Every finding on record at Jacksonville Rehabilitation and Nursing

Based on observations, interviews, record review, and a review of facility in-service training, the facility failed to follow proper dish sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents receiving food from the facility's kitchen. The facility also failed to log proper temperatures for the dish machine. Sanitation is important in health care settings serving nursing home residents. The findings include:On 04/27/2026 at 9:50 AM, during an interview with Dietary Aide (DA) C, she was asked if she was the person responsible for cleaning the residents' dishes and operating the facility's low-temperature dishwasher. She replied yes. She was asked to demonstrate her process for cleaning the dishes. She ran the dishwasher. The temperature on the machine's temperature gauge did not change and remained at 120 degrees Fahrenheit. She did not test the sanitation level. She did not record the temperature or the sanitation level on the dishwasher log. She was asked to demonstrate her process again. She asked if she could get another employee to assist her. Dietary Director (DD) F ran the dishwasher. The temperature gauge remained at 120 degrees Fahrenheit. DD F tested the sanitation level in the machine. The testing strip did not change colors. DD F replaced the sanitation bucket connected to the dishwasher. DD F ran the dishwasher again. The temperature gauge remained at 120 degrees Fahrenheit. The facility moved to serving food on paper products.An observation of the kitchen's dish machine log for the months of November 2025, December 2025, January 2026, February 2026, March 2026, and April 2026 revealed a consistent temperature recording of 140 degrees Fahrenheit for the rinse and wash after breakfast, lunch and dinner. Dietary Aide (DA) C ran the dishwasher once and the temperature gauge remained at 120 degrees Fahrenheit. Dietary Director F ran the dishwasher twice and the temperature gauge remained at 120 degrees Fahrenheit. A review of dishwasher in-service training dated 04/27/2026, the date of the above mentioned observations, revealed:Aides must run the dishwasher twice before washing dishes. First run make sure that the temperature (temp) (120-140) is accurate and then prime the sanitizer for accurate ppm (parts per million) (50-100). Second run is to double check temp make sure temp is moving between (120-140). After checking the temp, get a test strip and test sanitizer. Sanitizer ppm must be between (50-100). If thermostat don't move from 120, use a thermometer to make sure the temp is correct. Please inform your supervisor if thermostat is not moving.The policy and procedure provided did not address the issue of concern. Furthermore, no other kitchen policy was supplied prior to the exit interview.

Based on observations and interview, the facility failed to ensure that ten (Residents #20, #119, #129, #8, #110, #77, #62, #72, #87 and #120) of 66 residents sampled, had adequately equipped communication systems allowing them to call for staff assistance and relaying the call directly to a staff member or to a centralized staff work area from each resident's bedside. Failing to ensure each resident has a working call light for summoning staff when assistance is needed can result in preventable falls, increased pain and anxiety. The findings include:A tour of the facility began on 04/28/2026 at 11:32 AM. During the tour several call lights on the third floor were found to be inoperable (rooms 301A, 301B, 302A, 302B, 303B, 303C, 304A, 304B, 307A, 307B, 307B, 307B, 307C and 308B). The call light box for 308C was disconnected from the wall socket and there was no call light in room [ROOM NUMBER]C at 11:45 AM. (photographic evidence obtained)On 04/29/2026 at 10:45 AM, an interview was conducted with the Director of Maintenance. He was asked if there were any concerns with the call light system. He stated there had been some concerns with some of the facility's call lights in the past but it doesn't happen often. He stated the call lights may have needed to be reset. While seated at the nurses' station on the third floor, he began to press several buttons on the call light box which revealed two error alert messages: Critical Alert. A critical alert has been detected in the Dome Light system, and Warning. A problem has been detected in the Wireless Devices system. This system may be partially functional. The system gave the same error alert for rooms #313A, 313B and 313C. (photographic evidence obtained) He again stated the system may need to be reset. He then went into an engineering room located near the nurses' station on the third floor. When he returned to the nurses' station he began pressing several buttons again. All of the error alerts remained illuminated. He then unplugged the system. He waited a few minutes before plugging it back in. There were no changes. The error alerts remained. He could not provide any evidence and/or documentation of previous repairs and/or replacements for the call lights identified. He was asked to conduct a tour of the rooms where concerns with call lights had been identified. The call lights were tested. The call lights in rooms 301B, 302A, 302B, 303B, 303C, 307B, 307C and 308B remained inoperable and did not illuminate outside of the residents' room doors or at the call box located at the nurses' station. He confirmed that the call light in 308C would need to be secured into the wall. The Maintenance Director stated he would have to notify facility administration about the inoperable call lights.A tour of room [ROOM NUMBER]C was conducted on 4/29/2026 at 11:01 AM with Unit Manager/Licensed Practical Nurse (LPN) S. She was asked about the missing call light. She stated she was not sure what had happened to the resident's call light and that he should have had one. She stated that she would notify the Maintenance Director.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections, by failing to 1) Ensure nursing staff properly performed hand hygiene while working with three (Residents #93, #70 and #74) of six residents observed during medication administration, and 2) Ensure urinary catheter bags did not rest on the floor for one (Resident #107) of nine residents observed with urinary catheters. The findings include:1.During an observation of medication administration on 04/30/2026 at 7:55 AM, Licensed Practical Nurse (LPN) A proceeded to pull medications from the medication cart for Resident #93 then entered Resident #93's room without performing hand hygiene upon entering. LPN A administered Resident #93's medications and exited the resident's room without performing hand hygiene. Upon returning to her medication cart at 8:00 AM, she proceeded to pull medications from the cart for Resident #70 then entered Resident #70's room without performing hand hygiene upon entering. LPN A administered Resident #70's medications and exited the resident's room without performing hand hygiene.2.During an observation of medication administration on 04/30/2026 at 8:10 AM, LPN B proceeded to pull medications from the medication cart for Resident #74 then entered the resident's room without performing hand hygiene upon entering. LPN B administered Resident #74's medications and exited the resident's room without performing hand hygiene.During an interview on 04/30/2026 at 8:30 AM, when asked to provide the policy regarding hand hygiene, the Director of Nursing (DON) expressed disappointment with his staff regarding their failure to perform hand hygiene appropriately. The DON then provided an in-service training attendance record with directives written out to perform hand hygiene . before preparing or administering medications, before opening the medication cart, before handling medication packages, before pouring/preparing meds, and to perform hand hygiene before/after each resident.A review of the facility's policy and procedure titled Hand Hygiene (reviewed January 16, 2025), revealed:Policy Explanation and Compliance Guidelines: 6.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.3. On 4/27/2026 at 12:02 PM, Resident #107 was observed lying in bed. His urinary catheter bag was lying on the floor beside his bed. (photographic evidence obtained)On 4/29/2026 at 4:45 PM during an interview with Certified Nursing Assistant (CNA) N, she was asked if she was caring for Resident #107. She stated yes and confirmed that she provided urinary catheter care for this resident. She was asked if the urinary drainage bag should be resting on the floor. She stated, No, the bag should never touch the floor.On 4/29/2026 at 4:55 PM, during an interview with Registered Nurse (RN) O, he was asked if he cared for Resident #107. He confirmed that he did. When he was asked about preventative interventions to try to minimize possible infection from the urinary catheter, he replied that good hand hygiene, changing gloves constantly, and keeping the catheter as clean as possible were important. He said the catheter/bag should never touch the floor. He was asked to observe Resident #107's urinary catheter bag. He confirmed that the resident's urinary catheter bag was resting on the floor. (photographic evidence obtained) He stated, Yes, I see it's on the floor. Sometimes when the beds are in low position like his is, the bags will touch the floor.

Based on observations, interviews, record review and a review of the facility's policies and procedures, the facility failed to provide a nourishing, palatable, and well-balanced diet that met the daily nutritional and special dietary needs of its residents, taking into consideration their preferences, by failing to adhere to therapeutic diet orders for a pescatarian diet and follow standardized recipes and portion control in accordance with professional standards for food service. These practices affected nine residents/resident meal trays (Residents #86, #24, #39, #75, #88, #61, #73, #28 and #81) observed during meal service on 4/27/26 and 4/30/26 and placed all residents receiving food from the facility's kitchen at nutritional risk, potentially impairing their ability to heal and/or contributing to a decline in their overall health status. The findings Include:1.On 04/27/2026 during the lunchtime dining observation on the 300 hallways between 11:30 AM and 1:00 PM, Resident #86's meal tray revealed two vegetable servings and one fruit serving. Her meal ticket identified her diet as No Added Salt (NAS), Mechanical Soft texture, dislikes chicken and pork; other: Pescatarian. Resident #86 reported that the meal components received were what the kitchen provided because she was a Pescatarian (someone who follows a vegetarian diet but adds fish and other seafood). (photographic evidence obtained)During a tour of the kitchen on 04/29/2026 at 10:56 AM, Resident #86's meal ticket identified her diet as No Added Salt (NAS), Mechanical Soft texture, dislikes chicken and pork; other: Pescatarian; Resident #86 was provided one vegetable and two starch servings. (photographic evidence obtained)On 04/30/2026 at 11:45 AM, another tour of the kitchen was conducted. The lunch menu on the tray line included drumettes/wingettes, French fries, green beans and a dessert. [NAME] E stated a serving of protein was four drumettes/wingettes.2.During tray line service on 04/30/2026 at 11:45 AM, Resident #24's meal ticket identified his diet as Consistent Carbohydrate Diet (CCD), NAS, large portions (one serving). Resident #24 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving. 3. During tray line service on 04/30/2026 at 11:45 AM, Resident #39's meal ticket identified his diet as General Regular, large portions (one serving). Resident #39 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving.4. During tray line service on 04/30/2026 at 11:45 AM, Resident #75's meal ticket identified his diet as Consistent Carbohydrate Diet (CCD), NAS, large portions (one serving). Resident #75 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving. 5. During tray line service on 04/30/2026 at 11:45 AM, Resident #88's meal ticket identified his diet as General Regular, large portions (one serving). Resident #88 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving. 6. During tray line service on 04/30/2026 at 11:45 AM, Resident #61's meal ticket identified his diet as General Regular, large portions (one serving). Resident #61 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving. 7. During tray line service on 04/30/2026 at 11:45 AM, Resident #73's meal ticket identified his diet as General Regular, double portions (one serving). Resident #73 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving.8. During tray line service on 04/30/2026 at 11:45 AM, Resident #28's meal ticket identified his diet as General Regular, double portions (one serving). Resident #28 was provided with one protein serving (4 drumettes/wingettes), one vegetable and one starch serving. (photographic evidence obtained)9. During tray line service on 04/30/2026 at 11:45 AM, Resident #81 was provided with an alternate meal(two sandwiches). No vegetables were provided. The resident's diet order was for a Regular, Mechanical Soft, Regular/Thin consistency, nutritional supplement three times a day, snacks three times a day.On 04/30/2026 at 2:03 PM, Dietary Aide (DA) C was asked to explain the process that occurred when the kitchen ran out of the vegetable that was listed on the menu. She replied, offer another vegetable. She was asked to explain what happened when the kitchen ran out of the protein that was listed on the menu. She replied, serve the alternate protein or meat. DA C was asked how often the kitchen provided substitutes. She replied, just this week. She was not aware of whether or not substitutes were documented or tracked. She was asked what was considered a large portion. She replied, large starch, large vegetable. She was asked what was considered a double portion. She replied, double the meat, vegetable and starch.On 04/30/2026 at 2:18 PM, DA D was asked to explain the process that occurred when the kitchen ran out of the vegetable that was listed on the menu. She replied, they provide something else/another food item. She was asked to explain what happened when the kitchen ran out of the protein that was listed on the menu. She replied, it would be the same. She was asked how often the kitchen provided substitutes. She said she was not sure but stated it happens sometimes. DA D was asked what was considered a large portion. She replied, If macaroni is served, provide 2 scoops/servings of macaroni. She was asked what was considered a double portion. She replied, If a sandwich is served, provide two sandwiches.On 04/30/2026 at 2:30 PM, [NAME] E was asked to explain the process used to determine how much food should be prepared for each menu to ensure there was enough food available for all residents. She replied, I prepare using the census report and use different size spoons to measure the amount provided to residents. She was asked to explain the process that occurred when the kitchen ran out of the vegetables listed on the menu. She replied, provide an alternate vegetable. She was asked to explain what happened when the kitchen ran out of the protein that was listed on the menu. She replied, provide an alternate protein/meat. [NAME] E stated substitutions were not provided often. She was asked how substitutions were tracked. She stated substitutions were not tracked. If a resident did not want a particular food item, they served an alternate food item. [NAME] E was asked what was considered a large portion. She replied, double vegetable and double protein. She was asked what was considered a double portion. She replied, double meat.On 04/30/2026 at 2:47 PM, the Dietary Director confirmed that the [NAME] determined how much food to prepare by using the census report, identifying how many large and double portion diets were needed, and by following the recipe book. The Dietary Director was asked to explain the process that occurred when the kitchen ran out of the vegetables listed on the menu. She replied, That normally does not happen. An extra and alternate vegetable is always prepared. She was asked to explain what happened when the kitchen ran out of the protein that was listed on the menu. She replied, There is normally extra protein in the steamer. The Dietary Director stated substitutions were provided maybe once monthly. Substitutions were tracked on the substitution log. If a resident did not want a particular food item served, an alternate was provided. The Dietary Director stated she was responsible for ordering the food. The census reports and large and double portion diets were used to determine how much food to order. The [NAME] determined how much of a food component to serve on the resident's plate by following the recipe and using proper serving scoops. The Dietary Director confirmed a large portion was one scoop and half or four ounces serving of vegetables would be six ounces. If a resident asked for double meat, they were provided with double meat. If a resident asked for double carbohydrate, they were provided with double carbohydrate. When she was asked who determined whether a resident could have double portions, she replied, The Registered Dietitian (RD) will add the order in the electronic medical record and call to inform the manager; meal tickets are audited each morning for changes.On 04/30/2026 at 5:07 PM, the Registered Dietitian (RD) was asked what was considered a large portion. She replied, extra portions, one or two scoops extra, or a larger portion on the plate. She was asked what was considered a double portion. She replied, double every food item including the dessert, two beverages; two trays. When she was asked if she was aware of Resident #86's diet order specifying a pescatarian diet, she replied no, but she said she knew of a few residents who did not eat chicken, pork or beef. She did not recall a resident on a pescatarian diet. She stated the RD and Dietary Manager created the diet slips. When asked to explain what was provided for Resident #86, who was Pescatarian, she replied, No chicken; they get the rest of the menu. We do not cook fish every day. Resident #86's diet consists of no meat. She is provided with double vegetables and double carbohydrates. When she was asked how the protein was supplemented, she replied, I don't have an automatic substitute if they don't eat the meat.On 04/30/2026 at 5:12 PM, a copy of the standardized recipe used to prepare the lunch meal (fried chicken) was requested from the Dietary Director. The Dietary Director stated, I don't have recipes for lunch. I did not know we were supposed to have a recipe for fried chicken. A short time later, the Dietary Director produced a recipe titled, Golden [NAME] Oven Fried Chicken. The provided recipe was inconsistent with the actual product prepared and served to the residents, which was fried drumettes/wingettes.A food and nutrition policy regarding menu planning and preferences was requested. The documentation provided was unrelated to this subject matter; therefore, no applicable policy was available for review.

Based on observations, interviews, record reviews, and a review of the facility's policies and procedures, the facility failed to provide transfer/discharge notification to the Long-Term Care (LTC) Ombudsman's office prior to or as soon as was practicable for eight (Residents #12, #115, #92, #64, #31, #25, #23 and #18) of 12 residents reviewed for transfer/discharge. Appropriate notification of the LTC Ombudsman's office provides added protection for residents from being inappropriately transferred or discharged , provides residents with access to an advocate who can inform them of their options and rights, and ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges. The findings include:On 04/29/2026 at 10:00 AM, the Director of Nursing (DON) provided a list of resident transfers/discharges for February 2026 and March 2026. On 04/29/2026 at 12:15 PM an email was received from the LTC Ombudsman's office confirming that there had been no Nursing Home Transfer/Discharge notifications from this facility in February 2026 or March 2026.1.A review of Resident #12's medical record revealed a re-entry from an acute-care setting on 11/29/2022 with diagnoses including dementia, psychotic disturbance, mood disturbance and anxiety. The resident was discharged from the facility on 03/24/2026. A review of the Minimum Date Set (MDS) Discharge Return Not Anticipated assessment with an Assessment Reference Date (ARD) of 03/24/2026 revealed a planned discharge.There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 2.A review of Resident #115's medical record revealed an admission date of 11/13/2025 with diagnoses including syncope and collapse. The resident transferred to an acute care hospital on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 3.A review of Resident #92's medical record revealed an admission date of 09/24/2021, with a re-entry on 10/18/2024 and diagnoses including metabolic encephalopathy. The resident transferred to an acute care hospital on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 4.A review of Resident #64's medical record revealed an admission date of 04/15/2025 with diagnoses including cerebral infarction (stroke). The resident had a planned discharge home on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 5.A review of Resident #31's medical record revealed an admission date of 03/09/2026 with diagnoses including tinea unguium (fungal infection). The resident was transferred to an acute care hospital on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 6.A review of Resident #25's medical record revealed an admission date of 03/18/2026 with diagnoses including acute cholecystitis (swelling and inflammation of the gallbladder). The resident was transferred to an acute care hospital on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 7.A review of Resident #23's medical record revealed an admission date of 02/05/2026 with diagnoses including osteomyelitis (infection) of the lumbar vertebra. The resident had a planned discharge home on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. 8.A review of Resident #18's medical record revealed an admission date of 04/23/2025 with a re-entry on 10/21/2025 and diagnoses including muscle wasting and atrophy - multiple sites. The resident had an unplanned discharge to an acute care hospital on [DATE]. There was no evidence in the resident's EMR of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office. The facility's 03/16/2026 performance improvement plan regarding its discharge planning process was offered for review. The facility identified inconsistencies in discharge coordination due to interdisciplinary communication gaps. Nothing in the plan addressed notification of the LTC Ombudsman's office of transfers/discharges. Audits conducted included whether the discharge summary was completed prior to discharge, whether the medication reconciliation was completed, whether discharge medications were provided with instructions, whether follow up appointments were arranged, and whether education was completed with the resident/family prior to discharge.On 04/30/2026 at 4:24 PM, an interview was conducted with the Administrator who confirmed that the facility lost their Social Services Director (SSD), and the task of notifying the LTC Ombudsman's office of transfers/discharges fell on nursing management. He also stated notification of the LTC Ombudsman's office was occurring monthly, typically by fax. On 04/30/2026 at 4:29 PM, an interview was conducted with Social Services Director (SSD) K, who had been working with the facility for about a week. He was asked if he was responsible for transfer/discharge notification of the LTC Ombudsman's office. He stated he was responsible for managing transfer/discharge notifications, ordering durable medical equipment (DME), completing transfer forms, completing discharge summaries, and notifying the receiving facilities of the residents' condition upon transfer/discharge. He stated the LTC Ombudsman's office should be notified every time the facility transferred or discharged a resident. On 04/30/2026 at 4:36 PM, an interview was conducted with the DON who confirmed that the responsibility of notifying the LTC Ombudsman's office had fallen onto the DON and the Administrator for the last 6-8 weeks while they did not have a Social Services Director in place. He confirmed that the facility had been forwarding a monthly log of transfers and discharges to the LTC Ombudsman's office via email at the end of every month for that month. A review of the facility's policy and procedure titled Discharges/Discharge Planning (effective date: 12/2008, revision date: 08/2023), revealed that it did not address notification of the LTC Ombudsman's office upon transfer or discharge of a resident.

Based on observations, interviews and record review, the facility failed to ensure that the resident environment for one (Resident #62) of 24 residents reviewed for safety, was as free of accident hazards as was possible, by allowing hazardous, sharp objects to remain accessible in Resident #62's room without identified safety parameters, which could negatively impact Resident #62 or any other resident who entered the resident's room and accessed these objects. The findings include:On 04/27/2026 at 12:02 PM, a white Bible was observed on Resident #62's tray table containing a pair of scissors. A multi-colored pocketknife was observed on the resident's windowsill, as well as a pack of razors. (photographic evidence obtained)On 04/29/2026 at 10:30 AM, the same white Bible containing a pair of scissors was observed, along with a pack of razors, on the resident's windowsill. (photographic evidence obtained)On 04/29/2026 at 11:19 AM, an interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager S. She was asked about residents keeping sharp objects in their rooms. She asked for clarification of the question. She was accompanied to Resident #62's room and her attention was directed toward the white Bible on the windowsill containing the scissors. She replied, Oh when she saw the scissors. She was asked if the resident should have scissors in his possession. She confirmed that he should not. She retrieved the scissors from the bible concealing them in her hand. She was shown a photograph of and was advised of the pocketknife observed in the resident's room on 4/27/2026 at 12:02 PM. She held the scissors and scanned the resident's room then walked out.An interview was conducted on 04/29/2026 at 12:17 PM with the Director of Nursing (DON). He was advised of the items observed in Resident #62's room. He confirmed that residents were not to have sharps in their possession. He stated the items were part of the resident's art supplies. He was asked about the facility's policy related to residents' possession of sharp objects. The DON advised that the facility did not have a policy that addressed residents possession of sharp objects or anything that identified hazardous items that residents were prohibited from having in their rooms.A review of Resident #62's medical record revealed an admission date of 05/06/2025 with diagnoses including depression. He was later diagnosed with other specified persistent mood disorders on 03/16/2026. Resident #62 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. He was completely independent for Activities of Daily Living (ADLs) and required little to no supervision from facility staff. A progress note from Resident #62's psychiatry and psychology visit on 02/10/2026 revealed the resident was, seen today due to major depressive disorder, recurrent, moderate and other specified anxiety disorder. They report experiencing low interest in activities and a depressed mood for approximately 12/14 days. They also report low energy and poor appetite nearly every day. Additionally, they report experiencing anxiety and uncontrolled worry nearly every day. The patient noted that these distressing symptoms initially began approximately one and one half years ago. They report that their current symptoms have been present since self-admission for back problems/lymphoma of unknown origin . They report worrying frequently about their health but state that they take things one day at a time. The patient also reported wanting to leave the facility and feeling depressed most of the time while in placement. Overall, these symptoms are causing mild subjective distress according to the GAD-7 (test used to screen for anxiety and measure it's severity), although the PHQ-9 (tool used to screen, diagnose and measure the severity of depression) indicates moderate distress based on the frequency of symptoms.

Based on observations, staff interviews, document review, and facility policy and procedure review, the facility failed to maintain the physical environment in a safe, functional, sanitary and comfortable environment in 16 resident rooms (#201, #208, #209, #210, #214, #219, #302, #304, #305, #307, #308, #309, #310, #313, #315, and #321) affecting 40 out of 117 residents in the facility, as well as an industrial size fan running in the hallway on the second floor with dirt and dust stuck to it, and a wheelchair in disrepair with food particles in the hallway on the third-floor. These concerns could negatively impact residents' enjoyment of their environment as well as their safety. The findings include: A tour of the facility conducted on 05/08/2025 at 10:15 am revealed the following observations. 1. room [ROOM NUMBER] had black biological growth under the toilet rim. 2. room [ROOM NUMBER] had a dark stain inside the toilet bowl. 3. room [ROOM NUMBER] had a black biological film on the rails around glass of the window. There was a dead cock roach on the floor near bathroom. The floor mat was dirty and torn next to the B-bed. The vent in the bathroom had a buildup of dust on it. The ceiling above the door appeared to have bubbled up paint from water damage and white biological growth on the paint. Two dead cockroaches were stuck to the wall in the bathroom. There was a large brown stain on the bathroom wall near the sink. There was dirt and debris on the floor. The threshold of the door into the room from the hallway was missing, leaving exposed screws. 4. room [ROOM NUMBER] had dark stains inside the toilet bowl. The floor around the base of the toilet were stained and the grout around the base of the toilet was dark black. 5. room [ROOM NUMBER] had stains on the cabinets The drawers to the cabinets did not close properly. There were brown stains on the wall. A cock roach was on the wall above the bathroom door. The toilet bowl had stains inside. There was a large brown stain on the wall in the bathroom. There was a hole in the wall around the plumbing under the bathroom sink. There were two dead roaches on the walls in the bathroom. There was a used urinal on the floor next to the toilet. 6. room [ROOM NUMBER] had black grout around the base of the toilet and the floors in the bathroom had dirt and stains. An industrial size fan was observed running in the hallway on the second floor. The fan had dirt and dust stuck to it. 7. room [ROOM NUMBER] had two dirty wash bins on the floor in the bathroom. There were used briefs in the garbage can in the bathroom. 8. room [ROOM NUMBER] had full garbage cans. There was cereal on the floor under the B-bed. 9. room [ROOM NUMBER] had brown-colored scratches on the toilet seat. 10. room [ROOM NUMBER] had wall damage in the bathroom. The toilet bowl was stained and the floor in the bathroom was stained and dirty. 11. room [ROOM NUMBER] had a dirty wash bin on the floor next to the toilet with a disposable plastic drinking cup in it. There was black biological growth on the underside of the toilet rim. The garbage in the bathroom was full. There was hole in the wall under the sink around the plumbing. 12. room [ROOM NUMBER] had broken floor tiles under the B-bed. The cabinet drawers did not close properly. There was a hole in the ceiling tile. There was dust on the vent in the bathroom. The floor mats were dirty. 13. room [ROOM NUMBER] had a hole in the wall under the bathroom sink around the plumbing. 14. room [ROOM NUMBER] had a live cock roach in the bathroom. This was confirmed by the third floor Unit Manager at 12:04 PM. 15. room [ROOM NUMBER] had a floor board missing. 16. room [ROOM NUMBER] had a dirty wash bin on the floor in the bathroom with a dead cockroach inside it. There was wall damage behind the toilet. A wheelchair stored in the hallway near room [ROOM NUMBER] had food particles on the seat and the wheels were damaged. This was verified by the third floor Unit Manager at 12:10 PM. (Photographic evidence obtained) During a second general environment tour on 05/08/2025 at 3:30 PM, all of the above issues were reviewed with the Director of Housekeeping and Administrator. The Director of Housekeeping verified that wash bins should be stored in a plastic bag in the individual residents' restrooms. The administrator stated that the toilets can be replaced if they cannot get the stains out and the holes near the plumbing can be patched immediately. They both confirmed that most of the concerns were problems that the facility should and could have corrected and the facility staff should be making sure are addressed daily. Review of the facility's documentation for maintenance work orders from 11/01/2024 through 05/08/2025 revealed no work orders were placed for the above-mentioned physical environment concerns identified. Review of the facility policy and procedure titled, Daily Housekeeping revealed: I. Purpose - Daily cleaning of resident rooms help to provide a sanitary environment. IV Procedure - 1. Empty and sanitize all trash receptacles. 3. Wipe the windowsill with damp rag and mild cleaning solution. Use scouring pad for any stubborn spots. 4. Clean windows, and any glass surfaces with glass cleaner solution. 7. Mop or dust mop the floor. Be sure to get all areas surrounding and underneath the furniture. Collect debris and remove in a dust pan. 8. Mop floor. C Restroom Cleaning. I. Purpose - Daily cleaning of the rest rooms helps to provide a sanitary environment, prevents odors, control infectious material, and prolong the useful life of equipment, paint and floor finishes. .

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The facility's high-temperature dish machine failed to reach the minimum final rinse temperature. This could potentially negatively affect all residents consuming meals from the facility's kitchen by exposing them to foodborne illnesses. The findings include: An initial tour of the kitchen was conducted on 7/22/24 beginning at 10:35 AM. A dish machine was observed near the rear of the facility. There were three five-gallon buckets of dish sanitizing soaps and a gallon of bleach on the floor under the machine. One of the buckets was labeled Low Temp Dish Machine Sanitizer (Photographic evidence obtained) A label was affixed to the machine with operation requirements for the model: HOT WATER SANITIZING: Final sanitizing rinse temperature: 180 degrees F (Fahrenheit); CHEMICAL SANITIZING: Final rinse minimum temperature 120 degrees F. (Photographic evidence obtained) At 11:15 AM, an interview was conducted with Kitchen Manager O. She was asked if the dish machine was a high- or low-temperature machine. She stated she did not know. She did not handle the dish machine; it was a task for the maintenance department. At this time Dietary Aide R was called over to test the machine. She was asked if the machine was a high- or low-temperature machine. She stated she was not sure. The final rinse temperature reached 130 degrees F. She was not sure if the chemicals were running. She ran the machine again. There was no evidence of the chemicals running through the lines leading from the buckets on the floor to the back of the machine into the water. When asked about this observation, Dietary Aide R stated she didn't know anything about it. She stated the chemicals should come from the bucket. She was asked what she should do in this instance. She said she didn't know, and that maintenance should be called. She was asked if she had used the dish machine to wash the dishes that would be used for lunch. She stated that she had. An interview was conducted on 7/22/2024 at 11:20 AM with the Maintenance Director. He stated the dish machine was used as a high temperature machine. He performed a test on the machine. The final rinse temperature reached approximately 130 degrees F. Again, the chemicals in the buckets did not move through the lines to the machine. The Maintenance Director stated the dish machine was not working. It should be pulling the chemicals from the bucket, and he was not sure why this was not happening. On 7/22/24 at 11:27 AM, the Maintenance Director explained to Kitchen Manager O that the dish machine was not pulling the sanitizing products from the sanitizer buckets. She stated she did not know anything about it and always calls them (maintenance) for help. She confirmed the dishes had been washed in the machine that morning. She then advised the dietary staff to get paper products for the lunch service and to have someone go buy more in case the repair company was not in before dinner was served. An interview was conducted with the Administrator on 7/23/24 at 9:54 AM. She provided documentation for service on the dishwasher dated 7/22/24. Per the invoice, the dishwasher was working properly; however, the dishwasher company did not service the chemicals and therefore could not determine why the chemicals weren't being dispensed. She stated the chemical service provider was scheduled to come on site today. On 7/23/24 at 10:27 AM, this surveyor was notified that the chemical service provider was in the facility, and met with the service technician, the Administrator and the Regional Nurse Consultant. The Administrator stated they were advised that the machine was high temperature and therefore the chemicals were not needed. She stated the machine was operable. They tested the dish machine. She stated the technician advised her that chemicals were not needed, as the machine's final rinse reached 80 degrees C (176 degrees F), therefore, there were no concerns. The service technician explained that additional troubleshooting was needed and advised that a more experienced technician would be coming out to assist him. They requested that the dish machine be retested . It was retested three times and each time it failed to reach the required final rinse temperature of 180 degrees F. The technician stated he was not sure what had happened because it had been working prior to this. The Administrator pointed to the the label affixed to the machine which read: Final rinse minimum temperature 120 degrees F. She was directed to the wording above that which read: CHEMICAL SANITIZING, and reminded her that she confirmed they were not using chemicals as the dish machine was a high-temperature machine, which meant the final rinse temperature needed to reach a minimum of 180 degrees F. The technician ran a fourth test. Again, the dish machine did not meet the minimum final rinse temperature. On 7/24/24 at 11:38 AM, the survey team was advised that the dish machine remained out of service. The Administrator stated a service technician for the dish machine itself, as well as a technician for the chemicals, would report to the facility simultaneously to conduct a diagnostic test. At the time of the survey exit on 7/25/24 at approximately 6:47 PM, neither of the service technicians had returned to the facility.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Expired buns were used during meal service, dietary staff were unable to explain how to test the dish machine, the dish machine test log was pre-dated with test results, the temperatures in the refrigerators in the 2nd and 3rd floor nourishment rooms were greater than 41 degrees Fahrenheit (F), and an open, unlabeled, undated candy bar was discovered in the 3rd floor nourishment room refrigerator. This could potentially affect every resident residing in the facility. The findings include: An initial tour of the kitchen was conducted on [DATE] beginning at 10:35 AM. A dish machine was observed near the rear of the facility. There were three five-gallon buckets of dish sanitizing soaps and a gallon of bleach on the floor under the machine. One of the buckets was labeled Low Temp Dish Machine Sanitizer (Photographic evidence obtained) A label was affixed to the machine with operation requirements for the model: HOT WATER SANITIZING: Final sanitizing rinse temperature: 180 degrees F (Fahrenheit); CHEMICAL SANITIZING: Final rinse minimum temperature 120 degrees F. (Photographic evidence obtained) At 11:15 AM, an interview was conducted with Kitchen Manager O. She was asked if the dish machine was a high- or low-temperature machine. She stated she did not know. She did not handle the dish machine; it was a task for the maintenance department. At this time Dietary Aide R was called over to test the machine. She was asked if the machine was a high- or low-temperature machine. She stated she was not sure. The final rinse temperature reached 130 degrees F. She was not sure if the chemicals were running. She ran the machine again. There was no evidence of the chemicals running through the lines leading from the buckets on the floor to the back of the machine into the water. When asked about this observation, Dietary Aide R stated she didn't know anything about it. She stated the chemicals should come from the bucket. She was asked what she should do in this instance. She said she didn't know and that maintenance needed to be called. She was asked if she had used the dish machine to wash the dishes that would be used for lunch. She stated that she had. An interview was conducted on [DATE] at 11:20 AM with the Maintenance Director. He stated the dish machine was used as a high temperature machine. He performed a test on the machine. The final rinse temperature reached approximately 130 degrees F. Again, the chemicals in the buckets did not move through the lines to the machine. The Maintenance Director stated the dish machine was not working. It should be pulling the chemicals from the bucket, and he was not sure why this was not happening. At 11:50 AM, several packages of unopened buns were observed on the counter. Several of these packages of buns were past the date of expiration. Per the daily menu, hamburgers were to be served for lunch. At 12:05 PM the meal assembly line was observed. [NAME] Q retrieved several bags of the expired buns. She tore open one of the bags and put the contents in a warming pan on the assembly line. She retrieved one of the buns and proceeded to place a meat patty on top of it. At this time she was stopped and advised that the buns were expired. She called out to Kitchen Manager O and made her aware of the expired buns. She was advised to discard the buns. The assembly line continued. [NAME] Q retrieved more bags of buns. She opened them and emptied them into a warming pan on the assembly line. [NAME] S retrieved one of the buns and began to place meat on it. She too was stopped and advised that those buns were expired as well. [NAME] Q called out to Kitchen Manager O to notify her of this. Kitchen Manager O began to walk toward the food assembly line. She stated the buns had been delivered earlier that day and asked how the surveyor knew they were expired. She was directed to the dates that were printed on the front of the bags of buns. She acknowledged that the buns were expired. She advised Dietary Aide M that he needed to check the expiration dates on all of the bread that had been received. On [DATE] at 10:38 AM during an interview with Dietary Aide N, he was asked to test the Quaternary space concentration level in the manual dish washing sink. He stated the test read 100 ppm (parts per million) but he wasn't sure if he had the right test strips. Kitchen Manager O came over to assist him. They stated Dietary Aide M had performed the test earlier along with the Regional Nurse Consultant and the Administrator; however, they weren't sure which strips were used to test the sanitation level. They used several strips from the two containers of test strips present. The test strip from the seventh test read 175 ppm. Per the sanitation log, the sanitation level was documented as 275 ppm for [DATE] for breakfast and lunch and 302 ppm for dinner. At this time it was also observed that the log had been completed for [DATE] and [DATE]. (Photographic evidence obtained) Kitchen Manager O was asked which were the correct strips to use and how had the log been completed in advance. She stated she did not know. The sanitation log for the manual was observed with the initials for the dates of [DATE] - [DATE]. On [DATE] at 12:49 PM, Dietary Aide M was interviewed. He stated he worked in the kitchen five days a week. He was responsible for testing the sanitation level in the manual dish washing sink. He stated he had not tested it on the morning of [DATE]. He used the clear strips which turn green to test, and when he did the test, he documented it on the log and initialed it. He was asked if he was the only person in the dietary department with his initials and he stated he was. He was shown the log that was pre-dated and the corresponding initials. He confirmed these were his initials and he had signed the log incorrectly. When asked why had he pre-dated the log he responded by saying he had a lot going on the previous day and he put an inaccurate date on the log. On [DATE] at 12:56 PM, per the Regional Nurse Consultant, the other initials on the sanitation log were for a dietary aide who is out on vacation. The Administrator stated Sunday, [DATE], was the last day she had worked. During a [DATE] tour of the nourishment room on the 2nd floor at 2:42 PM, a refrigerator was observed designated for resident use. A temperature log was present for this refrigerator/freezer. Licensed Practical Nurse (LPN)/Unit Manager C accompanied this surveyor closely during the tour. Upon opening the refrigerator, two thermometers were present. One read 42 degrees F and the other read 44 degrees F. LPN C stated the refrigerator had been in use. She was advised that the temperature could be retaken at another time. She stated she would ensure that this refrigerator would not be opened until the temperature could be retaken. During a [DATE] tour of the 3rd floor nourishment room at 2:49 PM, a refrigerator was observed designated for resident use. A temperature log was present. A review of the log revealed that the neither temperature for the freezer or the refrigerator had been taken for [DATE]. A thermometer in the refrigerator read 48 degrees F. An open, undated candy bar was in the freezer. (Photographic evidence obtained) An interview was conducted on [DATE] at 3:43 PM LPN/Unit Manager K. She was shown the findings in the refrigerator in the nourishment room on the 3rd floor. She stated it was the responsibility of the kitchen staff to clean to refrigerator. She stated the overnight nurses were responsible for the temperature logs, and she could not explain why the log was not completed. She was shown the thermometer which read 48 degrees F. She asked if she could remove it and get another one. She was made aware that a thermometer needed to be present and the refrigerator's temperature needed to be 41 degrees F or less. During a [DATE] follow-up visit to the nourishment room on the 2nd floor at 3;48 PM, LPN C confirmed that the refrigerator had not been reopened. She accompanied the surveyor to check the thermometers in refrigerator. Both thermometers displayed a temperature greater than 43 degrees F. LPN C confirmed the readings. She stated she was not sure what could be going on because it (the refrigerator) had been working. She stated the overnight nurses were responsible for checking the temperatures and she did a follow-up check upon her arrival on Mondays through Fridays at 7:00 AM. During an interview with the Administrator on [DATE] at 3:07 PM, she stated there was no specific training in the kitchen process. She was asked if she was aware that the sanitation log for the manual dish washing sink had been pre-dated and initialed. She stated no. She did not know who one of the dietary staff who signed the log was. She was reminded that she previously advised the survey team that the employee was on leave and had been out since last week. She asked if this could be another staff member. She was informed that Kitchen Manager O confirmed the identity of that Dietary Aide and there were no other staff members with those initials. She stated she would speak with the Kitchen Manager about the problem.

Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, by failing to employ either a certified dietary manager or a certified food service manager when a registered dietitian was not employed on a full-time basis. This had the potential to affect all of the residents in the facility. The findings include: A tour of the kitchen was conducted on 7/22/24 at 10:35 AM. The surveyor was greeted by Kitchen Manager O, who was asked if she was the Certified Dietary Manager (CDM). She stated she was the Kitchen Supervisor, not the CDM. She stated she would go get the CDM. She left and returned with Registered Dietitian (RD) P. RD P was asked if she was the CDM and she replied that she was not. Kitchen Manager O then asked, Well who's the CDM? During the interview, RD P stated she was in the facility three days a week. An interview was conducted with the Administrator on 7/22/24 at 3:28 PM. She was asked to provide the dietary manager credentials for Kitchen Manager O. On 7/23/24 at 9:49 AM, the Administrator provided a copy of the job application for Kitchen Manager O. There was no documentation to support the employee was a CDM, had earned an associate's degree, had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting, or had any certification for food service management. On 7/23/24 at 1:13 PM, an interview was conducted with the Administrator. She stated Kitchen Manager O had a high school diploma. There was another RD who was in the facility three days a week and Employee P was the Regional RD. She stated RD P was available to assist by phone as needed. She provided the license for a RD who was not in the facility during the survey. She stated the RD supervised Kitchen Manager O and was responsible for the clinical duties. Kitchen Manager O was responsible for the oversight of the kitchen when the RD was out. She was asked again for the kitchen manager's credentials. She stated she only had the high school diploma, but stated again that the Regional RD was always available by phone for assistance. On 7/23/24 at 2:55 PM, the Administrator stated the facility RD was in the facility three times a week on Mondays, Tuesdays, and Thursdays. During an interview on 7/24/24 at 1:09 PM with the Administrator, she confirmed that RD P was in the facility once a week. She stated the facility RD was in the facility twice a week. RD P was available by phone for any questions. She confirmed that Employee O was the Kitchen Manager; however, she was not certified. During an interview on 7/24/24 at 1:31 PM with RD P, she stated she was not an employee of the facility. She stated she was the Regional Dietitian. She worked for a company that was contracted by the facility. She stated she worked with various dietitians in different buildings and assisted on an as needed basis. She assisted with the clinical duties in the facilities, but she was not responsible for the budget. She stated Kitchen Manager O worked with the individual who handled the budget. She did not identify that individual. During an interview on 7/25/24 at 3:07 PM with the Administrator, she stated there was no specific training in the kitchen process. Kitchen Manager O was not a CDM, nor was she receiving training for that. She stated her understanding of the regulation was that if she had a dietary director and a dietitian that consulted, she didn't need a CDM. The regulation was reviewed with her and she was referred to Florida Administrative Code 59A-4.110 (Food and Nutrition Services). The Administrator stated she was responsible for the food budget. Kitchen Manager O was responsible for ordering and purchasing the food. They put in two orders per week. She stated the RD and Kitchen Manager O were responsible for food storage and food service operations. At approximately 5:00 PM on 7/25/24, the Administrator acknowledged the requirement and the facility's noncompliance.

Based on observations, staff interviews, and facility record and policy review, the facility failed to maintain the physical environment in a safe, comfortable, and sanitary manner in eight (Rooms 215, 219, 221, 223, 302, 305, 318, and 319) of 46 rooms in the facility, as well as the 3rd floor elevator area. Door frames were not maintained structurally, a floorboard was raised near the 3rd floor elevator causing a tripping hazard, and holes in walls were identified as well as broken/missing floor tile. The facility also failed to maintain a comfortable and sanitary environment for one (Resident #87) of two residents reviewed for enteral feeding from a total survey sample of 35 residents, by leaving enteral nutrition product splattered and dried on the pump and pole throughout the survey. These concerns could affect residents' comfort and safety. The findings include: 1. On 7/22/24 at 1:48 PM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. (Photographic evidence obtained) On 7/23/24 at 9:47 AM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. A piece of black tape had been applied to one section of the door frame. (Photographic evidence obtained) On 7/22/24 at 11:43 AM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor on both sides of the frame. Tile was missing on the floor. The wall behind the A-bed was observed with a hole in the sheetrock. (Photographic evidence obtained) On 7/22/24 at 11:50 AM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. Tile was missing on the floor near the door frame, and there was damage to the wall in the corner above the floor molding in the bathroom. (Photographic evidence obtained) On 7/22/24 at 12:01 PM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. There was a hole through the concrete wall under the sink. The floor molding was absent under the vanity area exposing the glue that was stuck to the wall. (Photographic evidence obtained) On 7/22/24 at 1:43 PM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. Tile was missing on the floor near the door frame. (Photographic evidence obtained) On 7/22/24 at 11:03 AM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. The floor molding was peeling back away from the wall. (Photographic evidence obtained) On 7/23/24 at 10:57 AM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. Tile was missing on the floor near the door frame and under the vanity area. (Photographic evidence obtained) On 7/23/24 at 11:03 AM, room [ROOM NUMBER]'s door frame to the bathroom was observed to be rusted and deteriorating at the bottom near the floor. Tile was missing on the floor near the door frame. The closet was in disrepair at the bottom corner. (Photographic evidence obtained) On 7/25/24 at 11:43 AM, a floor board in the hallway near the elevator on the third floor was raised higher than the level of the floor presenting a tripping hazard. (Photographic evidence obtained) During an interview on 7/25/24 at 11:20 AM with the Maintenance Director, he stated he was aware that the door frames were in disrepair. He had tried to reconstruct the frames in some of the rooms; however, in order to fix them he would have to cut the existing frame with a saw because the frames are made of steel. Then he could fill them in with a wood frame and paint them to match the existing frame. In order to cut the frames, they would have to move the residents out of the rooms due to the flying sparks that the sawing would produce. He stated the facility was almost at capacity, so he was not sure how they could accomplish the renovations. He did not know where they would house the residents during renovations. He said he would need to talk with the Administrator about how they could do it. He had not reported the abovementioned disrepairs to the Administrator. During an interview on 7/25/24 at 12:10 PM with the Administrator, she stated she was not aware of the condition of the abovementioned door frames. She was aware of the age of the building, and they had made many improvements/upgrades to the building in the time she had been here as the Administrator. The concerns were described to her and she shook her head to indicate that she was unaware. She stated the facility conducted Angel Rounds in which the department heads made rounds daily and used a checklist to identify whether there were any problems in the residents' rooms. The checklists were given to the Administrator to be used for any repairs that needed to be made. When she was informed of the Maintenance Director's description of the process to make repairs, she stated the facility was almost at capacity, and it would be difficult to move the residents for a long period of time. A review of the Angel Rounds checklists the facility staff used for daily rounds in the rooms identified for the months of May, June, and July 2024, revealed no noted deterioration of the door frames to the bathrooms or holes in the walls. Noted chipping on the floor in room [ROOM NUMBER] on 5/9/24, 5/16/24, 5/20/24, 5/28/24, and 6/11/24. Noted door needed paint in room [ROOM NUMBER] on 6/28/24. (Copies obtained) 42630 2. On 7/22/24 at 1:34 PM, Resident #87 was observed lying in bed with the covers pulled up over her head. Her enteral nutrition pole was observed to the right of her bed. No enteral nutrition product was hanging. The enteral nutrition pump was observed with beige splatters on the screen and the side of the pump. (Photographic evidence obtained) On 7/23/24 at 9:34 AM, Resident #87 was observed in her bed with her eyes closed. Her enteral nutrition pump was observed to the right of her bed on a pole with no enteral nutrition product hanging. The pump screen was sticky to the touch with clear matter smeared on the screen and beige matter observed on the side of the pump. (Photographic evidence obtained) On 7/24/24 at 7:20 AM, Resident #87 was not in her room. Her enteral nutrition pump was observed with no enteral nutrition product hanging. The pump was sticky to the touch on the screen with clear matter smeared on the screen and beige matter on the sides of the pump. (Photographic evidence obtained) On 7/25/24 at 9:18 AM, Resident #87 was not in her room. Her enteral nutrition pump was observed with enteral nutrition product hanging. The pump was sticky to the touch on the screen with clear matter smeared on the screen and beige matter on the sides of the pump. (Photographic evidence obtained) On 7/25/24 in an interview with Licensed Practical Nurse (LPN) A at 9:20 AM, she was asked if she was the nurse caring for Resident #87 today. She replied yes. When she was asked who was responsible for cleaning resident care equipment such as enteral nutrition pumps, she replied, I don't know who cleans them. She was asked if she cleaned them. She stated no. On 7/25/24 at 9:25 AM, in an interview with Certified Nursing Assistant B, she was asked who was responsible for cleaning resident care equipment such as enteral nutrition pumps. She stated, I can't answer that, I've never cleaned one. I assume the nurses would clean them, or if they asked us to clean them, I would, but I have never been asked to. A review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment (undated) revealed: Policy Statement: Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, including measurable objectives and timeframes for two (Residents #66 and #113) of 35 residents in the total survey sample. This resulted in the facility having failed to provide Resident #66 with needed toenail care and having failed to change Resident #113's midline dressing, which could lead to pain, difficulty mobility and dressing for Resident #66, and potential infection and pain for Resident #113. The findings include: 1. A review of Resident #66's medical record revealed he was admitted to the facility on [DATE] with his most recent readmission on 6/20/24. His diagnoses included seizures; viral hepatitis C without hepatic coma; personal history of TIA (transient ischemic attack - mini stroke); atherosclerotic heart disease; heart failure; protein-calorie malnutrition, and chronic kidney disease. A review of the 5-day minimum data set (MDS) assessment dated [DATE], revealed that Resident #66 scored 14 out of 15 possible points on the brief interview for mental status (BIMS) assessment, indicating he was cognitively intact. Per the MDS assessment, the resident had no upper or lower extremity range of motion impairment. He was independent with eating, oral hygiene and toileting. He required supervision with showering/bathing, upper body dressing and partial assistance with lower body dressing. He required substantial/maximal assistance with putting on/taking off footwear, was occasionally incontinent of urine and always continent of bowel. A review of Resident #66's care plan, initiated on 3/28/24 and revised on 7/3/24, revealed the following Focus Area: I am currently independent with all my ADLs but at times I may need cueing. Goal: I [resident's name] will continue to be independent in ADLs. Interventions: Check my fingernails and toenails and trim as needed unless I am diabetic, then please notify my nurse. During an interview on 7/23/24 at 9:40 AM with the resident's sister/emergency contact, she stated Resident #66 needed his toenails clipped. She had spoken to staff and his toenails had not been clipped since his admission. She stated she was not aware of whether or not the facility had a podiatrist. An interview was conducted on 7/24/24 at 10:49 AM with Certified Nursing Assistant (CNA) L. She stated she had been a CNA since 2021 and had been employed at the facility for four months. She had received training on resident rights, abuse and neglect, and activities of daily living (ADL) care. She stated she was familiar with Resident #66. The resident was independent and able to make his needs known. He smoked. His sister was very involved in his care, and the resident liked to sleep a lot. She stated she emptied his urinal and made his bed when she was able to catch him out of it. The facility had a shower team that was responsible for providing baths/showers to all of the residents. The shower team provided showers Monday through Friday and the CNAs were responsible for any showers scheduled or requested on Saturdays and Sundays. She stated the CNAs clipped the residents' fingernails and toenails. The podiatrist came in and clipped the toenails for residents who were diabetic. When asked about Resident #66's toenails, CNA L stated she had never clipped them. She had asked him about them and the resident stated they were alright. She could not provide a date or time that this conversation took place. On 7/24/2024 at 2:55 PM, Resident #66 was observed resting in bed. He stated he had received a shower earlier this morning. The CNA commented that he needed his toenails clipped; however, she did not clip them. He stated he could not remember the last time anyone had clipped them, but he wanted them clipped. He stated he was not a diabetic and his toenail length did not prohibit or hinder his walking; however, it did cause him some pain. His toenails were exceptionally long. The left great toe measured at 3.8 cm (centimeters), the left 2nd toe measured 1.6 cm, the left 3rd toe measured 1.1 cm, the left 4th toe measured 3.2 cm, and the left 5th toe measured 0.5 cm. The right great toe measured 4.2 cm, the right 2nd toe measured 1.6 cm, the right 3rd toe measured 1.5 cm, the right 4th toe measured 2.6 cm, and the right 5th toe measured 1.8 cm in length from the end of each toe. (Photographic evidence obtained) An interview was conducted on 7/25/24 at 11:15 AM with CNA I, a member of the shower team. She stated the shower team was in the facility daily at 5:30 AM. Their duties included shampooing residents' hair, assisting them with dressing, and shaving the men. They were also responsible for cutting residents' fingernails. A facility nurse or podiatrist was responsible for cutting residents' toenails. CNA I was familiar with Resident #66 and stated his showers were scheduled on Mondays, Wednesdays, and Fridays. His toenails needed clipping for some time. She stated the resident had not complained of pain to her. She reported the long toenails to a nurse and wasn't sure what was done with that information. When she was asked for the date she reported the resident's long toenails to the nurse, she replied that she wasn't sure, but It's been a while. During an interview on 7/25/24 at 2:42 PM with the Social Services Director (SSD), she stated the podiatrist was in the facility monthly. Resident could be seen sooner if staff, the resident and/or their representative requested they be seen. She said if the resident could wait, she would add them to be seen the following month. New residents were seen as needed, if they transitioned to long-term care, or when they became Medicaid approved. If they were Medicaid pending and it was not a dire need, the resident would have to wait until they were approved. The staff will notify me if a resident needs to be seen. I announce to all staff when they're coming in and ask if there's anyone who needs to be seen. Sometimes if it's the same day, they'll add the person to the list. She stated she spoke Resident #66's sister one to two weeks ago and she requested the resident be seen by the podiatrist. During an interview on 7/25/24 at 3:19 PM with Licensed Practical Nurse (LPN) E, he stated a member of the shower team made him aware of Resident #66s toenails on the day of this interview. It was the first time he had ever heard anything about the resident's toenails. He stated he talked to the podiatrist about adding the resident to the list to be seen on their next visit to the facility, and they agreed he would be seen the next week. A review of the list of podiatry visits for 7/2024, 6/2024, and 4/2024, provided by the SSD, revealed that Resident #66 was not seen. The SSD confirmed he had not been seen during any of the monthly visits reviewed. 42630 2. On 7/24/24 at 7:50 AM, Resident #113 was observed with an intravenous (IV) line in his right arm. The resident was non-verbal and was unable to converse when asked questions. The IV line was covered by a gauze dressing with 7/6 Midline 20 cm (centimeters) long written on it. The gauze was covered by a transparent dressing. The hub of the IV was visible and the area above the hub was obscured by the gauze dressing. A review of the resident's medical record revealed no orders for IV line care, such as routine flushes or routine dressing changes. Further review revealed that the resident had IV fluids ordered and administered on the following dates: 7/6/24: May insert midline. 7/6/24: Dextrose-Sodium Chloride IV Solution 5-0.9%: use 75 milliliters (ml) per hour for dehydration for 2 days. 7/8/24: Dextrose-Sodium Chloride IV Solution 5-0.9%: use 75 milliliters (ml) per hour for dehydration for 2 days. 7/10/24: Dextrose-Sodium Chloride IV Solution 5-0.45%: use 80 milliliters (ml) per hour for dehydration for 4 days. A review of all orders (current and discontinued) for Resident #113 revealed no IV flushes, dressing changes or other IV maintenance orders. On 7/24/24 at 11:40 AM, during an interview with LPN E, he was asked how often IV midline dressings were changed in the facility. He stated, Normally as needed, if soiled or wet from a shower. Most only have them for a short time, maybe five days for antibiotics. He confirmed that he was caring for Resident #113 today and when asked if this resident had a midline, he replied, Yes, he has his for a longer time because he will get fluids as needed. When he was asked how often the line was flushed, he replied, We do it every shift. He was asked to review the resident's medication administration record (MAR) for orders for IV flushes. He opened the MAR and while reviewing it he stated, The order may have come off; it might have had a stop date. He was asked to observe Resident #113's midline dressing. Upon observing the dressing, he was asked what the date on it said. He stated, It looks like 7/6. We have a company that comes in to place the midlines. He was asked if he had changed this midline dressing and he replied that he had not. A review of the resident's comprehensive care plan (initiated 5/15/24) revealed no focus areas related to intravenous lines including maintenance, flushes, or dressing changes for the IV line. On 7/24/24 at 1:03 PM during an interview with the Director of Nursing (DON), she was asked who updated residents' care plans. She stated, The MDS (Minimum Data Set) nurse does the majority of them, social services does behaviors and cognitive, and smoking and activities is done by activities staff. She was asked if a resident had a new diagnosis, who was responsible for adding the new care plan focus area. She stated the MDS coordinator was responsible. When asked how the MDS coordinator was made aware of new diagnoses/issues to add to the care plan, she replied, Through our daily meeting and review of the 24-hour reports. On 7/24/24 at 1:09 PM, during an interview with Registered Nurse (RN) F, she confirmed that she was the facility's only MDS coordinator. When she was asked how she was made aware of new diagnoses that required new care plans, she replied, During clinical meetings, we review 24-hour reports, all new orders and new admissions. When she was asked if Resident #113 was care planned for his IV line care/flushes/dressings, she replied, I did resolve that today, because the line was discontinued today. She was asked when she discontinued this care plan and she replied, About twenty minutes ago. She was asked to provide the discontinued care plan for review. She pulled up a care plan on her computer for IV medications related to fluid deficit with a date initiated of 7/10/24 for Resident #113. She confirmed that she created the care plan on 7/10/24. She was asked if any other IV line care/flushes would be expected on the care plan other than the IV Dressings per MD orders that was listed. She replied, No, that would all fall under the dressings, all the flushes and care., referring to the care plan intervention for IV DRESSING: Per MD Orders, and indicating that other interventions such as IV care/flushes were understood under the dressing change intervention with no specifics required. The care plan, as presented by RN F during this interview revealed: Focus Area: RESOLVED: Resident is on IV medications r/t (related to) fluid deficit (date initiated 7/10/24, revision on 7/24/24, resolved on 7/24/24) Goal: RESOLVED: Resident will have no complications r/t IV therapy through the review date.(9/25/24) (date initiated 7/10/24, revision on 7/24/24, resolved on 7/24/24) Interventions: RESOLVED: IV dressings per MD (medical doctor) orders (date initiated 7/10/24, revision on 7/24/24, resolved on 7/24/24) RESOLVED: Monitor/document/report as needed signs of infection at the site: drainage, inflammation, swelling, redness, warmth (date initiated 7/10/24, revision on 7/24/24, resolved on 7/24/24) RESOLVED: Monitor/document/report as needed signs of leaking at the IV site, edema at the insertion site, taut, shiny or stretched skin, leaking of IV solution at the insertion site. This was the facility's only care plan with any interventions for IV lines. This care plan included no specific interventions related to IV line flushes or other care. On 7/24/24 at 12:27 PM, the Administrator was asked to provide information about when and who placed the midline IV for Resident #113. On 7/25/24 at 8:45 AM, the Administrator provided a form dated 7/6/24 from an outside vascular access provider, which revealed a midline IV was placed for Resident #113 in his right arm, basillic vein on 7/6/24 at 6:30 PM. The form indicated the dressing must be changed in 24 hours. A review of the facility's policy titled Flushing Midline and Central Line IV Catheters (revised 2/2024) revealed: Purpose: The purposes of this procedure are to maintain patency of midline and central line IV catheters; General Guidelines: 1. Prior to procedure, assess catheter type for flushing protocols and the use of saline only or saline/heparin. Flushing Protocols: 1. Flush catheters at regular intervals to maintain patency AND before and after the following: a. administration of intermittent solutions; Documentation: The following information should be documented in the resident's medical record: 2. Type of solution used for flushing and amount administered; 4. The condition of the IV site before and after administration; 6. Resident's response; 7. The signature and title of the person recording the data. A review of the facility's policy titled Midline Dressing Changes (undated) revealed: Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings. General Guidelines:1. Change the midline dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. 5. If a gauze dressing is used, cover the gauze with a TSM (transparent semi-permeable) dressing and change the dressing every 48 hours. Documentation: 1. The following information should be documented in the resident's medical record: a. date and time the dressing was changed; b. location and objective description of insertion site; d. whether flushed; positive blood return; and whether end cap or extension tubing was changed; f. type of dressing placed (TSM or gauze) h. signature and title of the person recording the date.

Based on record review and interviews, the facility failed to document the basis for a resident's transfer to an acute care hospital, the specific resident needs that could not be met in the facility, and the service available at the acute care hospital to meet the resident's needs for one (Resident #118) of one hospitalized resident reviewed, from a total survey sample of 35 residents. The findings include: A review of Resident #118's medical record revealed that she was admitted to the facility on [DATE] with a transfer to the emergency roiagnom on [DATE]. Her diagnoses included acute respiratory failure with hypoxia. Further review of the record revealed no documentation of Resident #118's transfer/discharge or information having been provided to the acute care hospital. There was no documentation by the resident's physician of the basis for the transfer, resident needs that could not be met by the facility, or services available at the acute care hospital to meet her needs. Further review of the medical record's progress notes revealed a total of two nursing notes: On 5/17/24 at 6:50 PM, Resident arrived to facility via stretcher accompanied by two attendants. Resident is alert and oriented x 4, no acute distress noted. Resident wears glasses, has her own teeth, mucus membranes are moist and pink, trachea is midline, lung sounds are clear, heart rate and rhythm is normal. Abdomen is soft and nondistended. Bowel sounds present in all four quadrants. Bilateral pedal pulses present. Resident is continent of bowel and bladder, able to make needs known. Currently on oxygen at 3 liters via nasal cannula. Resident did not have any belongings with her. On 5/18/24 at 12:45 AM, Resident sitting in room on the bed, complain of chest pain, resident does not have a history of chest pain, oxygen on via nasal cannula at 3 liters. Resident is her own responsible party, resident requested to be sent to ER (emergency room ). No Nursing Home Transfer and Discharge Notice (Agency for Health Care Administration (AHCA) Form 3120-0002 was located in the medical record. Documentation on the Nursing Home Transfer and Discharge Notice for an emergent transfer to an acute care hospital must be completed by a physician or a physician's written order for transfer must be attached. An explanation to support the need for the transfer must be documented on the form with additional documentation attached as needed. The form must be signed and dated by the physician/designee. When a facility transfers a resident emergently to an acute care hospital, this is considered a facility-initiated transfer, not a discharge, because the resident is expected to return. Documentation in the resident's medical record must include the basis for the transfer, the specific resident needs that cannot be met by the facility, the facility's attempts to meet the resident's needs, and the services available at the acute care hospital to meet the resident's needs. This documentation must be made by the resident's physician. There was no documented evidence in the resident's medical record of the facility having provided appropriate information to the acute care hospital upon her transfer to the emergency room . The information that must be provided includes the following: Contact information of the practitioner responsible for the resident. Resident representative information including contact information. Advance Directive information. Special instructions or precautions for ongoing care, as appropriate. There was no documented evidence in the resident's medical record verifying that she was provided with a transfer notification or a notification of discharge. On 7/25/24 at 12:15 PM, the Administrator was asked to provide documentation of Resident #118's discharge. She went to her office and returned shortly thereafter stating there was a discharge order. A copy of the order was requested. On 7/25/24 at 12:30 PM, the Director of Nursing (DON) provided a copy of all orders for Resident #118. When asked, the DON confirmed that there was no discharge order. An interview was conducted on 7/25/24 at 2:10 PM with the DON, who stated she was familiar with Resident #118. When asked where Resident #118 was transferred/discharged , she stated the resident went to [acute care hospital] and it would not be documented. She stated she knew where she went because residents automatically went to this acute care facility when 911 was called. When asked to review Resident #118's electronic medical record (EMR) for physician's documentation of an order or authorization of transfer, she confirmed that there was none. When asked if the physician was notified of Resident #118's change in condition and where documentation of that could be found, she stated, I cannot confirm that but assume from the progress note they would have. When asked if in this type of situation the physician would be notified, she stated, Yes, in a situation like this they would normally call the MD (Medical Doctor). When asked if Resident #118 was expected or planned to return, the DON stated, Per word of mouth when she was brought here, she didn't want to stay. She was talked into staying until she complained of chest pain and wanted to go to the ER. When asked if there was any documentation of the resident's leaving the facility such as the time she left or how she was transported, the DON confirmed that it was not documented in the medical record.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that four (Residents #64, #99, #100, and #66) of 35 residents in the total survey sample, received the necessary care and services to maintain good grooming and personal hygiene. The findings include: 1. On 7/22/24 at 1:18 PM, Resident #64 was observed lying in bed awake. His fingernails were elongated with brown debris under them. He was asked if he preferred his nails this length. He stated, No, of course not. He picked up nail clippers from his bedside table and stated, I have nail clippers. He was asked if he trimmed and cleaned his own fingernails. He stated, No,I can't do that. I need the staff to trim them for me. He tossed the nail clippers back on the bedside table. On 7/23/24 at 11:00 AM, Resident #64 was observed lying in bed awake. He was asked if any staff had offered to trim his fingernails. He stated no and showed his hands. He was asked for permission to measure his fingernails. He agreed. (Photographic evidence obtained.) Measurements obtained: Left hand fingernails (from tip of finger to end of nail): Thumb: 1.2 centimeters (cm) Index finger: 0 Middle finger: 0 Ring finger: 1.0 cm Fifth finger: 1.2 cm Right hand fingernails (from tip of finger to end of nail): Thumb: 0.9 cm Index finger: 0 Middle finger: curved over finger tip 0.5 cm Ring finger: curved over finger tip 0.9 cm Fifth finger: 0.7 cm A review of the resident's medical record revealed diagnoses including diabetes type 2 and cerebral vascular accident (stroke). Further review revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. The assessment also revealed the resident had no behaviors such as refusal or rejection of care. A review of the active person-centered care plan revealed: Focus: Resident is currently independent with all ADLs (activities of daily living) but may need cueing. Goal: Resident will continue to be independent in ADLs. Interventions: Check resident's fingernails and toe nails and trim as needed, unless diabetic, then please notify nurse. A review of the certified nursing assistant tasks completed for the past 30 days revealed no section marked for provision of nail care. 2. On 7/22/24 at 1:10 PM, Resident #99 was observed sitting on the edge of his bed eating lunch. His fingernails were elongated. (Photographic evidence obtained) He was asked if he preferred his nails this length. He replied, No, no, I don't want them this long. If I get an itch and I scratch, I might cut my skin. Look at how long they are. On 7/23/24 at 11:10 Am, Resident #99 was observed lying in bed, dressed for the day. He was asked if any staff had trimmed his nails. He laughed and said no. He was asked for permission to measure his fingernails. He agreed and held his hands out. Measurement obtained: Left hand (from tip of finger to end of fingernail): Thumb: 1.2 cm Index finger: 1.0 cm Middle finger: 1.2 cm Ring finger: 1.0 cm Fifth finger: 1.0 cm Right hand (from tip of finger to end of fingernail) Thumb: 1.2 cm Index finger: 1.0 cm Middle finger: jagged but not elongated Ring finger: 1.0 cm Fifth finger: 0.8 cm A review of Resident #99's medical record revealed diagnoses including cerebral infarction (stroke) and macular degeneration (vision impairment). Further review of the record revealed a Quarterly MDS assessment dated [DATE], which documented a BIMS score of 11 out of 15 possible points, indicating moderately impaired cognition. The MDS review also revealed the resident had no behaviors such as refusal or rejection of care. A review of the person-centered care plan created for Resident #99 revealed: Focus: Resident requires extensive assist x1 staff with personal hygiene. Goal: Resident will not have any further decline with ADL function. Interventions: Check resident's fingernails and toe nail length and trim as needed, unless diabetic, then please notify nurse. A review of the certified nursing assistant tasks completed for the past 30 days revealed no section marked for provision of nail care. 3. On 7/22/24 at 1:20 PM, Resident #100 was observed in his bed, stated his toenails were very long, and he had not seen a podiatrist since his admission. His feet were observed and his right great toenail and 2nd and 3rd toenails were elongated. His left great toenail was thickened and half missing. His left 2nd and 3rd toenails were also elongated. (Photographic evidence obtained) A review of the resident's medical record revealed diagnoses including hemiplegia/hemiparesis following cerebral infarction affecting his right side and an 8/19/23 physician's order for: Podiatry PRN (as needed). Further review of the medical record revealed no documented evidence of any podiatry consults/notes. A Quarterly MDS assessment dated [DATE], documented a BIMS score of 15 out of 15, indicating intact cognition. The MDS also revealed the resident had no behaviors such as refusal or rejection of care. A review of the person-centered care plan created for Resident #100 revealed: Focus: Resident requires extensive assist x1 staff with personal hygiene. Goal: Resident will not have any further decline with ADL function. Interventions: Check resident's fingernails and toe nail length and trim as needed, unless diabetic, then please notify nurse. Please notify nurse if toenails need to be trimmed. A review of the certified nursing assistant tasks completed for the past 30 days revealed no section marked for provision of nail care. On 7/25/24 at 9:30 AM, during an interview with Certified Nursing Assistant (CNA) D, she stated she was on the shower team and provided the residents' showers. She was asked if she provided fingernail cleaning and trimming. She stated, Yes, we clean under the nails and we try to get the nails trimmed. If we don't have enough time, we will ask the CNAs assigned to the residents to trim their nails. She was asked to observe Resident #64s fingernails. Upon observation, his fingernails were observed to be elongated with brown debris under them. She asked the resident if he would like his nails trimmed today. He stated, Yes, I have a shower today at 10:00. He was asked if staff had offered to clean or trim his nails prior to today. He replied no. He held his hands up and stated, Look, I can trim the first and second finger myself but I can't do the other ones. CNA D was then asked to observe Resident #99s fingernails. Resident #99 held his hands out and his fingernails were observed to be elongated with brown debris under the nails. CNA D asked Resident #99 if he wanted his fingernails trimmed today. He sated yes. CNA D was then asked to observed Resident #100's toenails. She stated, The nurses do the toenails. She was asked if the CNAs were instructed to report the need for toenail trimming to the nurses. She replied yes. She was asked if she had reported to her nurse that Resident #100 was in need of having his toenails trimmed. She replied, I don't recall but I think I did. She was asked when she reported this to her nurse. She replied, I don't remember when but it would have been on one of his shower days. On 7/25/24 at 12:09 PM, during an interview with the Director of Nursing (DON), she was asked who was responsible for trimming residents' toenails. She stated, We usually let the podiatrist do those. If they're not diabetic the nurses could do it, but usually the podiatrist will do the toenails. She was asked how often the podiatrist came to the facility. She replied, He is regularly scheduled monthly, but if there is an urgent need, he will make a special visit. When she was asked who was responsible for trimming residents' fingernails, she replied, CNAs do those. The shower team will do them on their shower day, but if it's in between shower day, the assigned CNA would trim the finger nails. She further stated residents received showers at least three times a week is the schedule, unless they ask for more. 4. A review of Resident #66's medical record revealed he was admitted to the facility on [DATE] with his most recent readmission on 6/20/24. His diagnoses included seizures; personal history of TIA (transient ischemic attack - mini stroke); heart failure; protein-calorie malnutrition, and chronic kidney disease. A review of the 5-day minimum data set (MDS) assessment dated [DATE], revealed that Resident #66 scored 14 out of 15 possible points on the brief interview for mental status (BIMS) assessment, indicating he was cognitively intact. Per the MDS assessment, he required supervision with showering/bathing, upper body dressing and partial assistance with lower body dressing. He required substantial/maximal assistance with putting on/taking off footwear. During an interview on 7/23/24 at 9:40 AM with the resident's sister/emergency contact, she stated Resident #66 needed his toenails clipped. She had spoken to staff and his toenails had not been clipped since his admission. She stated she was not aware of whether or not the facility had a podiatrist. A review of Resident #66's care plan, initiated on 3/28/24 and revised on 7/3/24, revealed the following Focus Area: I am currently independent with all my ADLs but at times I may need cueing. Goal: I [resident's name] will continue to be independent in ADLs. Interventions: Check my fingernails and toenails and trim as needed unless I am diabetic, then please notify my nurse. An interview was conducted on 7/24/24 at 10:49 AM with Certified Nursing Assistant (CNA) L. She stated she had been a CNA since 2021 and had been employed at the facility for four months. She had received training on resident rights, abuse and neglect, and activities of daily living (ADL) care. She stated she was familiar with Resident #66. The resident was independent and able to make his needs known. He smoked. His sister was very involved in his care, and the resident liked to sleep a lot. She stated she emptied his urinal and made his bed when she was able to catch him out of it. The facility had a shower team that was responsible for providing baths/showers to all of the residents. The shower team provided showers Monday through Friday, and the CNAs were responsible for any showers scheduled or requested on Saturdays and Sundays. She stated the CNAs clipped the residents' fingernails and toenails. The podiatrist came in and clipped the toenails for residents who were diabetic. When asked about Resident #66's toenails, CNA L stated she had never clipped them. She had asked him about them and the resident stated they were alright. She could not provide a date or time that this conversation took place. On 7/24/2024 at 2:55 PM, Resident #66 was observed resting in bed. He stated he had received a shower earlier this morning. The CNA commented that he needed his toenails clipped; however, she did not clip them. He stated he could not remember the last time anyone had clipped them, but he wanted them clipped. He stated he was not a diabetic and his toenail length did not prohibit or hinder his walking; however, it did cause him some pain. His toenails were exceptionally long. The left great toe measured at 3.8 cm (centimeters), the left 2nd toe measured 1.6 cm, the left 3rd toe measured 1.1 cm, the left 4th toe measured 3.2 cm, and the left 5th toe measured 0.5 cm. The right great toe measured 4.2 cm, the right 2nd toe measured 1.6 cm, the right 3rd toe measured 1.5 cm, the right 4th toe measured 2.6 cm, and the right 5th toe measured 1.8 cm in length from the end of each toe. (Photographic evidence obtained) An interview was conducted on 7/25/24 at 11:15 AM with CNA I, a member of the shower team. She stated the shower team was in the facility daily at 5:30 AM. Their duties included shampooing residents' hair, assisting them with dressing, and shaving the men. They were also responsible for cutting residents' fingernails. A facility nurse or podiatrist was responsible for cutting residents' toenails. CNA I was familiar with Resident #66 and stated his showers were scheduled on Mondays, Wednesdays, and Fridays. His toenails needed clipping for some time. She stated the resident had not complained of pain to her. She reported the long toenails to a nurse and wasn't sure what was done with that information. When she was asked for the date she reported the resident's long toenails to the nurse, she replied that she wasn't sure, but It's been a while. During an interview on 7/25/24 at 2:42 PM with the Social Services Director (SSD), she stated the podiatrist was in the facility monthly. Resident could be seen sooner if staff, the resident and/or their representative requested they be seen. She said if the resident could wait, she would add them to be seen the following month. New residents were seen as needed, if they transitioned to long-term care, or when they became Medicaid approved. If they were Medicaid pending and it was not a dire need, the resident would have to wait until they were approved. The staff will notify me if a resident needs to be seen. I announce to all staff when they're coming in and ask if there's anyone who needs to be seen. Sometimes if it's the same day, they'll add the person to the list. She stated she spoke Resident #66's sister one to two weeks ago and she requested the resident be seen by the podiatrist. During an interview on 7/25/24 at 3:19 PM with Licensed Practical Nurse (LPN) E, he stated a member of the shower team made him aware of Resident #66s toenails on the day of this interview. It was the first time he had ever heard anything about the resident's toenails. He stated he talked to the podiatrist about adding the resident to the list to be seen on their next visit to the facility, and they agreed he would be seen the next week. A review of the list of podiatry visits for 7/2024, 6/2024, and 4/2024, provided by the SSD, revealed that Resident #66 was not seen. The SSD confirmed he had not been seen during any of the monthly visits reviewed. A review of the facility's policy titled Care of Fingernails/Toenails (revised 2/2024) revealed: Purpose: The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual who administered the care. 4. Any difficulties in cutting the residents nails. 6. If the resident refused the treatment,the reason, and interventions taken. A review of the facility's policy titled Assisting the Nurse in Examining and Assessing/Evaluating the Resident (undated) revealed: Components of the Observation: Activities of Daily Living: 4. Grooming: As you provide the resident with personal care needs, you should note: b. assistance needed with bathing, hair and nail care, dressing and undressing, mouth care.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure physician-ordered medication was available and provided to one (Resident #18) of 35 residents in the total survey sample. The findings include: On 7/24/24 at 9:40 AM, Licensed Practical Nurse (LPN) A was observed during medication administration. As she prepared medications for Resident #18, she stated the Prozac 60 mg (milligrams) ordered daily at 9:00 AM and due for administration at this time was not available in the medication cart. She stated the medication was on order from the pharmacy and it would be on the next pharmacy delivery. A 7/25/24 review of the Medication Administration Record (MAR) revealed the Prozac 60 mg ordered daily for Resident #18 was not administered on 7/23/24 or 7/24/24. In an interview with Unit Manager C on 7/25/24 at 9:05 AM, she was asked what the facility's system for back-up medications was. She stated the facility had a Pyxis machine for medications needed on admission or when medications had not been delivered yet. She was asked to review the contents of the Pyxis machine. Upon entering the medication room on the 2nd floor, she was asked if there was a list of medications in the Pyxis. The list was provided and reviewed. Prozac was not found on the list. She was asked if she could look up Resident #18 to confirm that Prozac was not available in the Pyxis for this resident. She did so and was able to confirm that Prozac was not available in the Pyxis for Resident #18, or for any other resident. In an interview with LPN A on 7/25/24 at 9:10 AM, she was asked if the Prozac for Resident #18 had arrived from the pharmacy. She opened the medication cart, reviewed the medications, and stated no. She was asked what the protocol was for a resident not receiving a medication for three consecutive days. She stated, She won't miss it today, I'll get it from the Pyxis. She was advised that a review of the Pyxis revealed Prozac was not available. She stated, I'll call the pharmacy again. The pharmacy delivers three times a day. She was asked if the resident's physician was aware that the resident had not received her Prozac for two days and today, the third day, the medication was not available for timely administration. She stated, I'm not sure if anyone called the physician. She was asked if she called the physician for the dose she was unable to administer yesterday. She stated, No, I didn't call the physician. A review of Resident #18's medical record revealed there was no notification to the resident's physician that the resident had missed her Prozac 60 mg on 7/23/24 and 7/24/24. A review of the facility's policy Administrating Oral Medications (undated) revealed: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Reporting: 1. Notify the supervisor if the resident refused the procedure. 2. Report other information in accordance with facility policy and profession standards of practice.

Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two errors were identified from 25 opportunities for error, resulting in a medication error rate of 8%, affecting two (Residents #18 and #52) of eight residents observed during medication administration from a total survey sample of 35 residents. The findings include: 1. On 7/24/24 at 9:40 AM, Licensed Practical Nurse (LPN) A was observed during medication administration. As she prepared medications for Resident #18, she stated the Prozac 60 mg (milligrams) ordered daily at 9:00 AM and due for administration at this time was not available in the medication cart. She stated the medication was on order from the pharmacy and it would be on the next pharmacy delivery. A 7/25/24 review of the Medication Administration Record (MAR) revealed the Prozac 60 mg ordered daily for Resident #18 was not administered on 7/23/24 or 7/24/24. In an interview with Unit Manager C on 7/25/24 at 9:05 AM, she was asked what the facility's system for back-up medications was. She stated the facility had a Pyxis machine for medications needed on admission or when medications had not been delivered yet. She was asked to review the contents of the Pyxis machine. Upon entering the medication room on the 2nd floor, she was asked if there was a list of medications in the Pyxis. The list was provided and reviewed. Prozac was not found on the list. She was asked if she could look up Resident #18 to confirm that Prozac was not available in the Pyxis for this resident. She did so and was able to confirm that Prozac was not available in the Pyxis for Resident #18, or for any other resident. In an interview with LPN A on 7/25/24 at 9:10 AM, she was asked if the Prozac for Resident #18 had arrived from the pharmacy. She opened the medication cart, reviewed the medications, and stated no. She was asked what the protocol was for a resident not receiving a medication for three consecutive days. She stated, She won't miss it today, I'll get it from the Pyxis. She was advised that a review of the Pyxis revealed Prozac was not available. She stated, I'll call the pharmacy again. The pharmacy delivers three times a day. She was asked if the resident's physician was aware that the resident had not received her Prozac for two days and today, the third day, the medication was not available for timely administration. She stated, I'm not sure if anyone called the physician. She was asked if she called the physician for the dose she was unable to administer yesterday. She stated, No, I didn't call the physician. 2. On 7/24/24 at 9:50 AM, LPN A was observed during medication administration. As she prepared medications for Resident #52, she placed six medications in a medication cup. The medication administration record (MAR) was observed at the cart to have seven medications ordered for this resident during this medication pass. LPN A greeted Resident #52 and gave him the medication cup with the six pills. This surveyor asked the resident how many pills were in his cup. He looked in the cup and stated six then took the medication. Upon returning to the medication cart, the nurse went back to the MAR for Resident #52 and checked off each medication as administered. She then moved on to the next resident on the MAR. She was stopped and asked if she had administered all of the ordered medications for Resident #52. She went back to the MAR and re-read the resident's medications. She was asked if there were six medications in the cup. She stated yes. She was asked how many medications were ordered. She replied, let me check and counted seven. She took the card of Lisinopril out of the cart and stated she had not administered the resident's Lisinopril. A review of the facility's policy titled Administration of Oral Medications (undated) revealed: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the Procedure: 3. Place MAR within easy viewing distance. 5. Select the drug from the unit dose drawer or stock supply. 9. Prepare the correct dose of the medication. Reporting: 1. Notify the supervisor if the resident refused the procedure. 2. Report other information in accordance with facility policy and profession standards of practice.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by 1) Failing to ensure the dishwashing machine reached appropriate temperatures, 2) Failing to ensure the refrigerator and freezer maintained appropriate temperatures, 3) Failing to ensure food temperatures were recorded daily, and 4) Failing to ensure the facility's nourishment rooms were maintained per requirements. The findings include: 1. On 7/11/22 at 10:54 AM, a tour of kitchen was conducted. At 11:07 AM, Dietary Aide H was observed using the dishwashing machine and was asked what type of machine it was. Dietary Aide H stated it was a high-temperature machine. She was asked what temperature it should reach when washing dishes and she stated, The final rinse should be 180 º F (Fahrenheit). When asked about the wash cycle temperature, Dietary Aide H stated, I'm not sure. I don't know. During this time, an observation was made of the dishwashing machine. It was run three separate times with a wash temperature of 110 ºF and rinse temperature of 150º F. The Dietary Manager (DM) was nearby and was asked about the machine. She was asked three times what type of dishwashing machine it was, low-temperature or high-temperature, and she reported both. Temperature logs for June 2022 and July 2022 were observed with high temperatures written on them. June temperature logs documented several days with a wash temperature below 160 ºF. The July 2022 log had six days of missing temperatures during the lunch meal, and several days with temperatures below the 160 ºF wash cycle standard temperature. (Photographic evidence obtained) The Dietary Manager was asked about the unacceptable dishwasher temperatures and what her plan was at this time. She stated, You're putting me in hard place. I guess we will use Styrofoam. At this time the Dietary Manager said nothing about the dishwashing machine being under repair or not meeting temperatures prior to the abovementioned observations. On 7/11/22 at 11:45 AM, the dishwasher technician reported the temperatures should be hotter. The rinse water should reach 185 ºF. The Maintenance Director, who was present at the time, asked the dishwasher technician, Isn't 120 ºF okay?, at which time the technician stated, It needs to be higher. On 7/11/22 at 3:09 PM, the Administrator was interviewed. She stated the Dietary Manager informed her of issues in the kitchen during the morning meetings, and that Two weeks ago, the Dietary Manager told me about a company coming to work in the kitchen but that is all. An interview with Maintenance Assistant J was conducted on 7/11/22 at 3:18 PM. He reported that he tested the water in the kitchen water heater three times a day for temperatures. He confirmed that he did not test the water after it went through the booster. He stated he was told by the Maintenance Director to check the temperatures. He reported that the temperature of the water heater was 155 ºF and the booster on the machine should be reaching 185 ºF to 190 ºF. During an interview with the Administrator on 7/11/22 at 3:25 PM, she reported she was not aware of anyone telling them to check the temperature of the dishwasher or the water heater. Maintenance Assistant J was interviewed again on 7/11/22 at 3:33 PM. He was asked who tested the two temperatures and who recorded the two temperatures needed. He stated, The first temp is the one I give to the dietary worker, and the rinse is the second one. The dietary staff write that one down. A review of the facility's policy on Sanitization (Revised in December 2008), revealed: The high-temperature dishwashing machine must be operated using the following specification: wash temperature (150ºF to 165ºF) for at least forty-five seconds; Rinse temperature 165ºF to 180ºF for at least twelve seconds. On 7/11/22 at 11:00 AM, an observation of the kitchen's refrigerator and freezer were made. The refrigerator thermometer read 46 ºF and the freezer read 20 ºF. On 7/13/22 at 11:15 AM, a second observation was made of the kitchen's refrigerator and freezer. The refrigerator thermometer read 42 ºF and the freezer thermometer read 30 ºF. (Photographic evidence obtained) The milk cartons on the tray line were tested on [DATE] at 12:19 PM. The Dietary Manager was asked to test milk cartons with the thermometer for appropriate temperatures. Two of three milk cartons were above 41 ºF. The first was 45 ºF and the second was 42 ºF. On 7/14/22 at 1:37 PM, an interview was conducted with the Dietary Manager who reported that the freezer had been broken since March or April 2022 and the part was ordered on 6/30/22. There was no date scheduled for repair. (Photographic evidence obtained) On 7/13/22 at 11:33 AM, observations of the Food Temperature logs were noted with several days of missing documentation for the dinner service. The dates missing food temperatures included: 7/7/22, 7/6/22, 7/9/22, 7/10/22, and 7/11/22. (Photographic evidence obtained). The Dietary Manager reported at 1:37 PM on 7/14/22 that food temperatures were taken every two hours while on the tray line steam table. Food temperatures were taken during the breakfast, lunch and dinner service. A review of the facility's policy titled Preventing Foodborne Illness-food Handling, stated functioning of the refrigeration and food temperatures would be monitored at the designated intervals throughout the day and documented according to state-specific requirements. On 7/13/22 at 9:53 AM, the nourishment room on the 3rd floor was observed with no thermometer in the refrigerator area. The refrigerator had stains and food residue inside and outside. The temperature log was filled out for everyday but there was no thermometer in the device. On 7/13/22 at 10:01 AM, the 2nd floor nourishment room was observed. There was a thermometer in the refrigerator, but it was broken. (Photographic evidence obtained) Temperature logs were posted on the refrigerator with no temperature filled out on the form. The microwave had soiled paper towels in it with crumbs and stains inside. (Photographic evidence obtained) It was also observed that soiled plastic containers were on top of the microwave. (Photographic evidence obtained) An interview was conducted with the Dietary Manager at 1:37 PM on 7/14/22. She reported that the nourishment rooms were checked by the dietary aides and dietary manager two times a day. She reported that the nursing staff also cleaned them. When asked who wrote temperatures down on the logs, she reported that the nursing staff was responsible for that task. No facility policy related specifically to nourishment rooms was provided at the time of the survey.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents fed by enteral means received appropriate treatment and services for two (Residents #100 and #70) of two residents reviewed who were receiving enteral nutrition from a total of 20 residents in the sample. The findings include: 1. An observation was made of Resident #100 on 7/11/22 at 2:55 PM. Her tube feeding rate was set at 50 ml per hour. An observation was made of Resident #100 on 7/12/22 at 1:30 PM. Her tube feeding rate was again set at 50 ml per hour with a water flush every four hours. An observation on 7/13/22 at 9:30 AM revealed the tube feeding pump rate was set at 50 ml per hour with a water flush every 4 hours. (Photographic evidence obtained) An observation on 7/14/22 at 10:26 AM revealed a tube feeding rate of 50 ml per hour and a water flush of 250 ml every four hours. A record review was conducted for Resident #100, revealing an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #100's Minimum Data Set (MDS) assessment, dated 6/1/22, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points, indicating moderate cognitive impairment. Activities of Daily Living (ADLs) included total dependence with eating, and bed mobility/transfers with extensive assistance of one person. The resident was documented as receiving 51% or more total calories from tube feeding, and her recorded body weight was 162.8 pounds on 6/1/22 and 158.8 on 7/12/22. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Water flushes were also ordered four times a day at 250 milliliters via G-tube (feeding tube) for hydration. A review of the care plan, initiated on 5/26/22, revealed the resident required tube feeding due to dysphagia with a goal to maintain adequate nutritional and hydration status as evidenced by a stable weight and no signs of malnutrition or dehydration through the next review date. An interview was conducted on 7/14/22 at 11:20 AM with the Registered Dietitian (RD). She reported that she based the resident's tube feeding rate on her specific needs. She calculated 30 to 35 per kilogram for residents who needed to gain weight. The RD stated if she needed to change the resident's tube feeding, she would put an order in and verbally tell the unit manager and physician or leave a note. She stated she checked the accuracy of the tube feedings monthly. She had Resident #100 on 60 for 22 hours a day and water flushes four times a day at 250 ml per flush. An interview was conducted with Licensed Practical Nurse (LPN) A at 12:34 PM on 7/14/22. She was asked to look up Resident #100's tube feeding order in the electronic medical record. LPN A reported the resident's order stated 60 ml every hour for 22 hours a day and flush with water every six hours. At this time, she was asked to observe the pump in Resident #100's room. She was asked whether the pump matched the order. She stated, No it does not match. The tube feeding pump was set at 50 ml per hour with water flushes every four hours. 2. An observation was made of Resident #70 on 7/12/22 at 4:30 PM. A tube feeding pump was observed and the resident's tube feeding rate was set at 50 ml per hour. On 7/14/22 at 12:00 PM, Resident #70 was observed. His tube feeding rate was set at 50 ml per hour. On 07/14/22 at 12:27 PM, an observation of the tube feeding pump in Resident #70's room was made with LPN G. The pump was set at 50 ml per hour. At the time of the observation, LPN G confirmed that the rate was set at 50 ml per [NAME]. She was asked to verify the order in the electronic medical record. She returned to the nurses' station to verify order and stated the tube feeding rate was ordered for 56 ml per hour for 22 hours a day. A record review conducted for Resident #70, revealed an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's MDS assessment, dated 5/12/22, revealed a BIMS score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident was totally dependent for eating. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The accompanying order for water flushes was for 150 ml every four hours. A review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) A Nutrition Note authored by the RD on 7/7/22 revealed a tube feeding order change. Body weights were recorded with no weight gain from May 2022 to July 2022. Weights included 99.6 lbs. (pounds) on 5/2/22 and 98.8 lbs. on 7/11/22. The resident's active Care Plan was reviewed and documented Resident #70 required tube feeding via a feeding tube due to dysphagia. An interview was conducted on 7/14/22 at 11:20 AM with the Registered Dietitian (RD). She was asked what rate Resident #70's tube feeding should be set at and she reported she had changed it on 7/8/22 to 56 ml per hour for 22 hours a day. She stated Resident #70 should be weighed monthly. She was trying to get him to an ideal body weight and the rate ordered was for weight gain. She stated, I am not sure why he has not gained weight. She reported his current tube feeding order should be for a total of 1848 calories daily. An interview was conducted with LPN G on 7/14/22 at 12:17 PM. She stated the registered nurses or licensed practical nurses were responsible for the tube feedings. She was asked about Resident #70's tube feeding rate and she reported it was 50 ml per hour. A review of the facility's policy titled Enteral Nutrition was reviewed. The policy stated, Adequate nutritional support through enteral feeding will be provided to residents as ordered. (Copy obtained)

Based on observation, interview, and record review, the facility failed to identify resident preferences consistent with residents' food allergies to meet the needs of one resident (#36) reviewed from a total sample of 20 residents. The findings include: During an interview with Resident #36 on 7/11/22 at 12:52 PM, she reported she was allergic to apples and pineapples but the kitchen kept sending pineapples and apples on her meal trays. At the time of the interview, a pineapple cup was observed on Resident #36's lunch tray. (Photographic evidence obtained) On 7/11/2022 at 12:54 PM, observation of Resident #36's lunch meal ticket, dated 7/11/2022 read, Note: no apple, no pineapples. (Photographic evidence obtained) On 7/11/2022 at 2:24 PM, a Medical Nutrition Therapy note revealed Resident #36's current diet consisted of: Pureed diet, honey-thickened liquids; Allergies: pineapple, apple; Food preferences (likes): banana, macaroni and cheese. On 7/13/2022 at 4:01 PM during an interview with Certified Nursing Assistant E, she stated she verified resident plates and tray tickets before passing the meals to the residents. If there were foods on the tray the resident was allergic to, the resident would not receive the tray and the nurse would be notified. On 7/14/2022 at 11:46 AM during an interview with the registered dietitian, she confirmed that food allergies/preferences were identified on admission during the resident interview. They were added to the resident's chart under the nutrition note, and they were printed on each meal ticket. The the kitchen staff were responsible for checking each meal ticket for allergies, likes and dislikes prior to sending the food to the resident. A review of Resident #36's active Care Plan, revised 3/19/2022, revealed the resident had a nutritional problem or potential nutritional problem related to gastrointestinal hemorrhage, type 2 diabetes mellitus, [CONDITION(S)], dysphagia, [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] disorder, [CONDITION(S)] disease, acute kidney failure, [CONDITION(S)], hypertension, cardiac murmur, coronary artery disease, and required a mechanically altered diet. Interventions included: food allergy: pineapple and apple. A review of the facility's policy and procedure titled, Food Allergies and Intolerances (undated), revealed: Residents with food intolerances and allergies will be offered appropriate substitutions for foods that they cannot eat. (Copy obtained)

Based on interviews and record reviews, the facility failed to maintain resident medical records that were complete and accurately documented for one (Resident #36) of five residents reviewed for nutrition and hydration services from a total sample of 20 residents. (Residents #36). The findings include: A review of the Nutrition Consult, dated 7/6/22, found that Resident #36 was documented as currently receiving the following supplement: House supplement 180 ml (milliliters) two times daily by mouth for meals and recommendation to increase house supplement to 180 ml three times daily. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #36's July 2022 Medication Administration Record (MAR), revealed: House Supplement three times a day, Readycare 2.0 180 ml TID (three times daily) and add thickening powder to reach a honey-thickened consistency. Start date 7/6/2022 at 5:00 p.m. Documentation verifying the supplement was provided to the resident was missing for dates 7/7/22, 7/8/22, 7/9/22, 7/10/22, and 7/11/22. (Copy obtained) During an interview with Licensed Practical Nurse (LPN) A on 7/13/22 at 12:17 PM, she confirmed that the house supplement Readycare twice a day order for 6/6/2022 was increased to three times a day on 7/6/22. When the electronic MAR was reviewed with LPN A, she stated she was not sure why there was no documentation for 7/7/22 through 7/11/22 to verify the supplement had been given. During an interview with LPN B on 7/13/22 at 12:22 PM, the nurse confirmed the new supplement order for three times a day started on 7/6/2022. The nurse was not sure why the medication administration record was blank for 7/7/22 through 7/11/22, indicating the supplement had not been provided on those days. During an interview with the Assistant Director of Nursing (ADON) on 07/13/22 at 12:25 PM, she stated she did not know why the July 2022 MAR was not signed from 7/7/22 through 7/22/11 for for the house supplement that was to have been provided three times a day. She further stated that no documentation meant the task had not been done. During an interview with Registered Nurse (RN) D on 07/13/22 at 1:10 PM, she confirmed that the supplement order for twice a day was discontinued on 7/6/2022 and increased to three times a day on the same day, 7/6 2022. She confirmed staff should have continued providing the house supplement twice a day and documenting same until it was discontinued on 7/6/22, they they should have begun documenting administration of the supplement three times a day per the new order. A review of the facility's policy and procedure titled, Supplement Policy and Procedure (Undated), revealed: Supplements will be provided in accordance with the MD (Medical Doctor) order and amount consumed will be documented on the MAR (Medication Administration Record). (Copy obtained)

Based on interviews, record review, and a review of the facility's policies and procedures titled, Abuse Prevention and Reporting and Investigation of Sexual Misconduct, the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in unwanted sexual contact for one (Resident #9) of four residents reviewed for abuse, from a total of 18 residents in the sample. The facility failed to develop and implement interventions necessary to protect Resident #9 from unwanted sexual contact by Resident #2, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This created a likelihood that Resident #9 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial harm from Resident #2. Resident #2 was assessed, and care planned on 3/20/2020 for inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no guidance for supervision. Interviews with staff indicated Resident #2 had always been grabby and would grab at females' breasts and buttocks regularly. On 5/11/2021, Certified Nursing Assistant (CNA) A was groped between her legs by Resident #2 while providing his care. On 7/23/2021, Resident #2 touched Resident #9 in the groin and breast area through her clothing. No increased supervision of Resident #2's inappropriate sexual behavior was put in place until 7/23/2021. After this incident, the facility placed him on 1:1 (one to one) supervision until he was Baker Acted (involuntary psychiatric admission) the same day. He has not returned to the facility. Resident #9 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm, not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. The Administrator was notified of the Immediate Jeopardy at 6:00 p.m. on August 6, 2021. The Immediate Jeopardy was ongoing as of the exit on August 6, 2021. The findings include: Cross reference F835 and F867 An interview was conducted with CNA B at 10:22 a.m. on 8/4/21. She explained Resident #2 was a handful and required constant staff attention and supervision. Even when he did not have a 1:1 formal assignment, his behaviors were so bad staff would have to take turns providing supervision for his behaviors. Resident #2 was touchy-grabby with the female staff and on occasion, would try to touch female residents. She stated Resident #2 had approached a couple of the female residents in the past, but those residents took care of it right then and there and stopped him. CNA C was interviewed at 10:30 a.m. on 8/4/21. She reported Resident #2 was very touchy-feely and grabby. He would try to grab female staff all the time, even if you were just walking by. Your arms, anywhere, he would just grab at you all the time. CNA C demonstrated by grabbing up and down the arm of this writer, saying Resident #2 would grab at the residents in this fashion. She stated Resident #2 would try to target and corner non-verbal female residents. He had a 1:1 supervision assignment on occasion, but staff all knew he was not to be left alone. They all watched and redirected Resident #2 constantly. Licensed Practical Nurse (LPN) D was interviewed at 12:50 p.m. on 8/4/21. She stated Resident #2 was recently Baker Acted for his very difficult behaviors. He has been a handful and needs to be watched all the time or he will get on the elevator and be gone. He inappropriately smacks and grabs staff's butts and he knows it is wrong. He did it to a female resident recently, and he has done that in the past. If Resident #2 went into another resident's room, she said she would remove him immediately. When asked what level of supervision was provided for him, she said all the staff knew to watch him. In an interview with the Administrator at 1:30 p.m. on 8/4/21, she explained that Resident #2 was inherited with the building when it was sold to the current owner. Resident #2 was developmentally disabled, had MS ([CONDITION(S)]) and was inappropriately placed in the first place. Due to his inappropriate touching behaviors, the facility tried to have him Baker Acted several times. They recently succeeded. An interview was attempted with Resident #9 at 3:15 p.m. on 8/4/21. She appeared slightly disheveled but stated she was doing fine. She stated she had just moved to this facility and was taking her medication; she was fine. She had no recollection of the event with Resident #2. She again reported being fine and said she was taking her medication. The second floor Unit Manager was interviewed at 3:20 p.m. on 8/4/21. She stated Resident #2 was a handful and required constant supervision. Sometimes he was on 1:1 supervision but all staff knew to watch him when he was out of his room. He would grab at female staff and try to touch them inappropriately. Resident #2 did try to get to some other residents, but she was unaware of any sexual contact. In an interview with the Administrator at 4:30 p.m. on 8/4/21, she further explained that Resident #2 was very child-like. He was very grabby and tried to grab her arms, butt or boobies whenever she walked past him. He would put his hand out and get a feel. He was like a baby but was very smart and played intellectually impaired when he knew he was in trouble. In the past month he became more sexually inappropriate with staff, then the incident occurred with Resident #9. Staff reported Resident #2 touched Resident #9's vaginal area and breast through her clothing. The Restorative CNA (RCNA J) who had been in the same room with both residents, walked out for two minutes and it happened. Resident #2 was removed from the room immediately and placed on 1:1 supervision. After the incident, the Administrator reviewed the videotapes (that have since self-erased). She stated she saw Resident #2 trying to reach for Resident #9's vaginal area. He made brief contact. She (Resident #9) shooed him away, then he tried to reach for her breast. He grazed it and that was when RCNA J walked back into the room. RCNA J stopped the behavior and took Resident #2 to his room. The Administrator said there was one other similar occasion in the past, but she was not employed by the facility during the time of that event. As a result of that incident, the female resident had to be moved to the 3rd floor. The Administrator was asked what interventions were in place for Resident #2 related to his sexual behaviors. She stated there was always a CNA by his door because he would roll out of bed and roll down the hall like a bowling ball. This June (2021) he was put on [MEDICATION(S)] injections (a hormone that can be used to lower sexual drive in males), which seemed to have made his behavior worse. She was asked what interventions had been implemented to keep other vulnerable residents safe. She stated staff were always watching him. It was pointed out that RCNA J had walked out of the room for two minutes and the incident occurred with Resident #9 in that short period of time. The Administrator said following similar instances in the past, Resident #2 was put on 1:1 supervision. She did not provide details of past events. She also explained there had been an employee victim. She stated she asked if the employee wanted to press charges against Resident #2, but the employee declined. The Administrator was asked what she could have done to prevent Resident #2 from victimizing a vulnerable resident after he clearly demonstrated a propensity for inappropriately touching female staff. She said the only thing she could have done was to provide 1:1 supervision, which was impossible as there was a staffing shortage. She hesitated and said, Well, not impossible, but it would create a staffing deficit. The Administrator turned to the DON who was in the room and asked what more they could have done. The DON concurred that they would have had to have provided 1:1 supervision of Resident #2, but she couldn't provide that. The DON said they had tried everything including searching for alternative placement and 1:1 staff supervision in the past. The Abuse Coordinator/Social Services Director (SSD) was interviewed at 4:59 p.m. on 8/4/21. She explained the facility soon came to realize that Resident #2 was a whole handful and then some. He was constantly counseled on not touching people, including staff. There was no rhyme or reason to his sexual acting out. It seemed to come from nowhere. He would try to grab you and has been known to try to touch staff on the breast or behind. The facility had attempted education, constant activities, and extended smoke breaks, but he didn't stay focused. Everyone was monitoring him at all times. He would try to get into all the offices downstairs, even if the doors were closed. She recalled there was one prior incident with a female resident earlier in the year. The SSD was asked if there were other vulnerable female residents on Resident #2's unit. Without directly answering, she said she had looked all over the state for more appropriate placement for him without success. After this last incident (with Resident #9), the Psychiatric APRN said this was not safe, and we could not do it any longer. When asked what the facility did to protect other residents, she said everyone always watched Resident #2. Fifteen- and thirty-minute checks and Baker Acts were attempted in the past, but he was not on 15-minute checks when the July 2021 incident occurred. A telephone interview was conducted with the Psychiatric APRN at 10:30 a.m. on 8/5/21. She was asked about Resident #2's sexual behaviors, and she stated he groped females. It was more than just groping, he did this repeatedly. She said it was not safe for him to come back to the facility, as other residents could not get away from him. She was asked if he had groped other residents inappropriately in the past. She stated he had, but could not report who, when or how often this had occurred. She explained that unfortunately, medication could not change Resident #2's behaviors. Medication changes were made, and the facility attempted to send him out (under a Baker Act) several times. The APRN explained that the day they found him fondling another resident, he had already been doing that to staff. She was asked if 1:1 supervision would have been appropriate for this resident to keep vulnerable residents safe. She did not answer but explained they had him on 1:1 supervision numerous times in the past. Resident #11 was interviewed at 11:15 a.m. on 8/5/21. She stated she felt safe in the facility. The only man who had ever touched her was Resident #2. He grabs all the girls. When asked if she had ever been grabbed by him, she replied yes. When asked where, Resident #11 stated he had grabbed her arm when they were in the elevator. In an interview with the DON at 1:30 p.m. on 8/5/21, she was asked about the behavioral analysis recommended by the Psychiatric APRN on her 5/13/21 evaluation. The DON replied that it was only a recommendation, but that day the APRN also started Resident #2 on [MEDICATION(S)] (antipsychotic), which worked, so they felt the behavioral analysis was not needed. In an interview with CNA/Unit Clerk G at 3:35 p.m. on 8/5/21, she stated she knew Resident #2 well. He was a grabber. He would grab staff in the crotch, the breast, wherever. He knew what he was doing because he knew right where to grab. She never saw him grab or touch any residents in the same manner. Personal Care Assistant (PCA) H reported in an interview at 3:45 p.m. on 8/5/21, that she knew Resident #2 well. She also described him as a grabber, as he would grab female staff in private places. She stated it was so bad with some of the aides, that they wouldn't go in and work with him. Restorative CNA (RCNA) J was interviewed at 4:07 p.m. on 8/5/21. When asked about the incident between Resident #2 and Resident #9, he confirmed he witnessed the incident. He stated he had just arrived at the facility when he saw Resident #2 touching Resident #9's breasts with both hands. Resident #2 was also rubbing Resident #9 on her thigh and groin region. It was so fast, it was approximately two seconds of contact when RCNA J yelled, Stop. Resident #2 stopped immediately and looked at RCNA J like he had been busted. RCNA J recalled a similar encounter with one other resident in the past and said Resident #2 had done this to an employee too. Resident #2 had touched the female employee inappropriately where she didn't want to be touched. In an interview with the Administrator at 11:40 a.m. on 8/6/21, she confirmed that the Abuse Prevention and Sexual Misconduct policy was what the facility followed for resident-to-resident incidents. She was asked if as a result of any of Resident #2's behaviors, other female residents on the unit had been interviewed to determine whether there were additional victims. She said no, but they were going to go do that right away. In an interview with the Regional Nurse Consultant at 2:50 p.m. on 8/6/21, she was asked if screening was done to assess for residents' ability to consent to sexual activity. She replied no, that it would be done on a case-by-case basis if resident(s) expressed a desire for sexual activity. A review of the facility's investigation revealed that on 7/23/21 at 1:00 p.m., RCNA J walked into the second floor day room and witnessed Resident #2 touching Resident #9 through her clothing in her groin and breast areas. Staff separated the two residents, removed Resident #2 from the room, and immediately placed him on 1:1 supervision. Resident #2 was Baker Acted that day as a result of the event and remained out of the facility under psychiatric care at the time of the survey. A written statement was obtained from RCNA J. In the undated statement, Employee J recalled walking into the day room on 7/23/21 at approximately 11:40 (no am/pm specified). He found Resident #2 groping a female resident on her breast and groin areas. 1. A review of Resident #2's clinical record, revealed he was admitted to the facility on [DATE] and was [AGE] years old. The Discharge Return Not Anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/23/21, noted he had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating moderately impaired cognitive skills for daily decision making. Resident #2 required extensive assistance with transfers and independently used a wheelchair. He was non-ambulatory (unable to walk). His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record found additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was care planned on 3/22/20, with a most recent review on 7/7/21, for multiple socially inappropriate/disruptive behavioral symptoms including, but not limited to: Inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Inappropriate behavior toward female staff as was included in the focus. The goal was not to harm himself or others due to the socially inappropriate/disruptive behaviors. Approaches included medications as ordered; Monitor for side effects and effectiveness; Assess whether behavior endangers resident/others; Intervene as needed; Avoid overstimulation; Convey acceptance; Maintain calm approach with resident; Observe/report socially inappropriate/disruptive behavior when around others; Obtain psychiatry/psychotherapy consult; Praise when appropriate; Remove from other residents' rooms and unsafe situations; Set limits and expectations; Support appropriate mood and behavior, and; Move to a quiet, calm environment when behavior becomes inappropriate. The care plan did not define inappropriate touching and did not specify what action should be taken or level of supervision should be provided as a result of sexually touching other staff or residents. There were no revisions to the care plan since October 2020 when Resident #2 was Baker Acted for non-sexual behaviors. (Photographic evidence obtained) Resident #2 was care planned 1/16/20 with a review on 7/7/21, for risk for elopement/exit seeking behaviors and for wandering in and out of residents' rooms. The goal was to be redirected when attempting to leave and to wander within a safe environment through the next review date. Approaches to wandering within the facility included alerting the front office that the resident wanders/exit seeks .; Escort to and from meals, therapy, and activities; Establish and maintain daily routine time to eat, dress, sleep, activity, etc.; Frequent supervision as needed; Provide distraction, conversations, etc.; Redirect away from exits/doors to common area, therapy, activities, etc. The care plan did not address what to do should he wander into or be located in another resident's room. (Photocopy obtained) Resident #2 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's Nursing Progress notes, found on 5/11/21, Resident #2 grappled a CNA. The CNA stated he was groping her between her legs and not letting her go while she was giving care. On 6/15/21, Resident #2 was observed pulling on other residents in the day room. On 7/22/21, he was crawling on the floor in his room and in and out of other resident room. The nursing note dated 7/23/21, reported Resident #2 and Resident #9 were observed in the day room. RCNA J walked into the room finding Resident #2 touching Resident #9 through her clothing in the groin and breast area. Staff separated the two residents, removed Resident #2 from the room, and immediately placed him on 1:1 supervision. He was Baker Acted that day as a result of the event. (Photocopies obtained) A Psychiatric Evaluation was completed by the Advanced Practice Registered Nurse (APRN) on 5/13/21, two days after Resident #2 inappropriately touched the CNA mentioned in the 5/11/21 Nursing progress note. The APRN documented staff requested the visit due to increased sexual acting out, grabbing staff inappropriately, and then attempting to hurt them. A consultation with the psychiatrist and facility DON was conducted, and a behavioral analysis was recommended for Resident #2. The facility was to have that done. [MEDICATION(S)] (antipsychotic) 5 mg (milligrams) was started. The APRN noted Resident #2's mood symptoms included grandiosity, distractibility, elevated/expansive/irritable mood. He was noted with poor insight and judgement. Under the Diagnosis, Assessment and Plan section, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress note dated 7/23/21, documented that Resident #2 was observed by staff inappropriately touching another female. He was removed and placed on 1:1 supervision. The assigned CNA placed him in bed. Resident #2 attempted to throw himself out (of bed) and wrapped the call light around his neck. He stated he would continue to try to hurt himself until he got out of the facility. A Psychiatric evaluation was completed on 7/23/21 by the APRN, who reported staff requested a Baker Act after Resident #2 was found groping yet another female. Staff report this is the second or third female they have found him doing this to. Due to this behavior and the (victim's) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This made it an unsafe environment for her. [Resident #2] needs to be Baker Acted. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) A Certificate of Professional Initiating Involuntary Examination (a form for initiating a Baker Act) was completed on 7/23/21 by the Psychiatric APRN. The form deemed Resident #2 unable to determine for himself whether a psychiatric examination was necessary. The APRN noted Resident #2 was inappropriately touching other female residents and staff, and after being redirected, attempted to throw himself on the floor and wrapped a call light around his neck. The APRN determined Resident #2 posed a threat of harm to himself and others. Resident #2 stated he would kill himself and continue trying to hurt others if he remained in the facility. 2. A review of Resident #9's (the victim of the 7/23/21 encounter) medical record revealed she was admitted on [DATE] and was [AGE] years old. The Quarterly MDS with an ARD of 7/27/21, recorded a BIMS of 4 out of a possible 15 points, indicating severely impaired cognition. Resident #9 had unclear speech but could make herself understood and understood others. She required supervision to independence with activities of daily living, and she ambulated independently with a steady gait. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Social Services assessment, dated 7/14/21, indicated Resident #9 was divorced. There was no information in the clinical record indicating whether Resident #9 had been assessed for her ability to consent to sexual activity. There was no evidence that any psychological evaluation or counseling was provided following the 7/23/21 incident with Resident #2. (Photocopies obtained) A Nursing Progress note dated 7/23/21, documented that Resident #9 was involved in a resident to resident event in the second floor day room. No injuries were observed. Notification was made to the Clinical Practitioner but attempts to contact Resident #9's friend were met with a disconnected phone number. The sheriff's office and the state abuse reporting agency were notified, and a state report was completed. The Interdisciplinary Team was also notified. The facility's Abuse Prevention Program policy (revised 7/2020) read, Our residents have the right to be free from abuse, neglect . and exploitation. This includes, but is not limited to . verbal, mental, sexual, or physical abuse . As part of the resident abuse prevention, the Administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . The policy defines sexual abuse as non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault . The policy continues by specifying that following an incident, the facility will: 6. Identify and assess all possible incidents of abuse . 7. Thoroughly investigate and document the event, and . . 9. Protect resident(s) during abuse investigation and protect resident(s) from further harm during the investigation by providing the resident(s) with a safe environment. The Reporting and Investigation of Sexual Misconduct section of the policy (revised 7/2020), instructed that all allegations of sexual misconduct by facility personnel must be reported immediately to the Administrator, Director of Nursing (DON) and Risk Manager . 1. Should an allegation of sexual misconduct be made against a member of the facility's personnel, the person receiving the allegation must report to his/her supervisor, the person in charge . or the DON. 2. The DON or designee must immediately report such information to the Administrator . . 4. The following actions must be taken in all allegations of sexual misconduct: a. Assess the resident for possible injuries. b. Provide medical treatment as indicated c. Notify proper authorities . 5. The Risk Manager or designee will conduct an investigation which will, at a minimum, include: a. Review the resident's medical record for events leading up to the incident; b. Interview the person reporting the incident; c. Interview witness to the incident; d. Interview resident; e. Interview resident's attending physician as needed to determine the resident's current level of functioning and medical condition; f. Interview staff members (all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview resident's roommate, family member and visitor as appropriate; h. Interview other residents to whom the employee provided care services; and i. Review any events leading up to the alleged incident. 6. Witness reports will be obtained in writing .

Based on interviews and record reviews, the facility's administration failed to provide appropriate services and adequate supervision to ensure the protection of vulnerable residents from sexual abuse for one (Resident #9) of 18 residents in the sample. The facility failed to develop and implement interventions necessary to protect Resident #9 from unwanted sexual contact by Resident #2, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This created a likelihood that Resident #9 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial harm from Resident #2. Resident #2 was assessed, and care planned on 3/20/2020 for inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no guidance for supervision. Interviews with staff indicated Resident #2 had always been grabby and would grab at females' breasts and buttocks regularly. On 5/11/2021, Certified Nursing Assistant (CNA) A was groped between her legs by Resident #2 while providing his care. On 7/23/2021, Resident #2 touched Resident #9 in the groin and breast area through her clothing. No increased supervision of Resident #2's inappropriate sexual behavior was put in place until 7/23/2021. After this incident, the facility placed him on 1:1 (one to one) supervision until he was Baker Acted (involuntary psychiatric admission) the same day. He has not returned to the facility. Resident #9 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm, not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. The Administrator was notified of the Immediate Jeopardy at 6:00 p.m. on August 6, 2021. The Immediate Jeopardy was ongoing as of the exit on August 6, 2021. The findings include: Cross reference F600 and F867 An interview was conducted with CNA B at 10:22 a.m. on 8/4/21. She explained Resident #2 was a handful and required constant staff attention and supervision. Even when he did not have a 1:1 formal assignment, his behaviors were so bad staff would have to take turns providing supervision for his behaviors. Resident #2 was touchy-grabby with the female staff and on occasion, would try to touch female residents. She stated Resident #2 had approached a couple of the female residents in the past, but those residents took care of it right then and there and stopped him. CNA C was interviewed at 10:30 a.m. on 8/4/21. She reported Resident #2 was very touchy-feely and grabby. He would try to grab female staff all the time, even if you were just walking by. Your arms, anywhere, he would just grab at you all the time. CNA C demonstrated by grabbing up and down the arm of this writer, saying Resident #2 would grab at the residents in this fashion. She stated Resident #2 would try to target and corner non-verbal female residents. He had a 1:1 supervision assignment on occasion, but staff all knew he was not to be left alone. They all watched and redirected Resident #2 constantly. Licensed Practical Nurse (LPN) D was interviewed at 12:50 p.m. on 8/4/21. She stated Resident #2 was recently Baker Acted for his very difficult behaviors. He has been a handful and needs to be watched all the time or he will get on the elevator and be gone. He inappropriately smacks and grabs staff's butts and he knows it is wrong. He did it to a female resident recently, and he has done that in the past. If Resident #2 went into another resident's room, she said she would remove him immediately. When asked what level of supervision was provided for him, she said all the staff knew to watch him. The second floor Unit Manager was interviewed at 3:20 p.m. on 8/4/21. She stated Resident #2 was a handful and required constant supervision. Sometimes he was on 1:1 supervision but all staff knew to watch him when he was out of his room. He would grab at female staff and try to touch them inappropriately. Resident #2 did try to get to some other residents, but she was unaware of any sexual contact. In an interview with the Administrator at 4:30 p.m. on 8/4/21, she explained that Resident #2 was very child-like. He was very grabby and tried to grab her arms, butt or boobies whenever she walked past him. He would put his hand out and get a feel. He was like a baby but was very smart and played intellectually impaired when he knew he was in trouble. In the past month he became more sexually inappropriate with staff then the incident occurred with Resident #9. Staff reported Resident #2 touched Resident #9's vaginal area and breast through her clothing. The Restorative CNA (RCNA J) who had been in the same room with both residents, walked out for two minutes and it happened. Resident #2 was removed from the room immediately and placed on 1:1 supervision. After the incident, the Administrator reviewed the videotapes (that have since self-erased). She stated she saw Resident #2 trying to reach for Resident #9's vaginal area. He made brief contact. She (Resident #9) shooed him away, then he tried to reach for her breast. He grazed it and that was when RCNA J walked back into the room. RCNA J stopped the behavior and took Resident #2 to his room. The Administrator said there was one other similar occasion in the past, but she was not employed by the facility during the time of that event. As a result of that incident, the female resident had to be moved to the 3rd floor. The Administrator was asked what interventions were in place for Resident #2 related to his sexual behaviors. She stated there was always a CNA by his door because he would roll out of bed and roll down the hall like a bowling ball. This June (2021) he was put on [MEDICATION(S)] injections (a hormone that can be used to lower sexual drive in males), which seemed to have made his behavior worse. She was asked what interventions had been implemented to keep other vulnerable residents safe. She stated staff were always watching him. It was pointed out that RCNA J had walked out of the room for two minutes and the incident occurred with Resident #9 in that short period of time. The Administrator said following similar instances in the past, Resident #2 was put on 1:1 supervision. She did not provide details of past events. She also explained there had been an employee victim. She stated she asked if the employee wanted to press charges against Resident #2, but the employee declined. The Administrator was asked what she could have done to prevent Resident #2 from victimizing a vulnerable resident after he clearly demonstrated a propensity for inappropriately touching female staff. She said the only thing she could have done was to provide 1:1 supervision, which was impossible as there was a staffing shortage. She hesitated and said, Well, not impossible, but it would create a staffing deficit. The Administrator turned to the DON who was in the room and asked what more they could have done. The DON concurred that they would have had to have provided 1:1 supervision of Resident #2, but she couldn't provide that. The DON said they had tried everything including searching for alternative placement and 1:1 staff supervision in the past. The Abuse Coordinator/Social Services Director (SSD) was interviewed at 4:59 p.m. on 8/4/21. She explained the facility soon came to realize that Resident #2 was a whole handful and then some. He was constantly counseled on not touching people, including staff. There was no rhyme or reason to his sexual acting out. It seemed to come from nowhere. He would try to grab you and has been known to try to touch staff on the breast or behind. The facility had attempted education, constant activities, and extended smoke breaks, but he didn't stay focused. Everyone was monitoring him at all times. He would try to get into all the offices downstairs, even if the doors were closed. She recalled there was one prior incident with a female resident earlier in the year. The SSD was asked if there were other vulnerable female residents on Resident #2's unit. Without directly answering, she said she had looked all over the state for more appropriate placement for him without success. After this last incident (with Resident #9), the Psychiatric APRN said this was not safe, and we could not do it any longer. When asked what the facility did to protect other residents, she said everyone always watched Resident #2. Fifteen- and thirty-minute checks and Baker Acts were attempted in the past, but he was not on 15-minute checks when the July 2021 incident occurred. A telephone interview was conducted with the Psychiatric APRN at 10:30 a.m. on 8/5/21. She was asked about Resident #2's sexual behaviors, and she stated he groped females. It was more than just groping, he did this repeatedly. She said it was not safe for him to come back to the facility, as other residents could not get away from him. She was asked if he had groped other residents inappropriately in the past. She stated he had, but could not report who, when or how often this had occurred. She explained that unfortunately, medication could not change Resident #2's behaviors. Medication changes were made, and the facility attempted to send him out (under a Baker Act) several times. The APRN explained that the day they found him fondling another resident, he had already been doing that to staff. She was asked if 1:1 supervision would have been appropriate for this resident to keep vulnerable residents safe. She did not answer but explained they had him on 1:1 supervision numerous times in the past. Resident #11 was interviewed at 11:15 a.m. on 8/5/21. She stated she felt safe in the facility. The only man who had ever touched her was Resident #2. He grabs all the girls. When asked if she had ever been grabbed by him, she replied yes. When asked where, Resident #11 stated he had grabbed her arm when they were in the elevator. In an interview with the DON at 1:30 p.m. on 8/5/21, she was asked about the behavioral analysis recommended by the Psychiatric APRN on her 5/13/21 evaluation. The DON replied that it was only a recommendation, but that day the APRN also started Resident #2 on [MEDICATION(S)] (antipsychotic), which worked, so they felt the behavioral analysis was not needed. In an interview with CNA/Unit Clerk G at 3:35 p.m. on 8/5/21, she stated she knew Resident #2 well. He was a grabber. He would grab staff in the crotch, the breast, wherever. He knew what he was doing because he knew right where to grab. She never saw him grab or touch any residents in the same manner. Personal Care Assistant (PCA) H reported in an interview at 3:45 p.m. on 8/5/21, that she knew Resident #2 well. She also described him as a grabber, as he would grab female staff in private places. She stated it was so bad with some of the aides, that they wouldn't go in and work with him. Restorative CNA (RCNA) J was interviewed at 4:07 p.m. on 8/5/21. When asked about the incident between Resident #2 and Resident #9, he confirmed he witnessed the incident. He stated he had just arrived at the facility when he saw Resident #2 touching Resident #9's breasts with both hands. Resident #2 was also rubbing Resident #9 on her thigh and groin region. It was so fast, it was approximately two seconds of contact when RCNA J yelled, Stop. Resident #2 stopped immediately and looked at RCNA J like he had been busted. RCNA J recalled a similar encounter with one other resident in the past and said Resident #2 had done this to an employee too. Resident #2 had touched the female employee inappropriately where she didn't want to be touched. In an interview with the Administrator at 11:40 a.m. on 8/6/21, she confirmed that the Abuse Prevention and Sexual Misconduct policy was what the facility followed for resident-to-resident incidents. She was asked if as a result of any of Resident #2's behaviors, other female residents on the unit had been interviewed to determine whether there were additional victims. She said no, but they were going to go do that right away. A review of the facility's investigation revealed that on 7/23/21 at 1:00 p.m., RCNA J walked into the second floor day room and witnessed Resident #2 touching Resident #9 through her clothing in her groin and breast areas. Staff separated the two residents, removed Resident #2 from the room, and immediately placed him on 1:1 supervision. Resident #2 was Baker Acted that day as a result of the event and remained out of the facility under psychiatric care at the time of the survey. A written statement was obtained from RCNA J. In the undated statement, Employee J recalled walking into the day room on 7/23/21 at approximately 11:40 (no am/pm specified). He found Resident #2 groping a female resident on her breast and groin areas. A review of Resident #2's clinical record, revealed he was admitted to the facility on [DATE] and was [AGE] years old. The Discharge Return Not Anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/23/21, noted he had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating moderately impaired cognitive skills for daily decision making. He was non-ambulatory (unable to walk), but was independent in his wheelchair. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record found additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was care planned on 3/22/20, with a most recent review on 7/7/21, for multiple socially inappropriate/disruptive behavioral symptoms including, but not limited to: Inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Inappropriate behavior toward female staff as was included in the focus. The goal was not to harm himself or others due to the socially inappropriate/disruptive behaviors. Approaches included medications as ordered; Monitor for side effects and effectiveness; Assess whether behavior endangers resident/others; Intervene as needed; Avoid overstimulation; Convey acceptance; Maintain calm approach with resident; Observe/report socially inappropriate/disruptive behavior when around others; Obtain psychiatry/psychotherapy consult; Praise when appropriate; Remove from other residents' rooms and unsafe situations; Set limits and expectations; Support appropriate mood and behavior, and; Move to a quiet, calm environment when behavior becomes inappropriate. The care plan did not define inappropriate touching and did not specify what action should be taken or level of supervision should be provided as a result of sexually touching other staff or residents. There were no revisions to the care plan since October 2020 when Resident #2 was Baker Acted for non-sexual behaviors. (Photographic evidence obtained) A Psychiatric evaluation was completed on 7/23/21 by the APRN, who reported staff requested a Baker Act after Resident #2 was found groping yet another female. Staff report this is the second or third female they have found him doing this to. Due to this behavior and the (victim's) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This made it an unsafe environment for her. [Resident #2] needs to be Baker Acted. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) A review of Resident #2's Nursing Progress notes, found on 5/11/21, Resident #2 grappled a CNA. The CNA stated he was groping her between her legs and not letting her go while she was giving care. On 6/15/21, Resident #2 was observed pulling on other residents in the day room. On 7/22/21, he was crawling on the floor in his room and in and out of other resident room. The nursing note dated 7/23/21, reported Resident #2 and Resident #9 were observed in the day room. RCNA J walked into the room finding Resident #2 touching Resident #9 through her clothing in the groin and breast area. Staff separated the two residents, removed Resident #2 from the room, and immediately placed him on 1:1 supervision. He was Baker Acted that day as a result of the event. (Photocopies obtained) A review of the facility's Nursing Home Administrator job description revealed, The primary purpose of the nursing home administrator is to manage operations effectively and efficiently and in accordance with all current applicable federal, state and local standards, guidelines and regulations, and as directed by the President/CEO and Director of Operations. Delegation of Authority: As the Administrator, you are delegated the administrative authority, responsibility, accountability necessary for carrying out your assigned duties. Under section 1. Duties and Responsibilities Administrative Functions, responsibilities included but were not limited to: Plan, develop, organize, implement, evaluate and direct the facility's programs and activities; Develop and maintain written policies and procedures that govern the operation of the facility; Ensure that all employees, residents, visitors and the general public adhere to established policies; Make routine inspections of the facility to assure established policies and procedures . are being implemented to include, but not limited to, provision of care and services, resident's rights and maintenance of a sanitary and safe environment for residents . A review of the facility's Abuse Prevention Program policy (revised 7/2020) found it specified Our residents have the right to be free from abuse, neglect. and exploitation. This includes, but is not limited to. verbal, mental, sexual or physical abuse. As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone. .6. Identify and assess all possible incidents of abuse. .7. Thoroughly investigate and document (abuse). 8. Report allegations as required by federal requirements. 9. Protect residents during abuse investigations and protect resident(s) from further harm during the investigation by providing the resident(s) with a safe environment; 10. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent further occurrences of abuse . Administrator is responsible for the overall implementation of the policies and procedures that prohibit abuse, neglect, involuntary seclusion, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Reporting and Investigation of Sexual Misconduct policy statement (revised 7/2020) read, All allegations of sexual misconduct by facility personnel must be reported immediately to the Administrator, Director of Nursing (DON) and Risk Manager. 1. Should an allegation of sexual misconduct be made against a member of the facility's personnel, the person receiving the allegation must report to his/her supervisor, the person in charge. or the DON. 2. The DON or designee must immediately report such information to the Administrator. (Photocopy obtained)

Based on interviews, record reviews, and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #9) out of four residents reviewed for abuse, from a total of 18 residents in the sample. It also placed all other vulnerable female residents at risk for serious adverse outcomes related to potential sexual abuse from Resident #2. Resident #2 was assessed, and care planned on 3/20/2020 for inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no guidance for supervision. Interviews with staff indicated Resident #2 had always been grabby and would grab at females' breasts and buttocks regularly. On 5/11/2021, Certified Nursing Assistant (CNA) A was groped between her legs by Resident #2 while providing his care. On 7/23/2021, Resident #2 touched Resident #9 in the groin and breast area through her clothing. No increased supervision of Resident #2's inappropriate sexual behavior was put in place until 7/23/2021. After this incident, the facility placed him on 1:1 (one to one) supervision until he was Baker Acted (involuntary psychiatric admission) the same day. He has not returned to the facility. Resident #9 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm, not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. The Administrator was notified of the Immediate Jeopardy at 6:00 p.m. on August 6, 2021. The Immediate Jeopardy was ongoing as of the exit on August 6, 2021. The findings include: Cross reference F600 and F835 An interview was conducted with CNA B at 10:22 a.m. on 8/4/21. She explained Resident #2 was a handful and required constant staff attention and supervision. Even when he did not have a 1:1 formal assignment, his behaviors were so bad staff would have to take turns providing supervision for his behaviors. Resident #2 was touchy-grabby with the female staff and on occasion, would try to touch female residents. She stated Resident #2 had approached a couple of the female residents in the past, but those residents took care of it right then and there and stopped him. CNA C was interviewed at 10:30 a.m. on 8/4/21. She reported Resident #2 was very touchy-feely and grabby. He would try to grab female staff all the time, even if you were just walking by. Your arms, anywhere, he would just grab at you all the time. CNA C demonstrated by grabbing up and down the arm of this writer, saying Resident #2 would grab at the residents in this fashion. She stated Resident #2 would try to target and corner non-verbal female residents. He had a 1:1 supervision assignment on occasion, but staff all knew he was not to be left alone. They all watched and redirected Resident #2 constantly. Licensed Practical Nurse (LPN) D was interviewed at 12:50 p.m. on 8/4/21. She stated Resident #2 was recently Baker Acted for his very difficult behaviors. He has been a handful and needs to be watched all the time or he will get on the elevator and be gone. He inappropriately smacks and grabs staff's butts and he knows it is wrong. He did it to a female resident recently, and he has done that in the past. If Resident #2 went into another resident's room, she said she would remove him immediately. When asked what level of supervision was provided for him, she said all the staff knew to watch him. During an interview with the Administrator at 1:30 p.m. on 8/4/21, she explained that due to his inappropriate touching behaviors, the facility had tried to have Resident #2 Baker Acted several times. The second floor Unit Manager was interviewed at 3:20 p.m. on 8/4/21. She stated Resident #2 was a handful and required constant supervision. Sometimes he was on 1:1 supervision but all staff knew to watch him when he was out of his room. He would grab at female staff and try to touch them inappropriately. Resident #2 did try to get to some other residents, but she was unaware of any sexual contact. In an interview with the Administrator at 4:30 p.m. on 8/4/21, she explained that Resident #2 was very child-like. He was very grabby and tried to grab her arms, butt or boobies whenever she walked past him. He would put his hand out and get a feel. He was like a baby but was very smart and played intellectually impaired when he knew he was in trouble. In the past month he became more sexually inappropriate with staff then the incident occurred with Resident #9. Staff reported Resident #2 touched Resident #9's vaginal area and breast through her clothing. The Restorative CNA (RCNA J) who had been in the same room with both residents, walked out for two minutes and it happened. Resident #2 was removed from the room immediately and placed on 1:1 supervision. After the incident, the Administrator reviewed the videotapes (that have since self-erased). She stated she saw Resident #2 trying to reach for Resident #9's vaginal area. He made brief contact. She (Resident #9) shooed him away, then he tried to reach for her breast. He grazed it and that was when RCNA J walked back into the room. RCNA J stopped the behavior and took Resident #2 to his room. The Administrator said there was one other similar occasion in the past, but she was not employed by the facility during the time of that event. As a result of that incident, the female resident had to be moved to the 3rd floor. The Administrator was asked what interventions were in place for Resident #2 related to his sexual behaviors. She stated there was always a CNA by his door because he would roll out of bed and roll down the hall like a bowling ball. This June (2021) he was put on [MEDICATION(S)] injections (a hormone that can be used to lower sexual drive in males), which seemed to have made his behavior worse. She was asked what interventions had been implemented to keep other vulnerable residents safe. She stated staff were always watching him. It was pointed out that RCNA J had walked out of the room for two minutes and the incident occurred with Resident #9 in that short period of time. The Administrator said following similar instances in the past, Resident #2 was put on 1:1 supervision. She did not provide details of past events. She also explained there had been an employee victim. She stated she asked if the employee wanted to press charges against Resident #2, but the employee declined. The Administrator was asked what she could have done to prevent Resident #2 from victimizing a vulnerable resident after he clearly demonstrated a propensity for inappropriately touching female staff. She said the only thing she could have done was to provide 1:1 supervision, which was impossible as there was a staffing shortage. She hesitated and said, Well, not impossible, but it would create a staffing deficit. The Administrator turned to the DON who was in the room and asked what more they could have done. The DON concurred that they would have had to have provided 1:1 supervision of Resident #2, but she couldn't provide that. The DON said they had tried everything including searching for alternative placement and 1:1 staff supervision in the past. The Abuse Coordinator/Social Services Director (SSD) was interviewed at 4:59 p.m. on 8/4/21. She explained the facility soon came to realize that Resident #2 was a whole handful and then some. He was constantly counseled on not touching people, including staff. There was no rhyme or reason to his sexual acting out. It seemed to come from nowhere. He would try to grab you and has been known to try to touch staff on the breast or behind. The facility had attempted education, constant activities, and extended smoke breaks, but he didn't stay focused. Everyone was monitoring him at all times. He would try to get into all the offices downstairs, even if the doors were closed. She recalled there was one prior incident with a female resident earlier in the year. The SSD was asked if there were other vulnerable female residents on Resident #2's unit. Without directly answering, she said she had looked all over the state for more appropriate placement for him without success. After this last incident (with Resident #9), the Psychiatric APRN said this was not safe, and we could not do it any longer. When asked what the facility did to protect other residents, she said everyone always watched Resident #2. Fifteen- and thirty-minute checks and Baker Acts were attempted in the past, but he was not on 15-minute checks when the July 2021 incident occurred. A telephone interview was conducted with the Psychiatric APRN at 10:30 a.m. on 8/5/21. She was asked about Resident #2's sexual behaviors, and she stated he groped females. It was more than just groping, he did this repeatedly. She said it was not safe for him to come back to the facility, as other residents could not get away from him. She was asked if he had groped other residents inappropriately in the past. She stated he had, but could not report who, when or how often this had occurred. She explained that unfortunately, medication could not change Resident #2's behaviors. Medication changes were made, and the facility attempted to send him out (under a Baker Act) several times. The APRN explained that the day they found him fondling another resident, he had already been doing that to staff. She was asked if 1:1 supervision would have been appropriate for this resident to keep vulnerable residents safe. She did not answer but explained they had him on 1:1 supervision numerous times in the past. In an interview with CNA/Unit Clerk G at 3:35 p.m. on 8/5/21, she stated she knew Resident #2 well. He was a grabber. He would grab staff in the crotch, the breast, wherever. He knew what he was doing because he knew right where to grab. She never saw him grab or touch any residents in the same manner. Personal Care Assistant (PCA) H reported in an interview at 3:45 p.m. on 8/5/21, that she knew Resident #2 well. She also described him as a grabber, as he would grab female staff in private places. She stated it was so bad with some of the aides, that they wouldn't go in and work with him. An interview was conducted with the Administrator at 11:40 a.m. on 8/6/21. She stated she was not sure if the Quality Assurance committee had ever addressed Resident #2's sexual behaviors, but she knew they had discussed his other behaviors. She stated the QA chairperson was out of town, but she would look to see if there was anything documented. No documentation was produced for review during the survey. She was asked again this day at 1:23 p.m. if the committee had ever addressed Resident #2's sexual acting out. She turned to the DON, who was also present in the room. The DON said no, the committee had only discussed behaviors in general. In the absence of the Quality Assurance committee's chairperson, the DON was interviewed at 2:15 p.m. on 8/6/21. She explained that the QA committee met monthly. Members included the Administrator, herself, the Medical Director and all department heads. The committee used incident reports, grievances and any issues identified in the daily standards of care (SOC) meetings to identify trends and issues that needed a quality performance and improvement (QAPI) plan. Any problem identified on the floor was brought to the committee. Once an issue was identified, a root cause analysis was conducted and interventions were developed. When asked whether a root cause was explored after Resident #2's ongoing sexual behavior, she admitted it was not. The DON explained that a root cause analysis could only have been completed if the issues had been brought to the committee. The Risk Manager was interviewed at 4:33 p.m. on 8/6/21. She confirmed she participated in the monthly QA meetings. She said they addressed risk management related to falls and accidents, but no audits had been completed for resident behaviors. When asked whether she deemed resident abuse and sexual abuse as a risk, she replied, definitely and affirmed that resident abuse/sexual abuse should definitely be taken to QAPI. A review of the facility's investigation revealed that on 7/23/21 at 1:00 p.m., RCNA J walked into the second floor day room and witnessed Resident #2 touching Resident #9 through her clothing in her groin and breast areas. Staff separated the two residents, removed Resident #2 from the room, and immediately placed him on 1:1 supervision. Resident #2 was Baker Acted that day as a result of the event and remained out of the facility under psychiatric care at the time of the survey. A written statement was obtained from RCNA J. In the undated statement, Employee J recalled walking into the day room on 7/23/21 at approximately 11:40 (no am/pm specified). He found Resident #2 groping a female resident on her breast and groin areas. A Psychiatric evaluation was completed on 7/23/21 by the APRN, who reported staff requested a Baker Act after Resident #2 was found groping yet another female. Staff report this is the second or third female they have found him doing this to. Due to this behavior and the (victim's) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This made it an unsafe environment for her. [Resident #2] needs to be Baker Acted. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) A review of Resident #2's clinical record revealed a Discharge Return Not Anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/23/21, which noted he had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating moderately impaired cognitive skills for daily decision making. He was non-ambulatory (unable to walk), but was independent in his wheelchair. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record found additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was care planned on 3/22/20, with a most recent review on 7/7/21, for multiple socially inappropriate/disruptive behavioral symptoms including, but not limited to: Inappropriate touching related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Inappropriate behavior toward female staff as was included in the focus. The goal was not to harm himself or others due to the socially inappropriate/disruptive behaviors. Approaches included medications as ordered; Monitor for side effects and effectiveness; Assess whether behavior endangers resident/others; Intervene as needed; Avoid overstimulation; Convey acceptance; Maintain calm approach with resident; Observe/report socially inappropriate/disruptive behavior when around others; Obtain psychiatry/psychotherapy consult; Praise when appropriate; Remove from other residents' rooms and unsafe situations; Set limits and expectations; Support appropriate mood and behavior, and; Move to a quiet, calm environment when behavior becomes inappropriate. The care plan did not define inappropriate touching and did not specify what action should be taken or level of supervision should be provided as a result of sexually touching other staff or residents. There were no revisions to the care plan since October 2020 when Resident #2 was Baker Acted for non-sexual behaviors. (Photographic evidence obtained) A review of Resident #2's Nursing Progress notes, found on 5/11/21, Resident #2 grappled a CNA. The CNA stated he was groping her between her legs and not letting her go while she was giving care. The nursing note dated 7/23/21, reported Resident #2 and Resident #9 were observed in the day room. RCNA J walked into the room finding Resident #2 touching Resident #9 through her clothing in the groin and breast area. Staff separated the two residents, removed Resident #2 from the room, and immediately placed him on 1:1 supervision. He was Baker Acted that day as a result of the event. (Photocopies obtained) A Psychiatric Evaluation was completed by the Advanced Practice Registered Nurse (APRN) on 5/13/21, two days after Resident #2 inappropriately touched the CNA mentioned in the 5/11/21 Nursing progress note. The APRN documented staff requested the visit due to increased sexual acting out, grabbing staff inappropriately, and then attempting to hurt them. A consultation with the psychiatrist and facility DON was conducted, and a behavioral analysis was recommended for Resident #2. The facility was to have that done. [MEDICATION(S)] (antipsychotic) 5 mg (milligrams) was started. The APRN noted Resident #2's mood symptoms included grandiosity, distractibility, elevated/expansive/irritable mood. He was noted with poor insight and judgement. Under the Diagnosis, Assessment and Plan section, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) The facility's Quality Assurance and Performance Improvement (QAPI) Plan policy (revised 4/2014) read: The facility shall develop, implement and maintain an ongoing facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality and resolve identified problems. Policy Interpretation and Implementation The objectives of the QAPI plan are to: 1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services; 3. Provide structure and processes to correct identified quality/safety concerns. .5. Help departments, consultants and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility and accountability; 6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents. Authority 1. The owner and/or governing body shall be ultimately responsible for the QAPI program. 2. The Administrator is responsible for assuring this facility's QAPI program complies with federal, state and local regulatory agency requirements. Implementation .2. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities . A review of the facility's 2021 QAPI Plan revealed: Vision: The (Facility name's) vision is to create a safe, healthy, and caring environment for residents, employees, families and visitors . Purpose: The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to create a safe, healthy, and caring environment. QAPI Plan Goals: . Goal #3: (Facility name) will work to be free from mistreatment, abuse, neglect, and/or misappropriation of resident's property . Governance and Leadership: (Facility's) governing body is ultimately responsible for overseeing the QAPI Committee. The Administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction . Feedback, Data Systems and Monitoring: (Facility name) will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the Plan, Do, Study, Act (PDSA) cycle of improvement to prevent recurrences . Performance Improvement Projects: The QAPI team at (Facility name) will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems, or if there are opportunities to make improvements . Systematic Analysis and Systemic Action: (Facility name) uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change . (Facility name) applies a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. (Facility's) approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. (Facility name) also has developed policies and procedures regarding expectations for the use of root cause analysis when problems are identified . (Copy obtained) The facility's Abuse Prevention Program policy (revised 7/2020) specified, Our residents have the right to be free from abuse, neglect . and exploitation. This includes, but is not limited to . verbal, mental, sexual or physical abuse. As part of the resident abuse prevention, the Administration will: .10. Establish and implement a QAPI review and analysis of abuse incidents and implement changes to prevent future occurrences of abuse.

Based on observations, clinical record review, facility record review, and staff and resident interviews, the facility failed to ensure each resident was free from harm by failing to provide adequate supervision and interventions to reduce the potential for elopements, accidents or injuries for 5 (Resident #104, #118, #10, #102 & #200) of 39 sampled residents. Additionally, Immediate Jeopardy (IJ) occurred on 5/2/12 regarding the elopement of Resident #104 and was ongoing at the time of exit. An Allegation of Compliance (AOC) was received and accepted by the State Agency and CMS Regional Office on September 10, 2012. The AOC revealed action items related to the Recertification survey conducted on 8/21/12 identifying IJ on 5/02/12 and ongoing at F323 S/S J, under 483.25(h) Free of Accident Hazards/Supervision/Devices. On September 11, 2012 an abbreviated follow-up survey was conducted to determine the status of the on-going IJ identified at F323. The facility was found to have implemented the action items in the AOC in order to identify and implement safety measure and elopement prevention throughout the facility, and monitoring was ongoing. The IJ at F323 was removed as of 8/30/12. At the time of the exit on 9/11/12, F323 remained out of compliance at S/S of D. The findings include: 1. Resident #104 was observed walking in the hallway on 5/24/12 at 3:55 PM. Attempts to interview the resident were met with garbled language that was not understood. Review of the medical record for Resident #104 revealed he was admitted into the facility on [DATE] after a Cerebral Vascular Accident (CVA). He also had a [DIAGNOSES REDACTED]. An Elopement Risk assessment dated [DATE] coded Resident #104 to be cognitively impaired, diagnosed as having Dementia and Depression, and to wander aimlessly up and down the halls and into other resident's rooms. The back side of the assessment form for interventions was blank. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of "4". Review of the MDS assessment dated [DATE] revealed a BIMS score of "6". (A score between 0 - 7 would indicate the resident was severely impaired.) Review of the nursing notes in the resident's clinical record revealed on 5/02/12 Resident #104 was found by a relative outside the facility walking down the street. Per the nurses note the Director of Nursing (DON) advised the nurse that the resident was competent and had a right to leave to the facility at will. Review of the care plan for Resident #104, dated 12/29/10, identified a problem with cognitive loss related to short and long term memory deficit, and daily decision making deficit. No interventions were listed for maintaining resident safety due to wandering, or elopement. Nurses note dated 5/14/12 revealed the resident had "increased wandering around facility" and for safety placed a Wanderguard bracelet on the resident's ankle. (The Wanderguard is an electronic device that alerts facility staff if a resident passes through a monitored zone.) Interview with the MDS (Minimum Data Set) coordinator on 5/23/12 at 1:00 PM revealed "The Director of Nursing writes the hard copies of the care plans that are preprinted and then I add to it if there is more to add. If something occurs it is my job to reassess the care plan and revise it." The MDS coordinator confirmed the care plan had not been revised to include safety measures for wandering or elopement. Additional information was obtained during the extended survey on August 20-21, 2012: An observation and attempted interview was conducted for Resident #104 on 08/20/12 at 10:30 a.m. The resident was attending activities in the third floor day room. The resident was interviewed at the completion of the activity. The resident was alert with confusion and oriented to person only. The resident ' s speech was garbled and difficult to understand. The resident did not know where he was or how long he had been in the facility. An interview was completed with certified nursing assistant (CNA) #111 on 08/20/12 at 10:47 a.m. She revealed Resident #104 had a slight case of dementia. He was forgetful and the staff had to watch him when he is eating because he would swallow foods whole. The CNA also revealed the resident would place his shoes under his bed and forget they were there. The CNA revealed Resident #104 did not have a wander guard in place. Observation of Resident #104 with CNA #111 confirmed there was no wander guard in place. Per the CNA the resident had a wander guard, but it had been removed because he really did not wander he just paced up and down the hall. On 08/20/12 at 10:52 a.m. an interview was conducted with Nurse #119. She revealed Resident #104 did not have a wander guard in place. She revealed Resident #104 did not attempt to leave the floor. He paced up and down the hall, but never tried to get on the elevator or go down the stairs. Nurse #119 looked at the back of her employee badge and revealed Resident #104 was listed as an elopement risk but did not have a wander guard. "We don't have Wanderguards up here." The nurse revealed she was not present when Resident #104 eloped and did not have any knowledge about the details surrounding the elopement on 5/2/12. Observation of Resident #104 on 08/20/12 at 12:30pm revealed the resident was ambulating in the hallway from his room to the dayroom. Resident #104 was observed and interviewed while sitting in the dayroom on 08/21/12 at 9:36 a.m. The resident was clean well groomed and no odors were noted. The resident was alert with confusion. He revealed he had his jacket on because he was cold. The resident ' s speech was garbled and he was hard to understand. The resident revealed he did not remember going for walk. He revealed that he had to get up in the morning and go look for work at the School Board Office. The resident motioned to his head and revealed he believed someone had hit him in the head in the past and that was why he couldn't remember. Observation of the resident's head revealed there were no signs of trauma. A medical record review for Resident #104 revealed the resident was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review Resident #104's medical record revealed he had not been documented as incompetent. The resident signed his acknowledgment of receipt and understanding of resident rights on 12/10/10 and Advanced Directives on 12/10/10. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/12 revealed Resident #104's Brief Interview for Mental Status (BIMS) score was 8. The resident was not coded for wandering behaviors. A review of the Quarterly MDS with ARD of 08/03/12 revealed the resident was coded as having a BIMS score of 13. The resident was not coded for wandering behaviors. A review of Resident #104's care plans revealed there was a care plan on file dated 12/29/10 for cognitive loss. The problem was the resident had cognitive loss related to short and long term memory deficit with daily decision making deficit. The short term goal was current cognitive level would not interfere with residents daily activity through the next 90 days. Approaches included talking with the resident in a non-judgmental way, provide an organized environment with set routine for activities of daily living and other daily activities, encourage the resident to become involved in the daily activities of the facility to prevent isolation and for socialization, remind the resident several times a day about upcoming events that resident seems to enjoy, encourage resident to participate in planning own treatment and care. The care plan was reviewed 03/16/11; 06/08/11; 09/02/11; 11/25/11; 05/18/12; 05/25/12 and 08/03/12. There were no updates or changes to the interventions. A review of Resident #104's care plans revealed there was an update on 05/25/12 with an elopement assessment completed. The resident stated he was not going anywhere, knew he was wearing a safety wander guard on his leg, and was okay with the use of the safety device. No other incidents of wandering to go for a walk. On 06/01/12 a resident elopement assessment was done; wander guard intact (0131). The resident understood the need for wander guard and letting his nurse know if he would like to leave the floor. Resident rounded on every two hours and will reassess in seven days. Additional elopement assessments were done on 6/8/12, 6/15/12, and 6/22/12. On 06/28/12 a care plan meeting was held with the resident present to discuss discontinued use of the wander guard. The resident pulled up his pants leg to show his wander guard and continued to answer questions the care plan team asked. He stated he was not going anywhere and wanted to have the ankle bracelet removed. Resident had not had any wandering or exit seeking episodes. No advanced behavior problems noted, will remain on the at risk elopement list times 90 days. On 07/05/12 continues to monitor for safety, no signs of exit seeking or wandering. Continue same routine daily. On 07/12/12 observed ambulating from room to day room in no acute distress. Visit by Dr. Delcompo on 07/11/12. No new order changes to address. Continue to monitor. On 08/13/12 no elopement issue noted. No new orders noted. Continue care plan times 90 days. The resident was care planned for a Wanderguard on 05/14/12. The problem or concern was the resident was wearing an alert system (Wanderguard, #0131) to keep him from wandering off the facility property. The short term goal was the wander guard system would assist to keep the resident on the facility ' s property at all times during the next 90 days. Approaches included: resident's dignity would be ensured at all times, resident would be assigned a wander guard number, that number would be placed in the elopement book on the resident ' s floor, resident would have an identification bracelet placed to ensure resident ' s return to the facility in case of elopement, resident would be observed every 30 minutes with redirection given as needed, monitor to ensure Wanderguard is tight but will not slip off resident. Leave enough room for comfort and area to wash beneath, resident's mind off leaving the facility, and involve the resident in exercise program to help with excess energy. The following updates were made to the care plan. On 05/25/12 resident has not attempted to leave the facility continue all approaches. On 6/01/12 resident continues to wear wander guard and had not made any attempts to leave the facility, all approaches ongoing. On 06/08/12 resident wearing wander guard; resident had not made any attempts to leave facility; continue plan of care for 90 days. On 06/08/12, resident wearing wander guard; resident had not made attempts to leave facility continue plan of care for 90 days. On 06/15/12 resident continues to be monitored under wander guard; resident had not made any attempts to leave facility. On 06/22/12 resident continues to wear Wanderguard and had not attempted to leave the facility. On 06/28/12, goal met, discontinued wander guard. On the Potential for Impaired Skin care plan there was note dated 06/28/12 that the wander guard was removed. The resident frequently removed the wander guard, the physician was notified, and okay to remove Wanderguard. Continue for elopement risk, resident safe. A review of the Care Plan Conference Sheet dated 06/28/12 revealed a care plan conference was held to discuss the removal of the Wander Guard. Resident #104 attended the conference. He had not had any episodes of exit seeking, wandering or any other issues that would put him at risk for elopement. He ambulates daily on the 3rd floor to the day room from his room; staff accompanies him when he wishes to attend activities off the floor and returns without any problems. Resident #104 is aware of the wander guard and agrees he wants to have it removed. There was an order on file dated 06/28/12 to remove the Wanderguard for Resident #104. A review of the Elopement Risk assessment dated [DATE] revealed the resident had no exit seeking behaviors, will continue to monitor. There were notes on 07/15/12; 07/17/12; 07/17/12; 07/19/12;07/21/12; 07/23/12; 07/25/12; 07/27/12; 07/29/12; 08/01/12; 08/07/12 that indicated the resident had no exit seeking behaviors noted at the time and would continue to monitor. A review of the Psychiatry Services note for Resident #104 dated 08/14/12 revealed Resident #104 had a history of [REDACTED]. The resident ' s association was circumstantial. The resident was noted to have decreased insight and judgment in social situations, daily activities and psychiatric condition. The clinic status was stable. The mental status exam revealed the resident was oriented to person. The resident had decreased memory, recent, intermediate and remote. Attention was okay for concentration. Language: decreased names objects, repeat phrases. Fund of knowledge, current events, and vocabulary and past events was decreased. Mood was depressed and anxious. Affect bland. [DIAGNOSES REDACTED]. Continue Remeron 30mg HS, depression; Trazadone HS. The Psychiatry Services dated 07/11/12 revealed the resident had the same assessment results. Similar results were noted on 6/13/12 and 5/10/12. On 08/201/12 at 3:00pm an interview with the Medical Director, who is also Resident #104's primary care physician, revealed things that have been implemented to ensure the safety of the residents included that the front door of the facility was locked. From a safety status, someone has to let him in and out of the facility. He revealed that access to the facility was granted by pressing the button located outside the entrance. He also revealed the receiving area of the building was pad locked, and the patio was attended by the CNAs. He revealed Resident #104 had dementia and his cognitive function was intermittent. He revealed the resident knew who he was and knew where his room was located. He revealed Resident #104 spent most of the day in the dayroom, required assistance with activities of daily living (ADL) care and was somewhat oriented to his surroundings. He revealed Resident #104 could not remember time. He also revealed Resident #104 was oriented times two intermittently. The medical director revealed he attended quality assurance (QA) meetings that were held every last Tuesday of the month. He revealed he was at the facility once a week and he had one Physician Assistant (PA) and one Advanced Registered Nurse Practitioner (ARNP) who worked with him at the facility. He revealed he was informed of issues in the facility through the physician communication book and by speaking with the PA and ARNP daily. He also revealed he discusses issues with the DON and things are brought to the QA meetings. If an issue is identified an in-service is done. He revealed he reviewed any new action plans or procedures. An interview with the MDS Coordinator, Nurse #28, on 08/21/12 at 1:53pm revealed the social services department completed the BIMS section for the MDS. She revealed sometimes you could understand Resident #104 and he always appeared to be nervous or scared. She revealed he was a little hard to understand at times, but he usually knew where he was and who he was. She revealed no significant change MDS was done after the increase in Resident #104's BIMS score. An interview with the Social Services Director (SSD) on 08/21/12 at 2:14pm revealed she interviewed Resident #104 and at the time of the interview his BIMS score was 13. Per the SSD the resident's mental status fluctuated. A review of the Wandering Resident Policy dated 05/25/12 revealed every effort would be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk of elopement. Policy and Implementation included: 1. All residents who are at risk for harm because of wandering (elopement) would be assessed by the interdisciplinary care planning team. 2. The resident ' s current MDS 3.0 would be reviewed to determine what changes have occurred that would trigger elopement episodes. 3. The resident ' s care plan would be modified to indicate the resident is at risk for elopement episodes. Staff would be informed at shift change of the medication modification to the resident ' s care plan. 4. Interventions into the elopement episodes will be entered onto the resident ' s care plan and medical record. 5. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses ' notes. 6. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident ' s care plan will be documented as to the implementation of a monitoring schedule. 7. If a resident is discovered to be missing, a search shall begin immediately. 8. Searches; however, will only be made for those residents who have been declared incompetent and not able to make the decision to leave the premises. Competency shall be determined by the absence of any legal document stating that the resident is not competent in decision making. A review of the Missing Residents Policy dated 05/25/12 revealed nursing personnel must report and investigate all reports of a missing resident. Policy Interpretation and Implementation included: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the charge nurse as soon as practical. 4. Should an employee discover that a resident is missing from the facility, he/she should determine if the resident is competent and able to make the decision to leave. If the resident is competent and able to leave the facility that elopement procedures should be stopped. Competency is determined by find(ing) out if there is legal documentation showing incompetence. Remember a competent resident cannot elope. It is his/her right to leave the facility at will. A review of the facility's incident documentation revealed the incident occurred on 05/02/12 at 4:50pm. Outcome of the incident was a resident elopement. Circumstances: Resident left building for a walk. Walked on the sidewalk beside nursing home and family member picked up resident. Family member called facility at 5:00pm and stated he picked up walking down sidewalk he will take him shopping with him and return him after errands completed. Resident returned to facility. Head to toe assessment done, no apparent injuries noted. Resident questioned about leaving the facility. Resident stated he went for a walk; will continue to monitor. 2. A review of Resident #118's record revealed that the resident sustained [REDACTED]. According to the resident record, the fall that occurred on 3/21/2012 resulted in injury and required the use of staples to close a laceration to the back of the resident's head. According to the clinical record, the fall that occurred on 3/21/2012 resulted in injury and required the use of staples to close a laceration on the back of the resident's head. The fall on 5/5/2012 occurred while the resident was walking to the bathroom and resulted in injury. According to nursing notes, the resident experienced swelling to the forehead and left eyebrow area. A review of Resident #118's care plans revealed that the resident was care planned for the potential for falls related to a history of an acute left subcortical stroke and unsteady gait. The care plan was dated for 2/1/2012. The goal of the care plan was to minimize risks for falls for the next 90 days. The care plan included the following interventions: Monitor frequently for safety to help when out of bed, place call bell within reach when in bed, maintain clutter free environment, keep floors free of spills, monitor for increased vision problems, and assist with ambulation as needed. Further review of the care plan revealed no evidence the interventions were revised or reviewed in order to reduce the potential for injury after the care plan was initiated on 2/1/12. An interview was conducted on 5/25/2012 at 12:10 PM with the Minimum Data Set (MDS) assessment coordinator about falls. The MDS coordinator confirmed that the care plan was not updated to reflect falls on 4/22/12 and 5/5/12 and did not contain any updated interventions to prevent future falls or protection from injury. Additional information was obtained during the extended survey on August 20-21, 2012: Observation of Resident #118 on 8/20/2012 at 11:20am in the presence of Activities Director, in his room, revealed he was wearing his Wanderguard on his left ankle. Interview with Resident #118 on 8/21/2012 at 9:39am revealed the resident was confused about why he needed to be staying in the facility. He stated he thought he would be going home soon and there was nothing wrong with him. He stated he goes home every night. He stated he does not know why he wears the Wanderguard device. The resident showed the surveyor his Wander guard device on his right ankle. Review of the medical record for Resident#118 revealed that there was a physician's order [REDACTED]." Review of the Minimum Data Set ((MDS) dated [DATE] revealed Section E Behavior E0900 Wandering, that the resident did not exhibit any wandering behavior. The MDS dated [DATE] revealed that the resident was scored as exhibiting wandering behavior 1-3 days during the assessment period. The MDS dated [DATE] revealed that the resident was scored as having exhibited wandering behavior 1-3 times during the assessment period. Review of Care Plan dated 7/11/12 for Resident #118 revealed that the resident is care planned for elopement and use of Wander guard. Interventions include watching the resident closely to make sure his Wander guard remains on him at all times. He will be observed every 30 minutes with re-direction as needed. He will have an identification bracelet placed to ensure resident ' s return to facility in case of elopement. The short term goal stated Wander guard system will assist to keep resident on facility's property all times. 3. An interview with Resident #10 on 5/22/12 at 3:22 PM revealed another resident had verbally abused her and an unsampled resident in the facility. The resident revealed she became very angry at the resident and was removed from the situation because she attempted to assault the verbally abusive resident. Interview with the unsampled resident on 5/23/12 at 1:43 PM confirmed that another resident had been verbally abusive to the resident and Resident #10. Per the unsampled resident, "the nurse stepped in and pulled her out of there because she was going to attack (the resident) for calling us names. I talked to the Administrator about it and told him what happened." Interview with a certified nursing assistant (CNA) working on the second floor on 5/25/12 revealed Resident #10 "can get real agitated at times and she doesn't want to be bothered. It's usually with other residents." She revealed if she observes a problem she tries to separate them and let them calm down. Interview with the Administrator on 5/24/12 at 11:30 AM revealed "When any verbal abuse occurs the facility counsels the residents after separating them and trying to redirect them. We don't report it anymore because the abuse registry won't take the reports. I try to reassure the victim that it wasn't always intentional, but related to the resident's illness or mental state. The facility has a very large population of psychologically impaired residents and they don't always behave appropriately." Review of the recent incident logs revealed a report was filed and an investigation was completed. The report revealed that Resident #10 was removed from the situation because she was going to hit the another resident. Review of the care plan dated 4/17/12 for Resident #10 revealed no problem with behaviors was identified or interventions were in place to try and prevent altercations. No revision of the care plan was completed after the altercation with another resident. 4. On 08/20/12 at 10:52 a.m. an interview was conducted with Nurse #119. She revealed Resident #102 was an elopement risk and did not have a wander guard in place. She stated, "We don't have Wanderguards up here." An observation and interview of Resident #102 on 08/21/12 at 9:41a.m. revealed the resident was alert with confusion. The resident revealed that she did not know how long she had been in the facility and she did not know where she was. The resident was informed she was in Summerbrook Health Care Center; she stated that she remembered hearing that name. The resident revealed things were going okay, but she would like to be at home. A medical record review for Resident #102 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the MDS with an ARD of 05/18/12 for the resident revealed she had a BIMS score of 03. The resident was coded as having no wandering behavior. A review of the Quarterly MDS with an ARD of 08/10/12 revealed the resident BIMS score was 09. A review of Resident #102's care plans revealed she had a care plan dated 06/13/11 for cognitive loss. The problem was the resident had cognitive loss related to short and long term memory deficit with daily decision making deficit. The short term goal was current cognitive level would not interfere with residents daily activity through the next 90 days. Approaches included talking with the resident in a non-judgmental way, provide an organized environment with set routine for activities of daily living and other daily activities, encourage the resident to become involved in the daily activities of the facility to prevent isolation and for socialization, remind the resident several times a day about upcoming events that resident seems to enjoy. The care plan was reviewed on 09/11/11; 12/02/11; and 02/24/12. A new care plan for cognition was developed on 05/23/12. The problem was the resident had cognitive loss related to short and long term memory deficit with daily decision making deficit. The short term goal was the resident's present level of cognition independence would not interfere with the resident's daily routine through the next 90 days. Approaches include minimizing the loss of dignity due to resident ' s current mental and/or physical limitations, inform resident what you will be doing and why before you begin. Allow resident time to response to statement, encourage resident to make daily decision about care and other daily decisions, encourage daily attendance in activities, use reality orientation and validate resident memories. The resident also had a care plan on file dated 05/12/12 for potential for side effects relayed to the use of psychotropic medications. The care plan was reviewed on 08/10/12 it was noted the resident was on medications for psychosis, depression, anxiety and dementia. Resident #102's care plans included a care plan dated 05/23/12 for potential for elopement. The problem was the resident had a potential for elopement, no new episodes in 60 days. The short term goal was the resident would remain on the facility's grounds at all times through the next review date. Approaches included ensuring the resident's need were met, staff will monitor location every 30 minutes; redirect when possible, attempt to determine the root cause of the elopement such as looking for someone/something or boredom. The resident's name and picture will be placed on their room door and in the elopement book. Encourage and assist resident to activities for socialization. Maintain a safe, risk free environment for resident. If resident leaves the facility, the guidelines in the elopement book will be followed. The care plan was reviewed on 08/10/12. Resident had had no episodes of elopement. Staff to monitor (the resident) when going off floor to activities. Continue care plan for 90 days. A review of the Psychiatric Notes dated 08/14/12 revealed Resident #102 had fair speech, decreased logic and fair thought content, episodic delusions, decreased insight and judgment in social situations, daily activities and psychiatric condition. Clinical status stable, oriented to person, memory fair, decreased fund of knowledge (current events, vocabulary and past events). The resident ' s mood was depressed and anxious. Affect bland. [DIAGNOSES REDACTED]. On 07/11/12 the resident's psychiatric condition was the resident had fair speech, decreased logic and fair, thought content included episodic delusions, decreased insight and judgment in social situations, daily activities and psychiatric condition. Clinical status stable, oriented to person, memory fair, decreased fund of knowledge (current events, vocabulary and past events). The resident's mood was depressed and anxious. Affect bland. [DIAGNOSES REDACTED]. A review of the Nurses' Notes for Resident #102 revealed a note dated 07/28/12 at 12:15 pm Resident noted attempt to go down (the) stairs times three. Complains of needing to go home and cook dinner. Episode times three. Had to redirect off elevator and continued stating she had to go home and eat; that the food was cooking on low heat. Was able to redirect with a cigarette after lunch. Resident stated she was not going to eat. Xanax 1 by mouth given to continue to monitor for behavior. An interview with CNA #99 for Resident #102 on 08/21/12 at 9:49 am revealed she assisted the resident with ADLs. She revealed the resident ' s mental status goes and comes; but she is more alert than confused and she had not observed any exit seeking behaviors. The CNA revealed 30 minutes walking rounds included making sure all the residents are accounted for and they do not need anything and assisting residents if needed. An interview with the MDS Coordinator, Nurse #28, on 08/21/12 at 1:53pm revealed she had no knowledge of the exit seeking occurrence with Resident #102 on 07/28/12. She revealed the staff usually notified the MDS department and informed them of changes. She revealed the care plan meetings were used to discuss what happened with residents and the order sheets were reviewed. She also revealed the physician was usually notified that there was an attempt of a resident to exit the facility. She revealed the care plan was usually updated and new interventions are added, like placing the resident closer to the nurses ' station, or rounding on the resident more frequently than the staff already did. She revealed the resident is confused, but this was the first time she was made aware the resident tried to exit the facility. 5. Observation of Resident #200 on 8/20/2012 at 11:08am in the hallway of level two revealed she had her Wander guard on her right wrist. She was not willing to cooperate with the nursing staff to pull up her sleeve to show the surveyor; however, the alarm did go off when she walked close to the stairwell door a few minutes later. Resident #200 was observed on 8/21/2012 at 9:44am in her room with her husband. The resident ' s husband reported that they are fine and ate breakfast. Resident #200 had her Wander guard device on her wrist. When asked what it was for she did not answer, but smiled and turned it around on her wrist. Review of the medical record for Resident #200 revealed she was admitted to this facility on 8/10/2012 from an acute care hospital and previ