Every finding on record at Good Samaritan Center

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment and environmental surfaces in a clean and sanitary condition for 1 of 1 kitchens observed, specifically related to the cleanliness of the kitchen floor, 3 out of 5 microwaves, and 3 out of 6 refrigerators, with the potential to affect all residents by increasing the risk of food contamination and infection.Findings include:During an initial observation on 04/13/2026 beginning at 9:50 AM, in the kitchen, the floor was observed to be in an unsanitary condition, with accumulated food debris, grease buildup, and dried residue present under and around the food preparation and cooking equipment. In the Camelia Dining Room there was food spillage and residue present on the interior walls and bottom surface of the refrigerator and food debris present on the turnplate and interior surfaces of the microwave. In the Magnolia Nutrition Room there was food spillage and residue present on the interior walls and bottom surface of the refrigerator and food debris present on the turnplate and interior surfaces of the microwave. In Camelia Nutrition room [ROOM NUMBER] there was food spillage and residue present on the interior walls and bottom surface of the refrigerator. In Camelia Nutrition room [ROOM NUMBER] there was food debris present on the turnplate and interior surface of the microwave.During an observation on 04/15/2026 at 10:58 AM, the kitchen floor remained in an unsanitary condition with the presence of accumulated food debris, grease buildup, and dried residue under and around the food preparation and cooking equipment, indicating a failure to maintain ongoing sanitation practices.Review of the Dietary Services Policies and Procedures Manual, Section 7 - Sanitation and Infection Control: General Sanitation of Kitchen, last reviewed 08/26/2026, read, The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.During an interview on 04/13/2026 at 11:02 AM, the Registered Dietician stated the cleanliness of the kitchen and nourishment rooms was not to expectations and required improvement.During an interview on 04/13/2026 at 10:15 AM, the Kitchen Manager stated the condition of the kitchen floor was not acceptable and required cleaning.During an interview on 04/16/2026 at 12:10 PM with the Administrator and DON, it was confirmed a Performance Improvement Plan (PIP) related to kitchen sanitation was initiated on 04/06/2026; however, no progress had been made prior to the survey, indicating ineffective implementation of corrective actions.

Based on observation, interview, and record review the facility failed to ensure residents had a clean, homelike environment for 1 of 3 units. Findings include:1) During an observation on 4/13/2026 at 9:55 AM of Resident #112's bathroom the lower wall surface and baseboard area were noted to be in poor repair. The wall adjacent to the floor showed visible discoloration/staining, peeling or damaged wall finish, and areas of cracked or deteriorated caulking/paint along the baseboard line. The baseboard was separated or poorly sealed in portions, creating gaps. [Photographic evidence obtained]Review of the facility maintenance log dated 3/20/2026 read, [Resident #112 room] repair base board. 2) During an observation on 4/13/2026 at 10:25 AM of Resident #42's bathroom wall there was visible wall damage, peeling loose paint, gaps/holes, and staining. Sections were broken or missing. There was no baseboard present. [Photographic evidence obtained]Review of the facility maintenance log dated 2/17/2026 read, [Resident #42's name] bathroom wall. 3) During an observation on 4/13/2026 at 10:45 AM there was a beige upholstered recliner next to the exit door to the patio in the memory care common living area. There was a resident sitting on the recliner. Both armrests showed torn areas with exposed underlying material. During an observation on 4/15/2026 at 4:20 PM the beige upholstered recliner next to the exit door to the patio in the memory care common living area was not occupied. The chair's seat cushion and armrest exhibited significant wear and deterioration. The surface material was cracked extensively across the seat area, with visible peeling and splitting of the upholstery. Both armrests showed torn areas with exposed underlying material. During an observation on 4/14/2026 at 9:34 AM there was a built-in cabinet unit located in the common living area of the memory care unit. The cabinet included drawers and door compartments; the front of one of the drawers was missing exposing unfinished wood. During an interview on 4/16/2026 at 8:52 AM the Administrator stated, I observed it [the beige recliner in the memory care unit]. I cannot tell you the exact date. I am not as good about using the maintenance log. I am used to telling her [Maintenance Director] we need to replace this. I don't have a tracking of it. I would expect life safety issues to be immediate right away. If it's a maintenance issue she [Maintenance Director] has to prioritize.During an interview on 4/16/2026 at 9:34 AM the Director of Environmental Services and Plant Services stated, I am aware of that [the cabinet door]. I would have to look at the maintenance log to know how long it has been like that. We are waiting for more dry wall that is why it has not been repaired [Resident #42's bathroom]. We are aware of that [the beige recliner in the memory care unit]. Usually there will be a blanket over the recliner to cover it. We purchase two at a time [recliners]. I am missing one of the maintenance guys and the new fellow has not been here that long. I give them the materials and the order. If it says completed [the repair], I go back and check if it was completed. I have not gone back to check those two rooms. [Resident #112's and Resident #42's rooms].During an interview on 4/16/2026 at 9:34 AM the Director of Environmental Services and Plant Services confirmed the built in cabinet in the memory care unit was missing the front cover, the beige recliner had tears in the seat and both arm rests, and [Resident #112's and Resident #42's] bathroom dry wall and base boards were in need of repair.Review of the facility policy and procedure titled Homelike Environment with a last review date of 8/26/2025 read, Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on record review and interview, the facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) prior to admission for a resident's serious mental disorder for 1 of 6 residents, Resident #2, reviewed for PASRR. Findings include:1) Review of Resident #2's admission record documented the resident was admitted originally admitted on [DATE] with diagnoses to include panic disorder (onset date of 2/7/2020) and hallucinations (onset date of 4/6/2021).Review of Resident #2's Preadmission Screening Resident Review form dated 3/4/2025 did not document a diagnosis of hallucinations or panic disorder.Review of Resident #2's patient summary dated 3/3/2025 documented hallucinations as a confirmed diagnosis. Review of Resident #2's [Name of psychiatric provider] note dated 3/6/2025 read, Dx [Diagnosis]: 2: panic disorder {episodic paroxysmal anxiety} without agorahobia-F41.0 Staff to monitor, document and report worsening symptoms of anxiety symptoms: excessive worry, not able to control worry, restless/agitation, being easily fatigued, poor concentration, irritability, muscle tension, sleep disturbance, and panic attacks 3: hallucinations, unspecified - R44.3 Increase Seroquel 50 mg [milligrams] BID [twice a day].Review of Resident #2's physician order dated 3/6/2025 read, Seroquel 50 mg Tablet (Quetiapine) 50 mg by mouth twice daily for hallucinations, unspecified.Signed by: [Medical Doctor #1]: Last Dose 4/15/2026). During an interview on 4/16/2026 at 9:19 AM the Administrator stated, [Resident #2's name] Level I PASSAR needs to be updated.Review of the facility policy and procedure titled admission Criteria with a review date of 8/26/2025 read, 7. All new admissions and readmission are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admission, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 of 7 dietary service areas observed by failing to secure hazardous chemicals in areas not intended for resident use but accessible to residents, with the potential to affect all residents, increasing the risk of accidental ingestion, inhalation, and/or skin and eye exposure to harmful substances.Findings include:During an observation on 04/13/2026 at 10:11 AM, in the unsecured Dogwood Nourishment Room, two chemicals were observed stored in an unlocked lower cabinet, Odoban Deodorizer and Disinfectant and Aero Assault II Insecticide Aerosol. The nourishment room was located adjacent to the Dogwood residents' common living area, where eight residents were present at the time of the observation. Although not intended for resident use, the nourishment room was not secured and lacked a locking mechanism or other access controls, allowing residents the opportunity to inadvertently enter and access the chemicals.Review of Safety Data Sheet (SDS) information for Odoban Deodorizer and Disinfectant documented the product presents potential hazards, including skin and eye irritation, and indicates the product should be stored securely to prevent unintended exposure to vulnerable individuals.Review of Safety Data Sheet (SDS) information for Aero Assault II Insecticide Aerosol documented the product presents potential hazards, including inhalation toxicity and flammability, and includes instructions to avoid exposure and ensure safe storage to prevent access and potential harm to vulnerable individuals.During an observation on 04/13/2026 at 11:00 AM, in the cafe nourishment area, seven chemicals were observed stored in an unlocked lower cabinet, Fabuloso Multipurpose Cleaner, Clorox Bleach Germicidal Wipes, Odoban Deodorizer and Disinfectant, Micro-Kill Bleach Germicidal Wipes, Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, clear spray bottle labeled Delimer, and clear spray bottle labeled Vinegar and Water Window Cleaner. The cabinet was located in a nourishment area within the dining room accessible to residents walking through the area or eating in the dining room, creating the opportunity for inadvertent access to hazardous chemicals.Review of Safety Data Sheet (SDS) information for Fabuloso Multipurpose Cleaner documented the product may cause eye and skin irritation and should be handled and stored securely to prevent unintended exposure.Review of Safety Data Sheet (SDS) information for Clorox Bleach Germicidal Wipes documented the product contains sodium hypochlorite and may cause skin irritation, eye damage, and respiratory irritation if inhaled, and should be stored securely to prevent exposure.Review of Safety Data Sheet (SDS) information for Odoban Deodorizer and Disinfectant documented the product presents potential hazards including skin and eye irritation and should be stored securely to prevent unintended exposure.Review of Safety Data Sheet (SDS) information for Micro-Kill Bleach Germicidal Wipes documented the product contains bleach-based disinfectant agents and may cause irritation to the skin, eyes, and respiratory tract, and should be handled and stored securely to prevent exposure.Review of Safety Data Sheet (SDS) information for Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes documented the product contains hydrogen peroxide and may cause eye and skin irritation and should be stored securely in accordance with safety precautions to prevent unintended exposure.Review of Safety Data Sheet (SDS) information for the clear spray bottle labeled Delimer documented the product is an acidic cleaning agent that may cause skin burns, eye damage, and respiratory irritation depending on concentration, and should be clearly labeled and stored securely to prevent exposure.Review of Safety Data Sheet (SDS) information for the clear spray bottle labeled Vinegar and Water Window Cleaner documented the product may cause mild eye and skin irritation and should be appropriately labeled and stored securely to prevent unintended exposure.During an interview on 04/13/2026 at 11:00 AM, the Dietician stated all chemicals are expected to be kept in locked and secure locations to reduce the risk of exposure to residents.During an interview on 04/13/2026 at 11:04 AM, the Administrator stated all chemicals are expected to be locked and secured to ensure resident safety.

Based on interview and record review the facility failed to ensure physician ordered parameters were followed for blood pressure medications for 2 of 6 residents, Residents #73 and #46, reviewed for unnecessary medications. Findings include: 1) Review of Resident #73's admission record documents diagnosis to include essential primary hypertension, anemia unspecified, depression unspecified, hyperlipidemia unspecified, essential tremor, vitamin B12 deficiency anemia unspecified, history of falling, hypothyroidism unspecified, overactive bladder, generalized anxiety disorder, insomnia unspecified, personal history of healed traumatic fracture, and mild cognitive impairment of uncertain etiology. Review of Resident #73's physician order dated 9/16/2025 read, Metoprolol tartare 25 mg [milligram] tablet 1/2 tablet=12.5 mg by mouth twice a day daily for essential primary hypertension hold for HR [heart rate] < 65 or SPBP [systolic blood pressure] < 100. Review of Resident #73's Medication Administration Record [MAR] for March 2026 documented metoprolol tartare 12.5 mg by mouth was administered at 0800 [8:00 AM] on 3/13/2026 with a heart rate of 61, on 3/30/2026 with a heart rate of 63, and at 2000 [8:00 PM] on 3/21/2026 with a heart rate of 64, on 3/22/2026 with a heart rate of 63, on 3/23/2026 with a heart rate of 64 and on 3/27/2026 with a heart rate of 58. Review of Resident #73's MAR for April 2026 documented metoprolol tartare 12.5 mg by mouth was administered at 0800 on 4/10/2026 with a heart rate of 61, at 2000 on 4/1/2026 with a heart rate of 58, on 4/2/2026 with a heart rate of 62, and on 4/10/2026 with a heart rate of 60. During an interview on 4/15/2026 at 10:37 AM Staff N, Licensed Practical Nurse (LPN) stated, I did administer that metoprolol. Honestly, most of the time it's written for a heart rate of 60. But I should not have administered it. I should have followed the order and held it. During an interview on 4/15/2026 at 1:03 PM Staff F, Registered Nurse (RN) stated, I did administer his medications outside of parameters and should not have. During an interview on 4/15/2026 at 1:44 PM the Director of Nursing (DON) stated, They [licensed nurses] should have followed the physician orders for the parameters. They should not have given the medication. Review of the policy and procedure titled Administering Medications last approval date of 8/26/2025 read, Policy Statement: Medications are administered in a safe and timely manner as prescribed by nurses at the Good Samaritan Center. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, as necessary. 2) Review of Resident #46's physician order dated 10/22/2025 documented, Hydralazine 10 mg, give 10 mg by mouth every 8 hours; hold if systolic blood pressure is greater than 115. Review of Resident #46's Medication Administration Record (MAR) for March and April 2026 documented hydralazine was administered outside of the physician-ordered parameters on 03/04/2026 at 2:00 PM, blood pressure was 112/73; medication administered by Staff I, RN, on 04/01/2026 at 2:00 PM, blood pressure was 108/62; medication administered by Staff I, RN, on 04/07/2026 at 2:00 PM, blood pressure was 108/66; medication administered by Staff I, RN, and on 04/08/2026 at 2:00 PM, blood pressure was 104/58; medication administered by Staff I, RN. During an interview on 04/16/2026 at 10:37 AM, the Director of Nursing (DON) stated, It is the expectation that nurses administer medications in accordance with physician orders, including adhering to ordered parameters.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles in 2 of 3 units. Findings include: 1) During an observation on 04/13/2026 at 11:28 AM, in Resident #6's room, one white oval tablet was observed in a medication cup on the resident's bedside table. During an interview on 04/13/2026 at 11:28 AM Resident #6 stated the tablet was metformin. Review of the physician order dated 01/27/2025 documented, Metformin 1000 mg tablet – 1000 mg by mouth twice daily for type 2 diabetes mellitus with hyperglycemia. During an interview on 04/13/2026 at 11:31 AM, Staff J, RN, stated, Medications should not be left at a resident's bedside. During an interview on 04/16/2026 at 10:37 AM, the DON stated, When administering medications, nursing staff are expected to remain with the resident until all medications are taken and should not leave medications unattended at the bedside. 2) During an observation on 4/13/2026 at 10:30 AM Resident #25 was not in her room. On top of her bedside table there was a zinc oxide ointment. [Photographic evidence obtained] During an interview on 4/13/2026 at 10:57 AM Staff A, Licensed Practical Nurse (LPN) stated, That [zinc oxide ointment] should not be there. 3) During an observation on 4/13/2026 at 10:34 AM Resident #86 was not in her room. There were three ampules of ipratropium albuterol at bedside next to a nebulizer machine. Review of Resident #86's physician order dated 2/14/2024 read, Ipratropium 0.5 mg-albuterol 3 mg (inhalation every 6 hours as needed for SOB [short of breath]/Wheeze. During an interview on 4/13/2026 at 10:58 AM Staff A, LPN, stated, That [ipratropium albuterol] should not be in her [Resident #86's] room. During an interview on 4/13/2026 at 12:57 PM the Director of Nursing stated, Medication should not be left unattended at bedside. [Resident #6's name] would not be able to self-administer metformin that is not one of the medications we would allow self-administration here in the facility. Review of the facility policy and procedure titled Medication Labeling and Storage with a last review date of 8/26/2025 read, Policy statement: The Good Samaritan Center stores all medications and biologicals according to the manufacturer's recommendations in locked compartments under proper temperatures, humidity and light controls. Only authorized nursing and pharmacy personnel have access to keys.

Based on observation, interview, and record review the facility failed to ensure full and effective implementation of the facility's developed performance improvement plan to correct the facility's identified quality deficiencies for kitchen sanitation.Findings include:During an initial observation on 04/13/2026 beginning at 9:50 AM, in the kitchen, the floor was observed to be in an unsanitary condition, with accumulated food debris, grease buildup, and dried residue present under and around the food preparation and cooking equipment. In the Camelia Dining Room there was food spillage and residue present on the interior walls and bottom surface of the refrigerator and food debris present on the turnplate and interior surfaces of the microwave. In the Magnolia Nutrition Room there was food spillage and residue present on the interior walls and bottom surface of the refrigerator and food debris present on the turnplate and interior surfaces of the microwave. In Camelia Nutrition room [ROOM NUMBER] there was food spillage and residue present on the interior walls and bottom surface of the refrigerator. In Camelia Nutrition room [ROOM NUMBER] there was food debris present on the turnplate and interior surface of the microwave.During an observation on 04/15/2026 at 10:58 AM, the kitchen floor remained in an unsanitary condition with the presence of accumulated food debris, grease buildup, and dried residue under and around the food preparation and cooking equipment, indicating a failure to maintain ongoing sanitation practices.During an interview on 04/13/2026 at 11:02 AM, the Registered Dietician stated the cleanliness of the kitchen and nourishment rooms was not to expectations and required improvement.During an interview on 04/13/2026 at 10:15 AM, the Kitchen Manager stated the condition of the kitchen floor was not acceptable and required cleaning.During an interview on 04/16/2026 at 12:10 PM with the Administrator and DON, it was confirmed a Performance Improvement Plan (PIP) related to kitchen sanitation was initiated on 04/06/2026; however, no progress had been made prior to the survey. Review of the Dietary Services Policies and Procedures Manual, Section 7 - Sanitation and Infection Control: General Sanitation of Kitchen, last reviewed 08/26/2026, read, The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.Review of the facility QAPI [Quality Assurance Performance Improvement]-Dietary Kitchen Sanitation and Regulatory Compliance initiated 4/6/2026 read, Through the rounding process, ongoing concerns regarding kitchen sanitation have been identified. Plan: Provide additional training and performance improvement plan to Dietary Director with specific goals to include: Expected Performance Standards: Maintain full compliance with all dietary and sanitation regulations. Ensure inspection readiness with no repeat deficiencies. Maintain staffing schedule with adequate shift coverage. Implement scheduling app. Review/Understand Florida Statues (Labor Laws) Keep food cost within approved budget. Utilize order guides. Upload invoices. Community coffee orders should be online or in email so it can be tracked. Complete required documentation accurately and on time. Ensure staff receive appropriate training and on going education. Texture Modification (Minced & Moist, Soft & Bite Sized) Appropriate usage of Simply Thick. Respond to communication from colleagues. Maintain a 40+ hour per week schedule. Communicate hours worked and planned time off. Additional Action Plan: Conduct weekly sanitation and infection control audits. Hold Dietary Manager accountable for assigned audits, checking daily logs and reporting identified concerns. Review past deficiencies and implement ongoing corrective actions. Create schedule 2 weeks in advance. Implement app. Reduce overtime. Track weekly inventory and reduce waste. Accountability schedule: Weekly communication with NHA [Nursing Home Administrator] and with Dietician to review progress. 30 day review to assess improvements. Final 60 day evaluation. Consequences of Not Meeting Expectations. Failure to demonstrate consistent and sustained improvement in the areas outlined above may result in further disciplinary action, up to and including termination of employment.Review of Performance Improvement Plan (PIP). Employee Name: [Dietary Director's name]. Job Title: Dietary Director. Department: Dietary /Food Service. Date Initiated: April 6, 2026. Purpose: This Performance Improvement Plan is being implemented to address concerns related to department oversight, regulatory compliance, and operational effectiveness within the dietary department. The goal is to provide clear expectations and support to help achieve consistent performance standards. Areas of Concern: Inconsistent compliance with food safety regulations. Department of Health and internal audits reveal inappropriate food safety and storage. Continue to observe personal drinks and other items in serving areas. Food items continue to not be appropriately labeled, dated and rotated. Serving spoiled/molded food. Lack of overall follow up on deficiencies identified from internal audits including infection control observations. Scheduling concerns leading to coverage issues. Scheduling app not implemented. Lack of adherence to Florida Statute (Labor Laws) for scheduling guidelines. Inventory management concerns resulting in food cost overages. Community coffee order- Lack of documentation and follow up. Consistent department trainings, educations, and disciplinary actions are not occurring. Weekly rounding reports (for Joint Commission POC [Plan of Correction]) not being completed. Lack of response to emails from NHA, Dietician and other IDT [Interdisciplinary Team] members. Menus- changes and corrections submitted by Dietician have not been implemented. Financial Accountability-Invoices are not consistently being added to One Drive folder. Time and Attendance - not consistently working 40 hours per week and not consistently submitting time off request in advance in writing. Expected Performance Standards: Maintain full compliance with all dietary and sanitation regulations. Ensure inspection readiness with no repeat deficiencies. Maintain staffing schedules with adequate shift coverage. Implement scheduling app. Review/Understand Florida Statues (Labor Laws). Keep food cost within approved budget. Utilize order guides. Upload invoices. Community coffee orders should be online or in email so it can be tracked. Ensure staff receive appropriate training and on-going education. Texture Modification (Minced & Moist, Soft & Bite Sized) Appropriate usage of Simply Thick. Respond to communication from colleagues. Maintain a 40+ hour per week schedule. Communicate hours worked and planned time off. Additional Action Plan: Conduct weekly sanitation and infection control audits. Hold Dietary Manager accountable for assigned audits, checking daily logs and reporting identified concerns. Review past deficiencies and implement ongoing corrective actions. Create schedule 2 weeks in advance. Implement app. Reduce overtime. Track weekly inventory and reduce waste. Accountability schedule: Weekly documentation with NHA and with Dietician to review progress. 30 day review to assess improvements. Final 60-day evaluation. Consequences of Not Meeting Expectations. Failure to demonstrate consistent and sustained improvement in the areas outlined above may result in further disciplinary action, up to and including termination of employment. Acknowledgement. I acknowledge that I have reviewed the Performance Improvement Plan and understand the expectations outlined. Employee Signature [Dietary Manager Signature] dated 4/6/26. Dietician/Manager Signature/Date: [Dietician Signature] dated 4/6/26. NHA Signature/Date: [Administrator's Signature] dated 4/6/26.During an interview on 4/16/2026 at 8:37 AM the Administrator stated, We have a performance improvement plan regarding the dietary staff issue and that will probably be escalated. On 4/6/2026 we implemented a PIP regarding the staff member. If it is a one off observation you kind of deal with it and provide education and a corrective action. If a trend is identified it is taken to QAPI.During an interview on 4/16/2026 at 8:37 AM with the Administrator a request was made for additional information regarding education and audits related to the PIP.During an interview on 4/16/2026 at 1:10 PM the Administrator stated, Concerns were first identified on March 15, 2026. Then on April 1st we had a DOH [Department of Health] inspection. The issue is identified through rounding and identified concerns. DOH visit was the trigger, concerns were not addressed and we put in a performance improvement plan in place. As the DOH is doing the walk through they say concerns. Again, to me the PIP is implemented once we realize that our normal process is not followed. Part of the process is to audit and correct things we find in real time. We became aware of the issue by auditing and not seeing corrections. Audits show minimal improvements [audits were not provided]. Minimal improvement was sustained. These are the kinds of rounds done and communication. I would go back in and ensure that it was fixed. I don't necessarily have evidence that it was fixed. From my perspective it is never perfect, but when you start seeing the same things over and over that's when we initiated a formal process. Maybe this weekly rounding process is part of the quality assurance process. We were not seeing improvement that is why we initiated a formal improvement plan. As of 4/16/2026 at 1:10 PM no additional documentation was provided.Review of the facility 2025-2026 Quality Assurance & Performance Improvement (QAPI) Plan for Good Samaritan Center At Advent Christian Village read, Guiding Principles: Guiding principle #4: QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals. Guiding principles #6: GSC [Good Samaritan Center] sets goals for performance and measures progress toward those goals. Scope: Housekeeping. We provide and ensure that all health and sanitation requirements are met through regular cleaning, disinfection, and sanitation of all aspects of the building.Review of the facility policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program with a last review date 8/26/2025 read, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation: The objectives of the QAPI program are to: 1. provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and process related to the delivery of quality care and services 4. establish systems through which to monitor and evaluate corrective actions. Implementation: 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective actions/performance improvement activities and revising as needed.

Based on record review and interview, the facility failed to conduct a comprehensive assessment in accordance with the specified submission timeframes for 1 of 4 residents reviewed for discharge status, Resident #8. Findings include: Review of Resident #8's medical records showed the resident was admitted on [DATE] with diagnoses including fracture of upper end of right humerus, hypertension, chronic pain syndrome, GERD (Gastroesophageal Reflux Disease), and anxiety disorder. Review of Resident #8's physician order dated 5/23/2024 showed it read, Discharge Home with Home Health Care. PT [Physical Therapy] to Evaluate and Treat as Required. Review of Resident #8's Interdisciplinary Notes dated 5/22/24 showed it read, Today SW [Social Worker] informed [Resident #8's Name] that her last day of therapy is 05/27/24 and her daughter will be picking her up on 5/28/24. [Resident #8's name] agreed. Review of Resident #8's transfer history showed the resident was discharged to home on 5/28/2024 at 2:00 PM. Review of Resident #8's electronic file did not show a Discharge MDS (Minimum Data Set) Assessment conducted when the resident was discharged on [DATE]. During an interview on 10/29/2024 at 2:45 PM, the MDS Coordinator, RN (Registered Nurse), stated, [Resident #8's Name] discharged and went home. The discharge assessment was not opened. Review of the facility policy and procedure titled Resident Assessments with the last review date of 8/20/2024 showed it read, Policy Statement. A comprehensive assessment of each resident is completed at intervals designated by OBRA [Omnibus Budget Reconciliation Act] regulations and PPS [Prospective Payment System] requirements . Policy Interpretation and Implementation: 1. OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include . g. Discharge Assessment (return anticipated and return not anticipated).

Based on observation, interview, and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed for nutrition, Resident #84, for 2 of 4 residents reviewed for discharge, Residents #70 and #117, and for 1 of 5 residents reviewed for unnecessary medication, Resident #219. Findings include: 1) Review of Resident #84's physician order dated [DATE] showed it read, Soft and Bite Sized/Thin Liquids. Review of Resident #84's Quarterly MDS dated [DATE] revealed no nutritional approach of a mechanically altered diet. During an interview on [DATE] at 3:00 PM, the MDS Coordinator, Registered Nurse (RN), stated, It should have been triggered. Any diet that is not regular should be triggered. The dietitian is the one who fills out that section. It will have to be modified. During an interview on [DATE] at 1:00 PM, the Registered Dietitian stated, Based on [Resident #84' name] dietary order, the section for mechanically altered diet should have been coded in the assessment. 49777 2) Review of Resident #117's medical records showed the resident was admitted on [DATE] with diagnoses including fracture of unspecified part of neck of left femur, chronic obstructive pulmonary disease (COPD), and iron deficiency anemia. Review of Resident #117's interdisciplinary notes dated [DATE] at 8:30 AM showed that the resident was transferred to a local hospice facility in lake city at 12:27 AM. Review of Resident #117's MDS dated [DATE] showed the resident was discharged to short-term general hospital under section A2105- Discharge Status. During an interview on [DATE] at 3:01 PM, the MDS Coordinator, RN, stated, I did this one. I was sure [Resident #117's name] went to hospital. He should have been coded a 10- discharge status hospice (institutional facility). 49289 3) Review of Resident #70's nursing note dated [DATE] showed it read, Resident's body was released to [name of funeral home, city, and state] at 3:50 PM. Review of Resident #70's physician order dated [DATE] showed it read, Discontinue as of [DATE]; Release body to [name of funeral home, city, and state]; expired. Review of Resident #70's MDS dated [DATE] showed it read, Section A2105. Discharge Status . 08. Intermediate Care Facility. During an interview on [DATE] at 12:22 PM, the MDS Coordinator, RN, stated, I should have put [code] 13 for 'deceased ' not [code] 8 for Intermediate Care Facility. I don't know what happened. I coded it wrong. [Resident #70's name] was deceased . We use the electronic RAI [Resident Assessment Instrument] Manual for policies and procedures on the MDS process. We don't have a printed policy because the RAI Manual is updated so often. 50123 4) Review of Resident #219's physician order dated [DATE] showed it read, Plavix 75 mg [milligram] by mouth once daily. Review of Resident #219's MDS dated [DATE] revealed that the resident was not receiving antiplatelet medication under Section N0415: High Risk Drug Classes-Use and Indication. During an interview on [DATE] at 10:00 AM, the MDS Coordinator, RN, stated, The system automatically triggers the classes. [Resident #219's name] is taking Plavix. I need to modify it. Review of the facility policy and procedure titled Resident Assessments with the last review date of [DATE] showed it read, Policy Interpretation and Implementation . 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to accuracy of such information. 12. Information in the MDS assessment will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for behaviors for 1 of 4 residents reviewed for nutritional services (Residents #74). Findings include: 1) Review of Resident #74's medical record revealed the resident was admitted on [DATE] with the diagnoses including mood disorder, anxiety disorder, dementia, and chronic congestive heart failure. Review of Resident #74's care plan dated 1/17/2024 revealed a focus for nutritional status that read, [Resident #74's name] dietary needs are sufficient at this time related to adequate PO [by mouth] intake . (A [Approach]) Resident prefers to eat on the dining room. Further review of the care plan revealed a focus for activities that read, [Resident #74's name] has potential for altered activity pursuit pattern, is at risk for social isolation. There was no care plan focus or intervention for behaviors related to eating in the dining room. During an observation on 10/28/2024 at 12:40 PM, Resident #74 was sitting at a table by herself outside of the nursing station in front of the television in the resident common area. There were no other residents in the common area. Several residents were sitting together at the tables in the dining room waiting for the afternoon meal service. At 12:45 PM, Resident #74 received a meal tray in the common area and began to eat her food and drink her fluids. At 1:07 PM, Resident #74 entered the dining room and Staff A, Certified Nursing Assistant (CNA), redirected the resident back to her chair and table in the common area away from the dining room. During an interview on 10/28/2024 at 1:07 PM, Staff A, CNA, stated, We put [Resident #74's name] out in the common area by herself away from the other residents for all her meals. She gets up a lot and wanders around and she puts her hands in other resident's plates, so we keep her out here for meals. She tries to carry her tray around the unit. During an observation on 10/29/2024 at 12:30 PM, Resident #74 was sitting at a table by herself near a side entrance/exit to the outdoor patio. There were no other residents or staff in the common area. Several residents were sitting together at the tables in the dining room. At 12:55 PM, Resident #74 received her afternoon meal tray consisting of a bowl of taco meat and vegetables, and a cup of chocolate milk with a sip cover. Resident #74 ate by herself while the nursing staff assisted other residents in the dining room or in their rooms, with meal delivery and setup. Resident #74 remained alone until she finished eating at 1:10 PM when she brought her bowl and cup to the dining cart in the dining room. During an observation on 10/30/2024 at 7:52 AM, Resident #74 was sitting by herself near a side entrance/exit to the outdoor patio. There were no other residents or staff in the common area. Several residents were sitting together at the tables in the dining room waiting for the morning meal tray service. Resident #74 ate by herself in the common area until 8:10 AM when she brought her bowl and drink cup to the tray cart in the dining room. During an interview on 10/30/2024 at 8:10 AM, Staff B, Licensed Practical Nurse (LPN), stated, It's better for her to eat alone where we can watch her. I believe she is care planned for not eating in the dining room. During an interview on 10/30/2024 at 9:50 AM, the Director of Nursing stated, I know that staff often seat [Resident #74's name] by herself in the common area away from the other residents for her behaviors. She wouldn't be care planned for dining alone or away from the dining room. If her preferences are the dining room, then the care plan should be based on her behaviors, whether she eats in the dining room or not. Review of the facility policy and procedure titled, Care Area Assessments last reviewed on 8/20/2024, showed it read, Policy Statement: Care area assessments (CAAs) are used to help analyze data obtained from the MDS [Minimum Data Set] and to develop individualized care plans. Policy Interpretation and Implementation . 2. The care area assessments (CAAs) process consists of the following steps . c. Define the problem(s): (1) Identify the functional, physical, and/or behavioral implications of the problem(s) . d. Make decisions about the care plan . (2) Evaluate the resident's goals, wishes, strengths, and needs . e. Document interventions on the care plan. Review of the facility policy and procedures titled Care Plans, Comprehensive Person-Centered last reviewed on 8/20/2024, showed it read, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan . b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable psychical, mental, and psychosocial well-being, including . c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure expired foods and test strips were discarded in the kitchen and walk-in cooler areas and failed to ensure the equipment were cleaned to maintain sanitary standards (Photographic evidence obtained). Findings include: During a walk-through tour of the kitchen on [DATE] at 9:26 AM with the Dietary Manager (DM) and the Dietary Director (DD), the interior door of the ice machine had a black slimy buildup, the blender (chopper/grinder) had water nesting in the bottom of the base, the can opener had a buildup of dried food particles on and around the blade and base of the can opener, the walk-in cooler had three containers of cottage cheese with an expiration date of [DATE] and a nectar juice container dated [DATE]. The test strips for the sanitation solution had an expiration date of [DATE]. During an interview on [DATE] at 9:35 AM, the Dietary Manager (DM) verified the presence of a black slimy substance on the interior door of the ice machine, and confirmed that the can opener had food particles located on the blade and base, the blender bowl (chopper/grinder) should have been inverted to prevent wet-nesting, the blender bowl had water standing in the bottom from being washed and placed back on the base, and the test strips had an expiration date of [DATE], and stated that she was not aware that the test strips were expired. During an interview on [DATE] at 10:45 AM, the Dietary Director (DD) stated that the expired products should have been discarded according to the policy. Review of the facility policy and procedure titled Sanitation and Infection Control dated [DATE] read, 4. Food Storage: a. Food that is stored is protected from contamination and growth of any pathogenic organisms. b. Among the food protection measures that are performed by the dietary department are . Foods with expiration dates are used prior to the date on the package. Review of the facility policy and procedure titled Cleaning Food Preparation Appliances dated [DATE] read, Policy: Small appliances and food appliances such as mixers and food processors will be cleaned and sanitized after each use. Procedure . 4. Rinse parts with warm water and place in dishwasher or sink. Wash and rinse following procedures for automatic or hand dish washing. 5. Air dry.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: During an observation on 7/24/2023 at 10:19 AM, Resident #39 was lying in bed. There was a Cortizone-10 cream on top of the bedside table. During an interview on 7/24/2023 at 10:19 AM, Resident #39 stated, I use the cream when I have pain on my back side. Review of Resident #39's physician orders revealed no orders for Cortizone-10 cream or medication self-administration orders. Review of Resident #39's care plan revealed no medication self-administration intervention. During an observation on 7/24/2023 at 10:23 AM, Resident #322's room was empty. There was a medication cup containing white powder on top of the drawer in front of the bed, with a label reading ABD (abdominal) fold groin and Resident #322's last name. Review of Resident #322's physician order dated 7/13/2023 orders read, Nyamyc 100000 UNIT/GM [gram] Powder- Give 100000 UNIT/GM Powder by External Give 1 Thin Layer Daily during each of 2 shifts Every day at 7am-7pm, 7pm-7am. Review of Resident #322's care plan revealed no medication self-administration intervention. During an interview on 7/26/2023 at 12:12 PM, the Director of Nursing stated, We do not use Cortizone cream on [Resident #39's name]. I would not know where it came from or why she had it. The residents are able to order items from the village and have them delivered. I would think that the staff was going to do personal care on [Resident #322's name] and left it there. [Resident #322's name] has an order for Nystatin Powder. She would be able to apply it herself. I do not see self-administration in [Resident #322's name] care plan. I do not see a self-administration assessment on Resident #39 or Resident #322. Review of the facility policy and procedure titled Nursing Home List of Items Not Allowed in Resident Rooms, last reviewed on 8/21/2022, read, Medications: (includes all prescriptions and over-the-counter drugs, which must be ordered by the physician in the facility) . Noxzema or any medicated creams or powders . Note . Many of our residents, due to mental impairments or poor eyesight, might inadvertently drink or eat some of the above items causing irreparable harm.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards to prevent the possible development and transmission of infection during wound care for 1 of 2 residents reviewed for wounds, Resident #3 (Phoyographic evidence obtained). Findings include: During an observation of wound care for Resident #3 on 7/26/2023 at 9:33 AM with the Wound Care Nurse and the Risk Manager/Registered Nurse (RN), the resident's leg was resting on top of a pillow with a barrier over the pillow. The Risk Manager lifted the resident's right leg revealing stains to the wound dressing on the bottom at the right heel. The Wound Care Nurse removed the soiled dressing. The Risk Manager placed the resident's leg back down on the barrier. The Wound Care Nurse proceeded to clean the wound. The Risk Manager lifted the resident's right foot and the Wound Care Nurse cleansed Resident #3's right heel. Blood stains were observed on the middle portion of the barrier. After cleaning the wounds, the resident's leg was placed back down on the contaminated blood-stained barrier. The cleaned open heel wound came in contact with the contaminated barrier and the open wound on the back of the resident's leg rested on the contaminated barrier. The Risk Manager folded the edge of the contaminated barrier by placing both hands on the bottom portion of barrier. The Risk Manager lifted the resident's leg and touched the open wound located on the back of the resident's right leg. The Wound Care Nurse covered the wounds to the right heel areas and open knee wound areas. Resident #3's wound located on the back of the leg was left uncovered. The Wound Care Nurse began to wrap the resident's wounds with gauze roll. The Risk Manager put her hand on the gauze roll to prevent the roll from falling while the Wound Care Nurse was wrapping the resident's leg. The resident's right leg was wrapped with gauze and placed on top of the contaminated barrier. During an interview on 7/26/2023 at 10:04 AM, the Wound Care Nurse stated, I did not need [the Risk Manager's name] to roll the wound with me. We could have placed a clean pad down after cleaning the wounds. I am not sure if the heel touched the pad. She should have just stood there and supported the leg once we were ready to wrap. I did not want [Resident #3's name] leg to fall since she moves. There is a risk for infection. During an interview on 7/26/2023 at 10:07 AM, the Risk Manager stated, I could not see if the foot was touching the pad from where I was standing. I closed the pad into itself in trying to keep it from coming into contact with me. The wounds were covered when I touched the roll of gauze. Review of Resident #3's physician order dated 7/18/2023 read, Right heel: Cleanse with NS [Normal Saline] or wound cleanse. Pat dry. Slightly moisten 4x4 collagen sheet and apply to wound. Apply absorbent pad, wrap with gauze roll from the bottom of toes to below the knee. Daily and PRN [as needed]. May include all wounds in gauze wrap. 1 time per day, every day at 7:00 AM. Review of Resident #3's physician order dated 7/18/2023, read, Right Lateral ankle: Cleanse with NS or wound cleanse. Pat dry. Apply 2x2 xeroform to wound. Cover with absorbent pad, wrap with gauze roll from the bottom of toes to below knee. May include heel wound in wrap. Daily and PRN. 1 time per day, every day at 7:00 AM. Review of Resident #3's physician order dated 7/24/2023 read, Right lower lateral ankle, Cleanse with NS, or wound cleanse and pat dry. Moisten and apply 1x1 collagen to wound. Wrap with rolled gauze. 1 time per day, every day at 7:00 AM. Review of Resident #3's physician order dated 7/25/2023 read, Right shin/leg: Cleanse open blister areas with NS or wound cleanse. Pat dry. Apply xeroform to areas. Apply absorbent pad and wrap with gauze wrap. (may include all foot in wrap) 1 time per day, every day at 7:00 AM. During an interview on 7/26/2023 at 12:20 PM, the Director of Nursing stated, The wound should not have come in contact with the area [contaminated barrier]. Review of the facility policy and procedure titled, Wound Care, last reviewed on 8/21/2022, read, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in Procedure . 12. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on a clean field.

Based on record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for behavioral services (Resident #2), resulting in Resident #2 engaging in multiple occasions of escalating aggressive behaviors and an elopement. Findings include: Review of Resident #2's records revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set Comprehensive assessment dated [DATE], Section E, documented behaviors including hallucinations, other behavioral symptoms not directed at others, and wandering 4 to 6 days. Changes in behavior were documented as worse. Review of Resident #2's progress notes documented the following: Behavior note dated 9/15/22 at 5:59 PM reads, resident became anxious saying goodnight to spouse wandering around court exit seeking hard to redirect. Nursing note dated 9/16/22 at 12:37 PM reads, resident noted with half of his hair shaved, found a pair of small clippers in his bathroom . noted the screen [on window] was 1/2 pushed out. Behavior note dated 9/16/22 at 5:57 PM reads, resident becoming more anxious and wandering aimlessly . going into other's rooms and rummaging through other's belongings. He is not easily redirected. Behavior note dated 9/18/22 at 6:44 AM reads, resident ambulating around court . agitated, restless. Ambulating at a fast pace. Resident would come to the med [medication] cart, and staying closely behind this writer, limiting movement, then resident would reach into drawers on the med cart . CNA (Certified Nursing Assistant) went to check on resident . discovered resident in [another residents] room . resident was standing in the room with no clothes on, then walked over to bed B and started to place a pillow over resident's head, lying in the bed. Staff was able to redirect resident away from bed B, but resident (#2) refused to leave the room. Behavior noted dated 9/18/22 at 1:07 PM reads, resident continue to be anxious and exit seeking . he has been behind nurse's desk trying to go through the plastic bins, he was redirected, but it doesn't last for long, not making sense when he talk [sic]. [Advanced Registered Nurse Practitioner name] was notified and gave orders to give stat [MEDICATION(S)] 0.5 milligram (mg) now and then start [MEDICATION(S)] 0.5 every eight hours as needed for anxiety and agitation. Wife was notified of behaviors and new order and gave consent to give medication. Behavior note dated 9/18/22 at 11:11 PM reads, resident has been agitated and restless since shift began. Has been redirected away from med carts numerous times . placing his hands inside drawers, touching the computer, etc. (sic). Went into a room down 300 hall and was discovered partially clothed trying to do something to one of the beds. Resident was standing in front of a table, that had been placed in front of the window in 300 hall music room. Staff saw resident pick table up from the floor and was able to take table away from resident before he threw it through the window. PRN (Pro Re Nata - as needed) [MEDICATION(S)] 0.5 mg given at that time (10:30 PM) for agitation/restlessness. Behavior note dated 9/19/22 at 9:54 AM reads, resident pacing about court looking for car, hard to redirect. Nurse observed resident opening windows several times this AM. Nursing note dated 9/19/22 at 4:10 PM reads, new order received for [MEDICATION(S)] 0.5 mg TID (three times a day) spouse notified. Behavior note dated 9/20/22 at 6:45 PM reads, resident restless, pacing at frequent intervals, turning over chairs, removing items from med cart, removing fall decorations from countertops, going in and out of resident rooms, not easily redirected. Resident went on patio climbed brick wall, noted shaking wooden wall, not easily (redirected). Resident urinated on floor, went in another resident room, and removed all of his clothing, not easily redirected. Behavior note dated 9/21/22 at 7:15 AM reads, resident was pacing the common areas and moving furniture, trying to reach behind the nurses' station to grab items. Resident also was redirected from trying to enter other resident's rooms. He was disrobing walking down the halls. Behavior note dated 9/22/22 at 11:37 PM reads, resident out in common area at start of shift. Resident invading others privacy. Trying to touch some of the female resident and causing them to get agitated and yell at him. Behavior note dated 9/23/22 at 9:15 PM reads, resident came up to this writer and stated, How can you stand it here with all the evil spirits walking around. Asked resident what he meant, and he continued to state he sees evil spirits everywhere and that he doesn't see them all the time, but he sees them right now. Resident redirected. Behavior note dated 10/2/22 at 11:36 PM reads, Anxious tonight. Observed over the brick wall at start of shift easily redirected inside. Redirected out of other's rooms several times. Resident moving and lifting up furniture. Behavior note dated 10/6/22 at 1:35 AM reads, resident was agitated all evening until staff assisted him to bed. Resident turning over furniture, taking his shirt off. Holding on to other residents. Trying to jump over wall into nursing station. Resident not easily redirected. Behavior note dated 10/7/22 at 6:15 AM reads, resident up this morning pacing hallway. Agitated. Redirected numerous times out of female rooms. Resident yelled at this writer that was a bunch of bull that I tell him all the rooms are female. Resident going from door to door shaking the handles. Resident knocking over furniture trying to go out to the patio. This writer sat in a chair by patio and resident told me I was in on the scam involving drugs and money and I was going to regret it. Redirection unsuccessful. Resident grabbed the back of the chair and flipped it over with this writer sitting in it. As I was trying to get up off the floor, resident bolted through patio door and jumped the brick wall. This writer went out to try and get resident in due to it being cold and dark. Resident picked up a wind chime and threw it at me. Resident pacing around brick wall shaking white fence. Other staff came to help, and resident jumped on the brick wall and was halfway over white fence. We grabbed his legs, and he jumped back down. Resident continues delusional [sic]. Grabbed a shepherd's hook [previously holding wind chime] and started hitting the windows of 100 hall rooms. After several redirections, resident through [sic] the shepherd's hook. Resident continues to try and get over white fence with staff continually asking him to get down and come inside. Resident continues to talk about drugs and money and how we are in on it. Male staff came to patio to assist. Resident did not have any change in behavior. Resident picked up lattice and propped it up on the white fence and attempted to climb up it, but it broke. Resident picked up another wind chime and threw it on the roof. Resident kept grabbing this writer's arm and telling me to go. Nursing note dated 10/7/22 at 3:23 PM reads, provider [Staff B's name] notified of residents increased behaviors. New orders to start [MEDICATION(S)] 0.25 mg at 12:00 PM in addition to his 8:00 PM dose wife aware. Nursing note dated 10/08/22 at 6:45 PM reads, resident restless in AM, pacing hall at frequent intervals, later less restless. Resident refused 2:00 PM [MEDICATION(S)], denies dizziness states I don't want to take it anymore. Wife reported resident having hallucinations. Resident restless in evening, moving tables, taking down decorations, easily redirected, but requires frequent redirection. Elopement note dated 10/9/22 at 6:44 AM reads, This writer was informed by the [200 hall nurse's name] via phone at 3:48 AM on 10/9/22 that resident was combative, agitated and physically aggressive. [200 hall nurse's name] said she could not get through to switchboard to call the on-call provider. Then this writer received another phone call from [200 hall nurse's name] that the resident broke a window, and he eloped through the broken window, and that she just called 911. Review of the documentation provided by the facility on 11/17/22 showed [Name of Psychology Service Provider] onsite visits to Good Samaritan Center conducted by Staff A, ARNP (Advanced Registered Nurse Practitioner), providing services to residents on 9/20/22 and 10/4/22. During an interview on 11/17/22 at 2:12 PM, the Director of Nursing confirmed Resident #2 was on the list to be seen by psychology services but was not seen prior to the elopement. During an interview on 11/17/22 at 3:41 PM, the Medical Director/Resident #2's attending physician stated, I would have expected him to be seen on one of those occasions when [Name of Psychological Service Provider's Name] was in the building prior to the elopement. Review of the medical services agreement between [Name of Psychology Service Provider] doing business as (dba) [Name of Psychology Service Provider] and the facility dba Good Samaritan Center dated 4/1/22 reads, Facility hereby engages [Name of Psychology Service Provider] to provide the following services to its patients . psychiatry and psychology services. [Name of Psychology Service Provider] will provide engaged services to facility's patients on a weekly, biweekly, or monthly basis depending on the need of the facility which will be a mutually decided between [Name of Psychology Service Provider] and facility. The agreement was signed by the facility Administrator on 4/12/22 and by [Name of Psychology Service Provider] medical director on 4/1/22. Review of facility's assessment tool Section 1.3. reads, Indicate if you may accept residents with, or your residence may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Table 2: Common diseases, conditions, physical and cognitive disabilities. Category. Psychiatric/Mood disorders. [CONDITION(S)] (hallucinations, delusions, etc.), Impaired Cognition, Mental Disorder, Depression, [CONDITION(S)] Disorder, [CONDITION(S)], Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. Section VII. Part 2: Services and care we offer based on our resident's needs. Table 4. Mental Health and Behavior. Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[CONDITION(S)] (post-traumatic stress disorder), other psychiatric diagnosis, intellectual or developmental disabilities. Psychiatrist sees patients in the facility each month and is available for phone consultation 24/7. Review of the facility's policy titled Behavioral Health Services with a revised date of February 2019 reads, Policy Statement. 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation. 2. Residents who exhibit signs of emotional psychosocial distress receive services and support that address their individual needs and goals for care.

Based on interview and record review, the facility failed to ensure residents were assessed using the quarterly review instrument specified by the State and approved by Centers for Medicaid and Medicare Services not less frequently than once every 3 months for 1 of 2 residents sampled for Minimum Data Set (MDS) review, Resident #1, in a total sample of 46 residents. Findings include: Review of Resident #1's medical record revealed the resident had not been discharged from the facility during the time period from 10/20/2021 to 3/3/2022 and that Resident #1's most recent Minimum Data Set assessment was a significant change assessment which was completed on 10/20/2021. During an interview on 3/3/2022 at 9:06 AM, the Director of Nursing (DON) verified that Resident #1's most recent Minimum Data Set assessment was a significant change assessment, which was completed on 10/20/2021, and that Resident #1 had not had a comprehensive assessment conducted since that date. During an interview on 3/3/2022 at 9:16 AM, Staff D, MDS Registered Nurse, stated, [Resident #1's Name] has missed a quarterly MDS assessment. It will need to be completed. Review of the facility policy and procedure titled, MDS Completion and Submission Timeframes, reads, Policy Interpretation and Implementation: 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.

Based on observation, interview, and record review, the facility failed to ensure resident equipment was maintained in a sanitary and safe operating condition for 1 of 5 residents observed with wheelchairs, Resident #6, in a total sample of 46 residents. Findings include: Review of Resident #6's records revealed the resident was admitted on [DATE] with the diagnoses to include [CONDITION(S)] following cerebral infarction, hypertension, and history of falling. Review of Resident #6's care plan revealed the resident had self-care deficit and required extensive assistance in self-care abilities including dressing, toileting, bathing related to [CONDITION(S)] on left side. On 2/28/2022 at 2:02 PM, the surveyor observed Resident #6 in bed, awake, alert, and oriented to name and place. There was a wide wheelchair at bedside that was unclean with reddish colored stains and food debris on the brake handles, the tread on the wheelchair tires was almost completely worn off and in disrepair, and the left wheel was tilted outward. During an interview with Resident #6 on 2/28/2022 at 2:02 PM, when asked if her wheelchair had been cleaned or checked, Resident #6 stated, Not that I know of. On 3/2/2022 at 8:42 AM, the surveyor observed Resident #6 was up on her wheelchair. Wheelchair remained unclean, with dust buildup, food debris on break handle, and rust buildup. The tread on the wheelchair tires was almost completely worn off and the left wheel was tilted outward. During an interview on 3/2/2022 at 8:44 AM, Resident #6 stated she came in here over three months ago and stated, I came in here last November and had this same wheelchair and have not seen them clean my wheelchair. During an interview with the Director of Nursing (DON) on 3/2/2022 at 8:55 AM, when asked how often the wheelchairs were cleaned and maintained, the DON stated, I do not know. Let me ask housekeeping. The DON confirmed Resident #6's wheelchair was unclean and confirmed that the tires needed repair. During an interview with the Environmental Service Director (ESD) on 3/2/2022 at 9:26 AM, in the presence of the DON, stated that she was the Environmental Service Director (ESD) for the past [AGE] years. She stated the wheelchairs are pressured cleaned bi-annually, every 6 months by the housekeeping staff. The maintenance department does the preventive maintenance. We clean all the wheelchairs in the entire building, including shower chairs. We take them out court by court (Dogwood, Magnolia, and Camellia units) and pressure clean them. They were last cleaned on January 5, 2022 [Resident #6's name] wheelchair is unclean and has some rust, the wheels are tilted, and agreed that it [wheelchair] has not been pressure cleaned since last January. On 3/2/22 at 9:30 AM, the DON and ESD confirmed that Resident # 6's wheelchair was unclean and needed some repair or replacement. During an interview with the Maintenance Supervisor on 3/2/2022 at 10:49 AM, when asked about the facility's preventive maintenance (PM) process on residents' wheelchairs, he stated, We do not have a PM for wheelchairs. It is done as needed. I will receive a work order from the courts [facility units], then I go and check the wheelchair and do what is needed. I have not seen [Resident #6' name] wheelchair until today when I received a work order. He confirmed that Resident #6's wheelchair wheel was bent outward, and he had to remove some parts. When asked if he does maintenance rounding to check on equipment/wheelchair condition, he stated, I do, but I did not see her wheelchair. The CNAs are probably using the old work order system, so I am not getting the work order sheet. They are aware to use the new work order system. Review of the work order log from December 2021 to March 2022 did not reveal Resident #6's name on the log. Review of the facility policy and procedure titled Resident Wheelchair Cleaning last reviewed on 12/29/2021, reads, Policy: The intent of this policy is to establish a procedure for the proper and safe technique to be used for cleaning manually operated wheelchairs. Review of the facility policy and procedure titled, Preventive Maintenance Program, last reviewed on 12/29/2021, reads, Policy: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for the residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director or designee is responsible for maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director or designee shall inspect aspects of the physical plant to determine if Preventive maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, rounding, life safety requirements, or experience. 3. If preventive maintenance is required, the Maintenance Director or designee shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director or designee shall develop a schedule to assist with keeping track of all tasks. 5. Documentation shall be completed of all tasks and kept in Maintenance Directors' office.

Based on record review and interview the facility failed to ensure care plans were updated to reflect a resident was no longer receiving hospice services for 1 of 2 residents sampled for hospice services, Resident #56 in a total sample of 44 residents. Findings: During an interview on 10/20/20 at 12:25 PM with Staff C, Registered Nurse/Unit Manager for Dogwood Court it was stated, I know it was about three to four weeks ago that hospice told me verbally that the resident was to be discharged from hospice services because he was getting better. The resident is no longer receiving hospice services. I don't update the care plan. During an interview on 10/20/2020 at 12:57 PM with Staff D, Registered Nurse (RN), who works in the Minimum Data Set (MDS) Department, it was stated she completed the significant change in MDS to show the resident was no longer receiving hospice services on 08/26/2020. I did not update the care plan to show that the resident was no longer receiving hospice services. Review of the care plan revealed the resident was receiving hospice services. Dated 10/20/2020 the care plan revealed it had been updated but continued to reflect the resident is receiving hospice services related to incontinence and dementia. A review of the policy and procedure last reviewed 02/2020 reads: Care plans are reviewed and/or revised when there is a significant change to the resident's condition.

Based on observation, interview, and policy and procedure review the facility failed to ensure medications were labeled when opened on 2 of 3 medication carts reviewed, in a total of 8 medication carts, failed to remove expired medications from active medications in 1 of 2 medication storage rooms, and 1 of 3 medication carts reviewed, in a total of 8 medication carts, and failed to secure medications. Photographic evidence. Findings: 1. An observation on 10/19/20 09:39 AM of medication cart 2 for Dogwood Court showed in the working stock drawer one flex pen of [MEDICATION NAME] Insulin for Resident #1 was not labeled with the date the insulin was opened. An observation on 10/19/20 at 10:15 AM of the medication storage room for Dogwood Court showed in the working stock medication refrigerator a 180 ml (milliliter) bottle of liquid [MEDICATION NAME] Suspension for Resident #39 with an expiration date of 10/13/20. During an interview on 10/19/202 at 10:30 AM Staff A, Licensed Practical Nurse (LPN) stated, I don't know when the Insulin was placed in the medication cart for Resident #1. The [MEDICATION NAME] Insulin should have the date on it that the Insulin was opened. The [MEDICATION NAME] in the refrigerator for Resident #39 is expired and should have been thrown away. An observation on 10/19/20 at 9:57 AM of medication cart 2 for Magnolia Court showed in the working stock narcotic drawer one blister pack with a count of 29 [MEDICATION NAME] for Resident #44 expired on 08/31/2020 and one flex-pen of [MEDICATION NAME] ([MEDICATION NAME]) Insulin for Resident #94 was not labeled with the date the insulin was opened. During an interview on 10/19/2020 at 10:09 AM Staff B, LPN stated, I didn't realize that the [MEDICATION NAME] for (Resident #44's name) was expired. The medication should have gone to the Director of Nursing to be destroyed. The insulin for (Resident #94's name) doesn't have the date the insulin was opened. A review of the policy and procedure titled; Expiration Dating, Storage and Documentation reads: The date opened should be recorded on the product when first accessed. Insulin is to be kept refrigerated until opened. Vials may be kept at room temperature, in the medication cart, for 28 days after first puncture. Insulin vials - all types- discard 28 days after first puncture. A review of the policy and procedure revised April 2019 read discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. During an observation of Resident #13's room, she was in bed with her overbed table over the bed. On top of the table were two over the counter medications, a one-ounce tube of antibiotic ointment with an expiration date of 2018 and a container of eyedrops. The eyedrop bottle was visibly dirty with dark colored small substances on the lid. The ointment had squeeze indentations in the middle of the tube. During an interview with Resident #13 on 10/19/2020 at approximately 9:50 AM she said she used the eyedrops since the spring and s needs the ointment for her leg. During an interview with the Staff A, LPN and Resident #13 on 10/21/2020 at 9:52 AM when Staff A, LPN asked the resident regarding the medications the resident stated to Staff A, You gave it to me. Staff A removed the medications and informed the resident she could not have them at bedside at this time and to ask for the medications if she needs them. The LPN stated she did not know the resident had the medications. Review of Resident #13's Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. Review of Resident #13's facility medical record revealed the record did not contain an assessment for the self-administration of medications. The resident's [DIAGNOSES REDACTED]. Review of the Progress Note dated 6/11/2020 revealed, [MEDICAL CONDITION] with no further eye drainage noted at this time. Review of Resident #13's care plan revealed there was no care plan for the self-administration of medications or for medications to be left at the bedside. During an interview with the Administrator on 10/21/2020 at approximately 11:00 AM she confirmed Resident #13 was not assessed for self-administration of medications.

Based upon record review and interview, the facility failed to revise a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, sexual expression, privacy, and mental and psychosocial needs for 2 of 3 sampled residents. (Residents #s 1 and 2) Findings: Review of Resident #1's medical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) dated [DATE] - Admission - under Section C - Cognitive Patterns revealed short term and long-term memory problems, no memory recall ability, Cognitive Skills for Daily Decision Making: Severely impaired - never/rarely made decisions. C0100 Brief Interview for Mental Status - Resident is rarely/never understood (no score). Quarterly assessment dated [DATE] revealed under Section C - Brief Interview for Mental Status (BIMS) a summary score of 7 = severely impaired. Review of the Sexuality Assessment Form for Resident #1, dated [DATE], revealed, Review of the following questions to assist in assessing the resident 's consent and appropriateness of sexual expression. File this form in the resident's medical record. Initial Considerations: Does the resident express a desire to be involved in a sexual relationship? To your knowledge, is the resident free of [MEDICAL CONDITION]? Does the resident have the capacity to give consent to sexual activity? (The documented answer, Yes.) Privacy: Can the resident distinguish between private versus public behavior and information? Is the resident aware of the need for privacy? Is the resident aware of appropriate time and place to express affection? (The documented answer, Yes.) Awareness of Relationship: Is the resident aware of who is initiating sexual contact? Is the resident aware of who their partner is? (The documented answer, Yes.) Can the resident state what level of sexual intimacy they would be comfortable with? (Left blank.) Ask the resident: Do you know what it means to have sex? Well yes, I had 9 children. What would you do if you want it to stop? Hit him in the head .then laughed. What if your partner wanted it to stop? I'd stop I guess. Ability to Avoid Exploitation: Is the behavior consistent with formerly held beliefs/values? Does the resident have the capacity to say no to any uninvited sexual contact? (The documented answer, Yes.) Recent BIMS (Brief Interview for Mental Status)/MMSE score 6. Determination of capacity to consent to sexual expression: I believe she knows what she wants re: sexual intimacy. Was the resident representative notified? Yes. (The resident's daughter's name was documented.) The form was signed by Social Services, Nursing, and the Medical Provider - APRN/NP-C (Nurse Practitioner Registered Nurse/Nurse Practitioner Certified). Review of the Progress Notes completed by the attending RN dated [DATE] at 11:15 AM revealed: Resident was found in room with a male resident by CNAs (Certified Nursing Assistants names). Resident was laying crossways on the bed and male resident was sitting beside her. Upon CNAs entering the room, both residents stood and began buttoning their shirt. Each resident only had two buttons undone, her on the bottom of shirt by waistline and his on the top part of shirt, by the neckline. Assessment of resident showed no bruising, redness or other physical indication of sexual activity. She stated on examination that he's my husband. We're on our honeymoon. My first husband died in a car accident and so I don't want anything to go wrong with this one. Resident is smiling and has a positive mood and appearance. No indication of any distress. Review of the Progress Notes completed by Social Services dated [DATE] at 5:46 PM revealed Behavioral Review Comments - (Resident's name) was found in her room with male resident at approx. 1:45 sitting on her bed holding his hand. They were escorted out of the room at that time. At approx. 2:15 the aide was making rounds and heard a noise coming from (Resident's name) room and she knocked on the door but did not receive a response. She then entered the room and found (Resident's name) lying on her bed unclothed with a particular male resident fondling her breast and performing oral sex to her peri area. They were separated and res (resident) was dressed. Her family was notified. She continues to pursue him after they were back in the common areas. He was sent to the 200 hall and the doors were closed off. She has been placed on 15 min checks for the next 24 hrs. She is still looking for her 'husband.' Review of Resident #1's care plan revealed one behavior plan documented on [DATE]: Problem: (Resident #1's name) has been resistance to care, inappropriate sexual gestures and verbal/physical aggression toward others. Goals: (Resident #1's name) resistance to care will not escalate to becoming combative with staff or others. Approaches: Allow input to care to the greatest extent possible, goal date of [DATE] and Resident will be easily redirected when exhibiting inappropriate sexual gestures and when lashing out to others, goal date of [DATE]. The approaches dated [DATE] included: Approach in a bright and cheerful manner, establishing rapport before initiating care, attempt to separate from targeted male residents as much as possible, avoid arguing if refuses care, lashing out or displaying sexual gestures, call by name with approach, encourage diversional activities and if becomes agitate, slow down and reapproach or try a different caregiver. Approach dated [DATE] read Complete 30 minute checks on resident. Approaches dated [DATE] included Close doors to 200 hall several times throughout the day to encourage separation from male resident, meals will be in main dining room or on court away from a specific male resident, remind Resident that he is not her boyfriend or husband prn (as needed), and Approach dated [DATE] reads: Please check on my location every 30 minutes. Review of Physician's notes revealed Resident #1 was seen by the Medical Director whom also is Resident #1's attending Physician on [DATE] for a behavioral concern regarding another resident and herself. Physician note read, By closing the door to the room they expressed knowledge of knowing they wanted/ needed privacy. Appears to be consensual. Although she has dementia, she is aware her husband is deceased and the she likes (Resident #2's Name). Wants to be with him. It appears to be a mutual relationship. Review of Resident #1's care plan did not include any additional revisions or care plan identified problems relating to sexual activities and did not contain information from the Sexuality Assessment Form dated [DATE]. 2) Review of Resident #2's facility medical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS Review of the MDS dated [DATE] - under Section C - Cognitive Patterns revealed C0100 Brief Interview for Mental Status - Resident is rarely/never understood. The annual assessment revealed under Section C - Brief Interview for Mental Status a summary score of 2 = severely impaired. Review of the Sexuality Assessment Form for Resident #2, dated [DATE] revealed, Review of the following questions to assist in assessing the resident's consent and appropriateness of sexual expression. File this form in the resident's medical record. Initial Considerations: Does the resident express a desire to be involved in a sexual relationship? To your knowledge, is the resident free of [MEDICAL CONDITION]? Does the resident have the capacity to give consent to sexual activity? (Yes.) Privacy: Can the resident distinguish between private versus public behavior and information? Is the resident aware of the need for privacy? Is the resident aware of appropriate time and place to express affection? (Yes.) Awareness of Relationship: Is the resident aware of who is initiating sexual contact? Is the resident aware of who their partner is? (Yes) Can the resident state what level of sexual intimacy they would be comfortable with? (Yes.) Ask the resident: Do you know what it means to have sex? (Whoopie and smiled/laughed.) What would you do if you want it to stop? (Yes.) What if your partner wanted it to stop? (Well I guess so.) Ability to Avoid Exploitation: Is the behavior consistent with formerly held beliefs/values? Does the resident have the capacity to say no to any uninvited sexual contact? (Yes.) Recent BIMS/MMSE score 1. Determination of capacity to consent to sexual expression: (Although he cannot really verbalize he does seem to know and desire intimacy. His sister has told me many times that he has always been a ladies' man and liked the company of women.) Was the resident representative notified? (Yes.) (The resident's sister name was documented.) The form was signed by Social Services, Nursing, and the Medical Provider: APRN/NP-C (Nurse Practitioner Registered Nurse/Nurse Practitioner Certified). Review of the Progress Notes completed by the attending Registered Nurse dated: [DATE] at 11:09 AM revealed, At approx. 1630 (4:30 PM) (CNAs names) notified this writer that they had discovered resident in a female resident's room with female laying on bed crossways and the resident sitting beside her. Upon CNAs entering room, both residents immediately stood up. Resident began buttoning the top two buttons of his shirt and female was buttoning the bottom two buttons on her shirt. Both resident's pants were on and an assessment of the female did not indicate and (sic) sexual activity. Residents stated they had gotten married and were on their honeymoon. Review of the Progress note dated [DATE] - 5:51 PM completed by the Social Worker/Abuse Prevention, (Resident #2's name) was found in female resident room at approx. 1:45 PM sitting on her bed holding her hand. They were escorted out of the room at that time. At approx. 2:15 the aide was making rounds and heard a noise coming from female resident room and she knocked on the door but did not received a response. She then entered the room and found female resident lying on her bed unclothed with (Resident #2's name) fondling her breast and performing oral sex to her peri area. They were separated and female res (resident) was dressed. Review of the physician's clinical visit notes for Resident #2 for the period of [DATE] to [DATE] revealed there was no documentation/assessment by the physician of the resident having the capacity to consent to sexual activity. Review of Resident #2's Care plan revealed a behavioral problem dated [DATE] as (Resident #2's Name) has an attraction to females and has become sexually intimate, kissing, fondling etc. with a goal of (Resident #2's Name) will not have sexual interactions with female and a goal date of [DATE]. Approaches dated [DATE] read: Close doors to 200 hall several times throughout the day to encourage (Resident #2's Name) to stay on his hall and common area, eat meals in 200 hall as needed, Instruct the resident that he cannot have a sexual relationship with females prn, redirect resident away from females when exhibiting too intimate behaviors as needed. Approaches dated [DATE] read: Encourage diversional activities, outside time, tv, snack, etc., evaluated by psychiatrist [DATE] and medications changes were made, please check my location every 30 minutes to assure I am safe. Approaches: Evaluated by Psychiatrist now and as needed. Close doors to 200 hall several times during the day throughout the day to encourage (Resident #2's Name) to stay on 200 hall. Eat meals in 200 hall DR as needed. Encourage diversional activities; outside time, tv, snack, etc. Evaluated by Psychiatrist and medication changes were made. [MEDICATION NAME] started. Instruct resident that he cannot have a sexual relationship with females prn. Please check my location every 30 minutes to assure I am safe. Redirect resident away from females when exhibiting too intimate behaviors as needed. During interviews on [DATE] beginning at 11:15 AM with staff (Staff A, CNA; Staff B, CNA; Staff C, CNA; Staff D, CNA; Staff E, CNA; Staff F, CNA; Staff G, LPN; Staff H, CNA; and Staff I, CNA), All staff reported that if they found Resident #1 and Resident #2 engaged in any sexual activity, they would immediately separate them and redirect them. During an interview with the Psychiatrist on [DATE] at 4:21 PM via telephone, he stated, They are both definitely a little confused, they both have cognition to know what they are doing. The doctor (Medical Director) feels this was consensual behaviors. I believe that they both have the capacity to consent. During an interview with the facility's Medical Director on [DATE] at 12:41 PM, when asked, How was this determination of capacity to consent for Resident #1 made? How are you able to document these residents can give consent? Her response was (For Resident #1), Both in talking with her before in the clinic and seeing her here in the facility. I saw here two to three times. She has expressed a desire to be engage in a sexual relationship. They sit and hold hands. When they were caught together, they were behind a closed door indicating they understood they needed privacy. During a second interview with the psychiatrist on [DATE] at 4:36PM, when asked how he determined that Resident #1 was capable of consent to sexual activity? He responded, I was able to determine (Resident #1) was capable of consent for sexual encounters after speaking with the resident and reviewing notes from the Medical Director. When asked, How he determined that Resident #2 was capable of sexual consent? He responded, I was able to come to the determination that Resident #2 was capable of sexual consent after speaking with the resident, receiving the information from the Medical Director about his historical sexual behaviors information received from the family. He showed enough understanding to give consent. During an interview with the Assistant Administrator on [DATE] at 4:50 PM with the Assistant Administrator, she was asked, How soon does the information from the sexual assessment form get care planned? She responded, Should be done immediately by social worker. During an interview with [DATE] at 4:59 PM with the Administrator, she reported, Once a sexual assessment form has been filled out and the whole assessment is finished, the care plan should be updated. If two residents were found to be engaging in inappropriate relationships, staff would keep residents separated if a low BIMS. During an interview on [DATE] AT 9:16 AM with the Social Service Coordinator of the secured dementia unit, when asked, What was the process for the Sexual Expression Form? Her response was, I sent the completed form to the Unit Manager and then it is forwarded to the Medical Director or APRN (Advanced Practical Registered Nurse). We would then meet to discuss what our next step would be. Review of the facility policy entitled Sexual Expression, dated (MONTH) (YEAR), It is the policy of Good Samaritan Center to protect residents' right to sexual expression and to ensure that the privacy, conscience and dignity of consenting parties are recognized and respected. For the purposes of this policy and procedures, sexual expression is defined as: Words, gestures, movements or activities (including reaching, pursuing, touching or reading) which appear motivated by the desire for sexual gratification. Residents have the right to sexual expression provided that, in each instance, the activity does not involve: (a) non-consensual acts, (b) acts with minors, or (c) acts that impact negatively on the resident community as a whole through public display. It is our policy to protect residents' rights to be free of sexual abuse by ensuring that involved parties are consenting adults who are competent to give consent. It the case of older adults with physical and/or cognitive impairment, the above noted provisions apply in additional to an assessment by the clinical staff to insure consent and appropriate care planning. Procedure: Good Samaritan Center recognized that all persons are sexual beings, and that residents have the right to seek out and engage in sexual expression as defined above. Sexual expression, including auto eroticism, will be addressed by the clinical team according to the following guidelines: 2. Sexual expression between residents - Where residents have expressed a desire for sexual expression and both consent and have been determined to have capacity to consent, the faculty will ensure their rights to privacy and dignity are respected. Resident #2's care plan did not include any additional revisions or care plan identified problems relating to sexual activities and did not reflect the Sexuality Assessment Form information.

Based on interview and record review, the facility failed to resolve a resident grievance in a timely manner for one of two residents reviewed for grievances of 42 total sampled residents. Resident #69. Findings: During an interview with Resident #69 on 4/2/19 at 8:38 AM she stated, I am missing a pink gown. I reported to the social service man. He wrote it down, but I have not heard from him. During an interview with Staff A on 4/3/2019 at 8:32 AM stated that he is the social worker for the Dogwood Court. The social worker stated that Resident #69 reported to him about the missing pink gown last year in (MONTH) (YEAR). The social worker stated, Oh the phantom gown. When asked what he meant by phantom gown, he just smiled. When asked if he followed up with the resident about the missing phantom gown, he replied no. When asked if a grievance form was completed, he stated the Director of Social Service is responsible for that. A review of the residents' inventory of personal effects dated and signed by resident and a Certified Nursing Assistant (CNA) on 8/25/07 revealed the following items listed on the form: Blouses- 2 pink, and one is black with white strips. Housecoats/Robes - 2 - one is blue with pink flowers, and other is pink with purple and blue flowers. During an interview with the administrator on 4/3/2019 at 8:52 AM about the missing personal clothing, she stated she will check with the social worker. During a follow up interview with Staff A on 4/3/2019 at 9:12 AM, he stated he worked in the facility in social services for the past seven years. When asked what is the process when a resident reports to him missing personal items, Staff A replied, I complete a missing item form, and then talk to the administrator. Staff A stated that the resident reported to him the missing clothing last (MONTH) (YEAR) and he completed a missing item form. When asked if he had resolved the reported concern, Staff A shrugged head and shoulder in a negative fashion. During an interview with the Director of Social Services (DSS) on 4/3/2019 at 10:34 AM, she stated she worked in the facility for about two years. When asked what is the process when she receives a missing item form, the DSS stated that she reads them, logs them, has separate grievance log and a missing item log, then she reports to Quality Assurance (QA). First, she stated; they try to search for the missing item, at times we replace some things, but we do not claim responsibility for missing items. The DSS confirmed that Resident #69 reported the missing clothing to Staff A. On 4/3/2019 at 10:02 AM, the Director of Environmental Services (DES) approached this Surveyor with a pink gown in a plastic bag. The DES stated that she found an unlabeled pink gown in the laundry room today, 4/3/2019. The DES brought and offered the pink gown to Resident #69 and stated that the resident agreed to have the pink gown. On 4/3/2019 at 11:10 AM, DSS presented a Report of Lost item dated 8/17/2018 for Resident #69. Under report of circumstances it read, Reported that a pink nightgown had been missing for a week. She described it as pink with lace on the front. Laundry Staff notified. Under results it reads, The item has not been located at this time. On 8/17/2018 item reported missing is not listed on inventory sheet. There was an addendum note at the bottom of the form with the initial JD that read, On 4/3/2019, I spoke to Resident's daughter, she was unable to recall having this item. Today, resident claimed a pink housecoat as the missing item/pink nightgown with white lace. Staff do not believe the nightgown was ever a part of her wardrobe. Staff A confirmed at 11:30 AM that he wrote the addendum notes today, 4/3/2019, eight months after the grievance was initially reported to him by Resident #69. An interview with the Administrator and Director of Social Services on 4/3/2019 at 10:22 AM confirmed that grievances are resolved promptly but unable to define the appropriate time line for a prompt resolution. The Administrator stated that we try to resolve the grievance immediately, if possible. During an interview with Resident #69 on 4/3/2019 at 11:18 AM, she stated, Someone brought in a pink gown this morning and asked me if it was the missing gown. It was not the gown that I got missing. She offered if this pink gown will replace my missing gown and I agreed, it is better than nothing. It took them that long to resolve this if you never came to help me. Review of the Residents' Grievance Policy and Procedure has no review or revision dates. Policy read: As a resident of Good Samaritan Center you and your family have the right to voice and file grievances that you are unable to resolve. Grievances are complaints about situations such as treatment, care, management of funds, billing, violation of rights, lost items, the behavior of other residents toward you. Your grievance will be addressed promptly and without discrimination or reprisal. Page 2 of the policy read, The completed Resident Grievance form will be forwarded to the designated Social Worker who will attempt to resolve the grievance to the resident/responsible party's satisfaction. The Good Samaritan Center staff will make prompt efforts to resolve grievances. If the resident/responsible party does not feel that the grievance has been satisfactorily resolved, then a conference may be arranged with the nursing home Administrator.

Based on interview and record review, the facility failed to ensure each resident received necessary care and services in timely manner to prevent mental anguish for 1 of 38 sampled residents .(#113) The findings include: 1. A review of the grievances for the facility, revealed a grievance dated 8/12/13, by the wife of resident #113, which stated the wife had told her husband's Certified Nursing Assistant (CNA) on 8/10/13 at 10:30 AM that her husband had had a bowel movement. The CNA stated "she would wait a few minutes, eat something and come back and check him in case he wasn't finished going." It further stated, the wife of the resident, reported it to the nurse. The CNA " returned over 30 minutes later to perform requested care." The grievance further stated on 8/11/13 at 10:30 am, the wife of the resident again requested the CNA give incontinence care to her husband as he had a bowel movement. The same CNA "told her she would go to lunch and care for" the resident when she returned. The grievance went on to state the CNA provided care for incontinence of bowel after 11:00 AM. The grievance revealed the Social Services person spoke with the CNA on 8/14/13 and the CNA "validated that she did decide to eat something on Saturday and then extended her snack to a lunch time without telling anyone so" resident #113 "could get help." The grievance form continued that the CNA "did not exactly recall what happened Sunday, but that she probably did take her lunch without assisting him first or telling any staff." A review of the resident's closed clinical record revealed a Quarterly Minimum Data Set assessment, dated 6/19/13, which revealed resident #113 was coded as needed total assistance for toileting. A review of the resident's Care Plan, with a start date of 12/27/11, revealed an approach for Assistance for Daily Living as "Check with me for needs prior to leaving my room." A care plan for no control of bowel and bladder started 12/27/11 stated "check and change ATC (around the clock) to maintain clean, dry and odor free." An interview with the Abuse Prevention Coordinator, who was also the director of Social Services, on 11/19/13 at 3:36 PM, revealed she did not identify the grievance made by the wife of resident #113 as an allegation of neglect, thus did not report the incident to appropriate agencies or protect resident during investigation.

Based on interview and record review, the facility failed to implement their policy and procedure for reporting, investigating and protecting residents during an investigation when allegations of neglect were made for 2 of sampled residents. The findings include: A review of the facility policy and procedure for Abuse, Neglect and Exploitation revealed the following policy statement "It is the policy of the Good Samaritan Center that during the course of an abuse investigation, the victim of the alleged abuse will be protected from further harm and or exploitation." It further stated "All alleged violations and all substantiated incidents will be reported to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation." It even further states"The Abuse Coordinator will report all allegations to Adult Protective Services," 1. A review of the grievances for the facility revealed a grievance dated 8/12/13, by the wife of resident #113, which stated the wife had told her husband's Certified Nursing Assistant (CNA) on 8/10/13 at 10:30 AM that her husband had had a bowel movement. The CNA stated "she would wait a few minutes, eat something and come back and check him in case he wasn't finished going. It further stated, the wife of the resident, reported it to the nurse. The CNA " returned over 30 minutes later to perform requested care." The grievance further stated on 8/11/13 at 10:30 am, the wife of the resident again requested the CNA give incontinence care to her husband as he had a bowel movement. The same CNA "told her she would got to lunch and care for" the resident when she returned. The grievance went on to state the CNA provided care for incontinence of bowel after 11:00 AM. The grievance revealed the Social Services person spoke with the CNA on 8?14/13 and the CNA "validated that she did decide to eat something on Saturday and then extended her snack to a lunch time without telling anyone so" resident #113 "could get help." The grievance form continued that the CNA "did not exactly recall what happened Sunday, but that she probably did take her lunch without assisting him first or telling any staff." A review of the resident's Quarterly Minimum Data Set assessment dated [DATE] revealed resident #113 was coded as needed total assistance for toileting. A review of the resident's Care Plan with a start date of 12/27/11 revealed an approach for Assistance for Daily Living as "Check with me for needs prior to leaving my room." A care plan for no control of bowel and bladder started 12/27/11 stated "check and change ATC (around the clock) to maintain clean, dry and odor free." An interview with the Abuse Prevention Coordinator, who was also the director of Social Services, on 11/19/13 at 3:36 PM, revealed she did not identify the grievance made by the wife of resident #113 as an allegation of neglect, thus did not report the incident to appropriate agencies or protect resident during investigation. 2. A review of the closed clinical record for resident #198 revealed a document entitled "Certificate of Professional Initiating Involuntary Examination" dated 9/17/12. The document stated resident #198 had hit a resident in the face with his fist and grabbing her arm with such force and grip that several staff were required to pry his hands loose." The document was completed by the Clinical Social Worker who was also the Abuse Prevention Coordinator. Further review of the clinical record revealed a Nurses progress note dated 9/16/12 which stated a resident was seated in front of her recliner when resident #198 walked in front of her." The female resident told resident #198 to get away from her and resident #198 "stood up and hit her on the right side of her face with a closed fist, then he grabbed her left arm causing a huge skin tear before staff was able to intervene. It took several staff members to peel his hands off of her, then a male CNA was able to escort him to his room and place him in his recline." Further review of nurses progress notes revealed resident #198 had been aggressive toward others on 9/2/12; punching a nurse in the stomach, 9/3/12; hitting at staff during care, 9/5/12; grabbing a resident's pant leg and "beginning to get aggressive, 9/12/12; "several episodes of aggression" "threw a roll of garbage bags across the room", 9/13/12; "picked up chair and threw "it toward window while standing inside the doorway, then turned and picked up 3 hole punch from shelf raising it over his head." The facility provided no evidence a thorough investigation was done regarding the resident to resident aggression. No evidence was provided to indicate the facility investigated to determine if the incident could have been prevented by sufficient staffing and supervision or if the resident had a care plan for aggressive behaviors and the care plan was implemented and was or was not effective, etc. The facility provided no evidence that the incident was reported to the appropriate state agencies. An interview with the Abuse Prevention Coordinator and the Administrator on 11/19/13 at 3:30 PM revealed the facility did not report the incident to the appropriate state agencies and neither identified the incident as possible neglect for resident #198 or his victim.

Based on record review and interview, the facility failed to ensure sufficient supervision for 1 of 38 sampled residents (#198). The findings include: A review of the closed clinical record for resident #198 revealed a document entitled "Certificate of Professional Initiating Involuntary Examination" dated 9/17/12. The document stated resident #198 had hit a resident in the face with his fist and grabbing her arm with such force and grip that several staff were required to pry his hands loose." The document was completed by the Clinical Social Worker who was also the Abuse Prevention Coordinator. Further review of the clinical record revealed a Nurses progress note dated 9/16/12 which stated a resident was seated in front of her recliner when resident #198 walked in front of her." The female resident told resident #198 to get away from her and resident #198 "stood up and hit her on the right side of her face with a closed fist, then he grabbed her left arm causing a huge skin tear before staff was able to intervene. It took several staff members to peel his hands off of her, then a male CNA was able to escort him to his room and place him in his recline." Further review of nurses progress notes revealed resident #198 had been aggressive toward others on 9/2/12; punching a nurse in the stomach, 9/3/12; hitting at staff during care, 9/5/12; grabbing a resident's pant leg and "beginning to get aggressive, 9/12/12; "several episodes of aggression" "threw a roll of garbage bags across the room", 9/13/12; "picked up chair and threw "it toward window while standing inside the doorway, then turned and picked up 3 hole punch from shelf raising it over his head." The facility provided no evidence supervision was increased for the resident prior to 9/16/12 when the aggressive episode occurred and the resident hit a peer in the face. After that incident and before the resident was removed from the facility, for an involuntary examination at a psychiatric facility, the facility provided the resident with 1-1 supervision. The facility provided no evidence a thorough investigation was done regarding the resident to resident aggression. No evidence was provided to indicate the facility investigated to determine if the incident could have been prevented by sufficient staffing and supervision.