Every finding on record at Jesup Ridge of Journey LLC

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that one Resident (R) R46 of 39 sampled residents were treated with respect and dignity and allowed the opportunity to retain her cross stitch sewing materials by staff removing her cross-stitch needles, scissors and thread from her room without her knowledge. This failure had the potential to cause unnecessary negative psychosocial effects for R46.Findings include:Review of R46's Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted with a diagnosis of chronic kidney disease.Review of R46's admission Minimum Data Set (MDS), located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/27/2026, revealed it was very important to R46 to do her favorite activities which included cross-stitch sewing.Review of R46's quarterly MDS, located in the resident's EMR under the MDS tab with an (ARD) of 06/08/2206, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, indicating moderate cognitive impairment.During an observation on 08/18/26 at 9:00 AM, R46 was observed in the hall asking the Certified Occupational Therapy Assistant (COTA) and the Restorative Certified Nurse Aide (RCNA) why she could not have her cross-stitch materials. R46 stated she could not find her cross-stitch materials to finish Christmas ornaments for her six grandchildren. She stated, this is the only thing I can give them. R46's voice continued to escalate, while she continued to ask any staff that walked by in the hall, why she could not have her cross-stitch items. Both the COTA and the RCNA stated they did not know the reason. R46 stated they just took everything this morning and I don't know why. R46 continued to say, in an elevated tone I need to do my cross stitch for my grandchildren, this is all I can give them.During an interview and observation on 08/18/2026 at 3:00 PM, R46 was observed in the hall again asking where her cross-stitch materials were and why she did not have them. Again, she stated I need to finish Christmas ornaments for her six grandchildren. She stated, this is the only thing I can give them.During an observation on 08/18/2026 at 2:30 PM, R46 was sitting in the lobby working on her cross stitch with her family member (FM). At 2:55 PM, R46's FM handed the Director of Nursing Services (DNS) R46's cross stitch material. R46 rolled down the hall in her wheelchair. At 3:00 PM on 08/18/26, R46 was observed sitting in the hall, her voice was elevated. Tears were observed on R46 cheeks, while she called out, I need my cross-stitch needles, I can't cross stitch without them, and I need to work on my grandkids' Christmas ornaments. R46 had tears on her face and stated she was mad. She stated they took everything (thread, needles and scissors) from me this morning but I don't know why.During an interview on 08/18/2026 at 4:00 PM, the Administrator stated she and the Director of Nursing Services (DNS) had removed items from R46's room without her knowledge, because there was a concern for resident safety. The Administrator stated R46's needles and scissors for her cross stitch had been removed on 08/18/2026. The Administrator stated an assessment for R46 had not been completed to determine if she was safely able to use her cross-stitch materials. She stated R46 had provided verbal consent but stated nothing was documented.During an interview on 08/19/2026 at 10:11 PM, R46's FM stated R46 has cross stitched for a long time and has made ornaments for her grandchildren for years. She stated cross stitch keeps her happy and healthy and this is my goal to keep (R46) happy. She stated cross stitch is good for her and it keeps her mind off her troubles. She stated she could not imagine R46 hurting herself with a needle. She stated she was not aware that staff were going to look in her room and remove items until she entered the facility on 08/18/2026 and she was told by the social worker. She stated she would have liked to have known before the facility removed the items and would have liked to be included in the decision.During an interview on 08/19/2026 at 11:01 AM, R46 stated staff took her cross-stitch thread, needles, and scissors on 08/18/2026. R46 stated she came into her room and the items were gone. She stated they discussed with her that they needed to remove the items for her safety, and she would require supervision when cross stitching. She stated, if I can't sleep I like to lay in bed and cross stitch. She stated they put a lock on the drawer but have not educated her on the key. She stated she was mad, no one realizes how long it takes to do these things. She stated it makes me sad I've done this for 10 years; I'm not going to hurt myself. R46 stated she did not know what the next step was to get her cross-stitch materials back.During an interview on 08/19/2026 at 1:25 PM, the Infection Preventionist (IP) stated all R46's cross stitch materials were removed from R46 room on 08/18/2026 and had started staff education on 08/19/2026.During an interview on 08/19/2026 at 3:00 PM, the Administrator stated they had decided to provide R46 with a lock on her nightstand so she could have her cross-stitch materials. She stated R46's nurse will keep the key and when she wants to get her cross-stitch materials she will ask the nurse for the key. The Administrator stated this way staff will know she is cross stitching so they can watch her for safety. She stated they will also put a red banner across the door so other residents will know not to come into her room. The Administrator stated there has never been a concern with R46 safety regarding her cross-stitch materials.During an interview on 08/21/2026 at 8:54 AM, the COTA stated she had witnessed R46 come out of her room on the morning of 08/18/2026 asking where her cross-stitch materials were. She stated she did not know where her items were. The COTA stated R46 was visibly upset and her voice became escalated.During an interview on 08/21/2026 at 9:15 AM, the Activities Director stated if an activity is important to the resident that resident should have the opportunity to do those activities while in the facility. She stated she was aware that it was important that R46 complete her cross stitch since that was a lifelong activity.During an interview on 08/21/2026 at 9:44 AM, the RCNA stated she had been made aware that when she was off the DNS and the Administrator had gone through rooms and taken personal items from residents. The RCNA stated when she witnessed R46 in the hall visually and verbally upset and asking about her cross-stitch materials she was confused because she thought residents could have whatever they wanted because this was their home. The RCNA stated she was educated about the new rules regarding R46 cross stitch.Review of the Resident Personal Belongings policy, revised 03/08/2024, revealed, The facility will support the resident's right to retain and use personal possession(s) to promote a homelike environment and maintain their independence.Review of the Activities policy, revised 03/08/2024, revealed, Activities.reflect choices of the residents.

Based on observations and staff interviews, the facility failed to maintain resident-use equipment in functional condition, including overbed tables with nonfunctional wheels and a tabletop that did not maintain a locked elevated position, and failed to maintain components of the resident environment in good repair, including a loose ventilation cover. These deficient practices had the potential to affect resident safety, comfort, and quality of life by creating risks associated with unstable equipment, difficulty positioning overbed tables for meals and care activities, and contact with improperly maintained environmental components for three of 27 total rooms and three of 18 sampled residents.Findings include:1. During an observation on 08/18/2026 at 9:40 AM, Resident (R), R8's overbed table was observed with a missing wheel. The table did not move freely as R8 attempted to pull it closer for use.During an observation on 08/18/2026 at 10:05 AM, R67's overbed table was observed with one wheel loose and unstable. The wheel wobbled when the table was moved, affecting the table's mobility and stability. When asked about the condition of the overbed table, R67 stated he believed the issue was related to the mat beside his bed. During the same observation, a metal ventilation grate located near the entrance to R 67's room was observed to be loose, not flush with the wall, and missing screws used to secure it in place.During an observation on 08/18/2026 at 10:50 AM, R23's overbed table was observed with a tabletop that failed to maintain an elevated position. When gentle pressure was applied to the tabletop, it lowered from its raised position. When asked about the condition of the table, R 23 stated he would like the overbed table repaired.During an interview on 08/21/2026 at 8:35 AM, the Maintenance Director (MD) stated maintenance concerns are identified through weekly rounds conducted by the maintenance department, daily rounds conducted by the Administrator, and maintenance work orders submitted through the facility's electronic maintenance system (TELS) by the nursing staff. The MD stated maintenance issues identified during rounds or reported through TELS are reviewed and addressed by the maintenance department. When informed of the observations involving R8's overbed table with a missing wheel, R 67's overbed table with a loose and unstable wheel, and R 23's overbed table that failed to maintain an elevated position, the MD stated he had not previously been aware of those concerns. The MD also observed the ventilation grate near R67's doorway entrance and confirmed it was loose and in need of repair. During the interview, the MD showed a list of orders he had received through TELS on his phone and stated that he was working through the list.2. During the initial tour on 08/19/2026 at 9:45 AM it was observed that the wall above the toilet and the ceiling in the bathroom of room [ROOM NUMBER] had significant peeling paint and the plaster/plasterboard appeared to be crumbling in several areas. The concerns were noted to effect two to three square feet.On 08/19/2026 at 10:14 AM, the walls above the toilet and the ceiling in the bathroom of room [ROOM NUMBER] had peeling paint and cracks with a built up dry flaky substance.During an interview with Maintenance Director (MD) on 08/20/2026 at 10:00 AM, the MD agreed that the walls and ceiling were in disrepair, and they were not what you would expect to see in a home-like environment.

Based on Record review, interview and policy review, the facility failed to obtain a Hospice Care Plan for one of three residents (Resident (R)16) reviewed for Hospice services in the sample of 39. The failure to Have this Hospice information readily available to facility staff could potentially lead to a disruption in the continuity of care between Hospice and facility staff. Findings include: Review of R16's electronic medical record (EMR) admission Record under the Profile tab identified that R16 was admitted to the facility for Hospice care. Review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 06/23/2026 identified a Brief Interview of Mental Status (BIMS) score of 12 out of 15 meaning mildly cognitively impaired.Review of R16's EMR under the Care Plan tab identified that R16 only had a facility-based care plan for Hospice services with no reference to the Hospice provider's care plan. Interview on 08/19/2026 at 11:40 AM with Unit Manger (UM),. The UM after reviewing the facilities care plan for Hospice also stated that this was not the Hospice entity's care plan for R16.Interview on 08/21/2026 at 3:40 PM with Floating Director of Nursing Services (FDNS,) it was identified that R16 did not have a Hospice plan of care from the Hospice entity at the facility because the Hospice care did not provide one.Review of the facility's undated policy titled, Hospice Services Facility Agreement, indicated under the sections identified as Policy Explanation and Compliance Guidance, under paragraph 6, it states The designated member of the facility working with Hospice representative is responsible for: Under section d. Obtaining the following information from Hospice: i. The most recent Hospice plan of care specific to each resident.

Based on observations, interviews and policy review, the facility failed to ensure facility staff implemented infection control measures to prevent the potential spread of infection as evidence by housekeeping staff observed touching multiple surfaces while in and out of a resident's room without changing gloves which could transmit organisms from surface to surface and a licensed staff failed to ensure that Personal Protective Equipment (PPE) was discarded in the resident's room after the completion of the administration of insulin. This deficient practice could transmit organisms from surface to surface Findings include:1. During a medication pass observation on 08/19/2026 at 12:20 PM, Licensed Practical Nursing (LPN), LPN 1 entered R 43's room wearing a gown and gloves (PPE) to administer insulin. At approximately 12:20 PM, LPN1 administered the insulin to the resident's right upper arm. Upon exiting the room, LPN1 removed the gown and gloves, rolled the gown, placed it under her right arm, and carried the used PPE down the hallway. LPN1 then discarded the PPE into the trash receptacle attached to the medication cart before performing hand hygiene with hand sanitizer.During an interview on 08/19/26 at 3:00 PM, the Infection Preventionist (IP) stated PPE used in an isolation room should be discarded in the room trash receptacle located near the door before exiting the room. The IP confirmed LPN1's observed practice of carrying the used PPE from the resident's room to the medication cart was not consistent with facility expectations.During an interview on 08/19/26 at 3:30 PM, LPN1 stated the PPE should have been discarded in the resident's room in the bin.Review of the facility policy entitled Transmission-Based (Isolation) Precautions (TBP), revised 02/16/24, revealed, It is our policy to take appropriate precautions to prevent transmission of pathogens based on the pathogens' modes of transmission. Section D Discarding personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.2. Observation on 08/18/2026 at 3:12 PM, revealed Housekeeper (HSK) 1 wearing gloves while pushing a housekeeping cart in the hallway. HSK1 stopped at room [ROOM NUMBER], removed a broom from the cart, opened the resident room door while wearing the same gloves, entered the room, and swept around the bed. Upon exiting the room, HSK1 continued to wear the same gloves and placed the broom back on the housekeeping cart. HSK1 then removed a mop from the cart and mopped the floor of room [ROOM NUMBER], while continuing to wear the same gloves. HSK 1 proceeded down the hallway to the Admissions Director's office, opened the office door using her same gloved hand, entered and exited the office, and subsequently touched a table located in the hallway while still wearing the same gloves. HSK1 then removed her gloves.During an interview on 08/18/2026 at 3:25 PM, HSK1 stated gloves should be changed every two minutes. She stated she should have removed her gloves when she left the room and washed her hands. HSK1 stated she had worn the same gloves all while, touched the doorknob, entered and exited the room, touched the broom and mop, touched the Admissions Director's doorknob, and touched the table near the door.During an interview on 08/18/2026 at 3:53 PM, the Infection Preventionist (IP) stated staff should not wear gloves in the hall and only put gloves on when they enter a room. She stated a housekeeper should remove her gloves prior to coming out of the room and then wash her hands.During an interview on 08/20/2026 at 4:10 PM, the Administrator stated all staff should follow proper handwashing procedures and gloves should not be worn in the hall.During an interview on 08/21/2026 at 5:35 PM, the Director of Nursing Services (DNS) stated gloves should never be worn out of the room and proper handwashing procedures should be followed.Review of the facility policy, Hand Hygiene, updated by the facility on 02/01/2024, revealed, .perform hand hygiene prior to donning gloves and immediately after removing gloves.

Based on record review, staff interview, and review of the facility's policy titled F582, F584 Beneficiary Notices, the facility failed to ensure each Medicare resident whose Medicare therapy services were terminated received a two-day notice prior to the discontinuation of skilled services to include the reason the services were ending or what the options were prior to the discontinuation of therapy services. This had the potential to affect three of three Residents (R) (R6, R159 and R37) who were reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review. This failure had the potential to provide the resident the wrong information for the appeals process. Findings include: Review of the facility's policy titled, F582, F584 Beneficiary Notices dated 8/2024, revealed, Policy: A Medicare beneficiary has the right to have Medicare make the decision to determine if skilled services are will not be covered by Medicare. Two processes are available: the expedited appeals process and the standard appeals process . The purpose of an expedited appeal is to keep services in place. The SNF [Skilled Nursing Facility] must give notice to the beneficiary at least three days prior to termination of all Part A services when the beneficiary still has days left in the benefit period, using the Notice of Medicare Provider Non-Coverage, Form CMS-10123, to inform the beneficiary of how to request an expedited redetermination and, if the beneficiary seeks an expedited determination . Guidelines: 1. ln order to request an expedited appeal, the resident or family must call the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), by no later than noon the following day. The beneficiary has the right to submit evidence to the BFCC-QIO . 5. Skilled Nursing Facilities (SNFs) must also issue a liability notice to Original (fee for service) giving the resident an option to start the standard appeals process. 6. Beneficiary Notices: a. Notice of Medicare Non-Coverage (NOMNC) i. Prepare and give the resident the NOMNC Form CMS-10123 at least 3 days before the end of the Medicare Part A stay . 1. Review of the undated admission Record located in the electronic medical record (EMR) under the profile tab for R6 revealed re-admitted to the facility on [DATE]. R6 had Medicare benefits and was discontinued from skilled therapy services on 3/18/2025 per the information provided by the facility. R6 had not exhausted his Medicare benefit days. The facility failed to issue the correct form regarding the ending of Medicare payment coverage for Part A services. The facility issued form CMS-R-131 which was to be used for Part B services. 2. Review of the undated admission Record located in the EMR under the profile tab for R37 revealed admission to the facility on 1/3/2025. R37 had Medicare benefits and was discontinued from skilled therapy services on 1/20/2025 per the document provided by the facility. R37 had not exhausted her Medicare benefit days. The facility failed to issue the correct form regarding the ending of Medicare payment coverage for Part A services. The facility issued form CMS-R-131 which is to be used for Part B services. 3. Review of the undated admission Record located in the EMR under the profile tab for R159 revealed admission to the facility on 3/28/2025. R159 had Medicare benefits and was discontinued from skilled therapy services on 4/14/2025 per the document provided by the facility. R159 had not exhausted her Medicare benefit days. The facility failed to issue the correct form regarding the ending of Medicare payment coverage for Part A services. The facility issued form CMS-R-131 which is to be used for Part B services. During an interview on 5/28/2025 at 3:40 pm the Administrator stated While I was out on leave our Social Services Director (who issues the notices) was told to use the different form. She did this for the last three months until we discovered the problem and corrected it. The residents were getting the wrong form for the notice, the CMS-R-131 which is for Part B services not Part A. The residents should have been given CMS 10123.

Based on record review, staff interview, and review of the facility's policy titled, Pre-admission Screening and Resident Review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR), when a resident with a mental disorder for one out of two Residents (R) (R31) reviewed for PASARR. This failure placed the resident at risk of not receiving appropriate services, or needs going unmet. Findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review effective 10/2024 indicated, This community will coordinate assessments with the preadmission screening and resident review (PASARR) program. Upon admission, the Social Worker or designee will, within the context of the established assessment process, the recommendations of the PASARR level ll and the PASARR evaluation report with be incorporated into the resident's assessment, care planning and transitions of care. Notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of the resident who has a mental disorder or intellectual disability for resident review. Review of R31's Face sheet located under the profile tab of the electronic medical record (EMR) revealed R31 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder, manic episode, and generalized anxiety disorder. Review of R31's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025, located in the resident EMR under the MDS tab for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicates moderate cognitive impairment. Review of R31's EMR under miscellaneous tab revealed a PASARR II was not located. Review of the PASARR I that was completed at admission revealed the diagnosis of bipolar. During an interview on 5/28/2025 at 5:48 pm with the Social Service Director (SSD) and Business Office Manager (BOM), they stated that they do not do PASARRs in-house. They stated that they have discussed with the Behavioral Health Unit (BHU) and the hospital on what to do when a resident has change in behavior, medications, and new mental illness diagnosis but have not received a response. We have looked into R31 because there have been some behavioral issues and medication changes that required hospitalization in 10/2024. Review of R31's progress note in the EMR under the progress notes tab revealed on 10/21/2024 that the resident was being charted for manic behavior. This charting continued with multiple episodes identified until 10/29/2024 when the resident was transported to a BHU. The resident was not released from BHU and returned to the facility on [DATE]. During an interview on 5/29/2025 at 2:38 pm, the SSD and BOM stated that the BHU should have completed another PASARR for the residents. They confirmed the only PASARR for R31 was from 2022. The SSD indicated she did not know how to complete the PASARR and what steps are to be followed. During an interview on 5/30/2025 at 9:17 am, the Administrator revealed that PASARRs are completed when they come into the facility. If a resident is sent out because of a change, the hospital or BHU will complete the PASARR. The Administrator was not aware that the PASARR needed to be completed in house when a resident had a new diagnosis of mental illness.

Based on record review, staff interview, and review of the facility's policy titled, Pre-admission Screening and Resident Review, the facility failed to identify and notify the appropriate state authorities for a Level II Preadmission Screening and Resident Review (PASARR), when a resident with a mental disorder experienced a significant change in condition for one out of two Residents (R) (R 31) reviewed for PASARR. This failure placed the resident at risk of not receiving appropriate services, or needs going unmet. Findings include: Review of policy titled, Pre-admission Screening and Resident Review, effective 10/2024 stated, Residents with newly evident or possible serious mental disorders will be referred for appropriate services based upon their assessed needs, and notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of the resident who has a mental disorder or intellectual disability for resident review. Review of R31's Face sheet located under the profile tab of the electronic medical record (EMR) revealed, R31 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder, unspecified, manic episode, unspecified, and generalized anxiety disorder. Review of R31's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025, located in the resident EMR under the MDS tab for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicates moderate cognitive impairment. Review of R31's progress note in the EMR revealed on 10/21/2024 a note indicating that the resident was being charted for manic behavior. This charting continued with multiple episodes identified 10/21/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/28/2024 and 10/29/2024 when the resident was transported to a Behavioral Health Unit (BHU). The resident was not released from the unit and returned to the facility until 11/12/2024. Review of R31 EMR under miscellaneous tab revealed a PASARR II was not located. The PASARR I indicated the mental illness diagnosis of bipolar and was completed on admission 8/3/2022. During an interview on 5/28/2025 at 5:48 pm, the Social Service Director (SSD) and Business Office Manager stated that they do not do PASARRs in house. We have looked into R31 because there have been some behavioral issues and medication changes that required hospitalization in 10/2024. The SSD indicated she was not aware of having to notify the state mental health authorities upon any significant changes. During an interview on 5/30/2025 at 9:17 am, the Administrator stated that R31 was sent out because of a change. The Administrator stated that he was not aware that after a resident with a mental disorder or intellectual disability has a significant change in their mental or physical condition will be referred for appropriate services based upon their assessed needs, and notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of the resident who has a mental disorder or intellectual disability for resident review.

Based on observation, staff interview, record review and review of the facility provided document titled Infection Control Program-Infection Control Guide for Long-Term Care on Perineal Care, the facility failed to adhere to infection control practices and policies during peri care and suprapubic catheter care related to performing peri care, staff changing gloves and performing hand hygiene for one of 42 sampled residents (R) (R26). Findings include: Review of the facility provided document titled Infection Control Program-Infection Control Guide for Long-Term Care on Perineal Care revealed, .8. Educate staff on proper procedures on perineal care. During perineal care, preform hand hygiene before and after and change gloves when solid to reduce the spread of infection. Review of R26's Physician Orders in the EMR under the Orders tab revealed an order for a suprapubic catheter. 1. Observation on 5/27/2025 at 10:22 am, Certified Nurse Aide (CNA)1 and CNA2 entered R26's room, was in Enhanced barrier precautions (EBP) to provide peri care and catheter care. CNA1 and CNA2 donned gloves and R26's to perform peri care and suprapubic catheter. While wearing the same soiled gloves, CNA1 and CNA2 placed on his pants and pulled them up. Then CNA1 and CNA2 placed the sling pad under R26, while wearing the same gloves. CNA1 reached out and pulled the mechanical lift over to the bedside. CNA1 and CNA2 both hooked R26's sling with the chains and then cranked the sling up and placed R26 in his wheelchair wearing the same solid gloves. CNA1 and CNA2 both touched the rails, linens, catheter bag and tubing wearing the same soiled gloves. CNA1 doffed the gloves and performed hand hygiene. CNA2 took the trash that was collected from the room, sat it on the floor, and went and performed hand hygiene. Interview on 5/27/2025 at 10:40 am, CNA1 and CNA2 both stated that they realized that they had touched R26's clothes without removing their soiled gloves. CNA1 voiced that she should not have touched items with gloved hand because this spreads germs and not what they were taught. 2. Observation and interview on 5/28/2025 2:39 pm revealed, CNA1 entered R26's room to preform peri care. Treatment Nurse and CNA1 performed hand hygiene, donned gloves, and gown. CNA1 unfastened R26's incontinent brief. Using one wet, soapy wash cloth, CNA1 made several wipes up and down across R26's peri area. There was no washing the head of the penis or pulling back the foreskin, washing in all directions, not using a clean area of the washcloth for each stroke. The area was not dried. CNA1 then washed the suprapubic catheter with one washcloth with no soap. R26 was rolled over and buttocks washed with one washcloth moving in all directions. Folding the washcloth over she then washed the buttocks on both sides and did not dry any of the buttocks. Then CNA1 went over to R26's bedside table, touched the covers, privacy curtain and the nightstand looking for a clean incontinent protector while wearing the same soiled gloves. CNA1 placed a clean incontinent protector that was found in the nightstand under R26 and pulled the soiled incontinent protector out from under R26. CNA1 moved R26's covers around to cover him up wearing the same soiled gloves. CNA1 collected in a bag the trash wearing the same soiled gloves. CNA1 pulled the privacy curtain back while wearing the same soiled gloves. CNA1 then removed the soiled gloves and performed hand hygiene. CNA1 stated after finishing the peri care that she should have changed the gloves between doing tasks. When asked about touching curtains, nightstands and covers, CNA1 stated he did not realize that he had done that but acknowledged that he was to take off the soiled gloves and not touch anything while wearing soiled gloves.

Based on staff interview, record review, and review of the facility's policy titled, Infection Control Program- Antibiotic Stewardship F881, the facility failed to ensure an antibiotic was not used without the presence of a diagnosed infection for one of four Residents (R) (R7) reviewed for antibiotic stewardship. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. Findings include: Review of the facility's policy titled, Infection Control Program- Antibiotic Stewardship F881 dated 10/2024 documented, .d. after order has been received, the infection control coordinator or designee should complete the surveillance document, utilizing the McGeer criteria, noting evidence for the infection. If the antibiotic does not fit the criteria, the physician will be contacted. Review of R7's admission Record located in the Reports tab of the electronic medical record (EMR) revealed, the resident admitted to the facility on [DATE]. Review of R7's Progress Note dated 5/29/2025 located in the Progress Notes tab of the EMR documented, Received UA [urinalysis] results and sent them to MD [physician], no CNS [culture and sensitivity] ordered. Review of R7's urine test results located in the EMR under the Lab tab documented, UWBC [Urine white blood cells]. There was no documentation in the EMR, paper chart, or on the lab result to indicate an CNS. Review of R7's physician orders dated 5/21/2025 in the EMR under the orders tab indicated Macrodantin oral capsule 100mg [milligram], give one capsule by mouth two times a day for 7 (seven) days with stop date of 5/28/2025 at 17:00 pm [5 pm]. Review of R7's Individual Screening Evaluation form found in the facility's Infection Prevention and Control Program (ICPC) binder revealed, the resident's symptoms first appeared on 5/22/2025. The form documented, UTI not dx [diagnosed]. Prophy [prophylaxis] for abnormal UA. Ordered by hospice Interview on 5/29/2025 at 1:35 pm, the Infection Preventionist (IP) revealed, that the antibiotic was ordered for R7, because of the abnormal UA dip stick performed by hospice, which looked like a UTI. The IP confirmed there were no evidence given to the physician of a urine culture results that indicated bacterial growth.

Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from sexual, verbal, and physical abuse by a resident. Specifically, the facility failed to protect Resident #7, who was cognitively impaired and wandered in the facility from sexual abuse by Resident #6, who had a history of sexually inappropriate behavior. On 10/18/2024, when staff were unable to locate Resident #7, they initiated a search and found the resident in Resident #6's bathroom seated on the toilet. Resident #6 stood in front of Resident #7 unclothed from the waist down with their genitals in their hand. Furthermore, on 08/09/2024, Resident #6 was found standing over the bed of Resident #8, a cognitively impaired resident, with their genitals in their hand and expressed inappropriate sexual gestures and comments. On 09/03/2024, Resident #6 grabbed the wheelchair of Resident #10 and prevented Resident #10 from moving about in their wheelchair. On 09/18/2024, Resident #6 voiced inappropriate sexual comments to Resident #9 as Resident #9 straightened their shirt. On 10/03/2024, Resident #6 was found masturbating in the doorway of Resident #2's room. These deficient practices affected 5 (Residents #2, #7, #8, #9, and #10) of 15 sampled residents reviewed for abuse. It was determined that the provider's non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of K. The IJ began on 08/09/2024, when Resident #6 expressed inappropriate sexual gestures and comments as they were found standing over the bed of Resident #8. On 11/15/2024 at 1:25 PM, the interim Administrator and Director of Nursing (DON) were informed of the IJ situation and provided a completed IJ template. A removal plan was requested. On 11/15/2024 at 1:25 PM, the interim Administrator and Director of Nursing (DON) were informed of the IJ situation and provided a completed IJ template. A removal plan was requested. An approved Credible Allegation of Compliance was received on 11/17/2024. Based on the validation of the Credible Allegation of Compliance, the State Survey Agency determined the deficient practice was corrected on 11/15/2024 and the immediacy of the IJ being removed on 11/16/2024. Findings included: A facility policy titled, F607 Abuse Prevention Program, Prevention of Abuse effective 04/2024, indicated, The community staff will not condone any form of resident abuse, neglect, exploitation, or mistreatment and will continually monitor the facility's policies, procedures, training programs, systems, etc. to assist in preventing resident abuse. A facility policy titled, F607, F943 Abuse Prevention Program, Training, effective 08/2024, indicated h. Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property including: 1. Verbal, mental, sexual and physical abuse. An Admission Record revealed the facility admitted Resident #6 on 07/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, hypertension, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #6's care plan, included a focus area initiated 08/13/2024, that indicated the resident sometimes had behaviors which included sexually inappropriate language to staff, grabbed staff, and made sexual comments and sexual gestures. Interventions directed to staff to administer medications as the doctor ordered (initiated 08/13/2024), attempt interventions before the behaviors began (initiated 08/13/2024), provide care in pairs (initiated 08/14/2024), and refer the resident for psychiatric services as needed (initiated 08/13/2024). Resident #6's nursing progress note, dated 08/09/2024 at 12:53 PM, revealed that while a hospice certified nursing assistant (CNA) provided a shower to the resident, the resident grabbed the hospice CNA between her legs and when the hospice CNA jumped back, Resident #6 asked the hospice CNA what she was jumping back for. During a telephone interview on 11/13/2024 at 9:28 AM, the hospice CNA stated as she dried Resident #6's back during the provision of a shower, she gave the resident a towel to dry their genital area and that was when the resident placed their hands between her legs. The hospice CNA stated she reported the incident to the facility and the facility provided another staff member to be present when care was provided to the resident. Resident #6's nursing progress note, dated 08/09/2024 at 4:07 PM, revealed that while a CNA obtained incontinence briefs, Resident #6 approached the CNA and stated, Are you going to put one of those on me, while they grabbed their groin area. Resident #6's nursing progress note, dated 08/09/2024 at 4:08 PM, revealed Resident #6 was found in a resident (Resident #8) of the opposite sex's room. According to the nursing progress note, when the roommate (Resident #3) of the resident (Resident #8) informed Resident #6 that the resident (Resident #8) was deaf, Resident #6 replied that is alright, we can still feel our way around and proceeded to grab their genital area. An Admission Record revealed the facility admitted Resident #3 on 05/16/2023. According to the Admission Record, the resident had a medical history that included diagnoses of heart failure and muscle weakness. A quarterly MDS, with an ARD of 08/08/2024, revealed Resident #3 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. An Admission Record revealed the facility admitted Resident #8 on 06/30/2023. According to the Admission Record, the resident had a medical history to include diagnoses of hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cognitive communication deficit, functional quadriplegia, and contracture of the right upper arm and right lower leg. A quarterly MDS, with an ARD of 07/01/2024, revealed Resident #8 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. During an interview on 11/16/2024 at 2:10 PM, Resident #3 stated they recalled when Resident #6 came into their room and stood by Resident #8's bed. According to Resident #3, they yelled for help and asked staff to remove Resident #6 from their room. Resident #3 stated when they informed Resident #6 that Resident #8 was deaf, Resident #6 stated some bad things. Per Resident #3, Resident #6 stated we can feel our way around and then grabbed their private parts. Resident #6's nursing progress note, dated 08/12/2024 at 10:43 AM, revealed the resident showed sexual behaviors towards staff. Resident #6's nursing skilled note, dated 08/14/2024 a 1:15 AM, revealed the resident commented to staff, I need help with a lot of things but right now I need a [person of the opposite sex]. Resident #6's history and physical (H&P), dated 09/02/2024, indicated the resident was sent to a behavioral health facility on 08/14/2024 for hypersexual behaviors, to include sexually inappropriate comments to staff and other residents. Per the H&P, the resident returned to the facility on [DATE] and nursing reported on 08/30/2024, the resident had similar hypersexual behaviors. Resident #6's social service (SS) note, dated 09/03/2024 at 10:30 AM, revealed SS was notified by the Unit 2 manager and nurse that resident had increased behaviors with people of the opposite sex. Per the SS note, SS requested to have the resident placed on 1:1 supervision. Resident #6's nursing progress note, dated 09/03/2024 at 10:33 AM, revealed the housekeeping staff reported to a nurse that Resident #6 was found standing over a resident of the opposite sex while the resident of the opposite sex laid in bed. Per the nursing progress note, the resident of the opposite sex could not ambulate due to a stoke and hollered to get help to remove Resident #6 from their room. Per the nursing progress note, Resident #6 was encouraged to avoid rooms of residents of the opposite sex. According to the nursing progress note, Resident #6 tried again to seek entry into a resident of the opposite sex room and was assisted back to their room. Resident #6's nursing progress note, dated 09/03/2024 at 11:10 AM, revealed Resident #6 grabbed the wheelchair of a resident of the opposite sex (Resident #10) and would not let the resident continue further in their wheelchair. Per the progress note, Resident #6 was assisted back to their room and placed on 1:1 observation. A quarterly MDS, with an ARD of 07/10/2024, revealed the facility admitted Resident #10 on 03/12/2024. According to the MDS, the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #10 had active diagnoses to include stroke and hemiplegia or hemiparesis. During an interview on 11/12/2024 at 11:24 AM, Licensed Practical Nurse (LPN) #13 stated on 09/03/2024, Resident #3 hollered for her to come to their room. According to LPN #13, Resident #6 had come into Resident #3 and Resident #8's room. LPN #13 stated when she entered the room, Resident #6 was leaned over Resident #8's bed. LPN #13 stated she did not know how long Resident #6 had been in Resident #8's room. LPN #13 stated also on 09/03/2024, as Resident #6 was in the hallway, the resident grabbed the wheelchair of Resident #10 and prevented Resident #10 from going forward. According to LPN #13, after this incident, Resident #6 was placed on 1:1 until the resident was transferred to a behavioral health facility on 09/04/2024. Resident #6's nursing skilled note dated 09/16/2024 at 10:58 PM, revealed the resident made sexual remarks to other residents and a CNA. Per the skilled note, staff explained to Resident #6 that they could not talk to residents of the opposite sex in that way, but the resident continued with sexual remarks. Resident #6's nursing skilled note dated 09/18/2024 at 12:30 PM, revealed as a resident of the opposite sex (Resident #9) was straightening their shirt, Resident #6 told the resident, let me see it all, lean over so I can see them [breasts], and I can tell by your mouth, you nasty. An Admission Record revealed the facility admitted Resident #9 on 05/31/2019. According to the Admission Record, the resident had a medical history to include diagnoses of type 2 diabetes mellitus, lack of coordination, muscle weakness, dementia, and cognitive communication deficit. A quarterly MDS, with an ARD of 09/23/2024, revealed Resident #9 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had moderate difficulty with hearing and usually understood others. During an interview on 11/12/2024 at 11:24 AM, LPN #13 stated as Resident #9 sat on their bed and repositioned their shirt, Resident #6 made some very inappropriate sexual comments to Resident #9. According to LPN #13, Resident #9 was very hard of hearing and did not hear anything Resident #6 stated. LPN #13 stated she reported the incident to the Administrator, as the staff was to report all allegations immediately to the Abuse Coordinator, who was the Administrator or call the Director of Nursing. During an interview on 11/16/2024 at 11:05 AM, LPN #6 stated abuse could be many things such as physical, sexual, and verbal to name a few. LPN #6 stated if a resident said something that was inappropriate or mean, it could be considered verbal abuse. Resident #6's skilled note, dated 10/01/2024 at 11:52 AM, revealed the resident was noted to have inappropriate behaviors towards opposite sex staff and residents. The skilled note indicated Resident #6 told a female staff member to come to their bed and told a resident of the opposite sex (Resident #15) that I got to put it somewhere. Per the skilled note, staff continued to redirect Resident #6 away from residents of the opposite sex and moved residents of the opposite sex from Resident #6. An Admission Record revealed the facility admitted Resident #15 on 01/19/2021. According to the Admission Record, the resident had a medical history to include diagnoses of dementia, altered mental status, and muscle weakness. A quarterly MDS, with an ARD of 07/18/2024, revealed Resident #15 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. Resident #6's SS note, dated 10/03/2024 at 11:00 AM, revealed SS notified nursing staff and the Director of Nursing (DON) that Resident #6 had increased sexual behaviors and inappropriate comments toward staff and other residents. Resident #6's IDT [Interdisciplinary Team]: Behavioral Health Evaluation, dated 10/04/2024, revealed the resident had a history of inappropriate sexual behavior. Resident #6's psychiatry follow-up note, dated 10/08/2024, revealed the resident was seen for a chief complaint of sexually inappropriate behaviors. According to the note, on 08/09/20224, Resident #6 exhibited sexually inappropriate gestures and comments towards a hospice CNA. The note indicated Resident #6 was sent to a behavioral health unit on 09/03/2024 as the resident grabbed the wheelchair of a resident of the opposite sex and would not let the resident go further in their wheelchair. Per the note, a couple of days after 09/11/2024, the resident began to make sexual remarks to CNAs and other residents. According to the note, while Resident #6 was on one-to-one supervision, on 09/18/2024, the resident made inappropriate sexual remarks to another resident of the opposite sex. Per the note, on 10/03/2024, Resident #6 was transferred to a behavioral health unit after they was found masturbating in the doorway of a resident of the opposite sex room (Resident #2). Per the note, Resident #6 returned to the facility on [DATE]. The note revealed that during the visit, the nurse practitioner explained to the resident that their behaviors were inappropriate and would not be tolerated in the facility. Per the note, Resident #6 was very aware of their behaviors, but claimed to forget what happened. Per the note, the resident was able to make decisions regarding their healthcare and living situation and expressed to the Social Services Director (SSD) that they no longer wanted to live in the nursing home and requested to be transferred to an assisted living, group home, or apartment. The note indicated the resident was ambulatory with a walker and able to move around the facility without difficulty. According to the note, Resident #6 should be kept from residents of the opposite sex as they were very aware of their behaviors. During an interview on 11/11/2024 at 10:02 AM, the Nurse Practitioner (NP) acknowledged the information she included in the psychiatry follow-up note dated 10/08/2024, all came from the physician's progress notes. The NP stated she has seen Resident #6 at the request of the social worker four times since the resident admitted to the facility. The NP stated there had no improvements in the resident's behavior and she made no medication changes because the facility sent the resident out for evaluation. A quarterly MDS, with an ARD of 09/22/2024, revealed the facility admitted Resident #2 on 01/06/2023. The MDS revealed Resident #2 had a BIMS score of 14, which indicated the resident had intact cognition. Resident #6's Progress Notes with a date of service 10/16/2024, revealed nursing reported that since Resident #6 returned from the behavioral health unit, the resident had less hypersexual behaviors, but still made inappropriate comments. Per the Progress Note, nursing had to watch Resident #6 closely because the resident kept sitting next to residents of the opposite sex in the common area, particularly those residents who had cognitive impairment and did not rebuke them. An Admission Record revealed the facility admitted Resident #7 on 10/17/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, neurocognitive disorder with Lewy bodies, hallucinations, and anxiety disorder. The facility's five-day report dated 10/25/2024, revealed on 10/18/2024 around 4:45 PM, LPN #9 observed Resident #7 seated on the toilet fully clothed in the bathroom of Resident #6. Per the report, Resident #6 stood in front of Resident #7, with their pants and incontinence brief down around their ankles, while they faced Resident #7 with their genitalia in their right hand. According to the note, LPN #6 and the DON entered the room and observed the same. Per the note, LPN #6 instructed Resident #6 to pull up their pants and incontinence brief and leave the bathroom. The note revealed LPN #6 assisted Resident #7 from the toilet, placed the resident into their wheelchair and removed the resident from the bathroom. The note indicated both residents were placed on one-to-one supervision and the police, the Medical Director, and the families of both residents were called. According to the note, Resident #7 did not have any apparent injuries to their face, their face was dry, and all their clothing was on correctly and not shuffled. The note indicated Resident #7 was not able to give any description of what occurred. The report indicated that upon conclusion of the investigation, while the facility was unable to substantiate sexual contact, it was determined that Resident #6 committed indecent exposure to a vulnerable person, Resident #7. Resident #6's nursing skilled note dated 10/18/2024 at 11:45 PM, revealed the resident was asked by a CNA if they understood what they done wrong and Resident #6 replied, Yes, I wanted [him/her] to suck it. During an interview on 10/28/2024 at 2:00 PM, the SSD stated Resident #7 was at the facility for a five-day respite, and the facility was aware the resident wandered. During an interview on 10/28/2024 at 3:38 PM, LPN #6 stated she heard a CNA say that he could not locate Resident #7. LPN #6 stated she looked in the resident's room and when she could not find the resident, she initiated a code so that staff would stop what they were doing and look for the resident. LPN #6 stated LPN #8 went into Resident #6's room and yelled for her as she walked by. According to LPN #6, Resident #7 was observed sitting on the toilet and she immediately told Resident #6 to pull up their pants up and leave the bathroom. Per LPN #6, she assessed Resident #7 and found the resident's clothing was not disturbed and their face was dry. During an interview on 10/28/2024 at 4:05 PM, CNA #8 stated Resident #7 wandered around the facility and went into other residents' rooms. CNA #8 stated he saw Resident #7 when he came on shift; however, when he rounded, he could not locate the resident. CNA #8 stated the facility called a code and staff found Resident #7 in Resident #6's room. During an interview on 10/28/2024 at 4:24 PM, LPN #9 stated as she looked for Resident #7, when she went into Resident #6's room, the bathroom door was closed. LPN #9 stated she found Resident #7 fully clothed and Resident #6 was naked from the waist down. According to LPN #9, staff had Resident #6 pull up their pants and escorted out of the room to a safe location. During an interview on 10/29/2024 at 2:15 PM, the DON stated she assisted when the code was called to look for Resident #7. According to the DON, the nurses handled the situation and she called the police. According to the DON, Resident #6 had behaviors/inappropriate comments, but she did not think the resident was dangerous. During an interview on 11/12/2024 at 2:05 PM, the surveyor reviewed each of the incidents that involved Resident #6 and the interim Administrator stated the only incident that was reported was the incident on 10/18/2024 as she did not think the other incidents were abuse as the other residents involved were hard of hearing or there were no signs that abuse occurred. The interim Administrator stated it was just part of living in the nursing home and since Resident #6 never exposed themselves, she did not consider the incidents as abuse. On 11/18/2024 at 6:47 AM, a removal plan was submitted by the facility and accepted by the state survey agency. It read as follows: Removal Plan F600 1. The facility will ensure residents are free from abuse, neglect, and exploitation. The facility will ensure interventions are implemented to prevent abuse involving resident-to-resident interactions and altercations for Resident #2, Resident #3, Resident #7, Resident #8, Resident #15, and Resident #9, and any other allegations of abuse. Residents in the facility are at risk and have the potential to be affected. Resident #6 is currently on 1:1, which began 10/18/2024, and remains on 1:1. Resident #6's care plan was updated to reflect the 1:1, and the facility is working on permanent housing out in the community with assistance from a local social services organization. A thirty-day discharge notice was issued to Resident #6 on 11/01/2024. Behavioral health services are following resident #6. Resident #6 was moved to a private room on 10/08/2024. Residents #7 and Resident #8 are no longer in the facility. Residents #2, #3, #9, and #15 were seen by behavioral health services on 11/16/2024 and visits have been completed, with no adverse outcome noted. Skin checks were performed on all female residents on 11/14/2024, along with all male residents on 11/15/2024, who were non-interviewable with no negative outcomes. Social Services performed psychosocial checks on Residents #2, #3, #9, and #15 on 11/14/2024 with no negative outcome. 2. Current staff and contracted staff (all departments) were educated by Administrator, Director of Nursing (DON), and Unit Manager (UM) on 11/13/2024. The members of the governing body (Corporate Regional Director of Clinical Services) educated the DON and the Administrator on 11/13/2024. The DON educated the UMs on 11/13/2024. The UMs educated current and contracted staff 11/13/2024. Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift. Ninety-nine percent (99%) of staff have been educated for current and contracted staff. The DON, the Administrator, and UM will educate the remaining staff who have not been educated prior to returning to work (all departments). Education was provided on the following: Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident safety. One as needed (PRN) staff member has not been educated on the policies and cannot work until education is provided. New hires will receive the abuse and neglect education upon hire. Education will be provided to employees, contract staff, and any new hires prior to working (all departments). 3. The governing body member Regional Director of Clinical Services and the Regional Directors of Operations (via phone) completed the education of abuse and neglect on 11/15/2024 with DON, Interim Administrator, Nurse Practitioner (NP), and Medical Director (MD). 4. The Administrator, DON, and/or UM were educated on the 24-hr reports and risk management reports and the Administrator and/or DON to ensure immediate interventions. The Administrator and DON were trained on this process by the Regional Clinical Director on 11/13/2024 and UM were trained by the DON on 11/13/2024. 5. The Administrator and/or DON will ensure immediate interventions are implemented with every occurrence and/or allegation of abuse and neglect to ensure resident safety and protection. Allegations of abuse & neglect will be reported timely to the state agencies as applicable (police, Ombudsman, physician, family). 6. An AD HOC [a Latin term used as a shorthand phrase for as or when needed] QAPI [quality assurance and performance improvement] meeting was conducted on 11/15/2024 with Administrator, DON, Regional Director of Clinical Services, Medical Director, and Nurse Practitioner. 7. The Medical Director and Nurse Practitioner were made aware on 11/15/2024?and agree with the immediate jeopardy removal plan. 8. Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident safety were reviewed on 11/13/2024 and no changes were made. 9. All corrections were completed on 11/15/2024. 10. The immediacy of the IJ was removed on 11/16/2024. On 11/18/2024, the survey team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. Observations conducted from 11/12/2024 to 11/18/2024, revealed Resident #6 was on 1:1 supervision. Review of the resident's medical record revealed Resident #6's care plan had been updated and facility staff worked to find alternate placement for the resident. 2. Review of facility documentation revealed facility staff, to include the Administrator, DON, NP, and MD, were educated about abuse on 11/13/2024 and interviews with staff revealed no concerns related to their understanding of abuse. Documentation further indicated the Administrator, DON, NP, and MD were educated on the 24-hour and risk management reports. Interviews with the staff revealed no concerns related to their understanding of the 24-hour and risk managements reports. 3. Review of the facility documentation revealed an AD HOC QAPI meeting was conducted on 11/15/2024. 4. Interview conducted with the MD and NP revealed their understanding of the facility's removal plan and no concerns were identified. 5. Review of the facility's abuse policies and procedures were conducted and revealed no changed had been made to the facility's policies and procedures.

Based on interview, record review, and facility policy review, the facility failed to report allegations of abuse to the state survey agency. On 08/09/2024, Resident #6 was found standing over the bed of Resident #8, a cognitively impaired resident, with their genitals in their hand and expressed inappropriate sexual gestures and comments. On 09/03/2024, Resident #6 grabbed the wheelchair of Resident #10 and prevented Resident #10 from moving about in their wheelchair. On 09/18/2024, Resident #6 voiced inappropriate sexual comments to Resident #9 as Resident #9 straightened their shirt. On 10/03/2024, Resident #6 was found masturbating in the doorway of Resident #2's room. These deficient practices affected 4 (Residents #2, #8, #9, and #10) of 15 sampled residents reviewed for abuse. It was determined that the provider's non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F609, at a scope and severity of K. The IJ began on 08/09/2024, when the facility failed to report an allegation of abuse to the state survey agency when Resident #6 expressed inappropriate sexual gestures and comments as they were found standing over the bed of Resident #8. On 11/15/2024 at 1:25 PM, the interim Administrator and Director of Nursing (DON) were informed of the IJ situation and provided a completed IJ template. A removal plan was requested. An approved Credible Allegation of Compliance was received on 11/17/2024. Based on the validation of the Credible Allegation of Compliance, the State Survey Agency determined the deficient practice was corrected on 11/15/2024 and the immediacy of the IJ being removed on 11/16/2024. Findings included: A facility policy titled, F607 F609 Abuse Program: Training, Reporting and Response, Covered Individual Responsibilities effective 08/2024, indicated, The facility, through the Administrator or their designee, will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property the results of all investigations to the proper authorities within prescribed time frames. An Admission Record revealed the facility admitted Resident #6 on 07/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, hypertension, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #6's care plan, included a focus area initiated 08/13/2024, that indicated the resident sometimes had behaviors which included sexually inappropriate language to staff, grabbed staff, and made sexual comments and sexual gestures. Interventions directed to staff to administer medications as the doctor ordered (initiated 08/13/2024), attempt interventions before the behaviors began (initiated 08/13/2024), provide care in pairs (initiated 08/14/2024), and refer the resident for psychiatric services as needed (initiated 08/13/2024). Resident #6's nursing progress note, dated 08/09/2024 at 4:08 PM, revealed Resident #6 was found in a resident (Resident #8) of the opposite sex's room. According to the nursing progress note, when the roommate (Resident #3) of the resident (Resident #8) informed Resident #6 that the resident (Resident #8) was deaf, Resident #6 replied that is alright, we can still feel our way around and proceeded to grab their genital area. An Admission Record revealed the facility admitted Resident #3 on 05/16/2023. According to the Admission Record, the resident had a medical history that included diagnoses of heart failure and muscle weakness. A quarterly MDS, with an ARD of 08/08/2024, revealed Resident #3 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. An Admission Record revealed the facility admitted Resident #8 on 06/30/2023. According to the Admission Record, the resident had a medical history to include diagnoses of hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cognitive communication deficit, functional quadriplegia, and contracture of the right upper arm and right lower leg. A quarterly MDS, with an ARD of 07/01/2024, revealed Resident #8 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. During an interview on 11/16/2024 at 2:10 PM, Resident #3 stated they recalled when Resident #6 came into their room and stood by Resident #8's bed. According to Resident #3, they yelled for help and asked staff to remove Resident #6 from their room. Resident #3 stated when they informed Resident #6 that Resident #8 was deaf, Resident #6 stated some bad things. Per Resident #3, Resident #6 stated we can feel our way around and then grabbed their private parts. Resident #6's nursing progress note, dated 09/03/2024 at 11:10 AM, revealed Resident #6 grabbed the wheelchair of a resident of the opposite sex (Resident #10) and would not let the resident continue further in their wheelchair. Per the progress note, Resident #6 was assisted back to their room and placed on 1:1 observation. A quarterly MDS, with an ARD of 07/10/2024, revealed the facility admitted Resident #10 on 03/12/2024. According to the MDS, the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #10 had active diagnoses to include stroke and hemiplegia or hemiparesis. During an interview on 11/12/2024 at 11:24 AM, Licensed Practical Nurse (LPN) #13 stated on 09/03/2024, Resident #3 hollered for her to come to their room. According to LPN #13, Resident #6 had come into Resident #3 and Resident #8's room. LPN #13 stated when she entered the room, Resident #6 was leaned over Resident #8's bed. LPN #13 stated she did not know how long Resident #6 had been in Resident #8's room. LPN #13 stated also on 09/03/2024, as Resident #6 was in the hallway, the resident grabbed the wheelchair of Resident #10 and prevented Resident #10 from going forward. According to LPN #13, after this incident, Resident #6 was placed on 1:1 until the resident was transferred to a behavioral health facility on 09/04/2024. Resident #6's nursing skilled note dated 09/18/2024 at 12:30 PM, revealed as a resident of the opposite sex (Resident #9) was straightening their shirt, Resident #6 told the resident, let me see it all, lean over so I can see them [breasts], and I can tell by your mouth, you nasty. An Admission Record revealed the facility admitted Resident #9 on 05/31/2019. According to the Admission Record, the resident had a medical history to include diagnoses of type 2 diabetes mellitus, lack of coordination, muscle weakness, dementia, and cognitive communication deficit. A quarterly MDS, with an ARD of 09/23/2024, revealed Resident #9 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had moderate difficulty with hearing and usually understood others. During an interview on 11/12/2024 at 11:24 AM, LPN #13 stated as Resident #9 sat on their bed and repositioned their shirt, Resident #6 made some very inappropriate sexual comments to Resident #9. According to LPN #13, Resident #9 was very hard of hearing and did not hear anything Resident #6 stated. LPN #13 stated she reported the incident to the Administrator, as the staff was to report all allegations immediately to the Abuse Coordinator, who was the Administrator or call the Director of Nursing. Resident #6's psychiatry follow-up note, dated 10/08/2024, revealed the resident was seen for a chief complaint of sexually inappropriate behaviors. According to the note, on 08/09/20224, Resident #6 exhibited sexually inappropriate gestures and comments towards a hospice CNA. The note indicated Resident #6 was sent to a behavioral health unit on 09/03/2024 as the resident grabbed the wheelchair of a resident of the opposite sex and would not let the resident go further in their wheelchair. Per the note, a couple of days after 09/11/2024, the resident began to make sexual remarks to CNAs and other residents. According to the note, while Resident #6 was on one-to-one supervision, on 09/18/2024, the resident made inappropriate sexual remarks to another resident of the opposite sex. Per the note, on 10/03/2024, Resident #6 was transferred to a behavioral health unit after they was found masturbating in the doorway of a resident of the opposite sex room (Resident #2). Per the note, Resident #6 returned to the facility on [DATE]. The note revealed that during the visit, the nurse practitioner explained to the resident that their behaviors were inappropriate and would not be tolerated in the facility. Per the note, Resident #6 was very aware of their behaviors, but claimed to forget what happened. Per the note, the resident was able to make decisions regarding their healthcare and living situation and expressed to the Social Services Director (SSD) that they no longer wanted to live in the nursing home and requested to be transferred to an assisted living, group home, or apartment. The note indicated the resident was ambulatory with a walker and able to move around the facility without difficulty. According to the note, Resident #6 should be kept from residents of the opposite sex as they were very aware of their behaviors. A quarterly MDS, with an ARD of 09/22/2024, revealed the facility admitted Resident #2 on 01/06/2023. The MDS revealed Resident #2 had a BIMS score of 14, which indicated the resident had intact cognition. During an interview on 11/12/2024 at 2:05 PM, the surveyor reviewed each of the incidents that involved Resident #6 and the interim Administrator stated the only incident that was reported was the incident on 10/18/2024 as she did not think the other incidents were abuse as the other residents involved were hard of hearing or there were no signs that abuse occurred. The interim Administrator stated as she looked back on each of the incidents, she could now see how the other incidents should have been reported. During an interview on 11/14/2024 at 11:01 AM, the DON stated the only incident that was reported to the state survey agency was the incident that occurred on 10/18/2024 between Resident #6 and Resident #7. On 11/18/2024 at 6:47 AM, a removal plan was submitted by the facility and accepted by the state survey agency. It read as follows: Removal Plan F609 1. The facility will ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment are reported to the state survey agency and all other state agencies that are applicable (police department, Ombudsman, physician, family, guardians) within the required time frame. Reporting to state immediately but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. [The residents] had full body skin assessments, and all other [male/female] residents were completed as well, on 11/14/2024. Visits by the social worker for psychosocial wellbeing for [the residents] related to allegations of abuse were completed on 11/14/2024 with no negative outcomes noted. [The residents] have been seen by behavioral health services with no adverse outcomes noted. Resident #8 is no longer residing in the facility. Residents in the facility are at risk and have the potential to be affected. The incidents with [the residents] were reported to the state agency on 11/15/2024 and were investigated. 2. Current facility staff and contracted facility staff (all departments) were educated by the Unit Managers (UM) on 11/13/2024?on the following: Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident protection. The members of the governing body (Corporate Regional Director of Clinical Services) educated the Director of Nursing (DON) and Administrator on 11/13/2024. The DON educated the Unit Managers on 11/13/2024, and the Unit Managers educated current and contracted staff on 11/13/2024. Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift. Ninety-nine percent (99%) of staff have been educated for current and contracted staff. The DON, Administrator, and Unit Managers will educate remaining staff who have not been educated prior to returning to work (all departments). 3. The Administrator, Interim Administrator, DON, Nurse Practitioner (NP), and Medical Director completed the education on abuse and neglect by the Regional Director of Clinical Services on 11/15/2024. 4. The Administrator, DON, and/or Unit Manager will review 24-hr reports and risk management reports Mondays through Fridays. The Registered Nurse (RN) supervisor will review 24-hour reports and incident reports on Saturdays and Sundays and report any unusual occurrences immediately to the Administrator. The Administrator and DON were trained on this process by the Regional Clinical Director on 11/15/2024 and the UMs were trained by the DON on 11/15/2024. 5. An AD HOC [a Latin term used as a shorthand phrase for as or when needed] Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 11/15/2024 with the Administrator, DON, Regional Director of Clinical Services, Medical Director, and NP. Discussed were the Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect which include identification of abuse, appropriate interventions in the event of alleged abuse and resident protection. The agenda also included potential IJ removal plan, residents that were affected, and interventions to prevent future occurrences. 6. The Medical Director and Nurse Practitioner were made aware on 11/15/2024 and agrees with the immediate jeopardy removal plan. 7. Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect were reviewed on 11/15/2024 and no changes were made. 8. All corrections were completed on 11/15/2024. 9. The immediacy of the IJ was removed on 11/16/2024. On 11/18/2024, the survey team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. Review of facility documentation revealed the facility notified the state survey agency of the allegations of abuse on 11/15/2024. 2. Review of facility documentation revealed facility staff were educated about abuse reporting on 11/13/2024 and interviews with staff revealed no concerns related to their understanding of the requirements to report allegations of abuse. 3. Review of facility documentation revealed the Administrator, interim Administrator, DON, NP, and MD were educated the requirements to report abuse on 11/15/2024. Interviews with the staff revealed no concerns related to their understanding of the requirements to report allegations of abuse. 4. Review of the facility documentation revealed an AD HOC QAPI meeting was conducted on 11/15/2024. 5. Interviews conducted with the MD and NP revealed their understanding of the facility's removal plan and no concerns were identified. 6. Review of the facility's abuse policies and procedures were conducted and revealed no changed had been made to the facility's policies and procedures.

Based on interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate an allegation of sexual abuse perpetrated by a resident. Specifically, on 10/18/2024, when staff were unable to located Resident #7, a cognitively impaired resident who wandered in the facility, staff initiated a search and found Resident #7 in Resident #6's bathroom seated on the toilet. Resident #6, who had a history of sexually inappropriate behavior, stood in front of Resident #7 unclothed from the waist down with their genitals in their hand. Furthermore, the facility failed to investigate allegation of verbal, sexual, and physical abuse perpetrated by a resident and implement effective measures to prevent further abuse by a resident, Resident #6, who repeatedly exhibited inappropriate sexual aggressive behaviors. Specifically, on 08/09/2024, Resident #6 was found standing over the bed of Resident #8, a cognitively impaired resident, with their genitals in their hand and expressed inappropriate sexual gestures and comments. On 09/03/2024, Resident #6 grabbed the wheelchair of Resident #10 and prevented Resident #10 from moving about in their wheelchair. On 09/18/2024, Resident #6 voiced inappropriate sexual comments to Resident #9 as Resident #9 straightened their shirt. On 10/03/2024, Resident #6 was found masturbating in the doorway of Resident #2's room. These deficient practices affected 5 (Residents #2, #7, #8, #9, and #10) of 15 sampled residents reviewed for abuse. It was determined that the provider's non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F609, at a scope and severity of K. The IJ began on 08/09/2024, when the facility failed to investigate an allegation of abuse to the state survey agency when Resident #6 expressed inappropriate sexual gestures and comments as they were found standing over the bed of Resident #8. On 11/15/2024 at 1:25 PM, the interim Administrator and Director of Nursing (DON) were informed of the IJ situation and provided a completed IJ template. A removal plan was requested. An approved Credible Allegation of Compliance was received on 11/17/2024. Based on the validation of the Credible Allegation of Compliance, the State Survey Agency determined the deficient practice was corrected on 11/15/2024 and the immediacy of the IJ being removed on 11/16/2024. Findings included: A facility policy titled, F607 Abuse Prevention Program, Investigation F600, F602, F603, F610 last revised 08/2022, indicated, Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The policy specified, Guidelines 1. Should an incident or suspected incident of resident abuse, mistreatment, misappropriation, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors, as able or as appropriate to the situation; h. Review all events leading up to the alleged incident. Per the policy, 15. Inquires concerning abuse reporting and investigation should be refereed to the Administrator or to the Director of Nursing Services. An Admission Record revealed the facility admitted Resident #6 on 07/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, hypertension, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #6's care plan, included a focus area initiated 08/13/2024, that indicated the resident sometimes had behaviors which included sexually inappropriate language to staff, grabbed staff, and made sexual comments and sexual gestures. Interventions directed to staff to administer medications as the doctor ordered (initiated 08/13/2024), attempt interventions before the behaviors began (initiated 08/13/2024), provide care in pairs (initiated 08/14/2024), and refer the resident for psychiatric services as needed (initiated 08/13/2024). Resident #6's nursing progress note, dated 08/09/2024 at 4:08 PM, revealed Resident #6 was found in a resident (Resident #8) of the opposite sex's room. According to the nursing progress note, when the roommate (Resident #3) of the resident (Resident #8) informed Resident #6 that the resident (Resident #8) was deaf, Resident #6 replied that is alright, we can still feel our way around and proceeded to grab their genital area. An Admission Record revealed the facility admitted Resident #3 on 05/16/2023. According to the Admission Record, the resident had a medical history that included diagnoses of heart failure and muscle weakness. A quarterly MDS, with an ARD of 08/08/2024, revealed Resident #3 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. An Admission Record revealed the facility admitted Resident #8 on 06/30/2023. According to the Admission Record, the resident had a medical history to include diagnoses of hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cognitive communication deficit, functional quadriplegia, and contracture of the right upper arm and right lower leg. A quarterly MDS, with an ARD of 07/01/2024, revealed Resident #8 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. During an interview on 11/16/2024 at 2:10 PM, Resident #3 stated they recalled when Resident #6 came into their room and stood by Resident #8's bed. According to Resident #3, they yelled for help and asked staff to remove Resident #6 from their room. Resident #3 stated when they informed Resident #6 that Resident #8 was deaf, Resident #6 stated some bad things. Per Resident #3, Resident #6 stated we can feel our way around and then grabbed their private parts. Resident #6's nursing progress note, dated 09/03/2024 at 11:10 AM, revealed Resident #6 grabbed the wheelchair of a resident of the opposite sex (Resident #10) and would not let the resident continue further in their wheelchair. Per the progress note, Resident #6 was assisted back to their room and placed on 1:1 observation. A quarterly MDS, with an ARD of 07/10/2024, revealed the facility admitted Resident #10 on 03/12/2024. According to the MDS, the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #10 had active diagnoses to include stroke and hemiplegia or hemiparesis. During an interview on 11/12/2024 at 11:24 AM, Licensed Practical Nurse (LPN) #13 stated on 09/03/2024, Resident #3 hollered for her to come to their room. According to LPN #13, Resident #6 had come into Resident #3 and Resident #8's room. LPN #13 stated when she entered the room, Resident #6 was leaned over Resident #8's bed. LPN #13 stated she did not know how long Resident #6 had been in Resident #8's room. LPN #13 stated also on 09/03/2024, as Resident #6 was in the hallway, the resident grabbed the wheelchair of Resident #10 and prevented Resident #10 from going forward. According to LPN #13, after this incident, Resident #6 was placed on 1:1 until the resident was transferred to a behavioral health facility on 09/04/2024. Resident #6's nursing skilled note dated 09/18/2024 at 12:30 PM, revealed as a resident of the opposite sex (Resident #9) was straightening their shirt, Resident #6 told the resident, let me see it all, lean over so I can see them [breasts], and I can tell by your mouth, you nasty. An Admission Record revealed the facility admitted Resident #9 on 05/31/2019. According to the Admission Record, the resident had a medical history to include diagnoses of type 2 diabetes mellitus, lack of coordination, muscle weakness, dementia, and cognitive communication deficit. A quarterly MDS, with an ARD of 09/23/2024, revealed Resident #9 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had moderate difficulty with hearing and usually understood others. During an interview on 11/12/2024 at 11:24 AM, LPN #13 stated as Resident #9 sat on their bed and repositioned their shirt, Resident #6 made some very inappropriate sexual comments to Resident #9. According to LPN #13, Resident #9 was very hard of hearing and did not hear anything Resident #6 stated. LPN #13 stated she reported the incident to the Administrator, as the staff was to report all allegations immediately to the Abuse Coordinator, who was the Administrator or call the Director of Nursing. During an interview on 11/16/2024 at 11:05 AM, LPN #6 stated abuse could be many things such as physical, sexual, and verbal to name a few. LPN #6 stated if a resident said something that was inappropriate or mean, it could be considered verbal abuse. Resident #6's skilled note, dated 10/01/2024 at 11:52 AM, revealed the resident was noted to have inappropriate behaviors towards opposite sex staff and residents. The skilled note indicated Resident #6 told a female staff member to come to their bed and told a resident of the opposite sex (Resident #15) that I got to put it somewhere. Per the skilled note, staff continued to redirect Resident #6 away from residents of the opposite sex and moved residents of the opposite sex from Resident #6. An Admission Record revealed the facility admitted Resident #15 on 01/19/2021. According to the Admission Record, the resident had a medical history to include diagnoses of dementia, altered mental status, and muscle weakness. A quarterly MDS, with an ARD of 07/18/2024, revealed Resident #15 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. Resident #6's psychiatry follow-up note, dated 10/08/2024, revealed the resident was seen for a chief complaint of sexually inappropriate behaviors. According to the note, on 08/09/20224, Resident #6 exhibited sexually inappropriate gestures and comments towards a hospice CNA. The note indicated Resident #6 was sent to a behavioral health unit on 09/03/2024 as the resident grabbed the wheelchair of a resident of the opposite sex and would not let the resident go further in their wheelchair. Per the note, a couple of days after 09/11/2024, the resident began to make sexual remarks to CNAs and other residents. According to the note, while Resident #6 was on one-to-one supervision, on 09/18/2024, the resident made inappropriate sexual remarks to another resident of the opposite sex. Per the note, on 10/03/2024, Resident #6 was transferred to a behavioral health unit after they was found masturbating in the doorway of a resident of the opposite sex room (Resident #2). Per the note, Resident #6 returned to the facility on [DATE]. The note revealed that during the visit, the nurse practitioner explained to the resident that their behaviors were inappropriate and would not be tolerated in the facility. Per the note, Resident #6 was very aware of their behaviors, but claimed to forget what happened. Per the note, the resident was able to make decisions regarding their healthcare and living situation and expressed to the Social Services Director (SSD) that they no longer wanted to live in the nursing home and requested to be transferred to an assisted living, group home, or apartment. The note indicated the resident was ambulatory with a walker and able to move around the facility without difficulty. According to the note, Resident #6 should be kept from residents of the opposite sex as they were very aware of their behaviors. A quarterly MDS, with an ARD of 09/22/2024, revealed the facility admitted Resident #2 on 01/06/2023. The MDS revealed Resident #2 had a BIMS score of 14, which indicated the resident had intact cognition. An Admission Record revealed the facility admitted Resident #7 on 10/17/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, neurocognitive disorder with Lewy bodies, hallucinations, and anxiety disorder. The facility's five-day report dated 10/25/2024, revealed on 10/18/2024 around 4:45 PM, LPN #9 observed Resident #7 seated on the toilet fully clothed in the bathroom of Resident #6. Per the report, Resident #6 stood in front of Resident #7, with their pants and incontinence brief down around their ankles, while they faced Resident #7 with their genitalia in their right hand. According to the note, LPN #6 and the DON entered the room and observed the same. Per the note, LPN #6 instructed Resident #6 to pull up their pants and incontinence brief and leave the bathroom. The note revealed LPN #6 assisted Resident #7 from the toilet, placed the resident into their wheelchair and removed the resident from the bathroom. The note indicated both residents were placed on one-to-one supervision and the police, the Medical Director, and the families of both residents were called. According to the note, Resident #7 did not have any apparent injuries to their face, their face was dry, and all their clothing was on correctly and not shuffled. The note indicated Resident #7 was not able to give any description of what occurred. The report indicated that upon conclusion of the investigation, while the facility was unable to substantiate sexual contact, it was determined that Resident #6 committed indecent exposure to a vulnerable person, Resident #7. The facility five-day report failed to show the incidents the events that lead to Resident #7 being found in Resident #6's bathroom and/or interviews with staff from all shifts. Resident #6's nursing skilled note dated 10/18/2024 at 11:45 PM, revealed the resident was asked by a CNA if they understood what they done wrong and Resident #6 replied, Yes, I wanted [him/her] to suck it. During an interview on 11/12/2024 at 2:05 PM, the surveyor reviewed each of the incidents that involved Resident #6. The interim Administrator stated the only incident that was reported was the incident on 10/18/2024 as she did not think the other incidents were abuse as the other residents involved were hard of hearing or there were no signs that abuse occurred. The interim Administrator stated as she looked back on each of the incidents, she could now see how the other incidents should have been reported and investigated. On 11/18/2024 at 6:47 AM, a removal plan was submitted by the facility and accepted by the state survey agency. It read as follows: Removal Plan F610 1. The facility will ensure that all alleged violations of abuse, neglect, exploitation, and mistreatment are appropriately investigated and reported to state agencies. All residents have the potential to be affected. On 11/15/2024 incidents involving [the residents] have been reported to the state and investigations started, skin assessments, and incident reports made. 2. Current facility staff and contracted staff (all departments) were educated by the nursing administration staff on the Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, education on behaviors and on documentation of behaviors and interventions in the electronic medical records, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident protection from abuse. New hires will receive the abuse and neglect education, and procedure and protocol upon hire. Education will be provided to employees, contract staff, and any new hires prior to working. Completion date 11/13/2024. A member of the governing body (Regional Director of Clinical Services) educated the Director of Nursing (DON), and Interim Administrator on 11/13/2024. A member of the governing body (Regional Director of Clinical Services) educated the DON, Interim Administrator, Medical Director, Nurse Practitioner (NP) and Administrator on 11/15/2024 for Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, education on behaviors and on documentation of behaviors and interventions in the electronic medical records, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect, which include identification of abuse, appropriate interventions in the event of alleged abuse and resident protection from abuse .The DON educated the Unit Managers, and the Unit Managers educated current and contracted staff. Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift. Ninety- nine percent 99% of staff have been educated for current and contracted staff. The DON, Administrator, and Unit Manager will educate remaining staff who have not been educated prior to returning to work (all departments). 3. The Interim Administrator, Administrator, DON, NP, and the Medical Director completed the education on abuse and neglect and reporting of abuse and resident protection by the Regional Director of Clinical Services on 11/15/2024. Completion date 11/15/2024 4. An AD HOC [a Latin term used as a shorthand phrase for as or when needed] QAPI [Quality Assurance and Performance Improvement] meeting was conducted on 11/15/2024 with the Administrator, DON, Regional Director of Clinical Services, Medical Director, and Nurse Practitioner to discuss the IJ and Removal Plan. 5. The Medical Director and Nurse Practitioner were made aware on 11/15/2024 and agree with the immediate jeopardy removal plan. 6. All corrections were completed on 11/15/2024. 7. The immediacy of the IJ was removed on 11/16/2024. On 11/18/2024, the survey team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. Review of facility documentation revealed the facility notified the state survey agency of the allegations of abuse on 11/15/2024 and began to conduct their investigations. 2. Review of facility documentation revealed facility staff were educated about abuse on 11/13/2024 and interviews with staff revealed no concerns related to their understanding of abuse prohibition. 3. Review of facility documentation revealed the Administrator, interim Administrator, DON, NP, and MD were educated the requirements to complete an investigation for all allegations of abuse on 11/15/2024. Interviews with the staff revealed no concerns related to their understanding of the requirements to conduct abuse investigations. 4. Review of the facility documentation revealed an AD HOC QAPI meeting was conducted on 11/15/2024. 5. Interviews conducted with the MD and NP revealed their understanding of the facility's removal plan and no concerns were identified.

Based on interview, record review, and facility policy review, the facility Administrator, who was responsible for the day-to-day operations of the facility, failed to provide oversight to ensure the abuse policy was implemented when a resident, with a history of sexually inappropriate behaviors, repeatedly exhibited verbal, sexual, and physical abuse towards other residents. Specifically, on 10/18/2024, when staff were unable to located Resident #7, a cognitively impaired resident who wandered in the facility, staff initiated a search and found Resident #7 in Resident #6's bathroom seated on the toilet. Resident #6, who had a history of sexually inappropriate behavior, stood in front of Resident #7 unclothed from the waist down with their genitals in their hand. Furthermore, the facility failed to investigate allegation of verbal, sexual, and physical abuse perpetrated by a resident and implement effective measures to present further abuse by a resident, Resident #6, who repeatedly exhibited inappropriate sexual aggressive behaviors. Specifically, on 08/09/2024, Resident #6 was found standing over the bed of Resident #8, a cognitively impaired resident, with their genitals in their hand and expressed inappropriate sexual gestures and comments. On 09/03/2024, Resident #6 grabbed the wheelchair of Resident #10 and prevented Resident #10 from moving about in their wheelchair. On 09/18/2024, Resident #6 voiced inappropriate sexual comments to Resident #9 as Resident #9 straightened their shirt. On 10/03/2024, Resident #6 was found masturbating in the doorway of Resident #2's room. These deficient practices affected 5 (Residents #2, #7, #8, #9, and #10) of 15 sampled residents reviewed for abuse. It was determined that the provider's non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.70 Administration, F835, at a scope and severity of K. The IJ began on 08/09/2024, when the Administrator failed to report an allegation of abuse to the state survey agency and conduct and investigation when Resident #6 expressed inappropriate sexual gestures and comments as they were found standing over the bed of Resident #8. On 11/15/2024 at 1:25 PM, the interim Administrator and Director of Nursing (DON) were informed of the IJ situation and provided a completed IJ template. A removal plan was requested. An approved Credible Allegation of Compliance was received on 11/17/2024. Based on the validation of the Credible Allegation of Compliance, the State Survey Agency determined the deficient practice was corrected on 11/15/2024 and the immediacy of the IJ being removed on 11/16/2024. Findings included: A facility policy titled, Administrator F837, last revised 08/2011, revealed Policy Statement A licensed Administrator is responsible for the day-to-day functions of the facility. Policy Interpretation and Implementation 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: a. Managing the day-to-day functions of the facility; and d. Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities. Resident record review indicated on 10/18/2024, when staff were unable to located Resident #7, a cognitively impaired resident who wandered in the facility, staff initiated a search and found Resident #7 in Resident #6's bathroom seated on the toilet. Resident #6, who had a history of sexually inappropriate behavior, stood in front of Resident #7 unclothed from the waist down with their genitals in their hand. Furthermore, on 08/09/2024, Resident #6 was found standing over the bed of Resident #8, a cognitively impaired resident, with their genitals in their hand and expressed inappropriate sexual gestures and comments. On 09/03/2024, Resident #6 grabbed the wheelchair of Resident #10 and prevented Resident #10 from moving about in their wheelchair. On 09/18/2024, Resident #6 voiced inappropriate sexual comments to Resident #9 as Resident #9 straightened their shirt. On 10/03/2024, Resident #6 was found masturbating in the doorway of Resident #2's room. (Refer to F600, F607, and F610). During an interview on 11/12/2024 at 2:05 PM, the surveyor reviewed each of the incidents that involved Resident #6. The interim Administrator stated the only incident that was reported was the incident on 10/18/2024 as she did not think the other incidents were abuse as the other residents involved were hard of hearing or there were no signs that abuse occurred. The interim Administrator stated it was just part of living in the nursing home and since Resident #6 never exposed themselves, she did not consider the incidents as abuse. The interim Administrator stated as she looked back on each of the incidents, she could now see how the other incidents should have been reported and investigated. On 11/18/2024 at 6:47 AM, a removal plan was submitted by the facility and accepted by the state survey agency. It read as follows: Removal Plan F835 1. The Governing Body will ensure facility administrative staff and facility staff receive education and can demonstrate knowledge of facility systems and competency of procedures for the prevention of abuse and neglect, abuse investigations and resident protection and safety of all residents. The Regional Director of Clinical Services provided education for Director of Administrator and Interim Administrator 11/13/2024 on the Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect. The Regional Director of Clinical Services provided education for Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect to the Administrator, Interim Administrator, Director of Nursing (DON), Nurse Practitioner (NP), and Medical Director (MD) on 11/15/2024. A member of the governing body (Regional Director of Clinical Services) educated the DON and the Administrator. The governing body member, Administrator, DON, Regional Director of Operations (via phone), Regional Director of Clinical Services reviewed the following policies, Behavior Assessment and Monitoring, Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect. The Administrator's and DON's job descriptions and education was reviewed on 11/15/2024 by the Regional Directions of Operations via phone. The DON educated the Unit Managers (UM), and the Unit Managers educated current and contracted staff. Current staff and contracted staff who have not been educated will be educated prior to their next scheduled shift. Ninety-nine percent (99%) of staff have been educated for current and contracted staff. The DON, the Administrator, and UM will educate remaining staff who have not been educated prior to returning to work (all departments). 2. The DON, UM, and the Administrator will review the 24-hr report and risk management report Mondays through Fridays found in the electronic medical records. The Registered Nurse (RN) supervisor will review the 24-hr report and risk management report found in the electronic medical records on Saturdays and Sundays and will report any unusual occurrence immediately to the Administrator. The Administrator and DON were trained on this process by the Regional Clinical Director on 11/15/2024 and the UMs were trained by the DON on 11/15/2024. 3. An AD HOC [a Latin term used as a shorthand phrase for as or when needed] QAPI [Quality Assurance and Performance Improvement] meeting was conducted on 11/15/2024 with the Administrator, DON, Regional Director of Clinical Services, Medical Director, and Nurse Practitioner. 4. The Medical Director was made aware on 11/15/2024 and agrees with the immediate jeopardy removal plan. The governing body member arrived 11/12/2024 and currently remains in facility. 5. Abuse and Neglect Policy and Procedure, When to Report Policy and Procedure, and Proper Investigation of Occurrences and Allegations of Abuse and Neglect were reviewed on 11/15/2024 and no changes were made. 6. All corrections were completed on 11/15/2024. 7. The immediacy of the IJ was removed on 11/16/2024. On 11/18/2024, the survey team conducted on-site verification to confirm the facility had implemented the above written removal plan, as follows: 1. Review of facility documentation revealed the interim Administrator, Administrator, DON, NP, and MD were educated the requirements related to the prohibition of abuse on 11/15/2024. Interviews with the staff revealed no concerns related to their understanding of the requirements to conduct abuse investigations. 2. Review of the facility documentation revealed an AD HOC QAPI meeting was conducted on 11/15/2024. 3. Interviews conducted with the MD revealed his understanding of the facility's removal plan and no concerns were identified. 4. Review of the facility's abuse policies and procedures were conducted and revealed no changed had been made to the facility's policies and procedures.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately assess the weight of one of four residents, Resident (R)#2 reviewed for nutrition. This failure could lead to an unnecessary change in diet and/or supplements provided to the resident. Findings include: Review of the October 2019 Resident Assessment Instrument [RAI] Manual showed on page K-3: Planning for Care -Height and weight measurements assist staff with assessing the resident's nutrition and hydration status by providing a mechanism for monitoring stability of weight over a period of time. The Measurement of weight is one guide for determining nutritional status. Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight. On page K-4: Definitions 5% Weight Loss in 30 Days Start with the resident's weight closest to 30 days ago and multiply it by .95 (or 95%). The resulting figure represents a 5% loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5% body weight. Review of R#2's Admission Record from the Electronic Medical Record (EMR) Profile tab showed an admitted [DATE] with medical diagnoses that included type II diabetes, chronic obstructive pulmonary disease (COPD), obesity, generalized anxiety disorder, transient cerebral ischemic attack, major depressive disorder, dementia, ulcers, and malaise. Review of the EMR Vital Signs - Weight tab showed the following recorded weights: 3/13/2023 172.1 pounds (lbs.) 3/6/2023 175.0 lbs. 2/27/2023 172.4 lbs. 2/20/2023 178.3 lbs. 2/13/2023 172.5 lbs. 2/6/2023 182.1 lbs. Review of R #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 3/28/2023 showed R#2 was coded as a significant weight loss (5% in 30 days or 10% in 180 days) and not on a physician prescribed weight loss program. The weight recorded on the MDS was the 3/13/2023 weight. However, the weight for the 30 days (172.5 lbs.) was only a 0.4-pound difference and did not equate to a significant weight loss. During an interview on 6/20/2023 at 1:00 p.m., the MDS Coordinator stated, I went back to the 2/6/2023 weight and not the 2/13/2023 weight which would have been 30 days. Further stated, Yes, this was coded incorrectly.

Based on record review, family interview, staff interviews, and review of the facility policy titled, Advance Directives Policy the facility failed to ensure Code Status was correct for one of four Residents (R) #26 reviewed for Advance Directives/Code Status. Specifically, R#26's code status documentation in the resident's Electronic Medical Record (EMR) indicated the resident was full code initiate Cardiopulmonary Resuscitation (CPR.) However, documentation signed prior to admission indicated DNR (Do Not Resuscitate). Findings include: Review of the facility's policy titled, Advance Directives Policy dated ,d+[DATE] read, in pertinent part, Advance directive will be respected in accordance with state and federal law and facility policy; and. The resident has the right to formulate an advanced directive. Guidance 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to made decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; and 4. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident and/or his/her family members, about the existence of any written advance directives. 5. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 6. In accordance with current . definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include but are not limited to b. Do Not Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Review of R#26's Admission Record, found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including malnutrition and type 2 diabetes. The record indicated R#26's son was her representative and her primary medical decision-maker. Review of R#26's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating (moderately cognitively impaired). Review of R#26's Active Order Set, dated [DATE] found in the EMR under the Orders tab, indicated an order for Full Code. Review of R#26's Hospice Admission Assessment, found in the EMR under the Misc. tab and dated [DATE] (two days prior to the resident's admission to the facility), indicated the resident's responsible party, her son, wished to designate R#26's Code Status as DNR. Review of R#26's Admission Telephone Orders, found in the EMR under the Misc. tab and dated [DATE], indicated an order for Pending DNR (awaiting MD signature). Review of R#26's Physician Order Report, dated [DATE] found in the EMR under the Orders tab, indicated an order initiated on [DATE] (the resident's date of admission to the facility) for R#26's Code Status to be Full Code. In addition, the Banner at the top of the resident's record in the EMR indicated the resident was Full Code. After the survey team requested information about the resident's code status on [DATE], a POLST (Physicians Orders for Life Sustaining Treatment) was uploaded into R#26's EMR under the Misc. tab. The POLST was dated [DATE], was signed by two physicians and the resident's son indicated R#26's code status was DNR. During an interview on [DATE] at 4:04 p.m., R#26's Representative stated that his mother's wish was for her code status to be DNR. He stated, Her bones won't ever handle anything like CPR. I was told her bones might snap like a toothpick and I don't want them doing that to her. During an interview on [DATE] at 1:59 p.m., the Administrator confirmed R# 26's code status order in her EMR had been incorrect from the date of her admission to the facility on [DATE] until [DATE] after the discrepancy in code status was brought to their attention by the survey team. The Administrator stated her expectation was the resident's code status should have been verified and correctly entered immediately after the resident's admission to the facility. The Administrator stated the breakdown in communication occurred when no follow up was done with R#26's son to ensure he wished for his mother to have a DNR designation related to her code status. During an interview with the Director of Nursing (DON) on [DATE] at 9:48 a.m., he confirmed his expectation was that the resident code status should be correctly entered into each resident's record.

Based on record review, staff interviews, and review of the facility policy titled, Psychotropic Drug Use Policy, the facility failed to ensure informed consents were obtained prior to the use of a psychoactive medication for two of six Residents (R) (R#1 and R#17) reviewed for psychotropic medication administration. Findings include: Review of the facility policy titled, Psychotropic Drug Use Policy revised date 10/2022 read, in pertinent part, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective and will not be used for discipline or convenience of the staff; and During the comprehensive, person centered care planning process, the resident and/or their representative should be informed of the prescribed treatment Document such in the clinical record. 1. Review of R#1's Admission Record, found in the Electronic Medical Record (EMR) under the Profile Tab, revealed the resident was admitted with diagnoses including malnutrition, history of traumatic brain injury and dementia with behavioral disturbance. Review of R#1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/22/2023, indicated a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete the assessment due to poor cognition). The assessment Section M (Medications) indicated the resident was receiving antipsychotic medications daily. Review of R#1's Active Order Set, dated 6/21/2023 and found in the EMR under the Orders Tab, indicated an order for Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth in the evening for dementia with behavioral disturbance. Review of R#1's Medication Administration Record (MAR), dated 6/1/2023 through 6/21/2023 and found in the EMR under the Orders Tab, indicated the Seroquel was being given per order. Review of R#1's EMR indicated no documentation of an informed consent had been obtained from the resident's Responsible Party (RP) for use of the Seroquel. During an interview with the Director of Nursing (DON) on 6/21/2023 at 12:02 p.m., he confirmed he was unable to locate a consent for R#1's Seroquel. He stated his expectation was consents should be in place for all psychotropic medication. 2. Review of R#17's EMR Admission Record under the Profile tab showed admission medical diagnoses that included type II diabetes, dementia, major depressive disorder, metabolic encephalopathy, altered mental status, cognitive communication deficit, dizziness, syncope and collapse. Review of R#17's EMR Orders tab showed prescriptions for aripiprazole (brand name Abilify, an atypical antipsychotic medication) 5 mg per day and bupropion (brand name Wellbutrin, an antidepressant medication) 100 mg per day, both for depression Review of R#17's EMR Misc. tab showed a consent for an antipsychotic medication signed in 2017. No consent for the psychoactive medication bupropion was found. On 6/22/2023 at 1:55 p.m. the DON provided a consent signed on 6/22/2023 for the bupropion. The DON stated, prior to today, there has been no consent for the bupropion (Wellbutrin). 28154

Based on record review, resident and staff interviews, and review of the facility policy titled, Documentation Guidelines, the facility failed to ensure a consent for the 2022 influenza vaccination season accurately reflected the wishes of the resident for one of five residents Resident (R) #7 reviewed for influenza vaccinations. This failure had the potential for facility staff to administer influenza vaccine against the wishes of the resident. Findings include: Review of the facility policy titled Documentation Guidelines, effective 4/2023, revealed under Policy Interpretation and Implementation number 6. Based upon the physician order, documentation of procedures and treatments shall include care-specific details and shall include at a minimum: d. Whether the resident refused the procedure/treatment. Review of R#7's Electronic Medical Record (EMR) undated Admission Record located under the Profile tab indicated R#7 was admitted with diagnoses including acute upper respiratory infection, and Type II diabetes mellitus with hyperglycemia. Review of R#7's of the Annual Minimal Data Set (MDS) tab in the EMR with an Assessment Reference Date (ADR) 2/3/2023 revealed the Brief Interview for Mental Status (BIMS) was a score of 11, indicating moderate cognitive impairment. Review of R#7's Medication Administration Record (MAR) for October 2022 revealed the administration of the influenza vaccine on 10/18/2022 including, documentation and monitoring for reactions for the following 48 hours. Review of R#7's Misc. tab in the EMR revealed the Informed Consent for Influenza Vaccination dated and signed on 9/14/2022 and the box checked documented that the resident did not give the facility consent to administer the influenza vaccination for the 2022 influenza season. Review of R#7's Immunization tab in the EMR, documented the resident had received the influenza vaccine every year since admission in 2017. Review of R#7's Progress Notes in the EMR dated 6/21/2023 at 8:58 p.m. revealed, Resident received the flu vaccine 10/18/2022. Asked resident today if he gave consent for the vaccine resident stated yes, it keeps [me] out of the hospital. Resident signed a consent form [dated 6/21/2023. During an interview with R#7 on 6/22/2023 at 12:35 p.m., the resident confirmed wanting the flu shot and had received the flu shot for years. He stated, yes, it keeps [me] out of the hospital. During an interview on 6/22/2023 at 12:42 p.m., the Director of Nursing (DON) contacted the nurse who gave the vaccination confirmed when the injection was administered, and R#7 did want to have the flu shot. The DON reported a conversation with R#7 confirmed the resident desired to have the flu shot and explained the documentation on the consent form was not accurate for the desires of the resident. During an interview on 6/22/2023 at 1:55 p.m., the Administrator confirmed the consent for the influenza administration for R#7 was incorrectly documented and had confirmed with R#7 that the influenza vaccination was consented in October 2022 and kept [the resident] out of the hospital.

Based on record reviews, staff and resident interviews and review of the facility policy, Care Plans - Comprehensive F656, F657, F658 the facility failed to ensure residents and responsible parties were invited to attend care plan meetings. This deficient practice affected three residents (R) (R# 1, R#3, and R#4) of four sampled residents. Findings include: A review of the facility policy, Care Plans - Comprehensive F656, F657, F658 (last revised 11/2017) Policy Interpretation and Implementation 10. Document in the resident record an explanation if the participation of the resident and their representative is determined not practicable for the development of the care plan. 1. R#1 admitted to facility on 5/23/16 and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R# 1's most recent Minimum Data Set (MDS) was a Quarterly Assessment with the Assessment Reference Date (ARD) of 11/15/21. R#1 was assessed and coded for a mental functioning level as being severely cognitively impaired. Review of the medical record for R#1 revealed no evidence of the responsible party ever being notified of any care plan meetings for this resident. R#1 had a Quarterly MDS Assessment on 6/10/21, 11/15/21, and 9/19/21 with no evidence of notification of a care plan meeting to R#1 or the responsible party for R#1. 2. R#3 initially admitted to the facility on [DATE] and then readmitted on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed the most recent MDS was a Quarterly Assessment with the ARD of 8/1/22. R#3 was assessed for a mental functioning status and was identified as severely impaired. Further review of the medical record did not reveal any evidence of the resident or the responsible party getting notification of care plan meetings. 3. R#4 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#4's most recent MDS was a Quarterly Assessment with an ARD of 8/9/22 at which time she was assessed and coded for a mental functioning level of 14 out of 15 indicating her cognitive level is intact. Further review of the medical record did not reveal any evidence of invitation to a care plan meeting for R#4 or responsible party for R#4 for the Quarterly assessment dated [DATE], Quarterly assessment dated [DATE], and Quarterly assessment dated [DATE]. During an interview with MDS Coordinator CC on 8/23/22 at 10:15 a.m., she reported that she stopped sending letters to the residents' responsible party for care plan meetings at the beginning of COVID-19. She stated that she is aware that the responsible party and the resident must be invited to the care plan meetings, but she stated that she has not documented that she contacted them either by letter, phone, or e-mail for quite some time now. She stated that she was aware that she was not notifying all the responsible party members and that she should have been doing so. It was reported that hospice representatives did attend the care plan meetings of their residents, but MDS CC did not verbalize why the responsible party or residents were not contacted to be able to attend these meeting personally or by phone. During an interview with the Administrator on 8/23/22 at 11:34 a.m., she stated the facility does conduct care plan meetings. She stated that she now understands that no family members were being notified since COVID-19 began in 2020. She thought the family members were being contacted by telephone. She agrees there is no documentation that the family members were ever contacted about the time and place of the care plan meetings. She also agreed that all the staff involved are aware the family is supposed to be called/included in the information about the care plan meetings. She confirms that she can't find any Sign-in sheets for R#1, R#3 and R#4, care plan meetings and she stated there should then be a care plan summary note in the nursing notes, but she could not find any of those either. She also stated that if the family could not be reached it should have been documented in that same care plan note. The Administrator acknowledged the system is broken and it is not in their Quality Assurance (QA) process at this time. She stated that she was not aware there was no documentation about the notification of family members, residents, or the responsible party being invited to these care plan meetings. During a follow up interview with the Administrator and the Director of Nursing (DON) on 8/23/22 at 12:09 p.m., they reported that they had searched all the records themselves and found no care plan summaries, no care plan sign-in sheets and no documentation to indicate that the residents or the responsible party had been notified of a care plan meeting since 2020. The Administrator stated that she expected the MDS coordinator and the staff to follow the policy related to care plan meetings and that the responsible party should be notified in advance of the date and time, like setting an appointment with them. They found none of this has been done since 2020 in this facility. During an interview with the MDS Coordinator CC, the DON and the Administrator on 8/23/22 at 3:11 pm, it was revealed that R#1's most recent MDS Assessment dates were: 11/15/21, 9/19/21 and 6/19/21. The MDS Coordinator CC stated that none of those three (3) MDS Assessments had care plan meeting documentation and that no family members were invited. She also confirmed that R#3 and R#4 did not have the opportunity to have input into their care plan meetings and that no family was invited to those meetings. On 8/24/22 at 9:47 a.m., during an interview with Resident #4, she was asked if she had ever been invited to a care plan meeting here at the facility and she stated that she didn't know what a care plan meeting was.

Based on observations and staff interviews, the facility failed to maintain the kitchen in a sanitary manner related to grease and food on the floor, dirt buildup on the air conditioner vents, and dirt and debris on the flour bin lid. This had the potential to effect 35 residents who received an oral diet. Findings include: During initial walk through of the kitchen on 10/12/21 beginning at 9:57 a.m. with the Dietary Manager (DM) the following concerns and sanitation issues were identified: 1. The lid on the flour bin had dirt and debris. 2. There were 4 crates (with boxes of food stored on top of the crates) covered in dirt, debris, and sticky brown substances located in the walk-in pantry. 3. There was grease built up on floor between stove and fryer as evidenced by sticky black oily substances on the floor. 4. The floor behind the stove was covered with onion peels, speckled brown substances, and a small container lid. 5. The window air conditioner vent was covered with a sticky brown substance. The DM wiped the vent with a paper towel and identified the substance on the vent as dirt. The window air conditioner unit was positioned directly in front of the stove with a pan of uncovered cornbread sitting on the stove. During an interview with the DM on 10/12/21 at 10 a.m. it was revealed that it was an oversight with not deep cleaning the kitchen floor, wiping the air conditioner vents, and maintaining cleanliness of the flour bin lid and crates. An interview on 10/14/21 at 10:23 a.m. with the Maintenance Supervisor (MS) and the Administrator revealed that both were unaware of the condition of kitchen window air conditioner vents, buildup of grease on the kitchen tiles, dirt and debris on the flour bin, and food on the floor. MS reported that the dietary staff is responsible for cleaning the exterior of the window air conditioner vent. The MS confirmed the air conditioner vent and floor was covered with grease. The Administrator confirmed that it is the kitchen staff responsibility to mop the kitchen floor and wipe the air conditioner unit vent. The Administrator stated that she had not been in the kitchen in a while. Policy for the kitchen was requested but not received.

Based on record review and staff interview, the facility failed to revise the care plan interventions to address the residents weight loss or address the Registered Dietician's recommendation of an appetite stimulant to address the weight loss for one of two residents (R#20) that experienced significant weight loss. Findings include: Record review revealed that R#20 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Activities of Daily Living (ADL) abilities as noted in her most recent quarterly Minimum Data Set (MDS) dated [DATE], was coded under Section G - Eating- Supervision requiring one-person physical assist, K - Swallowing/Nutritional Status-Loss of liquids/solids from mouth when eating or drinking, Holding food in mouth/cheeks or residual food in mouth after meals. Review of a Consultant RD (Registered Dietician) /LD Note dated 9/3/2021 documented the following for R#20 CBW (Current Body Weight) 124.7 pounds. BMI at 19/below NL (Normal limits) 89% of IBW (Ideal Body Weight). (Residents) Comparison Weight 2/8/2021: 154.4 pounds, 5/10/2021: 141.7 pounds. A decrease of 32.7 pounds or an average decrease of 4 pounds a month. Review of the Registered Dietician's form titled, Physician Recommendation Sheet dated 9/3/2021 documented Problem #1: weight loss with a Recommendation for an appetite stimulant. Review of a care plan with a Focus of alteration in nutritional status related to decreased energy needs with a stated Goal of I will have had no significant unplanned weight change by next review. The care plan was noted to be initiated on 1/26/2021 with a target date of 10/26/2021. Further review revealed that R#20's Quarterly Assessment was completed on 9/18/2021; however, review of the interventions revealed there was not any evidence that the resident's care plan had been revised to address the resident's appetite suppressant or the resident's weight loss. Interview with Dietary Manager (DM) on 10/14/21 at 1:00 p.m. revealed the Registered Dietitian (RD) is at the facility once a month. She stated the weights are in the computer. DM stated the weights must not be correct because that would be a big drop in weight. DM stated R#20 was weighed on 10/13/21 and the resident's current weight is 117 (lbs.) During an interview with the Director of Nursing (DON) on 10/14/21 at 3:38 p.m. revealed Patient at Risk (PAR) meetings are held weekly. DON stated she was not aware that R#20 had a significant weight loss of 20%. The DON also stated if a resident has weight loss, they should have a care plan to address weight loss. Interview on 10/14/21 at 3:31 p.m. with Registered Nurse (RN)/MDS Coordinator revealed she tries to update care plans every morning when she reads the order. MDS stated she was not aware that R#20 had significant weight loss. MDS verified that R#20 did not have a care plan that addressed the residents weight loss. Interview with the DON on 10/14/21 04:28 p.m. revealed the RD completed a recommendation remotely. The DON stated the RD did not send her the recommendation and she was not aware of the 9/3/2021 recommendation for the appetite stimulant for R#20. Interview with the RD on 10/14/21 at 4:38 p.m. revealed she emails the DON and Dietary Manager her recommendations. She stated they then submit it to the doctor for his approval. She stated she has email confirmation of her recommendations she sent to the DON and Dietary manager.