine from the catheter bag. STNA #107 then assisted STNA #125 transfer Resident #5 to bed via a sit to stand mechanical lift. Neither STNA #107 nor #125 donned an isolation gown. STNA #107 put gloves on then provided catheter care, cleaning the insertion (suprapubic catheter site) for Resident #5 and provided peri care. Both STNA #107 and #125 then transferred Resident #5 back to her chair from the bed, (STNA #125 did not remove her gloves from peri/catheter care and neither STNA's washed their hands after providing personal care or prior to the transfer). STNA #125 collected the soiled linen, still wearing the same gloves and both STNA's exited the room without washing their hands. Interview on 09/15/24 between 4:16 P.M. and 4:18 P.M. with STNA #125 and #107 revealed staff were not required to wear PPE except for gloves during catheter care. STNA #125 and #107 revealed staff only wore PPE if a resident was on isolation and Resident #5 did not require isolation. STNA #125 confirmed she did not remove her gloves or wash her hands before leaving Resident #5's room. STNA #107 also confirmed he did not wash his hands prior to leaving the room. 5. Record review for Resident #9 revealed an admitted [DATE]. Diagnosis included neuromuscular dysfunction of the bladder dated 02/26/24. Review of the quarterly MDS dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 had an indwelling catheter and was dependent for personal hygiene. Review of the care plan for Resident #9 dated 08/19/24 revealed Resident #9 had impaired immunity related to the suprapubic catheter. Interventions included provide care separately from my roommate. SP catheter care as ordered with gauze dressing and paper tape. The care plan did not include an intervention for use of PPE related to the indwelling catheter. Review of the physician orders for Resident #9 dated 07/16/24 cleanse s/p catheter site with normal saline, apply new gauze sponge and secure with paper tape as needed for drainage. May change catheter if dislodged, leaking or obstructed dated 02/26/24 and measure and record output every shift. The physician orders revealed no orders for Enhanced Barrier Precautions (EBP) related to the catheter. Interview on 09/15/24 at 306 P.M. with the DON confirmed Resident #9 was not on EBP and had no PPE for staff use in or near his room. Observation on 09/15/24 at 3:17 P.M. confirmed Resident #9 had a catheter. Interview on 09/15/24 at 3:19 P.M. with RN #109 confirmed she was Resident #9's charge nurse. Resident #9 had an indwelling catheter. RN #109 revealed Resident #9 did not require isolation including EBP during catheter care. 6. Record review for Resident #8 revealed an admitted [DATE]. Diagnosis included multiple sclerosis, neuromuscular dysfunction of the bladder and colostomy status. Review of the quarterly MDS dated [DATE] revealed Resident #8 was cognitively intact. Resident #8 had an indwelling catheter and an ostomy. Resident #8 was dependent for bathing and personal hygiene. Review of the care plan for Resident #8 dated 05/17/24 revealed Resident #8 had an indwelling catheter related to neurogenic bladder. Interventions included to monitor and document intake and output. The care plan did not include an intervention for use of PPE related to the indwelling catheter or ostomy. Review of the physician orders for Resident #8 revealed orders to gently cleanse stoma site with mild soap and water, pat dry, change ostomy bag and wafer every night shift every Sunday and as needed dated 08/07/24. Provide catheter care every shift and may irrigate foley catheter with 60 ml sterile water PRN for occlusion dated 04/15/24. Interview on 09/15/24 at 3:07 P.M. with the DON confirmed Resident #8 was not placed on EBP and had no PPE for staff use in or near his room. Observation on 09/15/24 at 3:18 P.M. confirmed Resident #8 had an indwelling catheter. Interview on 09/15/24 at 3:20 P.M. with RN #109 confirmed she was Resident #8's charge nurse. Resident #8 had an indwelling catheter and ostomy. RN #109 revealed Resident #8 did not require isolation including EBP during catheter/ostomy care. 7. Observation on 09/19/24 at 9:51 A.M. of the washing laundry area revealed in the small room was two washing machines. Laundry Aid #134 revealed the washing machine closest to the wall was not working. Both washing machines sat side by side. Next to the working washing machine (on the opposite side of the broken one) was a large overflowing container of soiled laundry. Approximately three feet out from the working washing machine (directly in front of the machine) was another large overflowing container of soiled laundry and a small container of soiled laundry. Behind the large container of soiled laundry (approximately two to three feet was a large trash can barrel partially filled with trash and no lid. In front of the broken washing machine was an additional large container of overflowing soiled laundry. Observation revealed Laundry Aid #134 brought an empty laundry cart in the room, rubbing the sides against the soiled laundry and the trash can as she was moving the cart to the washer door. Laundry Aid #134 then emptied the linens into the laundry cart from the washing machine. Laundry Aid #134 backed the cart up against soiled laundry cart, (soiled clothes touching clean linen) and the trash can. Laundry Aid #134 then pulled a soiled barrel of linen up to the washing machine door, took out each piece of linen and shook each piece of soiled linen out over the soiled linen barrel sitting directly up against the clean cart which had the linen just removed from the washer. Interview on 09/19/24 at 10:52 A.M. with Housekeeping Laundry Supervisor #156 revealed the biggest challenge in the laundry room was space. Housekeeping Laundry Supervisor #156 revealed clean and dirty laundry should never touch, the clean cart should have been removed before loading the next load in the washer. Housekeeping Laundry Supervisor #156 revealed the second washing machine in the room had been broken for the previous six to seven years which created a challenge to keep up with the soiled laundry. Review of the policy titled, Enhanced Barrier Precautions undated revealed an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic ulcers, surgical wounds, and chronic venous stasis ulcers), and indwelling medical devices, (e.g., central lines, urinary catheters, feeding tubes, tracheostomies, PICC lines and midline catheters) even if the resident is not known to be infected or colonized with a MDRO. Make gowns and gloves available immediately near or outside of the residents room. Position a trash can inside the resident room and near the exit for discarding the PPE after removal. PPE for EBP is only necessary when performing high contact care activities (dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, PICC lines or midline catheters). EBP should be used for the duration of the affected residents stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Therapist should also gown and glove when working with residents on EBP. 22653 8. On 09/08/24 at 11:16 A.M., Licensed Practical Nurse (LPN) #115 was observed monitoring the blood sugar of Resident #138. A glucometer was withdrawn from the top drawer of the medication cart with no indication it was used for a single resident. After Resident #138's blood glucose level was read the glucometer was placed back into the top medication cart drawer without cleaning/sanitizing it. The glucometer was removed from the drawer to check the results and placed on top of the medication cart. LPN #115 placed the glucometer back into the drawer at 11:25 A.M. On 09/15/24 at 11:25 A.M., LPN #115 verified the glucometer could potentially be used for another resident but stated only Resident #138 had routine blood glucose monitoring ordered. LPN #115 stated the glucometer was cleaned once a shift. LPN #115 then removed the glucometer from the drawer and wiped it with an alcohol pad. On 09/15/24 at 1:36 P.M., the Director of Nursing (DON) stated bleach wipes were supposed to be utilized in cleaning and disinfecting glucometers. Review of the facility's glucometer disinfection policy (implementation date not recorded) revealed blood glucometers would be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. If the manufacturers were unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter would not be used for multiple residents. The glucometers would be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that was effective against HIV, Hepatitis C and Hepatitis B virus. Glucometers would be cleaned and disinfected after each use regardless of whether they were intended for single resident or multiple resident use. The procedure indicated two disinfectant wipes were to be utilized. The first wipe was to clean to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, the second wipe was to be used to disinfect the glucometer thoroughly. Although requested, no manufacturer guidelines were provided.

Based on observation and interview, the facility failed to maintain comfortable temperatures on the [NAME] unit and South unit and failed to maintain resident equipment in good repair. This affected three residents (#6, #22, and #24) of three reviewed for environment The facility census was 36. Findings include: 1.On 09/15/24 at 12:36 P.M., Residents #6, #22, and #24 were observed sitting in the common area by the [NAME] unit nurses station and they all stated it was freezing in the facility and they requested blankets. On 09/15/24 at 12:46 P.M., an interview with State tested Nurse Aide (STNA) #125 confirmed it felt cold on the [NAME] unit and STNA #125 had to obtain blankets for Residents #6, #22, and #24. On 09/15/24 at 12:50 P.M., an observation of facility air temperatures with Housekeeping Supervisor #156 revealed the temperature of the [NAME] unit common area by the nurses station was 70 degrees Fahrenheit (F). Further observations of air temperatures throughout the facility revealed the hallway of the South unit was 69 degrees F and spot checks of resident rooms on the South unit revealed air temperatures of 69 degrees F to 70 degrees F. These temperatures were verified by Housekeeping Supervisor #156 at the time of observation. On 09/15/24 at 1:05 P.M., an interview with the Administrator stated the facility had adjusted the air conditioner to get ahead of the hot weather they were supposed to have that day. 2. An observation on 09/18/24 at 2:02 P.M. revealed Resident #24's bed in the lowest position located with the left side of the bed against the wall. The bed did not have a headboard attached to the bed frame and there were no bolts observed either in the bedframe or on the floor underneath the bed. The headboard for the bed was observed leaned against the wall between the bed and the wardrobe. An observation on 09/19/24 at 9:05 A.M. revealed Resident #24 was lying in bed watching television with the left side of the bed against the wall and the bed was in lowest position. The headboard for Resident #24's bed was still leaning against the wall between the bed and the wardrobe with the securing brackets lying on the floor beside the headboard. Further observation revealed the baseboard heating unit located along the bottom of the wall where the left side of the bed was against. The front covering of the baseboard heating unit had been broken off from the securing brackets to the baseboard heating unit which allowed for the heating element to be exposed to the privacy curtain and the bed sheets and blanket. The baseboard heating unit was not in use at the time of the observation. An interview on 09/19/24 at 9:05 A.M. with the Director of Maintenance (DOM) #116 confirmed Resident #24's bed did not have the headboard attached to the bedframe and the headboard was leaning against the wall between the bed and wardrobe. The DOM #116 also confirmed the front covering of the baseboard heating unit had been broken off the securing brackets exposing the heating element to the privacy curtain and the bed sheets and blanket. A review of the facility's policy titled, Safe and Homelike Environment dated 02/23 revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and home like environment.

Based on observation, interview, activity calendar review, activity director job description review and record review, the facility failed to provide individualized activities in accordance with assessments for five residents (#9, #12, #22, #27, and #32) of six residents reviewed for activities. The facility census was 36. Findings include: 1. Record review for Resident #9 revealed an admitted [DATE]. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Aphasia following cerebral infarction, cognitive communication deficit and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. The resident had impairment on both sides of the upper and lower extremities and required assistants for all activities of daily living (ADL). Review of the care plan dated 08/09/24 for Resident #9 included the resident had little or no group activity involvement related to cerebral vascular accident, cognitive communication deficit, and anxiety. Interventions included activities staff will orient and re-orient Resident #9 to facility's activity programming and encourage him to attend facility programming as well as self-directed activities. Offer Resident #9 one on one (1:1) visits as needed and when preferred such as sensory activities for end-of life care, music, massage, and spiritual. Provide Resident #9 with a monthly activity calendar in his room. Interview on 09/15/24 at 4:54 P.M. with Resident #9 revealed staff do not offer activities for him. Resident #9 confirmed he rarely left his room or got out of bed due to his stroke and revealed he would like to do some activities in his room. Observation and interview on 09/16/24 at 11:34 A.M. with Scheduler/Medical Records #122 revealed activities have been offsince the middle of August 2024. The Dietary Manager and the Maintenance man tried to help when they could. Observation with Scheduler/Medical Records #122 while in Resident #9's room revealed Resident #9 did not have an Activity calender posted in his room. Scheduler/Medical Records #122 looked throughout Resident #9's room with Resident #9's permission and found an activity Calender on a stand from July 2024, under some papers, across the room from where Resident #9 was lying in his bed. Scheduler/Medical Records #122 confirmed Resident #9 was unable to see or even reach the calender and verified the calendar was from July 2024. An interview with Resident #9, during the observation, confirmed he never received an updated activity calender. Interview on 09/16/24 at 11:41 A.M. with Dietary Manager #163 revealed she helped fill in while the Activity Director was out. Dietary Manager #163 revealed she tried to do both departments, but it was difficult. Sometimes in the morning while passing by residents rooms, she would try to poke her head in the door and say hi to residents. Interview on 09/16/24 at 11:54 A.M. with the Administrator confirmed the Activities Director had not been at the facility since 08/19/24. The Administrator confirmed Resident #9 rarely got out of bed or left his room. Review of the July 2024 Participation Record for Resident #9 revealed Resident #9 had daily, one on one visits, two to five times a week Monday through Friday. Review of the August and September 2024 Activity Participation Record with the Administrator for Resident #9 revealed no 1:1 visit were made with Resident #9. The Activity Participation Record indicated if the resident refused, document refusals on the other side. Administrator confirmed Resident #9 did not have any refusals of activities documented for August or September 2024. 22653 2. During an interview on 09/15/24 at 10:36 A.M., Resident #12 stated he was unaware of any activities except bingo once. Resident #12 indicated he would be interested in attending activities if they offered activities he was interested in. Resident #12 stated he had heard there were activities held off the secure unit. Review of Resident #12's medical record revealed diagnoses including heart disease, history of mini stroke and stroke, hearing loss in bilateral ears, age-related physical debility, visual loss in both eyes, depression and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was able to make himself and was able to understand others. Resident #12 was assessed as cognitively intact. The MDS indicated it was very important to Resident #12 to listen to music he liked, to be around animals such as pets, to keep up with the news, do things with groups of people, do favorite activities, and go outside to get fresh air when weather was good. An activity interest data collection tool dated 08/09/24 indicated Resident #12 preferred to spend time with others. Resident #12 indicated preference for independent and group activities. Naps were part of Resident #12's daily activity routine. Interests included voting, fishing, hunting, baseball, basketball, football, restaurants, listening to music, garden club, television, movies, cooking/baking, board games, cards, bingo, word puzzles, books, magazines, walking, talking/conversing, phone use, live music/entertainment, holiday parties, Bible study, devotions, worship services, animals/pets, and clubs/organizations. Review of a care plan initiated 08/09/24 indicated Resident #12 was dependent on staff for meeting his emotional, intellectual, physical, and social needs due to cognitive deficits, immobility, and physical limitations. Interventions included ensuring the activities Resident #12 was attending were compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate. Interventions also included inviting and reminding Resident #12 to scheduled activities, providing Resident #12 with a monthly activity calendar in his room, and providing Resident #12 with supplies for individual activity participation as needed. Review of the August 2024 activity participation record revealed bingo was offered eight times and refused every time. Resident #12 participated in exercise activities five times with no refusals noted. Resident #12 was recorded as visiting with peers/socializing 21 days. Rolling/walking was recorded 27 days. One social/party/special event was offered/attended. Resident #12 refused four offers of trivia and watched television every day. Review of the September 2024 activity participation record revealed bingo was offered three times. Staff recorded Resident #12 was sleeping when arts and crafts were offered on 09/16/24. No exercise/sports were offered. going outside was offered once and refused. Peer visits/socializing was documented 11 days out of 15 days. Rolling/walking was recorded 13 of 15 days. Resident #12 watched television every day. Observations on 09/15/24 at 9:45 A.M. revealed Resident #12 was lying in bed with his eyes closed. The television was playing. At 10:14 A.M., Resident #12 was sitting on the side of the bed. Although the television was playing Resident #12 was not paying attention to it. At 10:52 A.M., Resident #12 ambulated to the room directly across from his and in less than ten seconds ambulated back to his room. At 2:08 P.M. Resident #12 was observed lying in bed with his eyes closed. At 2:55 P.M., Resident #12 again ambulated to the room across the hall but did not stay. Observations on 09/16/24 at 8:07 A.M. revealed Resident #12 was sitting in a stationary chair in his room feeding himself. Resident #12 was exhibiting no interest in the television which was playing. At 8:36 A.M., Resident #12 carried clothing to the doorway and placed them on the floor in the hall. Resident #12 looked toward the room across the hall where the resident was in bed. At 8:54 A.M., Resident #12 ambulated to the room across the hall where he spoke with a resident who was still in bed and conversed briefly before returning to his room. At 11:15 A.M., Resident #12 ambulated to the room across from his, sat on the resident's bed and asked if she needed anything. Resident #12 then stated he was going back to his room. At 11:22 A.M. Resident #12 was lying in his bed with his eyes closed. At 12:10 P.M., Resident #12 ambulated back to the room across the hall. At 12:12 P.M., Resident #12 ambulated back to his room. At 12:127 P.M., Resident #12 was sitting in his room alone eating. At 1:34 P.M., 11 residents were observed in the main activity area playing bingo. At 1:50 P.M., Resident #12 ambulated to the room across the hall and asked if the resident had a good nap. At 1:52 P.M. Resident #12 ambulated back to his room and laid in bed. During an interview on 09/16/24 at 1:37 P.M., State tested Nursing Assistant (STNA) #155 stated she worked the secure unit three to four days a week. The Activity Director had been off work for about three weeks but was uncertain of her last day worked. STNA #155 stated other staff tried to pitch in and do activities. The Activity Director used to have some activities on the secure unit or would offer to take residents from the secure unit to activities off the unit. STNA #155 stated there was no separate activity calendar for residents on the secure dementia unit. STNA #155 reported she was uncertain if residents were being offered activities off the unit and indicated she had not seen staff offering to take residents to bingo which was occurring at the time but stated maybe she was off the unit when offered. (There was only one aide scheduled for the unit and one nurse who went between the secure unit and another hall.) Resident #12 would participate in porch time. The facility used to have church services on the secure unit but the services had not been offered for a while. STNA #155 stated there were coloring papers residents could do. STNA #155 stated Resident #12 had refused activity participation in the past. During an interview on 09/16/24 at 1:57 P.M., Licensed Practical Nurse (LPN) #151 stated she worked part time and worked various units. LPN #151 stated many of the residents on the secure unit had coloring supplies and some would do math worksheets. LPN #151 had not witnessed anybody offer to take residents to bingo that afternoon. During an interview on 09/16/24 at 3:26 P.M. the Administrator stated the Activity Director had been out on Family Medical Leave (FMLA) with her last day worked 08/19/24. It was anticipated the activity director would be off work for a full 12 weeks. The Administrator indicated Recreational Therapist #200 was helping to cover duties of the activity director remotely. Recreational Therapist #200 assisted with developing calendars and training staff. The Administrator stated there were no specific activities held on the secure unit such as lavender scents, calming music, and therapeutic stuffed animals. The DON indicated Resident #12 had resided on the non-secured unit but he was exit seeking. Observations were shared regarding lack of activities offered to residents on the secure unit. During an interview on 09/17/24 at 10:01 A.M., Recreational Therapist #200 stated she had been providing off-site assistance with the facility's activity program. Recreational Therapist #200 assisted in creating calendars, helped with care plans and monitor to ensure staff were keeping up with assessments and progress notes. Recreational Therapist #200 stated she would inform staff what needed done and then would review the information. A resident's had assessments to determine preferences when they were admitted . Recreational Therapist #200 stated she had spoken to the facility's Activity Director who was on leave to determine what kind of activities she had been offering and conversed with the Administrator for input on activities to place on the calendar. The activity calendars were discussed with two to three activities scheduled per day. Recreational Therapist #200 stated sometimes she leaves the listed activity vague and will schedule an activity of choice in which residents who show up determine what they would like to do or will schedule cards and the residents choose which game they want to play at the beginning of the activity. Recreational Therapist #200 stated two activities were scheduled most days because she was told residents liked one activity in the morning and one in the afternoon. Some days volunteers would provide additional activities. Recreational Therapist #200 verified there was only one activity calendar for the entire facility as residents did not necessarily need lower function activities for dementia residents. Staff just provide additional assistance. The observations on 09/15/24 and 09/16/24 on the secure unit were discussed. Recreational Therapist #200 stated because she was not on-site all she could do was review and help plan activities. Review of the activity director job description revealed the activity director was responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program designed to meet the social, psychosocial and therapeutic needs of the resident. This included the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that were individualized to match the skills, abilities and interests/preferences of each resident in compliance with Federal and State regulations. 3. Review of Resident #27's medical record revealed diagnoses including dementia with behavioral disturbance, hypertension, heart disease, anxiety disorder, restlessness and agitation. An activities interest data collection tool dated 01/19/24 indicated Resident #27 preferred to spend his time alone. Activity participation preference was independent. Naps were part of the resident's daily activity routine. Interests included fishing, hunting, baseball, basketball, football, entertainment, listening to music, singing, television, movies, checkers, books, news, magazines, reminiscing, exercise, talking/conversing, live music/entertainment, socials, holiday parties, worship services, and animals/pets. A care plan initiated 06/14/24 indicated Resident #27 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included ensuring the activities Resident #27 attended were compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate. Interventions also included establishing and recording Resident #27's prior level of activity involvement and interests by talking with residents, caregivers, and family on admission and as necessary, introducing Resident #27 to residents with similar backgrounds, interests and encouraging/facilitating interaction. The care plan instructed staff to invite, encourage and assist Resident #27 to group activities of potential interests. Supplies were to be provided for individual activity participation as needed. An annual MDS dated [DATE] indicated Resident #27 had moderate difficulty hearing, was usually able to make himself understood and was sometimes able to understand others. Cognitive skills were not assessed. The MDS indicated Resident #27 had delusions and had behavioral symptoms directed toward others one to three days. The MDS indicated it was somewhat important for Resident #27 to listen to music he liked, be around animals such as pets, keep up with the news, and go outside for fresh air. Observation on 09/15/24 at 9:44 A.M., 10:19 A.M., 11:29 A.M., 11:55 A.M., 2:06 P.M. and 2:58 P.M. revealed Resident #27 lying in bed with his eyes closed. Other than medication administration and meals, no interaction was observed. Observations on 09/16/24 at 8:07 A.M., 11:10 A.M., and 12:29 P.M. revealed Resident #27 was lying in bed with no evidence of activities being offered/provided. At 1:54 P.M., Resident #27 was semi-sitting on the side of the bed. No involvement or offering of activities was observed. Items available in the dining area of the secure unit were notebooks with coloring pages, puzzles, word searches, Bibles, a ball, a bowling set without a bowling ball, and a television. No residents were observed utilizing the items. An activity calendar posted outside the secured unit indicated bingo and popcorn was scheduled at 2:00 P.M. in the main activity room. Observations on 09/16/24 at 1:34 P.M. revealed bingo was already occurring. No residents from the secure unit were observed. During an interview on 09/16/24 at 1:37 P.M., State tested Nursing Assistant (STNA) #155 indicated she had not personally observed staff offering to take residents from the secure unit to play bingo. During an interview on 09/16/24 at 1:57 P.M., Licensed Practical Nurse (LPN) #151 indicated she had not personally observed staff offering to take residents from the secure unit to play bingo. 4. During an interview on 08/16/24 at 10:00 A.M., Resident #32's representative stated the facility's activity director had broken her leg about a month before the survey and there had not been many activities since. Review of Resident #32's medical record revealed diagnoses including epilepsy, dysphagia, depression, delirium, dementia, and mood disorder. An activities interest data collection tool dated 05/14/24 indicated Resident #32 preferred to spend time alone. His activity participation preference was independent. Naps were part of Resident #32's daily activity routine. Community activities included baseball, basketball, and football. creative activities included crafts, listening to music, television, and movies. Educational /cognitive interests included checkers, news. mystery, and western books- needed large print. Social activities included talking/conversing, live music/entertainment, holiday parties, Bible study, and clergy visits. Resident #32 was also interested in animals/pets and traveling. An Admission MDS dated [DATE] indicated Resident #32 was sometimes able to make himself understood and sometimes understood others. Resident #32 was assessed as severely cognitively impaired with delusions. Resident #32 had exhibited physical and verbal behavioral symptoms directed toward others 1-3 days and other behavioral symptoms not directed towards others 1-3 days. The behaviors significantly interfered with Resident #32's care and significantly disrupted care or living environment of others. The MDS indicated the behaviors did not interfere with participation in activities or social interactions. Resident #32 had inattention and disorganized thinking which fluctuated. Resident #32 provided information for the activity portion of the MDS and reported it was very important for him to have reading material, listen to music he liked, and be around animals such as pets. It was somewhat important to keep up with news, do things with groups of people, do favorite activities, go outside and get fresh air when weather was good, and participate in religious services or practices. Observations on 09/15/24 at 9:40 A.M. revealed Resident #32 was propelling himself in the wheelchair in the halls of the secure unit. Licensed Practical Nurse (LPN) #113 redirected Resident #32 back toward the middle of the hall. At 10:10 A.M., Resident #32 was sitting in a wheelchair by the nursing station. LPN #113 encouraged Resident #32 to stay near her. At 11:58 A.M., Resident #32 was sitting in the wheelchair by the nursing station to eat lunch. At 2:05 P.M., Resident #32 was sitting in the wheelchair by the nursing station. Resident #32 was alert but forgetful, unable to state staff names telling them he did not know them. At 3:00 P.M. Resident #32 was sitting in the wheelchair by the nursing station. Other than eating, the only activity Resident #32 was involved with during the observations was watching people pass and responding when spoken to. Observations on 09/16/24 at 11:12 A.M. revealed Resident #32 was lying in bed. Resident #32 appeared to be restless with his legs moving around. The television was playing. The left side of Resident #32's bed was placed against the wall. The door to the room (from the hall) was open blocking Resident #32 from seeing the television. At 11:45 A.M., Resident #32 was propelled from his room and placed by the nursing station. Fluids were provided. At 1:53 P.M., Resident #32 remained by the nursing station with his only activity being watching staff. On 09/16/24 at 1:37 P.M., STNA #155 verified when the door was open Resident #32 was unable to see the television while he lay in bed. Observations on 09/17/24 at 8:40 A.M., Resident #32 was observed sitting in the dining area of the secure unit. The television on. Resident #32 exhibited no interest in watching the program but was watching other residents in the dining room. At 11:28 A.M., Resident #32 was sitting in the wheelchair in the hall by the nursing station. As Resident #32 started to move his wheelchair, STNA #155 stated Resident #32 needed to stay by her and he could not follow another resident into her room. There were no signs of stimulation or activity provided. Resident #32 stayed in the hall. At 11:40 A.M., STNA #155 propelled Resident #32 into the dining area where the television was playing. Resident #32 exhibited no interest in the program but started focusing on the exit door pushing on the bar to exit. STNA #155 had walked up the hall and started delivering trays. When Resident #32 would start toward or push on the door STNA #155 would call Resident #32's name or state no and he would move away from the door. No activities were offered to distract the behavior. At 12:00 P.M., after Resident #32's tray was delivered he sat at the table and ate feeding himself. At 2:15 P.M., Resident #32 sat in the wheelchair by the nursing station. Resident #32 was alert with no signs of an activity being offered. 44808 5. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including traumatic brain injury, age-related physical debility, intracranial injury with loss of consciousness, post traumatic stress disorder, depression, and anxiety. Review of the activities interest data collection tool, dated 01/19/24, revealed Resident #22 interests included rides, children/youth, baseball, basketball, football, entertainment, restaurants, library, crafts, poetry, listening to music, singing, garden club, television, movies, cooking/baking, word games, trivia, books, news, discussions, reminisce, exercise, humor, conversing, live music/entertainment, socials, holiday parties, worship services, animals/pets, and traveling. Review of the progress note, dated 08/29/24 at 2:32 P.M., revealed Resident #22 enjoyed both independent and group activities, including arts and crafts, cards, games, television, resident council, and special events. The note further indicated Resident #22 was dependent on staff for wheelchair mobility and activities staff would continue to encourage participation. Review of the activities care plan, revised 09/03/24, revealed Resident #22 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitations. Interventions included encourage ongoing family involvement, invite resident to attend monthly resident council meetings, invite resident to scheduled activities, provided one-on-one bedside and in-room visits when unable to attend out of room activities, preference for rock and classical music radio stations, preference for animal planet and nickelodeon television viewing, provide with supplies for individual activity participation as needed, escort to activity functions, and preference for watching television and visiting with peers when not participating in an activity. Review of the activities calendar for August 2024 revealed there was no documentation of participation or refusals for arts and crafts, beauty shop, cards, coffee talk, current events/morning news, exercise/sports, games, gardening/outside/patio, independent phone/computer, movie, nail care, people watching, puzzles, word puzzles, radio, music listening, reading, relaxation, reminiscing, rolling/walking, sensory stimulation, resident council, social/party/special events, trivia, mail, music and memory program, outings, pet visits, and one-on-one visits. Resident #22 participated in family visits daily, participated in peer socialization for 20 out of 31 days, participated in television viewing for 24 out of 31 days, refused bingo four times and was sleeping at the time of bingo four additional times, and Resident #22 was sleeping for all three religious activities documented. Review of the activities calendar for September 2024 revealed there was no documentation of participation or refusals for arts and crafts, beauty shop, cards, coffee talk, current events/morning news, exercise/sports, gardening/outside/patio, independent phone/computer, movie, nail care, people watching, puzzles, word puzzles, radio, music listening, reading, relaxation, reminiscing, rolling/walking, sensory stimulation, resident council, social/party/special events, trivia, mail, music and memory program, outings, and one-on-one visits. Resident #22 participated in family visits daily, participated in peer socialization for 15 out of 17 documented days, participated in television viewing for 15 out of 17 documented days, participated in one pet visit, participated in one game, refused bingo one time and was sleeping at the time of bingo two additional times. On 09/15/24 and 09/16/24, random intermittent observations of Resident #22 revealed she was sitting in her wheelchair in the common area by the nurse's station with a tablet that was not turned on. Resident #22 was not observed participating in any scheduled activities. On 09/16/24 at 12:35 P.M., an interview with the Administrator confirmed the activities documented on the activities logs for Resident #22. The Administrator stated there were additional activities records that the Activities Director had completed prior to being on emergency medical leave in August 2024. On 09/16/24 at 1:57 P.M., an interview with the Administrator stated she was unable to locate any additional documentation of activities for August 2024 for Resident #22.

Based on medical record review, policy review, and interview, the facility failed to ensure psychotropic medications were only administered when needed, failed to ensure approval for gradual dose reductions were addressed in a timely manner, and failed to ensure monitoring of target symptoms were documented. This affected three (Residents #10, #21 and #27) of five residents whose records were reviewed for medication use. Findings include: 1. Review of Resident #10's medical record revealed diagnoses including schizoaffective disorder (bipolar type), affective mood disorder, mild cognitive impairment, anxiety disorder, dementia with mood disorder, and depression. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was usually able to make herself understood and was usually able to understand others. The memory/cognitive skills were not assessed. The MDS indicated Resident #10 had exhibited behavioral symptoms not directed toward others one to three days. The behaviors pur Resident #10 at significant risk for physical illness or injury, significantly interfered with Resident #10's care, and put others at significant risk of injury. The MDS indicated this was a worsening of behaviors. The MDS indicated Resident #10 received antipsychotics on a routine basis only and had no gradual dose reductions (GDR) attempted. Resident #10 also received anti-anxiety medications. a. Review of physician orders revealed an order for trazodone 25 milligrams (mg) every night at bedtime. Review of a medication regimen review (MRR) dated 01/09/24 indicated Resident #10 had been receiving hypnotic therapy with trazodone 25 milligrams (mg) every night at bedtime for some time without a GDR. The pharmacist inquired if a reduction or discontinuation could be attempted. If no GDR was warranted, the pharmacist requested documentation be added to the medical record as to why a reduction might be detrimental to the resident's mental or physical health. A response by a certified nurse practitioner (CNP) dated 01/30/24 revealed it was okay for a GDR. However, there was no order on how to proceed with the gradual dose reduction No change in orders were found. Review of a MRR dated 04/08/24 revealed the pharmacist addressed the ongoing use of trazodone without a GDR. The pharmacist asked if an attempt could be made to reduce the trazodone to 25 mg every other night or if there could be a note made regarding why a reduction was contraindicated. On 04/16/24 the trazodone was increased to 50 mg every night at bedtime. Review of the response dated 04/27/24 revealed an order was given to discontinue the trazodone. On 09/23/24 at 11:15 A.M., the response from 01/30/24 as well as the lack of an order was addressed with the Administrator and Director of Nursing (DON). The Administrator and DON were informed no documentation was located indicating staff attempted to call the physician or CNP to clarify the response that a GDR was approved. On 09/23/24 at 11:37 A.M., the Administrator verified there was no evidence of a GDR of trazodone being attempted on 01/30/24 after the CNP review of the MRR conducted 01/09/24. The Administrator stated the CNP visited Resident #10 on 01/10/24 (prior to the response) and had made no changes to the trazodone dosage. The Administrator stated the DON indicated she was trying to get a clarification order for the approval for a GDR but verified there was documentation of any attempts to clarify the response. Between 11:37 A.M. and 5:30 P.M., the Administrator provided a psychiatry note dated 01/16/24 which indicated an evaluation of psychotropic medications with no GDR recommended. The Administrator verified this occurred before the 01/30/24 response to the MRR which indicated an agreement to a GDR of the trazodone. The Administrator then provided a psychiatry note dated 02/26/24 which indicated a reduction in the trazodone was contraindicated. The Administrator verified there had been a gap in the time the response for reduction was received on 01/30/24 and 02/26/24 in which Resident #10 continued to receive the trazodone. b. Review of physician orders revealed between 08/30/24 and 09/07/24, Resident #10 had an order for ativan (anti-anxiety) 1 mg every four hours as necessary. Between 09/07/24, Resident #10 had an order for ativan 1 mg every two hours as necessary. Review of the September 2024 Medication Administration Record (MAR) revealed the ativan ordered on an as necessary basis was administered 25 times. There was no evidence of non-pharmacological interventions being attempted prior to its administration 12 of the 25 times administered. On 09/30/24 at 10:45 A.M., the Administrator verified there was inconsistent documentation of non-pharmacological interventions being attempted prior to the use of the ativan ordered on an as necessary basis. 2. Review of Resident #27's medical record revealed diagnoses including dementia with behavioral disturbance, heart disease, anxiety disorder, restlessness and agitation. An annual MDS dated [DATE] indicated Resident #27 was usually able to make himself understood and was sometimes able to understand others. Cognitive skills were not assessed. The MDS indicated Resident #27 had delusions and had verbal behavioral symptoms directed toward others 1-3 days. A care plan initiated 09/25/23 indicated Resident #27 used psychotropic medications related to dementia with psychosis. Interventions included monitoring and recording the occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression toward staff/other etc and document per facility policy. A care plan initiated 08/01/24 indicated Resident #27 was receiving anti-anxiety medications related to anxiety disorder. Interventions included monitoring and recording the occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression toward staff/other etc and document per facility policy. Review of physician orders included: 08/15/24-08/27/24 seroquel (anti-psychotic) 25 mg twice a day 08/27/24 - increase seroquel to 50 mg twice a day 08/12/24 ativan 0.5 mg every six hours as necessary for restlessness, anxiety or agitation Review of the September 2024 MAR revealed 24 doses of the ativan ordered on an as necessary basis had been administered. Comparison of the September 2024 MAR and progress notes revealed ativan ordered on an as necessary basis was administered the following dates/times without documentation of non-pharmacological interventions being attempted prior to administration: 09/01/24 at 8:24 P.M., 09/02/24 at 7:37 P.M., 09/03/24 at 7:48 P.M., 09/07/24 at 9:00 P.M., 09/16/24 at 7:34 A.M., and 09/17/24 at 10:38 A.M. On 09/18/24 at 10:00 A.M., the Director of Nursing (DON) verified there was inconsistent documentation of non-pharmacological interventions being attempted prior to the use of the ativan ordered on an as necessary basis. The DON also verified there was no documentation regarding monitoring for the antipsychotic use in regard to target symptoms or how often they were identified unless they were in the progress notes. Review of the facility's Use of Psychotropic Medication policy (implementation date unknown) revealed the indications for use of any psychotropic drug would be documented in the medical record. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial and environmental causes had been identified and addressed. Non-pharmacological interventions that had been attempted and the target symptoms for monitoring shall be included in the documentation. Residents who used psychotropic drugs shall received gradual dose reductions unless clinically contraindicated, in an effort to discontinue the drugs. Residents who used psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the drugs. 47569 3. A review of the medical record for Resident #24 revealed admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, high blood pressure, major depressive disorder, and history of falling. Resident #24 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment and is dependent on staff for assistance with transfers, bed mobility and activities of daily living (ADL) task completion. A review of the physician orders for Resident #24 revealed an order dated 04/30/24 for medication Depakote extended release (ER) oral tablet 250 milligrams (MG) give one tablet two times a day related to mood disorder due to known physiological condition, an order dated 08/14/23 for antianxiety medication Buspirone oral tablet 15 mg give one tablet by mouth two times a day for anxiety, an order dated 08/19/23 for antidepressant medication Zoloft oral tablet 100 mg give one tablet by mouth in the morning for depression, and an order dated 09/18/24 for antianxiety medication lorazepam 0.5 mg give one tablet by mouth every 12 hours as needed for anxiety for 14 days. A review of Resident #24's medication administration record (MAR) dated 09/01/24 to 09/19/24 revealed the medications Depakote, Buspirone, and Zoloft had been administered per orders. The medication lorazepam had not been administered as needed for anxiety. Further review revealed there was no documentation on Resident #24's behaviors marked or monitored and there was no documentation on any non-pharmacological interventions implemented for Resident #24 behaviors. A review of the care plan for Resident #24 revealed the anxiety disorder care plan dated 08/16/24 with interventions including to monitor for effectiveness, the depression disorder care plan dated 08/16/24 with interventions including to monitor for effectiveness. A review of Resident #24's Point of Care (POC) tasks section for dated 08/19/24 to 09/19/24 revealed there were no entries or documentation implemented for daily monitoring Resident #24's behaviors. An interview on 09/18/24 at 9:50 A.M. with State tested Nursing Assistant (STNA) #119 revealed resident behaviors are sometimes documented in POC tasks, if the resident does not have a task for documenting behaviors, then the nurse is notified of any type of behavior which is documented in the progress notes by the nurse. An interview on 09/18/24 at 10:03 A.M. with the Director of Nursing (DON) confirmed the was no documentation of non-pharmacological interventions or any type of daily documentation of behaviors for Resident #24. 4. A review of the medical record for Resident #21 revealed admitted [DATE] with diagnoses including vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease, high blood pressure, restlessness, and agitation. Resident #21 had impaired cognition and required limited to moderate assistance from staff to complete Activities of Daily Living (ADL) tasks. Resident #21 was receiving hospice services for end stage chronic kidney disease. A review of the physician orders for Resident #21 revealed an order dated 07/17/24 for anti-anxiety medication Ativan 0.5 milligram oral tablet give one tablet by mouth every four hours as needed for anxiety or agitation for six months, an order dated 08/15/24 for anti-anxiety medication Ativan 0.5 mg oral tablet give one tablet by mouth in the morning for anxiety, agitation or restlessness and give one tablet by mouth in the evening for anxiety, and order dated 08/16/24 for antipsychotic medication Seroquel 25 mg oral tablet give 0.5 tablet (12.5 mg) by mouth in the afternoon related to vascular dementia with agitation, and an order dated 08/15/24 for antipsychotic medication Seroquel 25 mg oral tablet give 0.5 tablet (12.5 mg) by mouth two times a day related to vascular dementia with agitation. A review of Resident #21's Medication Administration Record (MAR) dated 08/01/24 to 08/31/24 revealed the medications Seroquel and Ativan had been administered per physician orders. The anti-anxiety medication Ativan had been given as needed on 08/09/24, 08/13/24, 08/14/24, 08/16/24, 08/19/24, 08/20/24, 08/22/24, 08/25/24, 08/26/24, 08/27/24, 08/28/24, 08/30/24, and 08/31/24 for anxiety and restlessness. Further review of Resident #21's MAR revealed there were no entries or documentation reflecting Resident #21's behaviors or non-pharmacological interventions attempted prior to the administration of the anti-anxiety medication Ativan as needed. A review of Resident #21's Treatment Administration Record (TAR) dated 08/01/24 to 08/31/24 revealed there were no entries or documentation reflecting Resident #21's behaviors or non-pharmacological interventions attempted by staff. A review of Resident #21's behavioral care plan dated 06/17/24 revealed Resident #21 will refuse to eat. Resident #21's psychotic medication care plan dated 07/30/24 revealed intervention including to monitor/record occurrence of the target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Resident #21's anti-anxiety medication care plan dated 06/17/24 revealed intervention including to monitor/record occurrence of the target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. A review of Resident #21's Point of Care (POC) task documentation listing dated 09/19/24 revealed there were no tasks implemented for staff to document Resident #21's behaviors daily. An interview on 09/18/24 at 9:50 A.M. with State tested Nursing Assistant (STNA) #119 revealed resident behaviors are sometimes documented in POC tasks, if the resident does not have a task for documenting behaviors, then the nurse is notified of any type of behavior which is documented in the progress notes by the nurse. An interview on 09/18/24 at 10:03 A.M. with the Director of Nursing (DON) confirmed the was no documentation of non-pharmacological interventions or any type of daily documentation of behaviors for Resident #21. A review of the facility's policy titled, Use of Psychotropic Medication dated 02/23 revealed, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication.

Based on observation, interview and review of the facility policy, the facility failed to ensure call lights were in place in three restrooms that were available for resident's use. This had the potential to affect seven residents, Resident #2, #3, #6, #15, #19, #28, and #30 who were identified by the facility as independent with mobility and transfers. The facility census was 36. Findings include: Observation on 09/15/24 at 9:11 A.M. revealed two restrooms located near the middle of the extended hall open to residents with a vending machine for Resident use at the end of the hall. A third restroom was located on the [NAME] residential hall. All three restrooms were identified as male or female restrooms and was wheelchair accessible, no further information was posted on the doors. Multiple observations from 09/15/24 through 09/19/24 revealed all three restrooms were unlocked at all times except when in use and none had a call system in place. Observation and interview on 09/19/24 at 8:32 A.M. with Maintenance Director #116 verified all three restrooms were kept unlocked at all times except when in use. None of the three restrooms were identified by who could use them other than male/female and they were identified as wheelchair accessible. Maintenance Director #116 confirmed all three restrooms locked from the inside. Maintenance Director #116 confirmed there was no call system in place in any of the three restrooms and residents had easy access to enter and use the restrooms. Review of the facility policy titled, Call Lights: Accessibility and Timely Response undated, revealed the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistants. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on medical record review and interview, the facility failed to ensure a resident's code status was consistent amongst documents. This affected one (Resident #21) of 16 residents reviewed for advanced directives. Findings include: Review of Resident #21's medical record revealed diagnoses including vascular dementia, basal cell carcinoma of the skin, chronic kidney disease, hypertension, cerebrovascular disease and anxiety disorder. Review of a signed Do Not Resuscitate (DNR) form dated 10/06/23 revealed the option of Do Not Resuscitate Comfort Care (DNRCC) was chosen and was effective immediately. Review of Resident #21's electronic health record revealed a heading with a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-A) (allows for the use of life-saving measures before cardiac or respiratory arrest, but only comfort care after). Review of the facility's report sheet revealed code status was indicated on the report sheets. Resident #21's code status was listed as DNRCC-A. Review of Resident #21's physician orders revealed an order dated 01/18/24 for a DNRCC-A code status. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 was sometimes able to make himself and was sometimes able to understand others. Resident #21 was assessed as moderately cognitively impaired. The MDS indicated Resident #21 was receiving hospice services. On 09/18/24 at 8:25 A.M., the Administrator verified there was a discrepancy between the order entered into the electronic health record and the actual DNR form. Review of a nursing note dated 09/18/24 at 8:54 A.M. revealed the code status of DNRCC was confirmed. Orders and the care plan were updated.

Based on medical record review and interview, the facility failed to ensure residents and their representatives were provided a summary of the baseline care plan. This affected one (Resident #32) of four residents reviewed for baseline care plans. Findings include: Review of Resident #32's medical record revealed diagnoses including epilepsy, depression, delirium, dementia, and mood disorder. Resident #32 was admitted to the facility 05/10/24. No baseline care plan was located. On 09/18/24 at 11:48 A.M., the Administrator verified she was unable to find a baseline care plan or evidence a summary of a baseline care plan was provided to the resident/representative. The Administrator stated she would have the Director of Nursing search to determine if there was one located elsewhere. On 09/18/24 at 1:26 P.M., the Administrator provided Resident #32's baseline care plan but no evidence a summary was provided to Resident #32 and his representative.

Based on observation, interview and record review, the facility failed to ensure individualized care plans were developed for two (Residents #1 and #6) of 14 residents reviewed for comprehensive care plans. The facility census was 36. Findings include: Record review for Resident #1 revealed an admitted [DATE]. Diagnosis included pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Resident #1 required set up or clean up assistants with meals. Review of the physician orders for Resident #1 revealed an order dated 05/21/24 for Heart Healthy diet, pureed texture, nectar consistency, Resident may request thin water 30 minutes after oral (PO) intake. No thin water with PO intake for aspiration precaution. Review of the care plan updated 04/09/24 revealed Resident #1 was at nutritional risk. Interventions included to provide the diet as ordered. The care plan did not include nectar thickened liquids or instruction about thin liquids. Review of the Nutritional Risk assessment dated [DATE] at 12:15 A.M. completed by Dietitian #164 revealed Resident #1 received a mechanically altered diet with thickened liquids related to difficulty swallowing, coughing with meals. Remains on Nectar-thick liquids. Interview on 09/17/24 at 11:00 A.M. with Regional Clinical Director #161 confirmed Resident #1's care plan did not include nectar thickened liquids with additional direction to include may request thin water 30 minutes after PO intake. No thin water with PO intake for aspiration precaution. 44808 2. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including adjustment disorder with depressed mood, dementia with anxiety, major depressive disorder, type two diabetes mellitus, and hypertension. Review of the diabetes care plan, last revised 11/16/22, revealed Resident #6 had diabetes mellitus and an intervention to stop smoking was initiated on 11/16/22. Review of the admission Minimum Data Set (MDS) Assessment, dated 11/18/22, indicated Resident #6 was not a tobacco user. Review of the annual MDS Assessment, dated 11/07/23, indicated Resident #6 was not a tobacco user. Resident #6's comprehensive care plan was reviewed on 12/01/22, 03/31/23, 06/09/23, 09/15/23, 01/31/24, 05/03/24, and 08/09/24 and the intervention to stop smoking remained on the care plan. On 09/15/24 at 4:55 P.M., an interview with the Administrator confirmed Resident #6's diabetes care plan included an intervention to stop smoking. The Administrator stated that to her knowledge, Resident #6 had never been a smoker.

Based on record review and interview, the facility failed ensure care plan revision for one resident, Resident #34 to reflect current functional abilities and weight bearing status. This affected one resident (Resident #34) of three residents reviewed for care plan revision. The facility census was 36. Findings include: Record review for Resident #34 revealed an admitted [DATE]. Diagnosis include fracture of the right femur, fracture of the shaft of the right tibia, fracture of shaft of right fibula, presence of right artificial wrist joint, displaced fracture of the shaft of first metacarpal bone, left hand. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 had impairment on both sides, upper and lower extremities. The resident used a wheelchair for mobility, was dependent for all activities of daily living (ADL) including eating, toileting, upper and lower body dressing, personal hygiene, sit to lying, lying to sit, and showers. Sit to stand and transfer was not attempted due to Resident #34's medical condition. Review of the physician orders for Resident #34 dated 07/25/24 revealed an order for non-weight bearing to all extremities due to fractures. Review of the order dated 09/03/24 reveled non-weight bearing to right lower extremity, weight bearing as tolerated to right upper extremity and left upper extremity, and weight bearing as tolerated to the left lower extremity with knee immobilizer. Review of the order dated 09/10/24 revealed a hoyer lift with two assists (for transfers). Review of the care plan dated 08/16/24 for Resident #34 revealed a functional abilities impaired/self-care and mobility deficit. Interventions included non-weight bearing to all extremities as ordered due to fractures. Review of the care plan revealed no revisions to reflect Resident #34's weight bearing status or assistance needed with care. Observation on 09/17/24 at 2:34 P.M. revealed Resident #34 was sitting up in his wheelchair, Resident #34 was propelling himself in the chair, grooming himself with use of both upper extremities. Interview on 09/17/24 at 2:38 P.M. with State tested Nursing Assistant (STNA) #107 revealed Resident #34 was able to feed himself with set up, washed his upper body independently and self-transferred at times even though he shouldn't. Interview on 09/17/24 at 3:40 P.M. with the Administrator confirmed Resident #34's care plan for functional abilities was not revised to reflect his current weight bearing and transfer status.

Based on observations, medical record review, and interview, the facility failed to implement fall interventions per resident care plans for one (Resident #12) of three residents reviewed for accidents. The facility also failed to ensure one resident, Resident #1 received thickened liquids as ordered. This affected one resident, Resident #1, of three residents reviewed for nutrition. The facility census was 36. Findings include: 1. Review of Resident #12's medical record revealed diagnoses including atherosclerotic heart disease, hypertension, history of falling, depression, visual loss in both eyes, mild dementia, generalized muscle weakness and abnormalities of gait and mobility. Review of a care plan initiated 08/05/24 revealed Resident #12 was at risk for falls related to confusion and lack of awareness of safety needs. An intervention was initiated for a fall mat to the exit side of the bed and to verify placement. On 08/23/24 an order was written for a fall mat to the exit side of bed and to verify placement every shift. A fall risk assessment dated [DATE] revealed Resident #12 remained at risk for falls. Risk factors identified included a history of falls in the prior 90 days, behaviors, need for assistance with elimination, use of devices for ambulation, co-morbidities and medication use. Observations on 09/15/24 at 10:14 A.M. and 2:08 P.M. and on 09/16/24 at 11:22 A.M. revealed Resident #12 was lying in a low bed. No mat was observed on either side of the bed. On 09/16/24 at 12:27 P.M., Resident #12 was able to identify other fall interventions but stated he did not use mats on the floor. On 09/16/24 at 1:52 P.M., Resident #12 was lying in bed without fall mats in place. On 09/16/24 at 12:35 P.M., State tested Nursing Assistant (STNA) #155 verified there was no fall mat in Resident #12's room. STNA #155 stated she was unaware there was an order for a fall mat. STNA #155 stated aides used report sheets to inform them of care and special instructions for residents' care. Review of the report sheet with STNA #155 revealed there was no instructions to use a fall mat for Resident #12. 2. Record review for Resident #1 revealed an admitted [DATE]. Diagnosis included pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Resident #1 required set up or clean up assistants with meals. Review of the care plan updated 04/09/24 revealed Resident #1 was at nutritional risk. Interventions included to provide the diet as ordered. Review of the physician orders for Resident #1 revealed an order dated 05/21/24 for Heart Healthy diet, pureed texture, nectar consistency, Resident may request thin water 30 minutes after PO intake. No thin water with PO intake for aspiration precaution. Review of the Nutritional Risk assessment dated [DATE] at 12:15 A.M. completed by Dietitian #164 revealed Resident #1 received a mechanically altered diet with thickened liquids related to difficulty swallowing, coughing with meals. Remains on Nectar-thick liquids. Observation on 09/18/24 at 11:49 A.M. revealed Resident #1 was in the dining room for the lunch meal. Observation revealed State tested Nursing Assistant (STNA) #136 was passing the residents their drinks while in the dining room. STNA #136 asked Resident #1 what she would like to drink, juice or chocolate milk. Interview on 09/18/24 at 11:51 A.M. with STNA #136 revealed Resident #1 could have any fluids she wanted to drink; she was not on thickened liquids. Interview on 09/18/24 at 1:00 P.M. with Resident #1 revealed she use to get thickened liquids, but she didn't like it, she had not received thickened liquids for long time. Resident #1 had a glass of ice water next to her on her bedside table. Interview on 09/18/24 at 1:10 P.M. with STNA #144 confirmed she refilled Resident #1's ice water cup while Resident #1 was in the dining room. STNA #144 revealed Resident #1 did not receive thickened liquids. LPN #137, who was nearby and overheard the conversation, confirmed Resident #1 was to receive nectar thickened liquids. Interview on 09/18/24 at 2:00 P.M. with STNA #124 revealed she frequently cared for Resident #1 and Resident #1 received thin liquids including with her meals. STNA #124 revealed it was not in her task (electronic medical record for STNA's) that Resident #1 was to have any thickened liquids. Review of the task record confirmed Resident #1 did not have thickened liquids documented in the task record. Interview on 09/18/24 at 2:04 P.M. with STNA #136 revealed Resident #1 was on thickened liquids for one day only 06/25/24 through 06/26/24. STNA #136 revealed the order hasn't been changed so we give her regular liquids, she can have regular liquids, the diet card she gets with her meals hasn't been updated, it says nectar thick liquids, but she can have regular. Observation on 09/23/23 at 8:55 A.M. revealed Resident #1 was sitting up in bed eating her breakfast. Resident #1 had a partially filled glass of water on her breakfast tray. The water was not thickened. Interview on 09/23/24 at 8:56 A.M. with STNA #119 confirmed Resident #1's water was not thickened. This deficiency represents non-compliance investigated under Complaint Number OH00157039.

Based on medical record review, review of pharmacy recommendations, policy review and interview, the facility failed to ensure all pharmacy recommendations were addressed by physicians. This affected one (Resident #27) of five residents reviewed for medication use. Findings include: Review of Resident #27's medical record revealed diagnoses including dementia with behavioral disturbance, hypertension, hyperlipidemia, heart disease, presence of coronary angioplasty implant and graft, anemia, anxiety disorder, restlessness and agitation. Review of a medication regimen review dated 09/22/23 revealed Resident #27 was receiving two antipsychotic medications, olanzapine and risperidone. The pharmacist asked for a diagnosis to support use. The pharmacist also indicated the medical record indicated the olanzapine and risperidone were used for psychosis and asked if the physician would consider discontinuing one of the medications to avoid duplicative therapy. The response dated 09/29/23 had a notation to change the diagnosis to dementia. The request regarding considering discontinuing one of the medications was not addressed. Although the response indicated the physician agreed, there was no order to discontinue either of the medications or why it would be contraindicated. Review of a medication regimen review dated 10/06/23 revealed Resident #27 had an order for olanzapine and risperidone to be administered on an as necessary basis. The pharmacist addressed Centers for Medicare and Medicaid regulations regarding use of antipsychotic medications being limited to 14 days. The pharmacist instructed, if continued treatment was needed, a prescriber must evaluate to determine if the continued use of the antipsychotic ordered on an as necessary basis was warranted. A new order could be issued after evaluation for a maximum of 14 days. The pharmacist also addressed, due to the use of antipsychotics olanzapine, risperidone and seroquel, Abnormal Involuntary Movements (AIMS) testing should be completed upon initiation of an antipsychotic medication and every six months thereafter. At the time of the review an AIMS test was not available in the electronic health record. The pharmacist suggested nursing complete an AIMS test at their earliest convenience. A response dated 10/29/24 simply indicated the physician agreed with the recommendation. During an interview on 09/18/24 at 9:35 A.M., the Director of Nursing (DON) verified the pharmacy reviews for September 2023 and October 2023 were not fully responded to. The DON stated once she received a physician response to the pharmacy recommendations she only looked at the response and did not review the recommendations to ensure they were being fully addressed. The DON stated she would research to determine if there were any further orders/documentation corresponding with the recommendations to reveal the recommendations were addressed. An additional interview on 09/18/24 at 10:00 A.M., with the DON verified she was unable to locate any additional information to indicate the pharmacy recommendations from September 2023 and October 2023 were addressed. Review of the facility's Medication Regimen Review policy (implementation date not documented) revealed facility staff were required to act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on observation, review of physician orders, policy review, and interview, the facility failed to ensure medications were administered in accordance with physician orders and policy. This affected two (Residents #15 and #138) of seven residents observed receiving medication. Two errors of 30 opportunities for error were identified resulting in a medication error rate of 6.6%. Findings include: 1. On 09/15/24 at 9:00 A.M., Registered Nurse (RN) #109 was observed administering medication to Resident #15. Among medication administered was colace (stool softener) 100 milligrams (mg). Review of Resident #15's physician orders revealed no order for colace 100 mg. There was an order dated 10/04/23 for two sennosides-docusate sodium 8.6-50 mg to be administered every morning for constipation that was not observed to be administered. On 09/15/24 at 12:40 P.M., RN #109 verified she had administered colace instead of sennosides-docusate as ordered. Review of the facility's Medication Administration policy (implementation date not recorded) revealed instructions to ensure the right drug was administered. 2. On 09/15/24 at 11:22 A.M., Licensed Practical Nurse (LPN) #113 was observed administering medication to #138. An insulin lispro 100 units per milliliter pen was used while preparing the drug. The insulin pen was undated as to when it was opened. LPN #113 verified this and continued to prepare the insulin for administration. LPN #113 prepared to administer the insulin after a needle was applied to the pen and she dialed the pen to two units. The pen was not primed. LPN #113 was stopped and stated she believed the pen automatically primed itself without further action needed on her part. Review of the facility's Insulin Pen policy (implementation date not documented) revealed a new needle would be used for each injection. Insulin pens were to be primed prior to each use to avoid collection of air in the insulin reservoir. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. Review of manufacturer information revealed insulin lispro kwik pens should be used within 28 days or discarded.

Based on medical record review, review of infection surveillance records, policy review and interview, the facility failed to address use of a prophylactic antibiotic for a resident with recent use of multiple antibiotics. This affected one (Resident #27) of five residents revealed for medication use. Findings include: Review of Resident #27's medical record revealed diagnoses including dementia with behavioral disturbance, benign prostatic hypertrophy (BPH), neuromuscular dysfunction of the bladder and heart disease. Review of physician orders since admission on 09/21/23 revealed the following orders for antibiotics: 02/16/24: cipro 500 milligrams (mg) twice a day for ten days for a urinary tract infection (UTI) 04/07/24: bactrim DS 800-160 mg every 12 hours for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms for seven days 04/10/24 nitrofurantoin 100 mg twice a day for seven days for infection in the urine 04/12/24 nitrofurantoin 100 mg twice a day for urinary tract infection for seven days 04/13/24: cipro 500 mg twice a day for 14 administrations for BPH with lower urinary tract symptoms 06/01/24 amoxicillin 875 mg twice daily for seven days for dental use 06/04/24: amoxicillin 875 mg twice a day for nine administrations for oral infection 06/12/24: amoxicillin-potassium clavulanate 875 875-125 mg twice a day for ten days for oral infection 06/15/24: macrobid 100 mg twice a day for seven days for cystitis 06/28/24: amoxicillin-potassium clavulanate 875-125 mg twice a day for ten days for dental/oral infection 07/29/24: cephalexin 500 mg twice for 14 administrations for UTI 09/13/24 cephalexin 500 mg three times a day for infection prevention until 09/28/24 09/15/24 cephalexin 500 mg three times a day for 13 days for infection prevention Review of infection surveillance records revealed a McGeer criteria for infection surveillance checklist dated 09/15/24 criteria was not met. On 09/18/24 at 12:15 P.M., the order for cephalexin for infection prevention for a laceration post fall, along with history of antibiotic use, and risk for multi-drug resistant organisms was discussed with the Director of Nursing (DON). The DON stated Resident #27 returned from the hospital with the order for the antibiotic to be given short term. The DON was asked about the facility's policy regarding use of prophylactic antibiotics for infection prevention and stated she would have to look for it. On 09/18/24 at 12:50 P.M. the DON provided a policy regarding Antibiotic Prescribing Practices (implementation date not listed) and stated it did not address the use of prophylactic antibiotics. The DON verified when she looked at McGeer Criteria for infection related to the cephalexin ordered prophylactically Resident #27 did not meet the criteria for infection. The DON indicated she had not addressed the use of the prophylactic antibiotic with the physician or nurse practitioner prior to the survey because it was ordered by a physician. Regardless of the risk for a multi-drug resistant organism, if a physician ordered the antibiotic she did not question its use. Review of the facility's Antibiotic Prescribing Practices policy (implementation date not recorded) indicated the decision to prescribe an antibiotic would be guided by medical knowledge, best practices and professional guidelines. Review of the Antibiotic Stewardship Program (implementation date not recorded) revealed the DON's role in antibiotic stewardship was to use their influence as nurse leaders to help ensure antibiotics were prescribed only when appropriate. Antibiotic orders obtained from consulting, specialty or emergency providers shall be reviewed for appropriateness.

Based on observation, medical record review, review of a facility investigation, facility fall policy review, facility assessment review and interviews, the facility failed to provide adequate supervision to Resident #1, who had a diagnosis of dementia with intermittent confusion and resided on the facility secured memory care unit on 06/08/24 to prevent a fall into a shallow pond outside the facility. This resulted in Immediate Jeopardy and actual harm on 06/08/24 when Resident #1 was unattended/unsupervised outside and fell into a pond. Upon assessment, the resident's hair and clothing were wet and she was observed to be coughing. The resident was subsequently transferred to the hospital for evaluation and treatment of aspiration (of pond water). Resident #1 returned from the hospital with an order for an antibiotic. Following the incident, Resident #1 also had emesis that looked like pond water per the nurse. The lack of supervision, at the time of the incident placed Resident #1 at risk for additional injury/death from possible drowning. In addition, a concern that did not rise to Immediate Jeopardy occurred when the facility failed to ensure comprehensive, accurate and individualized elopement assessments and care plans were in place for Resident #2, #3, #4, #5, and #7 to prevent actual and/or potential elopement. This affected six residents (#1, #2, #3, #4, #5 and #7) of six residents reviewed for accidents and/or elopement. The facility census was 33. On 07/01/24 at 4:25 P.M., the Licensed Nursing Home Administrator (LNHA) and Corporate Minimum Data Set (MDS) Nurse #151 were notified Immediate Jeopardy began on 06/08/24 at 5:25 P.M. when Resident #1 was left unattended outside the facility and fell into a pond located near the patio off the facility secured memory care unit. Following the incident, on 06/08/24 at 5:50 P.M. Resident #1 was transported to the hospital for evaluation and treatment of possible aspiration of pond water. Resident #1 returned from the hospital on 06/08/24 at 11:31 P.M. with a new order for an antibiotic treatment due to aspiration pneumonia. The Immediate Jeopardy was removed on 06/12/24 when the facility implemented the following corrective actions: On 06/08/24 at 5:40 P.M. Licensed Practical Nurse (LPN) #101 completed an assessment on Resident #1. At 5:50 P.M. the resident was transported to the emergency room . On 06/08/24 the Administrator/Director of Nursing (DON) provided 1:1 education to staff including Registered Nurse (RN) #103, LPN #102, and LPN #101 who were directly involved in the Resident #1's fall/incident. An emphasis was placed on ensuring residents were not left alone outside and had on proper footwear. On 06/08/24 the DON and/or designee educated all staff (three RNs, nine LPNs, 14 State tested Nursing Assistants) on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility fall related policies including proper footwear and not leaving residents unattended outside. All nursing staff were educated except one LPN, LPN #100 who was out on medical leave and would be educated prior to her return to work. On 06/08/24 an audit revealed no other residents were at risk for being left alone outside as this and the root cause analysis determined that the fall would not have occurred had Resident #1 not been left alone outside. Immediate education provided to staff. On 06/08/24 audits of risk management were conducted and would be reviewed by the LNHA twice weekly for four weeks to ensure no other incidents occur related to residents being left alone outside unattended twice weekly times four weeks. On 06/10/24 Resident #1's care plan was reviewed and updated to reflect Resident #1 was not to wear flip flops while outside. On 06/10/24 the LNHA conducted a formal and written Root Cause Analysis (RCA) with members of the AD HOC Quality Assurance and Performance Improvement (QAPI) that included the Medical Director, DON, Maintenance, LNHA and social service designee. On 06/10/24 a QAPI Performance Improvement Plan (PIP) was initiated to report on the above monitoring and auditing procedures. All findings from the PIP would be presented at the monthly Quality Assessment and Assurance (QAA) meeting. Monitoring/auditing and reporting would continue for a minimum of three months On 06/12/24 Maintenance Director #150 filled in the pond with dirt. On 06/12/24 assessments were completed by LPN #102 and LPN #108 for all 30 facility residents to identify residents who are at risk for elopement. On 07/01/24 Regional MDS Nurse #151 verified elopement assessments and care plans were completed to ensure accurate and consistent information and assessments. On 07/01/24 Regional MDS Nurse #151 verified fall assessments and care plan audit for all 33 residents were completed to ensure accurate and consistent information. Although the Immediate Jeopardy was removed on 06/12/24, the deficiency remains at Severity Level 2 (potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing and monitoring corrective actions and addressing inaccurate resident assessments and care plans related to safety/elopement risk. Findings include: 1. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including idiopathic epilepsy, anxiety disorder, dementia, and bipolar disorder. Review of a plan of care dated 06/13/23 revealed Resident #1 required assistance with mobility related to weakness and impaired balance. Interventions included assistance as needed from staff, wheeled walker, and manual wheelchair for locomotion. An additional plan of care dated 06/23/23 revealed Resident #1 was at risk for falls related to muscle weakness with impaired mobility, decreased balance, and endurance. Interventions included staff to ensure Resident #1 was wearing appropriate footwear (correct client footwear i.e. non-skid socks/shoes) when ambulating or mobilizing in wheelchair, review information on past falls and attempt to determine cause of falls and educate resident/family/caregivers/ as to causes of falls. A physician order dated 07/05/23 revealed Resident #1 was to reside on the memory care unit due to diagnosis of dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1's Brief Interview Mental Status (BIMS) score was 15 which indicated Resident #1 was cognitively intact. The MDS also revealed Resident #1 used a walker. Once Resident #1 was standing, Resident #1 required partial/moderate assistance with walking 10 feet. Resident #1 required supervision or touching assistance to walk 50 feet and make two turns. An occupational therapy note dated 06/07/24 revealed Resident #1 had been going out with nursing staff outside to water plants. Resident #1 appeared to be in good spirits with gardening activity. Collaborated with staff to ensure carryover with new activity over the weekend. Review of the census on 06/08/24 revealed there were a total of 30 facility with 11 of the residents (including Resident #1) residing on the secure unit. On 06/08/24 four of the 11 residents required one person assistance, two residents were frequently incontinent, and one resident was identified to be at risk for elopement. A progress note dated 06/08/24 at 5:25 P.M. revealed Resident #1 was outside watering plants. Resident #1 went to retrieve water from pond. Resident #1 was wearing flip flops and slid into the pond. Resident #1 was removed from the water and assessed by Registered Nurse (RN) #103. Resident #1 was assisted in the shower to wash pond gunk off and to further assess skin. Audible crackles were heard in all of Resident #1's lung fields. A call was placed to the on-call provider and an order was received to transfer Resident #1 to the emergency department (ED) for evaluation of possible aspiration of pond water. A progress note dated 06/08/24 at 5:50 P.M. revealed Resident #1 was transported to the emergency department (ED). Review of hospital records dated 06/08/24 revealed Resident #1 was seen due to a fall with aspiration into respiratory tract. Resident #1 was ordered antibiotics (to treat the aspiration). A progress note dated 06/08/24 at 11:11 P.M. revealed a RN from the hospital called and reported Resident #1 had a chest x-ray that revealed minimal left lower lobe infiltrate. Resident #1 was started on an antibiotic at the hospital and was ordered the antibiotic, Amoxicillin to be continued at the facility. A progress note dated 06/08/24 at 11:31 P.M. revealed Resident #1 returned from ED with new orders for Amoxicillin. A written statement by RN #103 dated 06/08/24 revealed RN #103 was being oriented on the memory care unit by LPN #101. LPN #101 left the memory care unit to make a phone call. RN #103 was charting at the nurse's station. Resident #1 requested to water the vegetable plants in the courtyard that was directly to the left of the nurse's station. RN #103 entered a code to unlock the door and allowed Resident #1 to exit into the courtyard. LPN #101 had stated therapy wanted Resident #1 to water plants over the weekend as part of the therapy program. The statement revealed RN #103 had complete visualization of Resident #1 and refilled the kitchen sized water pitcher approximately three times. Resident #1 would come to the door each time the pitcher needed refilled, and RN #103 would put the code in and open the door. The statement indicated Resident #1 was alert and oriented to person, place, time, and situation. Resident #1 ambulated without any assistive devices and had a steady gait. While Resident #1 was watering plants, another resident (Resident #2), had been walking in the hallway past the nurse's station several times. Resident #2 walked down the hall towards the dining room and pushed open the exit door. RN #103's statement revealed she ran from the nurse's station to the alarming exit door and observed Resident #2 on the sidewalk rounding the corner towards the front of the facility. RN #103 used the walkie-talkie to call for assistance but did not hear a response from anyone. Resident #1 was back at the courtyard door holding up an empty water pitcher. RN #103 held up one finger and told Resident #1 to hang on for a minute. RN #103 ran to the door at the front of the unit to see if staff could be summoned to get Resident #2. When RN #103 opened the door from the memory care unit, LPN #102 was observed walking Resident #2 inside. Resident #2 was taken back onto the memory care unit. RN #103 immediately ran back to check on Resident #1. RN #103 opened the door to the courtyard but could not see Resident #1. Resident #1 called out, I'm over here. RN #103 thought Resident #1 had fallen into some weeds. RN #103 ran to Resident #1 and asked if she was okay and if Resident #1 had hit her head. Resident #1 was completely wet. Resident #1's hair was wet with muddy particles. RN #103 was unaware there was a pond in the courtyard area. The statement indicated Resident #1 stated she was okay and felt stupid and hoped no one was looking out the windows. Resident #1 denied hitting her head and denied any pain. Resident #1 stated she was bending over to fill the water pitcher and lost her balance and slipped. Resident #1 was wearing flip flop style sandals. RN #103 asked Resident #1 if she went all the way under the water. Resident #1 answered yes. Resident #1 was coughing and stated she felt she had swallowed some of the water. LPN #101 showed up in courtyard and assisted RN #103 with getting Resident #1 out of the pond. As RN #103 was assisting Resident #1 back to the building, Resident #1 slipped in the grass and fell to her knees. RN #103 told Resident #1 not to put shoes back on because they were wet and slippery. Resident #1 struggled to get from knees to standing with RN #103 assistance. Resident #1 had a small laceration to the right knee and stated her second toe hurt. Resident #1 requested a shower. Resident #1 had expiratory coarse crackles in posterior left base of lung and frequent loose sounding cough. LPN #101 made notification calls and Resident #1 was transferred to the ED for evaluation. A written statement by LPN #102 dated 06/08/24 revealed she was notified by RN #103 that Resident #2 was outside the facility. LPN #102 met RN #103 in the parking lot and assisted Resident #2 back into the facility. A facility investigation dated 06/08/24 revealed Resident #1 was heard yelling for help while RN #103 was assisting Resident #2. Resident #1 was found sitting in the fishpond in courtyard. Resident #1 stated she went over to the pond to rinse her hands and slipped and fell into the pond. Resident #1 was assisted out of the pond and no injuries were noted. Resident #1 denied any pain. Neurological checks were initiated. Auscultation of Resident #1's lungs revealed some crackles. Resident #1 was assisted into the shower and was resting in bed. The immediate intervention was to send Resident #1 to the ED for evaluation and treatment. The facility investigation noted Resident #1 was oriented to person, place, and situation. Predisposing physiological factors included impaired memory; and predisposing situation factors included Resident #1 was wearing improper footwear (flip flops). A progress note dated 06/09/24 at 12:52 A.M. revealed Resident #1 was sitting on the side of the bed and had a medium watery emesis that was tan/orange in color. A progress note dated 06/09/24 at 1:22 P.M. revealed Resident #1 continued an antibiotic for aspiration pneumonia. Some crackles were heard in Resident #1's lower lungs. A progress note dated 06/10/24 at 9:55 A.M. revealed an interdisciplinary team (IDT) meeting put a new intervention in place for Resident #1 to wear proper footwear while outside. A progress note dated 06/11/24 at 1:24 P.M. revealed IDT also implemented interventions to educate Resident #1 on safety awareness and for Resident #1 to have staff assistance while outside. A psychiatric note dated 06/12/24 revealed Resident #1 reported feeling bored and her mood was lousy. Resident #1 reported chronic depression and anxiety due to being in the facility. Resident #1 had ongoing confusion and agitation at times. Resident #1 was being treated for aspiration pneumonia. An occupational therapy note dated 06/12/24 revealed Resident #1 ambulated without a device in room with supervision. An occupational therapy note dated 06/25/24 revealed Resident #1 was encouraged to participate in activities to promote safety and independence. Resident #1 reported not being able to water the garden due to not being allowed outside. Interview on 07/01/24 at 8:41 A.M. with STNA #126 revealed there was usually only a nurse on the memory care unit. STNA #126 stated there were several residents on the memory care unit who were exit seeking. Interview on 07/01/24 at 8:50 A.M. with RN #103 revealed she had been orienting with LPN #101 on 06/08/24, the day Resident #1 fell in the pond. RN #103 stated LPN #101 had left the memory care unit and Resident #1 asked to water the plants in the courtyard. Staff had been told to let Resident #1 water the plants on the weekends. RN #103 stated she filled the water pitcher several times for Resident #1. Resident #2 had been stating he needed to leave. Resident #2 went to the exit door in the dining room and pushed the door until it alarmed, and the door unlocked. RN #103 ran to the exit door and saw Resident #2 was going around the building towards the front. RN #103 used the walkie-talkie to alert other staff that assistance was needed, and Resident #2 had exited the building. RN #103 stated she ran towards the other end of the hall where the door to the facility was located to see if she could get a staff member to help her. RN #103 stated as she ran past the nurse's station, she saw Resident #1 standing at the door where the courtyard was. RN #103 stated she held up her index finger and asked Resident #1 to give her a minute. When RN #103 opened the door from the memory care unit to the front hallway, she observed LPN #102 bringing Resident #2 back into the facility. After Resident #2 was back on the memory care unit, RN #103 ran to check on Resident #1. When RN #103 went out to the courtyard, she did not see Resident #1. Resident #1 then called out over here. RN #103 stated she was not aware there was a pond in the courtyard until she found Resident #1. RN #103 revealed she found the resident, her head was wet, and Resident #1 was still in the pond. Resident #1 stated she went to get water from the pond to fill up the pitcher and fell into the pond. Resident #1 was vomiting up muddy water and was sent to the hospital for evaluation. RN #103 stated LPN #101 arrived and assisted with getting Resident #1 out of the pond. RN #103 stated the pond had been filled with dirt after Resident #1 fell . Observation on 07/01/24 at 8:58 A.M. revealed bare dirt in the courtyard where the pond used to be. Observation of the memory care unit revealed the nurse's station and exit to the courtyard were approximately halfway down the hall from the entrance to the memory care unit. The exit door where Resident #2 exited was at the opposite end of the hall from the entrance to the memory care unit. Interview on 07/01/24 at 9:03 A.M. with Resident #1 revealed she was not allowed to go out to the courtyard now. Resident #1 stated (on 06/08/24) she fell into the pond headfirst. Resident #1 stated she was wearing flip flops and it was slimy around the pond, and she lost her balance and fell . Resident #1 stated she was very embarrassed that she fell . An Interview on 07/01/24 at 10:50 A.M. with the family of Resident #1 revealed therapy requested Resident #1 be permitted to water the plants in the courtyard. The family member stated they were told an alarm had sounded and was reset and Resident #1 fell in the pond. The family member stated they were not told Resident #1 had been left alone when the fall occurred. Interview on 07/01/24 at 12:16 P.M. with the LNHA revealed the pond Resident #1 fell into was about a foot deep. The LNHA then indicated the pond may have gotten deeper in some parts. The LNHA stated there was a net across the top of the pond and there were lilies growing through the netting. The LNHA revealed RN #103, who was working on the unit at the time of the incident was a new nurse and 06/08/24 was her third day of being oriented. The LNHA verified RN #103 was the only staff member on the memory care unit when Resident #1 was outside watering plants and Resident #2 exited to the outside of the facility. The LNHA verified Resident #1 was left unattended in the courtyard while RN #103 located Resident #2 and brought Resident #2 back to the memory care unit. The LNHA verified Resident #1 was not being supervised when Resident #1 fell into the pond. Interview on 07/01/24 at 12:26 P.M. Maintenance Director #150 revealed the pond was approximately six feet wide, 10 to 12 feet long and probably 12 to 18 inches deep. Maintenance Director #150 stated there was netting under the water in the pond and there were lilies and cattails growing in the pond. Maintenance Director #150 stated the pond had been there a long time. It looked like someone had dug a hole, lined it with rubber, filled it with water, and placed rocks around the sides of the pond. Maintenance Director #150 stated he drained the pond and rented a skid steer to fill the pond in after Resident #1's fall. Review of the Fall Prevention Program policy revised on 02/2023 revealed residents with low/moderate risk were encouraged to wear shoes or slippers with non-slip soles when ambulating. When a resident experienced a fall, the facility obtained witness statements in the case of injury and documented all assessments and actions. Review of the facility assessment revised on 05/21/24 revealed the facility was licensed for 49 beds with 16 beds being on the (secured) memory care unit. The facility assessment indicated assessments were completed on all residents and the care plan was personalized to help meet resident's preferences related to daily schedules, waking, bathing, activities, naps, food, and going to bed. 2. Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included vascular dementia, chronic kidney disease, and anxiety. The quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of eight which indicated cognitive impairment. The MDS revealed Resident #2 had wandering behavior. The elopement risk assessment dated [DATE] revealed Resident #2 was up ad lib without assistive devices. Resident #2 had a history of elopement at home, leaving the facility without informing staff and wandered aimlessly. Resident #2 was at risk for elopement as evidenced by wandering and exit seeking. A progress note dated 06/08/24 at 5:53 P.M. revealed Resident #2 had agitation, was exit seeking, and packing belongings. At approximately 4:00 P.M. Resident #2 exited the emergency exit door in the dining room. Resident #2 was met in front of the facility by LPN #102 and brought back into the memory care unit. An elopement risk assessment dated [DATE] revealed Resident #2 was at risk for elopement and appropriate interventions had been reviewed. An elopement risk assessment dated [DATE] revealed Resident #2 was at risk for elopement and the appropriate interventions had been initiated and reviewed. A progress note dated 06/14/24 at 3:34 P.M. revealed Resident #2 was exit seeking and pushing on the doors. A care plan dated 06/14/24 revealed Resident #2 was at risk for elopement. Interventions included to distract resident from wandering, assess Resident #2 for proper footwear, and offer snacks and activities. A progress note dated 06/15/24 at 12:40 A.M. revealed Resident #2 was redirected back to his room multiple times. A progress note dated 06/22/24 at 8:00 P.M. revealed Resident #2 was found at the nurse's station and had called 911. A progress note dated 06/22/24 at 9:27 P.M. revealed Resident #2 had been exit seeking throughout the day. Resident #2 was redirected but continued to wander and look out exit doors. A behavior note dated 06/23/24 at 12:55 A.M. revealed the nurse was at the nurse's station and did not hear Resident #2 exit the entrance door to the unlocked part of the facility. Resident #2 was redirected back to the memory care unit. A progress note dated 06/24/24 at 12:29 A.M. revealed Resident #2 was pacing and exit seeking. Interview on 07/01/24 at 2:39 P.M. Regional MDS Nurse #151 verified Resident #2 was identified as an elopement risk and did not have an elopement care plan in place until 06/14/24. Regional MDS Nurse #151 verified the assessments and care plans were not accurate. Regional MDS Nurse #151 stated she was currently auditing assessments and care plans. 3. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder, dementia, and anxiety disorder. An elopement risk assessment dated [DATE] revealed Resident #3 was not at risk for elopement. A care plan dated 09/06/23 revealed Resident #3 was an elopement risk with interventions to distract Resident #3 from wandering, provide structured activities, and identify a pattern of wandering. An elopement risk assessment dated [DATE] revealed Resident #3 was not at risk for elopement. An elopement risk assessment dated [DATE] revealed Resident #3 was not at risk for elopement. A progress note dated 03/06/24 at 8:13 A.M. revealed Resident #3 was pacing back-and-forth, going in and out of other resident's rooms. A progress note dated 03/20/24 at 4:12 A.M. revealed Resident #3 was pacing the unit. A progress note dated 04/13/24 at 5:53 P.M. revealed Resident #3 had been pacing most of the day. The quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 7 which indicated cognitive impairment. The MDS revealed Resident #3 did not have wandering behavior. An elopement risk assessment dated [DATE] revealed Resident #3 was not at risk for elopement. An elopement risk assessment dated [DATE] revealed Resident #3 was not at risk for elopement. A progress note dated 06/22/24 at 9:25 P.M. revealed Resident #3 had been exit seeking in the morning. Interview on 07/01/24 at 2:39 P.M. Regional MDS Nurse #151 verified Resident #3 had a care plan in place for being at risk for elopement, had documentation of wandering and exit seeking, but was assessed as not being an elopement risk. Regional MDS Nurse #151 verified the assessments and care plans were not accurate. Regional MDS Nurse #151 stated she was currently auditing assessments and care plans. 4. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses that included dementia, schizophrenia, and developmental disorder. A care plan dated 12/04/23 revealed Resident #4 was at risk for elopement with exit seeking behaviors at times. Interventions included to distract Resident #4 from wandering, identify pattern of wandering, and provide structured activities. The quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact and had no wandering behavior. An elopement risk assessment dated [DATE] revealed Resident #4 was at risk for elopement. An elopement risk assessment dated [DATE] revealed Resident #4 was not at risk for elopement. Interview on 07/01/24 at 2:39 P.M. Regional MDS Nurse #151 verified Resident #4 had a care plan in place for risk of elopement. Resident #4 had been identified as at risk for elopement on 05/22/24. On 06/12/24 Resident #4's elopement risk assessment revealed Resident #4 was not at risk for elopement. Regional MDS Nurse #151 verified the assessments and care plans were not accurate. Regional MDS Nurse #151 stated she was currently auditing assessments and care plans. 5. Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses that included schizoaffective disorder, mood disorder, mild cognitive disorder, epilepsy, and dementia. A care plan dated 01/17/23 revealed Resident #5 was at risk for elopement. Interventions include to assess for fall risk. The quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 3, which indicated severe cognitive impairment. Wandering behaviors was not completed on the MDS. An elopement risk assessment dated [DATE] revealed Resident #5 was at risk for elopement. An elopement risk assessment dated [DATE] revealed Resident #5 was not at risk for elopement. Interview on 07/01/24 at 2:39 P.M. Regional MDS Nurse #151 verified Resident #5 was identified as an elopement risk on 05/30/24 with an elopement risk care plan in place. On 06/12/24 Resident #5 was not identified as an elopement risk. Regional MDS Nurse #151 verified the assessments and care plans were not accurate. Regional MDS Nurse #151 stated she was currently auditing assessments and care plans. 6. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included dementia, history of traumatic brain injury, and anxiety disorder. An elopement risk assessment dated [DATE] revealed Resident #7 was at risk for elopement. A progress note dated 06/29/24 at 6:05 P.M. revealed Resident #7 was exit seeking several times and setting the alarms off. Resident #7 was redirected but continued to exit seek. Review of Resident #7's care plan revealed no care plan in place for elopement risk. Interview on 07/01/24 at 2:39 P.M. Regional MDS Nurse #151 verified Resident #7 was identified as an elopement risk and did not have an elopement care plan in place. Regional MDS Nurse #151 verified the assessments and care plans were not accurate. Regional MDS Nurse #151 stated she was currently auditing assessments and care plans. This deficiency represents non-compliance investigated under Complaint Number OH00155248.

Based on observation, record review, review of facility staff statements, review of the Centers for Medicare and Medicaid (CMS) guidance related to sexual activity and consent, review of the facility Alzheimer's and Dementia policy and procedure manual and staff, resident, family and Physician (#120) interviews, the facility failed to ensure comprehensive assessments were completed and individualized interventions were initiated for Resident #32 and Resident #35, who had impaired cognition and resided on the facility's secured memory care unit to address the resident's total behavioral and psychosocial care needs and to address the capacity of the residents to engage in consensual sexual activity. This resulted in Immediate Jeopardy on 07/16/22 when Resident #32 was found in a bed in a vacant room on top of Resident #35 having sexual intercourse without the prior determination of Resident #35's capacity to consent to the interaction. Resident #35's impaired cognition and communication placed her at risk for actual physical and/or psychosocial harm as a result of the incident. The reasonable person concept involves the resident's ability to understand the potential consequences and choose a course of action for a given situation. Decisions of capacity to consent to sexual activity must balance considerations of safety and resident autonomy. This affected two residents (#32 and #35) of three residents reviewed for behavioral healthcare. The facility census was 42. On 07/25/22 at 3:15 P.M. the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 07/16/22 at 1:28 P.M. when State tested Nursing Assistant (STNA) #104 could not find Resident #32 or Resident #35 in their respective rooms on the memory care unit. STNA #104 noticed a vacant room on the unit with the door shut and upon knocking and opening the door, discovered both residents naked with Resident #32 on top of Resident #35 engaging in sexual activity. STNA #104 reported the observation to Registered Nurse (RN) #101 who notified Licensed Practical Nurse (LPN) #103. LPN #103 separated the residents but failed to immediately investigate the incident to determine Resident #35's capacity to consent to the interaction. In addition, there was no evidence of any further behavioral assessments, monitoring or interventions being initiated following the observed sexual encounter. The Immediate Jeopardy was removed on 07/28/22 when the facility implemented the following corrective actions: · On 07/25/22, Resident #35 and Resident #32 were assessed by a licensed nurse and with documentation in the medical record. No physical findings were noted. · On 07/26/22, the Administrator met with the Medical Director, Physician #120, to discuss State Agency findings and the facility abatement plan, no additional recommendations were made at that time. · On 07/26/22, Social Service Designee (SSD) #114 assessed Resident #35 and Resident #32 for any psychosocial or behavioral changes from their normal baseline. · On 07/26/22, SSD #114 completed a social service assessment for Resident #35 and Resident #32. · On 07/26/22, SSD #114 completed a social service assessment for all 14 facility residents with a Brief Interview for Mental Status (BIMS) score below 12 and/or with known behavioral health needs. · On 07/26/22, a plan for a Social Service Assessment to be utilized for all residents upon admission, quarterly and with any significant change in condition. This assessment assesses psychosocial factors with 15 questions regarding mood, nine questions regarding behaviors (including inappropriate sexual behaviors) and five questions regarding substance abuse. This assessment will be used to determine a baseline status for the resident. · Beginning 07/26/22, any resident determined by the clinical health team (attending physician, nurse practitioner, SSD #114 and DON) to have an emergent behavioral health need will be scheduled to be seen by psychology, psychiatry or counseling. The facility has a relationship with an outside psychiatry provider (Physician #142) to provide behavioral health intervention. · Beginning 07/26/22, DON/MDS LPN #132 began updating care plans and Kardex (care cards) for any resident with a newly identified need or intervention including Resident #32 and Resident #35 based on record review and social service assessment identified behaviors. The care plans, tasks and Kardex will have clear identification of behaviors to be monitored and appropriate staff interventions. Moving forward any member of the interdisciplinary team (IDT) can update a care plan within their prescribed scopes of practice. · Beginning 07/26/22, DON/MDS LPN #132 developed a plan for behavioral tracking to be ordered by the physician and included on the Treatment Administration Record (TAR) to include specific behaviors the facility would track as current tracking was vague and nonspecific. Floor nurses will be required to chart on behaviors each shift. · On 07/26/22, the Administrator provided education to SSD #114 on the new policy related to social service assessments being completed upon admission, quarterly and with any significant change in condition. Any findings on the assessment are to be brought forward to the clinical team for IDT discussion of care planning needs and behavior tracking if warranted. · Beginning 07/26/22, the DON/designee provided education to all clinical staff related to reporting and documenting any changes in the residents' normal behavior based on Kardex and care plans as well as the new need to track behaviors of those with identified needs via physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Baseline information will be updated on the Kardex so STNAs know what a resident's baseline is and any Kardex changes will be completed timely. Training will also be provided to the same staff related to the location within care plan and tasks of any behavioral specific intervention locations. Any staff not present for the education will be educated by phone. · On 07/26/22, an Ad hoc Quality Assessment Performance Improvement (QAPI) committee meeting was held with Physician #120, Administrator, DON, SSD #114, Activity Director #143, CDM #144, and Chief Operating Officer (COO) #123 to review the Immediate Jeopardy abatement plan and on-going audits. · On 07/26/22, the facility implemented a plan for the DON and/or designee to audit behavior tracking for completion on five random residents; audit for the completion of the social service assessments or progress notes due for the week; audit five care plans for timely revision, and audit Kardex updates. Audits will be done five times weekly for four weeks and three times weekly for four weeks. Results of the audits will be reported to the QAPI ad hoc committee weekly for review and recommendations and presented to the quarterly QAPI meeting. · Beginning on 07/27/22, the facility created a policy, Sexual Expression of Residents, and educated all clinical staff on the policy. Any staff not present were educated by phone and the policy was placed in the agency staff binder. · On 07/28/22, a plan for any resident exhibiting sexual interest with a Brief Interview for Mental Status (BIMS) score under eight will be assessed by a physician, nurse practitioner or other qualified medical professional to determine capacity to consent and the Sexual Expression of Residents policy will be followed for those with capacity. Information from the IDT will be provided to the physician regarding the need for the consent assessment. Following the completion of the physician's assessment, information will be shared with the resident, responsible party and IDT. Appropriate areas of the medical record will be updated based on the determination. The physician/qualified medical professional will follow the CMS guidance under F600 related to sexual capacity and consent in addition to their medical judgement when making the consent determination. Residents' capacity to consent will be documented in the medical record and then added to the plan of care and Kardex. · On 07/28/22, a plan for any Resident with BIMS under 8 and deemed to not have capacity to consent will have increased monitoring from facility staff of a one-on-one nature, increased diversional activities, 15-minute checks etc. will be implemented depending on residents and the situation so interventions are individualized. If facility staffing did not permit for one-on-one monitoring, the physician would be notified for further instruction and the DON/on-call nurse would be contacted to ensure adequate staff was present and the one-on-one would be provided until it was no longer required. · On 07/28/22 at 1:19 P.M. Resident #35 was moved off of the secured unit away from Resident #32 and was placed on enhanced monitoring with documentation every 15 minutes. The memory care unit has added a second staff member on all shifts to assist with supervising Resident #32. Although the Immediate Jeopardy was removed on 07/28/22 the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #35 received Hospice services since admission on 06/21/21 due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Symptoms can include but are not limited to symptoms of dementia, such as memory loss and visual problems. Record review revealed a plan of care, dated 06/22/21 which reflected Resident #35 had a problematic manner characterized by ineffective coping, wandering related to cognitive impairment, inability to locate own room, restlessness, end stage disease, major depressive disorder, anxiety disorder and terminal diagnosis. The care plan revealed the resident would crawl on the floor, would open closed doors, enter other rooms and rummage through items, pull linens from beds, disrobe due to confusion and had periods of terminal restlessness and agitation. The care plan also revealed the resident had a short attention span and impaired communication ability. Interventions included to allow resident to wander on unit, escort resident to and from dining room and activities, place familiar objects/furniture/pictures in her surroundings, provide assistance in locating own room, provide directional cues (i.e. pictures, name on doors), provide supervision during recreation programs and remove items that may trigger the resident to leave the facility (i.e. boots, coat). The care plan revealed the resident would reside on the facility memory care unit for safety. Record review revealed Resident #35 also had a behavior plan of care, initiated 06/22/21 which indicated when her gait was unsteady, weak, or unsafe, the resident would intentionally place herself on the floor and crawl on her hands and knees. The care plan revealed the behavior had been long term and was a means of safe mobility for the resident. The care plan revealed Resident #35 would crawl into other residents' rooms and lay on the floor or crawl into other residents' beds and indicated the resident would also disrobe. Interventions included to monitor behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved and situations and document behavior and potential causes. Interventions also included to administer medications as ordered, monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, caregivers to provide opportunities for positive interaction, attention, stop and talk with resident as passing by and intervene as necessary for safety. Additional interventions included to approach/speak in a calm manner and offer assistance with toileting, walking, snacks, beverages etc., keep environment free of clutter and obstacles, monitor and assess for pain, injury, impaired skin integrity from crawling on the floor, re-dress as needed, transfer to a wheelchair and encourage to sit in areas of supervision and when observed on the floor crawling offer to assist to standing position and walk back to room. Record review revealed the facility had not assessed or developed a comprehensive or individualized plan care for Resident #35 related to human sexuality needs or preferences or the resident's capacity to consent to sexual activity. Record review revealed an initial social service assessment, dated 06/26/21. The assessment listed wandering as the only behavior Resident #35 displayed. No questions related to sexual activity or the resident's interest in sexual activity were included in the assessment. Review of Resident #35's historical Minimum Data Set (MDS) 3.0 assessments revealed no Brief Interview for Mental Status (BIMS) score was completed due to memory problems during the 06/28/21, 09/28/21 or 03/29/22 assessments. The MDS 3.0 assessment, dated 12/29/21 revealed the resident had a BIMS score of seven (out of 15) reflecting severe mental impairment. Review of Resident #35's annual MDS 3.0 assessment, dated 06/29/22 revealed no BIMS score was calculated as Resident #35 was rarely/never understood. The assessment revealed the resident had short-term and long-term memory problems including that she did not know the current season, location of her own room, staff names or faces or that she was in a nursing facility. The MDS indicated Resident #35 had moderate impairment for making decisions regarding tasks of daily life, inattention, disorganized thinking and physical behaviors directed towards others one to three days in the seven-day lookback period. The assessment revealed Resident #35 required the extensive assistance of one staff for bed mobility, transfers and walking in the room or corridor and also utilized a wheelchair. Review of Resident #35's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? every shift for behavior monitoring and an order (dated 07/06/21) for a psychological evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no evidence Resident #35 had been seen for the psychological evaluation from the time the order was obtained on 07/06/21 through current date. Review of Resident #35's July 2022 Treatment Administration Record (TAR) indicated the prompt, did resident show any signs of these behaviors? was marked off with a checkmark indicating administered except on 07/06/22 (morning), 07/09/22 (evening), 07/10/22 (evening), 07/12/22 (morning), 07/13/22 (morning and evening), 07/14/22 (morning and evening), 07/18/22 (evening) and 07/20/22 (morning) which were marked as 8 indicating other/see nurses' notes. Further correlation with Resident #35's nurses' notes revealed on 07/06/20 behaviors not observed (BNO); on 07/09/22 no behaviors were displayed; on 07/10/22 no behaviors were displayed; on 07/12/22 behaviors not observed; on 07/13/22 behaviors not observed; on 07/14/22 behaviors not observed; no note was related to behaviors on 07/18/22 and on 07/20/22 behaviors not observed. The behavior tracking did not indicate what specific behavior(s) were being monitored and/or if behaviors had actually occurred or not. Record review revealed no additional social service assessments or social service notes from 06/28/21 through 05/30/22 for Resident #35. The social service progress note, dated 05/30/22 was related to COVID-19 cases. Review of a nurse's note, dated 07/16/22 at 10:55 P.M. and authored by the DON revealed Resident #35's previous nurse (RN #101) had advised her Resident #35 was found in an empty room with another resident. The nurse stated when the door was opened, Resident #35 and a male resident were noted to be in an embrace and both of their pants were off. The note documented Resident #35 requested to be left alone at that time with the other resident, but the nurse re-directed her to her room at that time. The note revealed a pain and skin assessment were performed on the resident with no new skin concerns noted. Resident #35 denied any pain or discomfort and denied any concerns or questions. The note revealed Resident #35 would continue to be monitored and re-directed as needed. A voicemail was left for the resident's power of attorney (POA)/son (Family Member (FM) #105) to return call. Review of Resident #35's medical record revealed no nursing process note/entry was completed by the nurse (RN 101) involved in the incident and who had direct first-hand knowledge of the incident on 07/16/22. Review of a nurses' note dated 07/17/22 and written by LPN #103 revealed FM #105 was updated and no questions or concerns voiced. The specifics of the communication to the family member were not documented. Review of a late entry nurse's note, dated 07/18/22 for 07/16/22 and written by RN #115 revealed the physician had been notified of the situation. The specifics of the communication to the physician were not documented. Review of a late entry nurse practitioner note, dated 07/23/22 and written for 07/18/22 revealed Resident #35 mouths and whispers her words and spoke very little. The note revealed Resident #35 was alert and confused. The note did not address Resident #35's behaviors or recent sexual encounter. As of 07/28/22, no assessment addressing decision making or the capacity to consent to sexual activity had been completed. Review of Resident #32's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the most recent social service assessment for Resident #32 was dated 12/09/21 and was incomplete. No questions related to sexual activity or the resident's interest in sexual activity were included in the assessment. A plan of care, revised 12/14/21 revealed Resident #32 had dementia and cognitive decline. Interventions included anticipate needs and observe for non-verbal cues, approach in calm manner, explain what you intend to do while providing care, orient as needed to person/place/time, re-direct to activities of interest during periods of wandering and introduce self. An additional plan of care, revised 12/14/21 revealed Resident #32 had dementia, the potential to be verbally aggressive to staff due to dementia, delusions at times that focused on others stealing things and he would call emergency services to report this. The care plan revealed Resident #32 became verbally aggressive with staff when attempts were made at redirection. Interventions included to administer medications as ordered and monitor/document for side effects and effectiveness, analyze key times, places, circumstances, triggers and what de-escalated behavior and document, assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc., assess resident's coping skills and support system, assess resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation, give the resident as many choices as possible about care and activities and psychiatric/psychogeriatric consult as indicated. The care plan revealed when the resident becomes agitated, intervene before agitation escalates and guide away from source of distress, engage calmly in conversation; if response was aggressive staff to walk calmly away and approach later. Record review revealed the facility had not assessed or developed a comprehensive or individualized plan care for Resident #32 related to human sexuality needs or preferences or the resident's capacity to consent to sexual activity. Review of Resident #32's quarterly MDS 3.0 assessment, dated 05/20/22 revealed Resident #32 had a BIMS score of six indicating severe cognitive impairment and had disorganized thinking. The assessment revealed Resident #32 wandered daily and was assessed to require supervision for bed mobility and transfers. Review of a social service progress note, dated 06/15/22 revealed a change in POA for the resident. A note, dated 06/16/22 revealed Resident #32 was able to go on outings with a female who did not reside in the facility. The note did not elaborate on the outings or how the decision for the outings to occur was made. A plan of care, related to mood state and revised 06/16/22 revealed Resident #32 had a potential for alteration in mood due to confusion, loss of familiar surroundings, and usual caregiver and usual routine in community. The care plan revealed Resident #32 had a strong desire for companionship and had a friend who often visited with him. Interventions included assess/monitor/document mood, be assuring and listen to concerns, encourage activities and conversation Resident #32 enjoyed, encourage group activities, medications as ordered and social services visit for one on one as needed. Review of Resident #32's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident had no orders in place to monitor for any type of behaviors. Review of a nursing progress note, dated 07/16/22 at 10:40 P.M. and authored by the facility DON revealed she spoke with Resident #32's son who was his POA (FM #106) and advised Resident #32 was found in an empty room with another resident. When the door was opened by another nurse, Resident #32 and a female resident were noted to be in an embrace and both of their pants were off. The note documented, Resident #32 requested to be left alone at that time with the other resident but the nurse re-directed Resident #32 to his room at that time. A pain and skin assessment were performed with no new skin concerns noted. FM #106 verbalized understanding and denied any further questions or concerns at this time. Resident #32 denied any pain or discomfort. The note revealed Resident #32 would continue to be monitored and re-directed as needed. Review of a late entry nurse's note, dated 07/18/22 for 07/16/22 and written by RN #115 revealed the physician had been notified of the situation. The specifics of the communication to the physician were not documented. Review of a late entry nurse practitioner note, dated 07/25/22 for 07/22/22 revealed there were no current concerns from staff regarding Resident #32. Resident #32 was oriented to person, had flight of ideas and answered most questions appropriately. The note reflected the resident received [MEDICATION(S)] 60 mg, [MEDICATION(S)] 125 mg twice daily and [MEDICATION(S)] for depression and anxiety. Resident #32 was to be monitored for suicidal ideation or actions. The note did not address Resident #32's behaviors or recent sexual encounter. As of 07/28/22, no assessment addressing decision making or the capacity to consent to sexual activity had been completed. On 07/21/22 at 9:17 A.M. interview with the Administrator and DON revealed both staff denied any allegations of abuse but indicated there had been a recent question/concern from staff (not identified) regarding Resident #35 and Resident #32, who on 07/16/22 had been in a room on the memory care unit hugging without pants on. The administrative staff revealed they had obtained three staff witness statements following the incident but denied submitting a self-reported incident (SRI) to the State agency regarding a potential incident of sexual abuse. The Administrator and DON indicated Resident #35 was alert to herself but felt the resident could voice her needs and felt Resident #32 was able to voice his concerns and wants. The administrative staff did not elaborate on how this determination was made. Review of LPN #103's witness statement, dated 07/16/22 revealed at 1:32 P.M. the east nurse notified her of needing assistance on the south hall and reported Resident #32 and Resident #35 had been observed having sexual intercourse. At 1:33 P.M. LPN #103 entered vacant room [ROOM NUMBER] (on the memory care unit) to observe Resident #32 laying in a prone position on top of Resident #35 who was on her back in bed with (their) pelvic areas together. Resident #32 appeared to be thrusting his pelvic area. Both residents did not have any clothing, underwear or pull-up on from the waist down. Neither appeared to be in distress. Resident #32 stated, get out you're embarrassing us. Resident #35 continued to lay in bed with eyes open and silent. LPN #103 re-directed the residents with success. Resident #32 was cued and assisted with dressing then assisted back to his room. Resident #32 stated, I was just laying in bed with the lady. It wasn't very long. Resident #35 was observed to be calm and lay in bed requesting to be covered up. Resident #35 assisted with getting dressed, declining to get up. Resident #35 reported she was ok and in no discomfort at this time; she did not describe the incident when asked. At 1:38 P.M. the DON was notified. Review of STNA #104's witness statement, dated 07/16/22 revealed around 1:10 P.M. while picking up trays she watched Resident #35 call over Resident #32 to come over to her in the dining room. Resident #35 whispered something to Resident #32 and Resident #32 asked if Resident #35 wanted a ride back to her room. At 1:25 P.M. while toileting another resident, STNA #104 noticed neither Resident #32 or Resident #35 were in their rooms. STNA #104 walked back down to the dining area and the residents weren't there but noticed the door to room [ROOM NUMBER] was shut. At 1:28 P.M. STNA #104 knocked and said hello but received no response. STNA #104 opened the door and found Resident #32 on top of Resident #35 both in the missionary position and both naked. Resident #32's hips were moving up and down and Resident #35 had her arms wrapped around Resident #32 grabbing his back. Neither resident appeared to be in any kind of distress. STNA #104 closed the door and immediately reported to the nurse at 1:32 P.M. Review of RN #101's witness statement, dated 07/16/22 revealed at 1:36 P.M. he was notified by care staff Resident #32 and Resident #35 were in a vacant room together. RN #101 observed Resident #35 laying on top of Resident #32, and both had their pants completely off. Resident #35 had her eyes closed and appeared to be pulling Resident #32 closer to her by his shoulders. This nurse immediately notified staff nurse (not identified in statement). At 1:37 P.M. the residents were re-directed. Resident #32 stated he felt embarrassed. Resident #35 reached for a blanket to cover herself. Privacy provided as Resident #32 was assisted back to his room. Staff nurse assessed both residents and notified the DON. On 07/21/22 beginning at 9:38 A.M. observation of the memory care unit revealed Resident #32 was dressed in a robe with just a shirt underneath and no pants visible and was walking down the hall from his room. On 07/21/22 at 9:40 A.M. during an interview with Resident #35, the resident denied any type of sexual encounters or other involvement with any male residents. Resident #35's voice was soft and she communicated with the surveyor mainly via nodding her head yes or shaking her head no. At the time of the interview, Resident #35 was lying in bed with a blanket wrapped up around her. On 07/21/22 at 9:44 A.M. during an interview with Resident #32, the resident stated, his memory was getting bad. Resident #32 denied having a girlfriend but did reveal last week (week of 07/10/22 to 07/16/22) a female who he could not name who was sitting on a tricycle had asked for help back to her room. Resident #32 got this female into her room and he could tell she took all of her clothes off so he joined her. Upon further interview, Resident #32 clarified he had sexual relations with this female before the nurse interrupted them including oral sex and vaginal intercourse. Resident #32 stated the female took her clothes off and did not ask to have sex but must have agreed she did not tell me to stop, that is why she had me take her to her room. Resident #32 stated this female sat by him at breakfast. Resident #32 revealed he did not recall who, but they raised hell with him and he re-iterated he would not have done anything if the female did not take her clothes off. On 07/21/22 at 9:58 A.M. interview with RN #101 revealed he had arrived to the memory care hall to check blood sugars when an STNA (not identified) told him Resident #32 and Resident #35 were in an empty room, Resident #32 was on top of Resident #35 and they were naked from the waist down. The STNA reported Resident #35 was holding Resident #32 and the activities appeared sexual in nature. RN #101 stated he went to grab the other nurse on duty [LPN #103] since he was a travel nurse and the nurse then separated Resident #32 and Resident #35. When RN #101 was asked about the residents' cognition, RN #101 stated Resident #35 did not talk much and would use yes/no questions unless she wanted something. RN #101 could not describe Resident #32's cognitive status. RN #101 was unsure if either resident had the capacity to consent to sexual activity as both were alert to self only. RN #101 explained the other floor nurse notified the DON. RN #101 verified no changes had been made for the supervision or behavioral monitoring of Resident #32 or Resident #35 since the incident. RN #101 explained Resident #32's attire on this date (07/21/22) was due to it being the resident's shower day. On 07/21/22 at 10:13 A.M. Resident #32 was observed seated on a bench next to Resident #36 outside of the nurses' station with his arm around this resident's shoulders. On 07/21/22 at 11:34 A.M. interview with STNA #102 revealed she did not work on 07/16/22 but was given information in report that STNA #104 had found Resident #32 and Resident #35 having sexual intercourse. STNA #102 explained they were now keeping a stronger eye on Resident #32 but there was no specified supervision level or documentation regarding this. The STNA revealed Resident #32 was friendly towards women in general. When asked about the resident's cognition levels, STNA #104 revealed she felt Resident #35 could maybe consent but stated with her training on dementia, dementia residents could not give consent to sexual activities. STNA #102 stated Resident #32 could give consent and an opportunity presented itself. STNA #102 explained Resident #32 would sit on his bed and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . STNA #102 revealed Resident #35 had behaviors in which she would disrobe three or four times a week and would need to be redirected. On 07/21/22 at 2:28 P.M. a telephone interview with FM #105 revealed he [TRUNCATED]