Every finding on record at Manchester Center for Rehabilitation and Healing L

Based on facility policy review, medical record review, observations, and interviews, the facility failed to perform an assessment for the use of a seatbelt for 2 residents (Resident #34 and #67) of 3 residents reviewed for physical restraints.The findings include: Review of the facility's policy dated 4/2017 titled Use of Restraints, revealed .individuals shall be reviewed regularly (at least quarterly) . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Type II Diabetes. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the comprehensive Care Plan initiated 4/26/2026 and revised 4/30/2026, revealed .Resident is at risk for falls r/t [related to] impaired mobility .use of proper assistive device . and .Resident requires PT/OT [physical therapy/occupational therapy] due to .impaired ROM [range of motion] .wheelchair management and mobility training . During an observation on 6/2/2026 at 3:00 PM, Resident #34 was in her power wheelchair with a lap belt secured around her waist. During an interview on 6/3/2026 at 1:37 PM, the Director of Rehab (DOR) stated Resident #34 was not assessed for the use of a lap belt. DOR stated Resident #34 does not utilize the lap belt on her power wheelchair. During an observation on 6/3/2026 at 3:30 PM, Resident #34 was in the common area seated in her power wheelchair with the lap belt secured around her waist. During an observation/interview on 6/3/2026 at 3:32 PM, the Director of Nursing (DON) confirmed Resident #34 had a lap belt secured around her waist and stated the resident had not been assessed for use of a lap belt. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Abnormal Posture, and Depression. Review of the MDS assessment dated [DATE] revealed Resident #67 scored a 13 on the BIMS indicating the resident was cognitively intact. Review of the comprehensive care plan dated 4/2/2026, revealed Resident #67 had .OT [occupational therapy] services related to .abnormal posturing of hemiplegic limb [paralysis on one side of the body] in current power chair .R [right] hand contracture [stiff and limits normal movements] . During an observation on 6/1/2026 at 3:53 PM, Resident #67 was observed sitting in her power wheelchair out in hallway with a lap belt secured across her right arm and waist. During an interview on 6/1/2026 at 5:00 PM, Certified Nurse Assistant (CNA) A stated Resident #67 had a belt on her power wheelchair to keep her from falling out, she thinks. CNA A further stated 2 residents on the hall had a power wheelchair with a lap belt. During an observation on 6/3/2026 at 12:25 PM, In Resident #67's room revealed Resident #67 was sitting in her power wheelchair with a lap belt secured around her right arm and waist. During an interview on 6/3/2026 at 1:37 PM, the DOR stated Resident #67 was not assessed by the therapy department for the use of a lap belt. During an interview on 6/3/2026 at 2:30 PM, the DON stated the lap belt was used for positioning the resident's right arm. The DON confirmed Resident #67 had not been assessed for the use of a lap belt since obtaining the wheelchair in 12/2024.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement the care plan for the use of a lap belt for 2 residents (Resident #34 and #67) and for falls for 1 resident (Resident #107) of 15 residents reviewed for care plans. The findings include: Review of the facility's policy dated 4/2017 titled Use of Restraints, revealed .care plans for residents in restraints . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Type II Diabetes. Review of an admission MDS assessment dated [DATE], revealed Resident #34 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive Care Plan initiated 4/26/2026, revealed .Resident is at risk for falls r/t [related to] impaired mobility .use of proper assistive device . and .Resident requires PT/OT [physical therapy/occupational therapy] due to .impaired ROM [range of motion] .wheelchair management and mobility training . No care planning was found for lap belt restraint. During an observation on 6/3/2026 at 3:30 PM, Resident #34 was in the common area seated in her power wheelchair with the lap belt secured around her waist. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Abnormal Posture, and Depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #67 scored a 13 on the BIMS assessment indicating the resident was cognitively intact. Review of the comprehensive care plan dated 4/2/2026, revealed Resident #67 had .OT [occupational therapy] services related to .abnormal posturing of hemiplegic limb [paralysis on one side of the body] in current power chair .R [right] hand contracture [stiff and limits normal movements] . During an observation on 6/1/2026 at 3:53 PM, Resident #67 was observed sitting in her power wheelchair out in hallway with a lap belt secured across her right arm and waist. During an interview on 6/1/2026 at 5:00 PM, Certified Nurse Assistant (CNA) A stated Resident #67 had a belt on her power wheelchair to keep her from falling out, she thinks. CNA A further stated 2 residents on the hall had a lap belt in their power wheelchairs. During an observation on 6/3/2026 at 12:25 PM, In Resident #67's room revealed Resident #67 was sitting in her power wheelchair with a lap belt secured around her right arm and waist. During an interview on 6/3/2026 at 12:30 PM, the Director of Nursing (DON) stated the lap belt for Resident #67 was used for positioning the resident's right arm. The DON confirmed Resident #34 and Resident #67's care plans were not accurate and did not reflect the use of the lap belt. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Age-Related Physical Disability, and Repeated Falls (added on 3/13/2026). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #107 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Further review revealed the resident required partial/moderate assistance with transfers, and substantial/maximal assistance with toileting. Review of the comprehensive care plan dated 3/11/2026, revealed Resident #107 had an intervention for Dycem to wheelchair. During an observation/interview on 6/2/2026 at 3:03 PM, Licensed Practical Nurse (LPN) B assisted Resident #107 to stand up from her wheelchair and confirmed Resident #107 did not have Dycem in her wheelchair. During an interview on 6/3/2026 at 11:11 AM, the Director of Nursing confirmed Resident #107 did not have Dycem in her wheelchair.

Based on medical record review, observations, and interviews, the facility failed to revise the care plan for 1 resident (Resident #107) of 15 residents reviewed for care plans.The findings include:Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Age-Related Physical Disability, and Repeated Falls (added on 3/13/2026).Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #107 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Further review revealed the resident required partial/moderate assistance with transfers, and substantial/maximal assistance with toileting.Review of the comprehensive care plan revised 6/2/2026, revealed Resident #107's care plan did not reflect bed in lowest position, floor mat to right side of bed, or nightlight. During an observation on 6/1/2026 at 11:54 AM, in Resident #107's room revealed the bed in lowest position, a floor mat on the right side of her bed, and a nightlight plugged in at the foot of her bed. During an observation on 6/2/2026 at 10:14 AM, in Resident #107's room revealed the bed in lowest position, a floor mat on the right side of her bed, and a nightlight plugged in at the foot of her bed. During an interview on 6/3/2026 at 11:11 AM, both the Director of Nursing and the Administrator confirmed Resident #107's care plan had not been revised to reflect bed in lowest position, floor mat to right side of bed, or nightlight.

Based on facility policy review, medical record review, observations and interviews, the facility failed to ensure proper infection control practices during medication administration for 1 resident (Resident #18) of 5 residents reviewed for medication administration.The findings include: Review of the facility policy titled, Administering Medications, dated 4/2019, revealed .Staff follows established facility infection control procedures .for the administration of medications . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Diabetes Mellitus, and Chronic Pain Syndrome. Review of the current physician's recapitulation orders for Resident #18 revealed, .Eliquis [medication to thin blood] 5 mg [milligram] .twice a day .Benzonate [medication for cough] 200 mg .every 8 hours .Duloxetine [medication for depression] 40mg .one time a day .Farxiga [medication for diabetes] 10 mg .one time a day .Furosemide [medication to reduce fluid in the body] 40 mg .twice a day .Gabapentin [medication for nerve pain] 400 mg .twice a day .Hydrocodone-Acetaminophen [medication for pain] 10/325 mg .every 8 hours .Metoprolol [medication for high blood pressure] 100mg .one time a day .Oxybutin [medication for urinary spasm] 5 mg .one time a day .Potassium 5mg .twice a day .Sertraline [medication for depression] 75 mg .one time a day . During observation of a medication administration on 6/2/2026 at 7:43 AM, Licensed Practical Nurse (LPN) B prepared medications for Resident #18 and removed the Eliquis 5 mg, Benzonate 200mg, Duloxetine 40mg, Farxiga10 mg, Furosemide 40 mg, Gabapentin 400 mg, Hydrocodone-Acetaminophen 10/325 mg, Metoprolol 100mg, Oxybutin 5 mg, Potassium 5mg, Sertraline 75 mg by placing the medications into her hand and then into the medication cup. Continued observation revealed LPN B administered the medications to Resident #18. During an interview on 6/2/2026 at 7:53 AM, LPN B stated she was able to touch the pills because they (medication/pills) were not hazardous medications/pills. During an interview on 6/2/2026 at 2:15 PM, the Director of Nursing (DON) confirmed it was her expectation for staff to follow infection control practices which includes not touching medications with hands.

Based on job description review, facility policy review, facility investigation documentation review, and interview, the facility failed to ensure 1 resident (Resident #1) was returned to her room after transportation to a medical appointment for 1 of 3 residents reviewed for accident hazards. The facility failure occurred on 5/8/2024 when Resident #1 was taken to a medical appointment by the Transportation Coordinator and returned to the facility at approximately 4:30 PM. The facility was under a code black at the time for serious weather conditions. The Transportation Coordinator failed to unload Resident #1 from the facility van and Resident #1 was locked inside the facility van for an unknown amount of time, estimated to be 3 to 4 hours. Licensed Practical Nurse (LPN) A became concerned about Resident #1 and the Transportation Coordinator due to the serious weather conditions around 7:00 PM shift change on 5/8/2024 and called the Nurse Practitioner (NP) to inquire about their location. The NP was present with the Transportation Coordinator during the call, and it was determined that the Transportation Coordinator had not unloaded Resident #1 from the facility van upon return to the facility from the medical appointment. LPN A found Resident #1 in the facility van and called 911 to obtain access to the vehicle. The facility's census on 5/8/2024 was 108.The facility was cited at F 689 Scope/Severity D. The facility was cited as past non-compliance. NO additional corrective actions are required.The findings include:Review of the Transportation Coordinator's job description, signed by the Transportation Coordinator on 10/17/2022, revealed .The Transport driver is responsible for safely transporting facility residents to and from appointments .Maintains a safe, secure, and healthy work environment by establishing, following, and enforcing standards and procedures .Review of the facility's policy titled Safety and Supervision of Residents, dated 5/19/2023, revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision .to prevent accidents are facility-wide priorities .Review of the facility's policy titled, CareRite Emergency Management Codes and Procedures, dated 7/14/2023, revealed .Severe weather/natural disaster (Code Black) .Review of the facility's undated policy titled, Policy: Facility Van Transportation, It is the policy of the facility to provide guidelines for safe van transportation practices for those residents that need transportations for their medical appointments .The Facility Transportation Driver will be approved to drive the Van .Only after they review and sign the Facility Transportation Driver job description, complete the Orientation Curriculum and prove role competency which covers Van use and safety performance expectations .Safety Rules .Keys for the vehicle will be kept in the administrative offices .Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Unspecified Fracture of Right Acetabulum (socket in the pelvis that forms the hip joint) with Routine Healing, Protein Calorie Malnutrition, Cognitive Communication Deficit, Hydronephrosis, Anemia in Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD), and Dementia.Review of the comprehensive care plan dated 4/12/2024, revealed .Has difficulty communication with other R/T [related to] Cognitive communication deficit .requires assist with activities of daily living .Assist with .transfers .Assist with ADLS [activities of daily living] and ambulation as needed .Dementia .AFTT [Adult Failure to Thrive] .Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Resident #1 had impaired functional range of motion on 1 side of the lower extremities and required a wheelchair for mobility. Resident #1 was dependent on staff for toileting hygiene and required substantial/maximal assistance for chair/bed-to-chair transfer. Resident #1 was frequently incontinent of urine and always incontinent of stool.Review of a physician's order dated 5/8/2024, revealed .Appointment with [orthopedic surgeon] on 05/08/24 [5/8/2024] at 1445 [2:45 PM] . The address to the orthopedic surgeon's office was listed in the physician's order and was 15 miles from the facility.Review of facility documentation dated 5/8/2024, revealed .Severe Weather/Code Black Initiated .5:30 pm .Review of a facility document dated 5/8/2024 at 7:55 PM, revealed .While on LOA [leave of absence] .Pt [patient] noted to be in locked transport vehicle after returning from an appointment .Resident Description: 'I went and had a haircut and it was free.' .Immediate Action Taken .911, NP, DON [Director of Nursing], Maintenance, administrator notified. Window broken by police, EMS [emergency medical services] and nurse entered van. Resident assisted off van and immediately assessed by NP, DON. Status is at baseline. Assisted with incontinence care. Labs drawn .Offered food and drink. Daughter notified of incident .No injures observed at time of incident .Alert .Wheelchair bound .No injuries observed Post Incident .Other Info .Code black for facility .Agencies/People Notified .911- Emergency Services .5/8/2024 [8:00 PM] .[NP] .5/8/2024 19:55 [7:55 PM] .DON .5/8/2024 20:00 [8:00 PM] .Next of Kin .5/8/2024 21:30 [9:30 PM] .Review of a Nursing Progress Note dated 5/8/2024 at 8:00 PM, revealed .Pt noted to have not returned from appt [appointment] at shift change. Staff nurse called NP to inquire about patient/transportation. Pt then noted to be in transportation van. NP made aware, 911 DON Maintenance, Administrator notified. Pt assisted out of van by staff .in cheerful mood and stated, 'I went to get a hair cut and it was free.' Vitals, labs .skin assessed. Food and fluids offered. 'I don't want a big dinner but I will take my cookies.' Pt assisted with PB [peanut butter] crackers and boost drink of choice. Assisted with incontinent care. Daughter notified of situation and came to center to visit her mother .resting in bed eyes closed with symmetrical rise and fall of chest .Review of the Weekly Skin Evaluation dated 5/8/2024 at 10:18 PM, revealed .No NEW open areas noted .No new alterations in skin integrity, Buttocks, sacrum, peri area without redness .Review of the Stressful Life Experiences Evaluation dated 5/8/2024 at 10:14 PM, revealed Resident #1 scored a 9. It was noted .An individual is considered to have screened positive if the sum of these items is 14 or greater .Review of the nurse practitioner Encounter note dated 5/8/2024, revealed .Chief Complaint/Nature of Presenting Problem .Lab review, facility incident .98YO [year old] female resident who is being seen for a lab review to follow up on an incident that happened at the facility. This provider received a call .around shift change wondering where the resident was as she was not on the hall. Instructed nursing to search the entire building which she had already done without success. Instructed nursing to look in transport van. Resident was located in the transport van, and this provider instructed nursing to call 911. Emergency services arrived, and resident was taken into the building .Past Medical History .Anemia .dementia .cognitive communication deficit .CKD .Resident reports that shewent [she went] to get her hair cut, and it was free .Pulse: 64 BPM [beats per minute] .Blood Pressure: 126/72 .O2 Saturation: 98 Room Air .Temperature: 97.4 .Respiratory Rate: 16 Breaths per minute .Physical Exam .Awake and alert in NAD [no acute distress]. Resident is joking with staff about her free hair cut .Respiratory: Normal respiratory effort. Normal to auscultation .No joint deformity, swelling, redness or muscle weakness .No tremor or cerebral signs noted .Cranial nerves .are grossly intact .Alert and oriented x 1 and able to follow commands .This provider was present when van was unlocked. Immediately entered van, and began a thorough assessment. Resident at baseline physically and mentally. She was brought back into her room, and placed into bed where this provider performed a full skin assessment with the DON. Resident was offered food .wanted .'cookies' .ate a few of those and dranke [drank] a chocolate boost .Review of the comprehensive care plan dated 5/8/2024, revealed .has had a Stressful Life Experience related to code black situation .Review of the psychiatric NP note dated 5/9/2024, revealed .Staff requests initial psychiatric evaluation .admitted post hospitalization after fall in home setting sustaining a right acetabular fracture and pubic [NAME] fracture. Resident does have a diagnosis of dementia .no psychotropic medications .I am asked to assess resident following an incident where resident was in a transport van for an extended period .Confusion is apparent during assessment .She tells me she is [AGE] years old .She voices feeling 'fine.' She does recognize going to orthopedic appointment, but was frustrated stated 'he told me nothing new. I thought I was going to be able to walk.' She could answer some questions appropriately, but answered 'I don't have any idea' to many questions. She does deny acute depression or anxiety. She does not mention the incident .There is no voiced or observed distress following incident .Physical Exam .Behavioral Disturbance: None observed or reported .Orientation: Awake and alert: person only .There does not appear to be any emotional or physical distress from incident. Resident appears to be at baseline as discussed with Medical staff .Review of the physician Encounter note dated 5/10/2024, revealed XXX[AGE] year-old female with a history that includes COPD, hypertension and dementia who is being seen for monthly evaluation today .stable with no acute issues or concerns .Physical Exam .Patient sitting in bed, no acute distress .Good aeration bilaterally, no wheezing or rhonci .Range of motion at baseline, no joint deformity or swelling .Alert, at baseline mental status .Psychiatric: Normal mood and affect .Patient is stable with no acute medal issues at this time .chronic medical conditions are stable at this time .Review of the facility reported incident documentation to the state agency, revealed the facility reported an allegation of .Deprivation of Goods and Services by Staff . The former DON became aware of the incident on 5/8/2024 at 7:55 PM. The former Administrator became aware of the incident on 5/8/2024 at 8:08 PM. Resident #1 was the alleged victim. Resident #1 had .Dementia with behaviors . and scored a 1 on the BIMS assessment which indicated the resident had severe cognitive impairment. The alleged perpetrator was identified as The Transportation Coordinator. The Nurse on hall made the allegation and reported it to .EMS and leadership . The alleged incident occurred 5/8/2024 at 7:55 PM. It was noted .Patient was left in van in parking lot No physical or mental harm identified .No noted changes to patient upon thorough examination/assessment by ANP [Advanced Nurse Practitioner] and Director of Nursing .Patient was immediately assessed; all systems were found to be within normal limits and status is at baseline. Root cause analysis initiated to determine what transpired to distract the transportation aide from remembering the patient was still in the van. Family was contacted by administrator and directly communicated with about the incident. Daughter came to facility and visited with the patient and expressed appreciation to leadership team for transparency and responsiveness to incident . Witnesses to the incident included LPN A. Police and EMS were notified by LPN A on 5/8/2024 at 7:55 PM. It was noted .Patient [Resident #1] was taken to appointment and then returned to center and not removed from van. Nurse [LPN A] discovered that transportation aide [Transportation Coordinator] and patient had not returned and initiated call to transportation aide [Transportation Coordinator] and then 911 for assistance in removing patient from van. Investigation was initiated and root cause analysis started including interviewing of all involved parties, transportation aide [Transportation Coordinator], nurse on hall [LPN A] . Report was made to Other Agencies on 5/8/2024 at 11:00 PM. The state agency was made aware via the .Submission Report . on 5/8/2024 at 11:30 PM by the former Administrator. It was noted .No physical or mental harm noted, post multiple assessments from interdisciplinary team, including MD, ANP, nurses and social worker . The allegation was reported to the resident representative .on the evening of the incident, Wednesday evening . It was noted .This was reported to the Police department, EMS, the Ombudsman and APS. Each agency has responded to this incident and were pleased with our responsiveness to this incident and our plan of correction. Police department has closed the investigation . Steps taken to investigate the allegation included .Resident was assessed and interviewed by multiple members of our interdisciplinary team, including the Director of Nursing, medical nurse practitioner, psychiatric nurse practitioner, medical doctor, respiratory therapist, and social worker. No distress or harm indicated. Daughter (who is an LPN of many years) also assessed patient and concluded that there was no physical or mental harm. She also expressed appreciation for our responsiveness to this incident .Interview with nurse from resident's hall, [LPN A] stated that she was aware of patient being at appointment and assumed that the severe weather contributed to the delay of return. At shift change, she [LPN A] called to check on patient and transportation driver [Transportation Coordinator], thus discovering that this incident had occurred. She [LPN A] then immediately went to the van, called 911 and remained with the patient, just outside the van, until access was obtained to assess the patient. Medical nurse practitioner and Director of Nursing were present when patient was removed from the van and thorough assessment was initiated .Interview was initiated with driver on the night of incident wherein she stated she had received several phone calls associated with other resident appointments and transportation matters while in the parking lot and was diverted from your normal routine. Additionally, the impending poor weather conditions contributed divergence from her normal routine. She [Transportation Coordinator] parked van in the back and went to check calendar and then did not unload patient. At just before 8:00 pm the nurse from the resident's hall [LPN A] called to inquire regarding whereabouts and then discovered the reality of the situation .Transport Driver [Transportation Coordinator] was most distraught by this incident and genuinely concerned for the welfare of the patient. There was no indication of malintent or impairment. Past performance reviews indicate very favorable employee status. Employee completely understood the severity of the incident and was more than apologetic .Other residents with recent facility transportation appointments were screened and interviewed as necessary with no voiced concerns or complaints .Director of Nursing .was interviewed, post arrival at center regarding condition of nurse, resident and patient incident. Per DON, patient was found to be in good spirits, pleasantly confused as is her baseline. DON reported that she and our nurse practitioner assessed patient and found her to be within her usual baseline health condition .Administrator interviewed transport driver [Transportation Coordinator] multiple times from the beginning of the investigation to the present and discovered her to be consistent with her memory of the incident, sincerity of sorrow the resident and family and acceptance of accountability for the incident .Resident was assessed by interdisciplinary team for potential harm physically, mentally, and psychosocially. All assessments findings were negative for harm and within normal baseline status of patient's history .Lab work was obtained and found to be within patient's normal ranges. Law enforcement investigation completion and closed per detective .who visited with patient on 5/10/24. APS [Adult Protective Services] screened all information pertaining to incident. Ombudsman also visited center on 5/10/24 and interviewed staff and patient and asked for copy of final plan of correction .The investigation concluded that while an incident did occur as reported, that the patient did not sustain injury or harm from incident, that an immediate and thorough action plan was initiated and completed to ensure the safety of the patient and that no other patients were affected by this incident. Additionally, policy and procedure reviews were implemented so as to minimize the potentiality of such an incident would occur in the future . Corrective Actions taken included .Employee disciplinary action was administered, including adjustment of transportation duties during investigation. Reeducation on Policy and Procedure were reviewed, updated and competencies were checked and verified .Director of Nursing, Plant Operations Director [Director of Maintenance] and administrator will directly oversee measures put in place and systematic changes made to ensure that practice will not reoccur .Assessment was completed by multidisciplinary team members, including MD, psych NP, medical NP, and social worker. Stressful life evaluation, stressful life care plan and repeated oversight and monitoring of patient's physical, mental and psychosocial health and wellbeing continues, including but not limited to lab comparison, skin evaluations, pain evaluations .Review of current policy and procedures pertaining to transportation and reeducation and validation of knowledge through competency assessment of driver were provided to ensure understanding and compliance .[Named Police department] detective .investigated incident and closed this case today, May 10 2024, after interviewing center team members, resident and plan of action initiated by center, post incident .APS also screened this incident and were satisfied with center's responsiveness to incident .Ombudsman visited center on May 10, 2024, interview resident. Only request was for finalized plan of correction details .Review of the [Named Police department] PRELIMINARY INVESTIGATIVE REPORT, revealed .Date 5/8/2024 .COMP .[LPN A] .VICTIM .[Resident #1] .Victim Injury .N .Event .Elderly left in vehicle .Occurred On .[5/8/2024] .On Wednesday, 05/08/2024 .responded to [facility name] for an older woman locked in a transport van. When we arrived on the scene, we were met by [LPN A] .she advised that [Resident #1] had been locked in a transport van for several hours. I tried to lock the jock the van and was unable because the lock jock was too short, and it was storming. We decided to break the passenger-side vent window to gain entry .ambulance service arrived on the scene to check out [Resident #1], and she was taken back to the Rehab clinic after ambulance service cleared her .online APS referral for neglect of the listed victim. Due to to the fact of the incident occurring at the same time of the dangerous weather on 5/8/2024 .Is there significant reason to believe crime may be solved with a reasonable amount of investigative effort .NO .Date Notified .05/08/2024 [5/8/2024] .20:02 [8:02 PM] .Date/Time Arrived at Scene .05/08/2024 [5/8/2024] 20:03 [8:03 PM] .Review of the EMS documentation dated 5/8/2024, revealed .Responded to emergency to patients location for welfare check on female that left inside a wheelchair van for 3 hours. Patient was awake, alert and oriented. Patient stated that she was fine and didn't want or need to go to the hospital. Staff stated that she was leaving work just before the storm hit and she thought to call and check on the driver and patient. The driver answered the phone from home and didn't realize that patient was still strapped in to the van. Maintenance man came with a key to move the van. Patient was unloaded under the front awning .[facility name] .Call Received .05/08/2024 [5/8/2024] 20:01 [8:01 PM] .Dispatched .05/08/2024 [5/8/2024] 20:13 [8:13 PM] .On Scene .05/08/2024 [5/8/2024] 20:20 [8:20 PM] .Depart Scene .05/08/2024 [5/8/2024] 20:50 [8:50 PM] .Review of an undated written witness statement from LPN A revealed .1955 [7:55 PM] called to check status of pts arrival to facility from appt. it was discovered pt was in the transport van. This nurse went to transport van. Pt was in van. I was directed to call 911. Called 911. Police arrived and gained access to inside the van. This nurse entered van. Pt sitting in secured w/c [wheelchair]. Alert and not in distress. Phone service restored. I called DON for direction. DON @ facility, Maintenance drove to front of building. NP present at this time. assessed NP, DON [with] transporting Pt to room .Review of an undated written witness statement from the Transportation Coordinator revealed .4:30 [4:30 PM] came Back to the facility, phone rang and [named non-emergency transport medical transportation company] called regarding Resident, [named healthcare facility] called Regarding time change for Resident. Cardiology called regarding time change For Resident pulled around Back to check calendar For Time change, and at approx [approximately] 8:00pm 500 hall nurse called to see if myself and resident were ok. I then realized I never unloaded resident .Review of an untitled facility document dated 5/8/2024, revealed .[Resident #1] .05/08/2024 [5/8/2024] .1400 [2:00 PM] Transport took patient to appointment .Daughter met her at the appointment .1630 [4:30 PM] Transport returned to the center. Received several code black alerts. Received multiple phone calls regarding appointments for other residents in which she had to retrieve calendar from office to confirm appointment and transportation. Due to impending weather transport aid reached out to Administrator and maintenance regarding parking of the van due to possible [NAME] damage. The decision was made to park the van in the back parking lot .1955 [7:55 PM] - Hall nurse called transport aide to ensure they were safe. She assumed bad weather had delayed their arrival back to the center. Transport aide realized she didn't remember unloading patient. 911 was called. EMS and Police on scene. Police broke side window out. Call was made to DON regarding status .2000 [8:00 PM] .DON and Maintenance on the way to center .2008 [8:08 PM]- Administrator made aware of situation and noted in WhatsApp high risk chat .2015 [8:15 PM] - Maintenance arrived at center with spare key 2020 [8:20 PM]- DON and NP arrived at centered. Van was pulled around to the front of the building .2026 [8:26 PM]- Patient unloaded from the van. Patient in good spirits and joking with staff. Pt transferred to her room and assessed. Labs drawn. Skin assessed. Food and fluids offered .2130 [9:30 PM] - Administrator arrived at center and initial assessment complete. Daughter notified of incident. Immediately started state notification .2300- Incident report to State .website .05/09/2024 [5/9/2024] am - email sent to new ombudsman's related to incident .1200 pm - reported to APS. APS screened the incident due to our response and interventions .1324 [1:24 PM] - Ad hoc emailed to high risk team .1330 [1:30 PM]- psych np telehealth app .Review of the undated ROOT CAUSE ANALYSIS REPORT, revealed .Date of Event 05/08/2024 [5/8/2024] .Resident left unattended in facility vehicle for extended period .Resident was transported by facility transport aide [Transportation Coordinator] to a scheduled appointment. Upon arrival back to the facility transportation aide failed to unload patient and return to room related to impending poor weather and multitude of phone calls diverting her from her normal routine. No harm resulted from incident .What were the expected sequence of events that were to take place? .Resident to get ready for appointment by hall staff. Transport aide assist resident into the van safely and appropriately. Transport aide assist resident off van and to appointment. Upon arrival back to the facility transport aide unloads patient and returns to appropriate hall/room .Was there any deviation from the expected sequence? .Yes. Resident was not unloaded and returned to appropriate hall/room after appointment due to resident resting quietly in the van, calls from transportation and cardiology diverting attention away from usual routine to obtain calendar and other work product to participate in lengthy calls with companies .If deviation occurred from the expected sequence, was it likely to have contributed to an adverse event? .Transport aide received multiple calls regarding other patient appointment, rescheduling ambulance transportation and impending poor weather conditions. The impending weather conditions prompted her to park in parking lot behind the building, different from where she had been parking. The multiple calls about appointments required her to obtain her computer, calendar, and phone to try and coordinate the appointments .Is the expected sequence of actions described in policy, procedure, written guidelines or included in staff education? .No .During an interview on 9/23/2025 at 2:23 PM, the NP stated she recalled the incident with Resident #1. LPN A called the NP on the night of the incident (the NP was unable to recall the exact time) and asked if the NP knew where Resident #1 was. Resident #1 had an appointment that day and LPN A wanted to know if she had been admitted after the appointment. The NP asked LPN A to look in the facility for the resident. LPN A stated she had already looked and couldn't find her. The NP told LPN A that the van was parked in the back of the facility and asked LPN A to look in the van. LPN A went to look in the van with the NP still on the phone. LPN A stated Resident #1 was in the van sleeping and she could see the resident sitting up in the van in her wheelchair. LPN A was unable to get in the van because the doors were locked. The NP told LPN A to call 911 and the NP called the Director of Maintenance (DOM). The DOM stated there was not a key at the facility. The NP told LPN A to break the window to get Resident #1 out. LPN A told the NP that the police were at the facility and had broken the window. The NP stated she was able to hear Resident #1 talking and she was alert. The NP was on her way to the facility when she was notified by LPN A. There was a storm and there were .trees all over the road . on the NP's way to the facility. The NP stated when she arrived at the facility, the NP was there and EMS and the police were leaving the scene. Resident #1 did not require transfer to the hospital from EMS. The NP assessed Resident #1 and stated she was at her baseline mentally with no skin changes or respiratory difficulty. Resident #1 did not show any signs of anxiety. The NP stated Resident #1 was in the van for .maybe 3 hours .I don't know for sure .Resident #1 was seen by the psychiatric NP on 5/9/2025 with no signs of psychosocial distress and Resident #1 had no recollection of the event. The NP stated she had seen Resident #1 multiple times after the incident with no concerns related to change in behaviors for Resident #1.During an interview on 9/23/2025 at 3:54 PM, the Director of Maintenance stated he was called at his house by the NP .sometime after 6 . The NP stated he needed to get to the facility as soon as possible because a resident was left in the facility van after transport to a doctor's appointment. The staff at the facility and police were unable to get into the van. The Director of Maintenance had keys to the van and came to the facility. The Director of Maintenance stated on the night of the incident when Resident #1 had been left in the facility van there were tornado warnings and it was hailing. The Director of Maintenance arrived at the facility .about 25 minutes . after he was notified and the police and ambulance were at the facility. They had obtained entrance to the van . and the van was parked in the back parking lot of the facility. EMS was there and leaving the scene when the Director of Maintenance arrived. Resident #1 was sitting in the wheelchair inside the van. The police officer asked the Director of Maintenance to move the van to the front of the facility so they could remove the resident from the van. Resident #1 seemed .confused . to the maintenance director but the maintenance director stated he was unaware of her baseline. Resident #1 didn't seem upset. The Director of Maintenance stated the Transportation Coordinator had transported the van that day called him about 4:30 PM on the day of the incident. The Transportation Coordinator said she had just returned from transporting a resident from an appointment and asked if he wanted to her to leave the van on the side of the building under the awning because of the weather that was coming in to protect it from [NAME]. The Director of Maintenance told the Transportation Coordinator to park the van in the back of the facility. The Director of Maintenance was present during a conversation between the former Administrator and the Transportation Coordinator and she stated the cause of leaving the resident in the van was because she was worried about the upcoming weather and wanted to get home before the storm.During a telephone interview on 9/23/2025 at 5:00 PM, the Transportation Coordinator stated she transported Resident #1 to an orthopedic appointment on the day of the incident. Resident #1's appointment was around .2:30 or 3:00 in the afternoon .the best that I remember . The Transportation Coordinator stated she was unable to state the exact time they returned to the facility, but it was .probably around 4:00 . The Transportation Coordinator parked the van in the back of the facility. This surveyor asked the Transportation Coordinator to describe the weather conditions and temperature at the time of the incident and the Transportation Coordinator stated .it's been a long time .I wish I could .there were tornado warnings and severe storms . The Transportation Coordinator stated she received a phone call when she returned to the facility from an ambulance company about another resident's appointment and exited the van to go inside to check the calendar. The Transportation Coordinator stated she had not unloaded Resident #1 from the van when she went inside to check the calendar. While inside the facility, The Transportation Coordinator received multiple other phone calls about other resident appointments the next day. The transportation process at the time of was to load the resident into van, take them to the appointment, and unload them and return them to their room. There was no sign out sheet at the time or checklists to ensure residents were unloaded after transport. The Transportation Coordinator confirmed she was aware residents were not to be left alone in the van at any time. The NP received a call from someone (unable to recall who the staff member was or what time it was) at the facility while she and the Transportation Coordinator were together asking if she knew where Resident #1 was and at that time the Transportation Coordinator knew she had forgotten to remove Resident #1 from the van after the appointment. The Transportation Coordinator was suspended from transportation duties until she had been educated on the new processes. The new processes included a sign in and out sheet for every transport, safety checklists to be completed before and after every trip, a 2nd attendant in the van during transport for residents depending on their BIMS score, no cell phones in the van except the business cell phone. The transport coordinator stated there was no one in the van with her at the time of the transport. The Transportation Coordinator stated she had seen Resident #1 on multiple occasions after the incident and she had no change in her behaviors. The Transportation Coordinator no longer works at the facility.During a telephone interview on 9/23/2025 at 5:42 PM, the former DON stated she re[TRUNCATED]

FACILITY Kitchen [DATE] 11:10 AM Steam table set up in dining room, vertical barrier hung between food station and the rest of dining room, as ceiling was being worked on. [DATE] 09:58 AM Observation of plating station showed dining area back to normal, with no repairs being done and barrier gone. [DATE] 8:30 AM Observation of kitchen workers showed appropriate hand sanitation and hair nets in place. During an interview on [DATE] at 8:42 AM, [NAME] O'Keefe, Dietary Manager the facility has a full-time qualified with ServSafe Certification that expires [DATE], with [AGE] years experience in healthcare foodservice. Menu was reviewed and the mechanical consistency of the meal is followed per orders from Speech therapy, RD and physician. Alternatives are offered for any meal. Copy of menu reviewed with DM. A tour of the kitchen followed. Brief tour of kitchen included temperature checks on all refrigerators and freezers, and all food products were properly stored at proper temperatures. Dry stored food products were dated with arrival date, stored at least 6 inches off floor, and canned products were free of dents and had intact seals. Egg products were pasteurized, and frozen thawing products were being thawed properly. Staff were wearing gloves, after proper hand hygiene, and hair nets. Hand washing stations were separated from those used for food preparation. No observed water damage or leaking pipes in food storage areas, and there was no observed ice build-up in freezers. Four unopened packages of 12 flour tortillas were in dry storage area with no arrival date and were expired on [DATE], which was 9 days past expiration. This will be cited at F812. Cutting surfaces and equipment was clean and in good working condition. Foods were prepared and plated under sanitary conditions in dining room, and all temperatures were appropriate, including cold items. Proper calibration of food thermometers and cleaning of the same was performed. Food was appealing and cooked to preserve nutritive value. Food prep areas were separate from dirty areas. Dinnerware sanitation was performed by chemical sanitation machine with a temperature of 120 degrees Fahrenheit, and chemical tests were performed with appropriate results. A 3 compartment sink was used for cleaning pots and pans and was tested with appropriate results. Random checks of serving pans revealed all were clean and dry, stored upside down or covered. Grease trap and dumpsters are closed and clean. Cleaning schedules and logs were reviewed with no concerns. Pest Control contract with CarePro Solutions, and they came once a month. The last visit was [DATE], and no infestation was observed. During an interview on [DATE] at 9:30 AM, Amy [NAME], Registered Dietician stated she worked 3 days a week and diets were followed and met the needs of the resident's. Food policies, including storage of foods brought in by family, were reviewed with no concerns. During an observation and interview in nourishment room on [DATE] at 9:56 AM, DM revealed snacks stored in upper cabinets, resident snacks and drinks only stored in refrigerator and nothing stored under the sink. All snacks and drinks had a good expiration date. Refrigerator and freezer temperatures were appropriate and a temp log was displayed and up to date on the front of refrigerator. DM stated it was dietary's responsibility to keep that room stocked and clean. Room was clean and sanitary.

Based on facility policy review, medical record review, the facility's documentation, and interviews, the facility failed to provide evidence that the allegations of abuse were thoroughly investigated for 2 residents (Residents #40 and #96) of 4 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Policy, dated 4/26/2022, showed .It is the policy of the facility that acts of physical .abuse .against residents are absolutely prohibited .DEFINITIONS .Physical Abuse is the inappropriate physical contact with a resident .This includes .slapping .Upon receiving .suspected incident of resident abuse .the Administrator/DON [Director of Nursing]/Designee will conduct an investigation .Witness reports will be in writing. Witnesses will be required to sign and date such reports .copy of .must be attached to the Abuse Investigation Report . Review of the facility's policy titled, Abuse Reporting & Investigating Policy dated 10/27/2022, showed .All reports of resident abuse .are .thoroughly investigated .Findings .are documented .All allegations are thoroughly investigated .individual conducting the investigation .interviews any witnesses to the incident .interviews the resident . Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #40 was cognitively intact and had no inattention, disorganized thinking or altered level of consciousness. Review of a nurse's progress note dated 10/5/2022 at 11:35 PM, showed Licensed Practical Nurse (LPN) #2 documented .nurse and tech were sitting outside of residents [Residents #40's and #96's] room. Door was closed. We heard stop it and what sounded like dishes landing on the floor .immediately entered room to find both residents standing .[ Resident #40] was holding .[Resident #96's] Left wrist .[Resident #40] stated that room mate slapped her .and scratched her .DON was notified and a VM [voice message] was left for administrator . During an interview on 12/6/2022 at 2:19 PM, Certified Nursing Assistant (CNA) #1 stated she cared for Residents #40 and #96 on the night of the altercation. The CNA stated she entered the room and observed Resident #40 holding Resident #96's wrist with her hands. Resident #40 stated Resident #96 thought Resident #40 was her brother, and slapped her across the cheek. During an interview on 12/6/2022 at 2:28 PM, Resident #40 stated the 2 residents were kidding around in the resident's room after she returned from bible study. She stated .She [Resident #96] thought I [Resident 40] was her brother and she grabbed me by the wrists .slapped me and was knocking things over . and the staff heard and came running.I told her I was not her brother . Resident #96 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Generalized Anxiety Disorder and Depression. Review of a significant change MDS dated [DATE] showed Resident #96 had severe cognitive impairment. Review of the facility's investigation report regarding the altercation between Residents #40 and #96 dated 10/5/2022 at 11:35 PM, showed LPN #2 stated she and CNA #1 entered Residents #40 and #96's room and observed Resident #40 was holding Resident #96's wrist. Resident #40 stated .she slapped and scratched me . The residents were immediately separated. The investigation did not include a witness statement from CNA #1 or Resident #40. During an interview on 12/7/2022 at 4:15 PM, the DON confirmed there was no witness statement from CNA #1 or Resident #40 regarding the altercation between Resident #40 and Resident #96 on 10/5/2022.

Resident #21 was admitted to the facility on [DATE] and had diagnoses including Dementia, Generalized Anxiety Disorder, Schizophrenia, Morbid Obesity, Cognitive Communication Deficit, Bipolar Disorder, Major Depressive Disorder, and Obsessive Compulsive Disorder. The diagnosis of Impulse Disorder was added on 9/19/2019 and the diagnosis of Psychotic Disorder was added 10/12/2021. Review of a PASARR dated 6/11/2012 showed a level 1 PASARR was completed and included the diagnosis of Schizophrenia. Resident #21 was not referred for level 2 services due to the resident not requiring specialized services. Review of the medical record showed a new PASARR had not been submitted to the stated designated authority after the diagnosis of Impulse Disorder was added on 9/19/2019 or the diagnosis of Psychotic Disorder was added on 10/12/2021. During an interview on 12/6/2022 at 10:25 AM, MDS Coordinator #2 confirmed a new PASARR had not been submitted to the state designated authority after the new mental health diagnosis of Impulse Disorder and Psychotic Disorder had been added for Resident #21. Resident #31 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Autistic Disorder, Legal Blindness, Diabetes, Seizures, and Intentional Self-Harm. A diagnosis of Psychotic Disorder with Delusions was added on 4/13/2021, and the diagnosis of Anxiety Disorder was added on 7/27/2021. Review of the Level 1 PASARR dated 3/19/2021 showed the resident did not have a known or suspected mental health condition. The PASARR showed the resident had been self-injurious and had not been prescribed psychoactive medications. The medical record showed a new PASARR had not been submitted to the state designated authority after the diagnosis of Psychotic Disorder with Delusions was added on 4/13/2021, or after the diagnosis of Anxiety Disorder which was added on 7/27/2021. During an interview on 12/6/2022 at 1:13 PM, MDS Coordinator #1 confirmed a new PASARR had not been submitted after the new mental health diagnoses of Psychotic Disorder with Delusions and Anxiety Disorder were added. 45837 Based on medical record review and interview, the facility failed to make a referral, to the state-designated authority, for a Level II Pre-Admission Screening and Resident Review (PASARR) after newly identified mental health disorders were diagnosed for 5 residents (Residents #3, #9, #86, #21, and #31) of 23 residents reviewed for PASARR. The findings include: Review of the PASARR form dated 10/24/2011, revealed Resident #3 had no evidence of mental illness or history of mental illness during the previous 2 years. Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Major Depressive Disorder and Generalized Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 was cognitively intact, and no behaviors were exhibited. Active diagnoses included Schizoaffective Disorder, Major Depressive Disorder and Generalized Anxiety Disorder. During an interview on 12/5/2022 at 2:50 PM, the Director of Nursing (DON) confirmed the PASARR for Resident #3 was completed prior to admission, and a new PASARR was not submitted to include the diagnoses of Schizoaffective Disorder, Major Depressive Disorder and Generalized Anxiety Disorder. Review of the Level I PASARR screen for Resident #9 dated 1/4/2021, showed a Level II was not required, as no mental health diagnosis was known or suspected. Resident #9 was admitted to the facility on [DATE] with diagnoses including Delusional Disorder and Anxiety Disorder. Review of the annual MDS assessment dated [DATE] showed Resident #9 had moderate cognitive impairment and exhibited delusions but no other behavioral symptoms. During an interview on 12/06/2022 at 6:01 PM, the DON stated that Resident #9 had new diagnoses of Delusional Disorder and Anxiety Disorder on admission, and confirmed a new PASARR was not submitted. Resident # 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Delusional Disorders and Unspecified Dementia. Review of a Level I PASARR for Resident #86 dated 8/14/2020, showed a diagnosis of dementia, and no Level II was required. Review of a physician's order dated 12/15/2020, showed Delusional Disorder as a diagnosis. Review of a quarterly MDS assessment dated [DATE], showed resident #86 had moderate cognitive impairment and behaviors of delusions. During an interview on 12/5/2022 at 2:53 PM, the DON confirmed a new PASARR was not submitted after a new diagnosis of Delusional Disorder was added.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure appropriate infection control practices were maintained for 1 resident (#115) of 5 residents reviewed for transmission-based precautions which had the potential to affect 11 of 116 residents. The findings include: Review of the facility's policy titled, Clostridium Difficile (an infection spread by bacterial spores found within the feces), revised on 10/2018, showed Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C.difficile [CDI] to prevent transmission to others residents .placed on contact precautions . Review of the facility's policy titled, Isolation, Cohorting, And Transmission Based Precautions, dated 9/28/2021, showed .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Based on CDC [Centers for Disease Control and Prevention] definitions, three types of Transmission-Based Precautions (airborne, droplet and contact) have been established .CONTACT PRECAUTIONS .In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Examples of infections requiring Contact Precautions .Diarrhea associated with Clostridium difficile .In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room .Gown .Wear a disposable gown upon entering the Contact Precautions room .After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces .Signage .The facility will implement a system to alert staff to the type of precaution resident requires . Resident #115 was admitted to the facility on [DATE] with diagnoses including Compression Fracture of the Vertebrae and Fusion of Lumbar Spine. Review of the admission MDS assessment dated [DATE], showed Resident #115 was cognitively intact, required extensive assistance for toilet use, and was always incontinent of bowel. Review of the hospital laboratory results dated [DATE], showed .PROCEDURE .C Diff .ANTIGEN .POSITIVE .A POSITIVE ANTIGEN RESULT INDICATES THE PRESENCE OF C.difficile . Review of a Nursing Progress Note dated 12/4/2022, showed .Results for stool sample show positive for c diff [CDI] toxins .NP [Nurse Practitioner] made aware; resident placed on contact isolation . Review of a Physician's Order dated 12/5/2022, showed .Contact Isolation every shift for C-DIFF [CDI] . Review of the Care Plan dated 12/5/2022, showed .C-Diff .Contact isolation 120422 [12/4/2022] .Staff and visitors to follow precaution, wear gloves, mask, gown, face shield . During an observation on 12/5/2022 at 9:42 AM, an isolation cart was outside of Resident #115's room (on the 500 unit). No signage was posted that indicated Resident #115 was on transmission-based precautions. Phlebotomist #1 entered Resident #115's room and obtained a laboratory specimen. Phlebotomist #1 wore a mask, gloves, and eye protection during the resident care interaction. Licensed Practical Nurse (LPN#1) informed Phlebotomist #1 during the resident care interaction that the resident was on contact isolation for C-diff and Phlebotomist #1 stated .no one told me . Review of facility documentation dated 12/5/2022, showed Phlebotomist #1 obtained laboratory specimens from 11 residents on 12/5/2022. During an interview on 12/5/2022 at 9:51 AM, Phlebotomist #1 stated she was not employed by the facility and had come to the facility to obtain labs. The phlebotomist stated she was informed that a mask and eye protection was required at all times on the 500 unit. Phlebotomist #1 confirmed she did not wear a gown when she obtained Resident #115's laboratory specimen and stated .I didn't know to wear them .I didn't know she was in isolation for c.diff. [CDI] . During an observation and interview, outside of Resident #115's door, on 12/5/2022 at 10:08 AM, LPN #1 confirmed Personal Protective Equipment (PPE) required for residents in transmission-based precautions was communicated via signage on the resident's door. LPN #1 confirmed Resident #115 was in contact isolation for c.diff and PPE required for the care of Resident #115 included mask, gown, gloves, and eye protection. The LPN confirmed no signage was present on Resident #115's door that indicated the resident was on contact isolation and required mask, gown, gloves, and eye protection during resident care interactions. During an observation and interview on 12/5/2022 at 11:30 AM, outside Resident #115's room, the DON confirmed no signage was present that indicated the resident was in contact isolation and what PPE was required. The DON confirmed residents in isolation required additional PPE to prevent the spread of infection and additional PPE required was communicated to anyone who entered the room via signage posted on a resident's door. During an interview on 12/5/2022 at 4:00 PM, the DON confirmed appropriate infection control practices were not maintained for Resident #115.

Based on review of facility policy, review of facility documentation, observation and interview, the facility failed to ensure dish machine water temperatures and sanitation levels were consistently and accurately checked and documented with each use potentially affecting 109 of 109 residents. The findings included: Review of a facility policy Sanitation Cleaning Dishes/Dish Machine created 2013 showed .all flatware, serving dishes and cookware will be washed, rinsed, and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation .prior to use, run the machine until verification of proper temperatures and machine function is met .staff should check the dish machine gauges throughout the cycle to assure proper temperatures .Low Temperature Dishwasher .Wash Temperature 120 degrees F [Fahrenheit] .Sanitation 50 ppm [parts per million] Hypochlorite . Review of a facility policy Dish Machine-Temperature Log not dated showed .Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes .the food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process .staff will be trained to record dish machine temperatures for the wash and rinse cycle at each meal . Review of the facility's dish machine temperature logs dated 12/2021- 9/30/2022 with exception of January 2022 and April 2022 which were not available for review, showed the facility was using a temperature log for a high temperature dish machine and recorded temperatures according to the acceptable range listed on the log for a high temperature dish machine. Review showed the Sanitizer PPM range was correct for the dish machine. The sanitizer PPM was not recorded in June 2022 on the following days: 6/1/2022,6/2/2022 , 6/3/2022, 6/4/2022, 6/5/2022, 6/6/2022 or 6/7/2022 at lunch and dinner. The sanitizer PPM was not recorded in September 2022 on the following days: 9/19/2022, 9/20/2022, 9/21/2022, 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022, 9/27/2022, 9/28/2022. Review showed on 9/28/2022 the breakfast dish machine temperature and sanitizer PPM were recorded but not lunch or dinner. On 9/29/2022 and 9/30/2022 no water temperature or sanitizer PPM was recorded breakfast, lunch, or dinner. In October 2022 no water temperatures or sanitizer PPM was recorded on the following days: 10/12/2022, 10/13/2022, 10/14/2022, 10/15/2022, 10/16/2022, 10/17/2022 and 10/18/2022 for lunch or dinner. Observation/interview with the Dietary Manager on 10/24/2022 at 8:30 AM, in the dish room, of the dish machine in operation showed the wash temperature was 130 degrees F, the rinse temperature was 129 degrees F and the sanitizer was 100 PPM. Observation of the manufacture recommendation face plate showed the wash temperature should be minimum 120 degrees F, rinse temperature minimum should be 120 degrees F, and sanitizer should be minimum 50 PPM available chlorine rinse. During an interview with Dietary Cook #1 on 10/24/2022 at 9:00 AM, she stated .I think the temperatures were just being written down, I did record temperatures on 9/21/2022 and 9/22/2022. I cannot tell you for sure that I check the temperature gauge . During an interview with Dietary Aide #1 on 10/24/2022 at 9:15 AM, she stated .I am going to be honest. I just wrote down what I thought it should be. I did look at the log and wrote the temperatures between the ranges in between. I did not check the sanitizer with the strips, and I have not been shown how to do that . During an interview with the Dietary Manager on 10/24/2022 at 9:20 AM, he stated the low temperature dish machine was installed on 12/3/2021 and the temperature logs were not changed to reflect the low temperature machine manufacturer recommendations and the Dietary staff and the Dietary Manager continued to record dish machine temperatures according to the recommendation of the high temperature dish machine instead of checking the temperature gauge and recording the correct temperatures. The Dietary Manager stated when he worked in the dish room he did check the sanitizer to ensure it was at minimum 50 PPM .it is my expectation that all temperatures .machine temperatures and sanitizer .should be recorded during each wash service after each meal . During the interview the Dietary Manager confirmed the sanitizer PPM and dish machine temperatures were not recorded consistently and accurately. During an interview with the Service Technician on 10/24/2022 at 11:45 AM, he stated .I am at the facility every other Monday to deliver chemicals. I check the temperatures in the kitchen and in laundry as well as the sanitizer, but I only do a service report monthly .the low temperature machine was installed on December 3, 2021, my service reports for the dish machine for January-September 2022 show water temperatures in the kitchen ranged from 125-135 and sanitizer 50 PPM. They are just not looking at the gauge on the machine for the accurate temperature. The temperature should be between 120-135, and sanitizer 50-100 PPM . During an interview with Dietary Aide #2 on 10/24/2022 at 3:30 PM, she stated .I have a bad habit of forgetting to check the temperature gauge on the dish machine, and not checking the sanitizer. I didn't know I was supposed to check the sanitizer until a couple of weeks ago. I have just been writing down temperatures on the log . During an interview with Dietary Aide #4 on 10/24/2022 at 3:45 PM, he stated .I have just been recording temperatures, but I don't check it. I am always in a hurry, or I forget. I have been checking and recording the sanitizer since we got the new machine . During an interview with Dietary Aide #3 on 10/24/2022 at 3:55 PM, she stated .I have only been here a couple of weeks and I have not checked or recorded temperatures or sanitizer since I have been here . During an interview with the Administrator on 10/25/2022 at 1:30 PM, he stated .We got a low temperature dish machine on December 4th, 2021 .the dietary staff continued with the high temp log. The dietary staff was not checking the temperature gauge on the dish machine to ensure adequate temperature and sanitation. My expectation would be temperatures and sanitizer would be checked and recorded with every meal service and logged with the actual temperature on the gauge and actual sanitizer level obtained and logged . During the interview the Administrator confirmed the facility failed to accurately and consistently obtain and document dish machine temperatures and sanitizer PPM since 12/4/2021.

Based on observation and interview, the facility failed to maintain resident rooms and hallways in good condition for 18 resident rooms (101, 102, 105, 203, 204, 213, 301, 302, 307, 308, 401, 402, 403, 406, 502, 505, 508, and 509) of 20 rooms observed of 60 total rooms and 5 of 5 hallways observed. The findings included: Observation with the Maintenance Director on 9/13/2022 at 10:45 AM, 20 of 60 total resident rooms were checked with 18 rooms found needing repair of either paint, drywall repair, wallpaper repair, molding repair, or window shades/blinds replaced or repaired. Sides of the room are identified as A side of the room is near the hallway, B side is near the outside window: room [ROOM NUMBER] was observed to have multiple areas on the walls in which the paint was peeling and chipped and the window shade had uneven blades. room [ROOM NUMBER] A side had spots of primer at the head of the bed and nail holes in the wall. room [ROOM NUMBER] A side was observed to have paint peeling at the head of the bed and behind the door. The paint was scuffed with black marks and peeling. room [ROOM NUMBER] the window shade had multiple broken blades, walls were scuffed with black marks and different colors of paint had been used for some wall repairs. room [ROOM NUMBER] had wallpaper with areas where white primer had been used and B side wall had scuffs and peeling paint. room [ROOM NUMBER] B side had a large area of wall board behind the bed unpainted, A side had areas of primer at the head of the bed, paint peeling on the wall by the door, and the window shade had multiple broken blades. On A side the wall was scratched and chipped, there was paint peeling observed above the air conditioner unit and holes in the wall behind the door were observed. room [ROOM NUMBER] A side walls were scuffed, had black marks and the window shade had multiple broken blades. room [ROOM NUMBER] was observed to have a window shade with multiple broken blades and the A side wall had scratched paint that was chipped and peeling. room [ROOM NUMBER] was observed to have a window shade with multiple blades broken and A side at the head of the bed had paint peeling and chair rail scratched and chipped. room [ROOM NUMBER] A side had a large area of paint and drywall that was peeled and the wall above the bedside chest was scratched and had black marks. room [ROOM NUMBER] A side wall was scuffed with black marks, observed paint that was scratched and peeling and black marks above the bedside chest. room [ROOM NUMBER] was observed to have a window shade with multiple broken blades, A side wall was scuffed at the head of the bead and chair railing was busted and broken. room [ROOM NUMBER] both A and B side were observed with large paint scratches with multiple long black and blue marks. room [ROOM NUMBER] was observed to have a window shade with broken blades, A side paint was chipped and peeling and the chair molding was scratched. room [ROOM NUMBER] B side wall board at head of bed was not painted, the wall above the air conditioner unit was scratched and A side had nail holes noted in wall beside the bed. room [ROOM NUMBER] both A and B side were observed to have wallpaper peeling and the window shade had multiple blades broken. room [ROOM NUMBER] was observed to have a window shade with blades broken. Observation of all hallways were found to have peeling and chipped paint throughout the hallways. During an interview with the Maintenance Director on 9/13/2022 at 11:35 AM, he confirmed the facility failed to maintain resident rooms and hallways in good repair. During an interview with the Administrator on 9/13/2022 at 12:35 PM, he stated .I am aware of blinds that need to be replaced and or repaired .we have had a plan for wall repair, floor repair and replacement, but we have had some hiccups along the way .During COVID outbreaks we have continuously had room moves walls get damaged, door frames and chair rail gets damaged. Aesthetically it is not as pleasant as we would like it to be .

Based on review of a facility policy, facility investigation, medical record review, observations and interviews the facility failed to prevent abuse of 1 resident (#2) of 6 residents reviewed. The findings included: Review of a facility policy Abuse, Neglect and Exploitation of Residents not dated showed .It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse .Sexual abuse is the 'non-consenting contact of any kind' and includes but is not limited to sexual harassment, sexual coercion, or sexual assault .It is the moral and legal responsibility of all staff members to identify, prevent .suspected or witnessed abuse . Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia without Behavioral Disturbance, Osteoarthritis, Type 2 Diabetes Mellitus, and Generalized Anxiety. Medical record review of Resident #2's annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. No behaviors were noted during the assessment period. The resident required limited assistance of one person assist with bed mobility, transfer, walking, locomotion on/off the unit and dressing. Resident #2 required extensive assistance of 1 person assist for toilet use, personal hygiene, and required supervision with set-up for eating. Review of a facility investigation dated 8/15/2022 showed on the morning of 8/15/2022 at approximately 9:45 AM, the Administrator/Abuse Coordinator, Director of Nursing (DON) and Social Service Director were made aware of a sexual abuse allegation of a male resident toward a female resident. The allegation came from a dietary employee. The employee stated that on the morning of 8/14/2022 at approximately 9:45 AM, a dietary co-worker approached her and stated he had just witnessed a male resident (Resident #3) put his mouth on a female resident's (Resident #2) nipple. The dietary staff was uncomfortable approaching the two residents and went to the Dietary Cook. The Dietary Cook also witnessed the same act. The Dietary Cook went to the weekend house supervisor setting at the nurse's station nearby to report the incident. The Dietary Cook stated the supervisor immediately went to where the residents were sitting assessed the situation, separated them, and returned to the nurse's station. The Dietary Cook reported approximately 10-15 minutes later she looked up and saw Resident #2 with her hand in/around the genital area of Resident #3 and stated it looked like to her Resident #3 was placing Resident #2's hand in that area. She went a second time and again reported the incident to the supervisor. The Dietary Cook stated the house supervisor immediately went to the dining room, assessed the situation and the residents, spoke briefly with them, and separated them. A head-to-toe assessment was completed on Resident #2 on 8/15/2022 by the DON findings were .skin reveals no sigh of trauma, redness, swelling bruising, skin tear or scratches noted. Skin is thin and fragile, but appears well hydrated, soft with rapid turgor. No trauma bruising, redness, swelling, tears, or scratches noted to trunk or chest area, as well as no notation of same to peri-area or buttocks . Medical record review of Resident #2's Social Service Note dated 8/15/2022 showed .it was observed that a male resident [Resident #3] and [Resident #2] had inappropriate conduct over the weekend. SW [social worker] interviewed [Resident #2]. She did not verbalize recognizing any type of inappropriateness at all. She was seen by psych [psychiatric] NP [Nurse Practitioner] with no s/s [signs/symptoms] of said incident/conduct . Medical record review of Resident #2's Psych Nurse Practitioner NP Progress Note dated 8/15/2022 showed .Staff requests follow-up due to psychotropic medication use; resident to resident incident .Staff report incident of resident-to-resident interaction with sexually inappropriate behavior. Male resident was noted to have resident's breast in his mouth . Observation/interview with Resident #2 on 9/12/2022 at 8:50 AM, showed the resident seated in a wheelchair in the hallway, she was well groomed, dressed appropriately in street clothes. No anxious or fearful behaviors were observed. During the interview the resident was pleasant, smiled, stated she was doing okay but was not able to answer questions appropriately related to the alleged incident. Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Alcohol Dependence, Muscle Weakness, Poisoning by Hydantoin Derivatives Accidental Unintentional, Attention and Concentration Deficit, and Epileptic Seizures. Medical record review of Resident #3's comprehensive care plan dated 7/27/2022 showed .has potential for alteration in mood and behaviors related to alcohol dependence .administer medications as ordered, cue and prompt as needed, pharmacy and Psych Service to review for lowest effective dose .remove from area of root cause of increased behaviors . Medical record review of Resident #3's admission MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment, no behaviors were observed during the assessment period. The resident required limited assistance with one person assist for bed mobility, transfer, walk in room, locomotion on unit, dressing, personal hygiene and extensive assist of one person for toilet use. Medical record review of Resident #3's Psych NP Progress Note dated 8/15/2022 showed .when I entered the building this AM, resident was noted to be sitting outside, slightly irritable. Then, I was informed of resident-to-resident incident where this resident had a female resident breast in his mouth. He was approached by the facility Administrator to investigate the incident, and he became irate, and stated he was going to leave the building AMA [against medical advice] I approached the resident and he told me he was leaving, stating 'let me out his [this] door.' I explained that I could not let him out. He then began to curse me, he became more anxious, had arisen from his wheel chair and was standing at the door .I asked if he had anyone to come and get him to a safe environment .he became increasingly agitated, and was not amenable to redirection .Based on his initial evaluation, the current level of agitation and ongoing discussion of his past physical violence, the decision was made to call the police for the resident safety. Police arrived and resident was taken to the emergency room where a report was called of resident's status and behaviors .Resident to ER [emergency room ] to address ongoing anxiety and potential aggressive behaviors . Medical record review of Resident #3's BIMS note dated 8/15/2022 showed .BIMS completed today. BIMS score 10. Category is moderately impaired . Medical record review of Resident #3's Social Service Note dated 8/15/2022 showed .had inappropriate conduct with a female resident over the weekend, upon being interviewed, he became belligerent, agitated and demanding to leave the facility. Police was notified. He went to the ER willingly for an evaluation. Brother .notified . During an interview with the Dietary Cook on 9/12/2022 at 9:30 AM, she stated .[Dietary Aide #1] and [Dietary Aide #2] told me to come look, they were washing dishes with the door open. I was in the back when I came up there, I saw [Resident #3] had her shirt up and [Resident #2] breast in his mouth. I said to myself 'oh hell no'. I ran to the dining room, I told the male resident to stop and went to the nurses' station right outside the dining room to tell someone something was going on. I told [Registered Nurse (RN) #2] the nurse in charge on the weekends. I told him that this guy is sucking on her breast, and you need to get him out of here. He said 'what is going on?', I told him again. He goes to them and says, 'scoot, go away from each other, stay apart' but the resident had stopped but her breast was still out of her shirt. Then about 15 minutes later I see them at the nurses' station in their wheelchairs he had her hand and was trying to get her to touch his penis. I was in the dining room, and I was knocking on the glass window to get [RN #2's] attention so he could see what was going on. [RN #2] was at the nurses' station, he had to get up to see what was going on. I said 'they are at it again', by the time he got to them they had stopped cause, it took him a minute to get up and check on them. He told them 'you guys need to go back to your room' .By this time, I was feeling she had been molested. I thought he should at least call the police . During an interview with Dietary Aide #2 on 9/12/2022 at 9:55 AM, she stated .I was in the dish room I was putting up dishes. The male resident came in the dining room they were setting beside each other in their wheelchairs. At first, I didn't think anything but then he put his arm around her. I asked [Dietary Aide #1] if they were allowed to do that. He said it was okay for them to have a relationship. I went out to put up dishes and came back in the dish room and he said 'hey, look at that'. The male resident had lifted the female resident's shirt, it looked like he was kissing on breast. I went and told [Dietary Cook] and she went and told [RN #2]. I did get education on abuse when I started but I didn't remember what to do except to report it. The female resident was not any distress she was just sitting there, but I knew that wasn't right. After that [RN #2] separated them. They were in the hallway by the coke machine in front of the nurses' station, it looked like he took her hand and placed it on his penis on top of his gown. I went back to the kitchen and told [Dietary Cook] and she went and told [RN #2] again. I think they separated them, but I don't know anything after that . During an interview with Dietary Aide #1 on 9/12/2022 at 10:25 AM, he stated .I was in the dish room, the residents were in the dining room, we [myself and Dietary Aide #2] saw him have her shirt up over her breast. He was groping and sucking on her breast. I went and told [Dietary Cook] she went and told [RN #2]. I did get abuse in service when I was hired. It happened all of a sudden, [Dietary Cook] was right there, and I told her. I didn't think about separating the residents .I didn't see anything else . During an interview with RN #2 on 9/12/2022 at 1:40 PM, he stated .I was at the nurses' station doing an in-service with a corporate person. [Dietary Cook] came to me and said someone needs to be separated, I stood up and said 'who?' and walked to the dining room. The female resident was sitting at a dining room table, and [Resident #3] was about 10 feet away from her and was continuing to roll away from her. I did not see her shirt raised exposing her breast. The second time [Dietary Cook] came to the desk she said they are back together again. I got up and walked around the desk this time he was further than 15 feet away from [Resident #2]. I told him he needed to go back to his room, and he did. I never heard not one word about sexual contact, or abuse in any form .I know [Resident #3] stayed on his hall the rest of my shift . During an interview with the Administrator on 9/12/2022 at 3:35 PM, he stated, .on the morning of the 15th the Dietary Supervisor .called me and reported an allegation of abuse that a dietary aide had reported to him. The incident occurred on 8/14/2022 at approximately 9:45 AM, in the dining room . During an interview with the Administrator on 9/13/2022 at 2:00 PM, the Administrator confirmed the facility had substantiated the allegation of sexual abuse of Resident #2.

Based on review of a facility policy, facility investigation, medical record review, observation, and interview the facility failed to report an allegation of abuse within the required 2-hour timeframe for 1 resident (#2) of 6 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect and Exploitation of Residents not dated showed .It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited .It is the moral and legal responsibility of all staff members to .report suspected or witnessed abuse .to their immediate supervisor on site, or social worker immediately .This will be subsequently be reported to the Administrator/DON [Director of Nursing]/designee .Once an allegation of abuse has been made the supervisor who initially received the report must inform the Administrator/Director of Nursing .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulations Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia without Behavioral Disturbance, Osteoarthritis, Type 2 Diabetes Mellitus, and Generalized Anxiety. Medical record review of Resident #2's annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. No behaviors were noted during the assessment period. The resident required limited assistance of one person assist with bed mobility, transfer, walking, locomotion on/off the unit, dressing and required extensive assistance of 1 person assist for toilet use and personal hygiene. Review of a facility investigation dated 8/15/2022 showed on the morning of 8/15/2022 at approximately 9:45 AM, the Administrator/Abuse Coordinator, Director of Nursing and Social Service Director were made aware of a sexual abuse allegation from a male resident toward a female resident. The allegation came from a dietary employee. The employee stated that on the morning of 8/14/2022 at approximately 9:45 AM, a dietary co-worker approached her and stated he had just witnessed a male resident [Resident #3] put his mouth on a female resident's [Resident #2] nipple. The dietary staff was uncomfortable approaching the two residents and went to the Dietary Cook. The Dietary Cook had also witnessed the same act. The Dietary Cook reported what was witnessed to the weekend house supervisor. The Dietary Cook stated the supervisor immediately separated the residents and returned to the nurse's station. The dietary Cook reported approximately 10-15 minutes she looked up and saw Resident #3 with her hand in/around the genital area of Resident #3 and stated it looked like to her Resident #3 was putting Resident #2's hand in that area. She went a second time and again reported the incident to the supervisor. The Dietary Cook stated the house supervisor immediately went to the dining room and separated the residents a second time. Medical record review of Resident #2's Social Service Note dated 8/15/2022 showed .it was observed that a male resident [Resident #3] and [Resident #2] had inappropriate conduct over the weekend. SW [social worker] interviewed [Resident #2]. She did not verbalize recognizing any type of inappropriateness at all. She was seen by psych [psychiatric] NP [Nurse Practitioner] with no s/s [signs/symptoms] of said incident/conduct . Observation/interview with Resident #2 on 9/12/2022 at 8:50 AM, showed the resident seated in a wheelchair in the hallway, she was well groomed, dressed appropriately in street clothes. No anxious or fearful behaviors were observed. During the interview the resident was pleasant, smiled, stated she was doing okay but was not able to answer questions appropriately related to the alleged incident. Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Alcohol Dependence, Muscle Weakness, Poisoning by Hydantoin Derivatives Accidental Unintentional, Attention and Concentration Deficit, and Epileptic Seizures. Medical record review of Resident #3's admission MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment, no behaviors were observed during the assessment period. The resident required limited assistance with one person assist for bed mobility, transfer, walk in room, locomotion on unit, dressing, personal hygiene and extensive assist of one person for toilet use. Medical record review of Resident #3's BIMS note dated 8/15/2022 showed .BIMS completed today. BIMS score 10. Category is moderately impaired . Medical record review of Resident #3's Social Service Note dated 8/15/2022 showed .had inappropriate conduct with a female resident over the weekend, upon being interviewed, he became belligerent, agitated and demanding to leave the facility. Police was notified. He went to the ER [emergency room ] willingly for an evaluation. Brother .notified . During an interview with the Dietary Cook on 9/12/2022 at 9:30 AM, she stated she was informed by Dietary Aide #1 and Dietary Aide #2 of an allegation of abuse involving Resident #3 and Resident #2. The Dietary Cook stated she went to the Dining Room and had seen Resident #3 had Resident #2's breast in his mouth. The Dietary Cook told Resident #3 to stop and then reported what was seen to the weekend house supervisor (Registered Nurse [RN] #2). The Dietary Cook stated RN #2 told the residents to separate. Continued interview revealed the Dietary Cook stated approximately 15 minutes later she observed the two residents again at the nurse's station and witnessed Resident #3 place Resident #2's hand on his penis. The Dietary Cook stated she again reported what was seen to RN #2 and he separated the residents a second time. During an interview with Dietary Aide #2 on 9/12/2022 at 9:55 AM, she stated .it looked like he [Resident #3] was kissing on [Resident #2's] breast . and stated she reported what was observed to the Dietary Cook who then reported the allegation to RN #2 who separated the residents. Dietary Aide #2 stated she then saw what looked like Resident #3 placing Resident #2's hand on his penis and she again reported that to the Dietary Cook who again reported what was witnessed to RN #2. During an interview with Dietary Aide #1 on 9/12/2022 at 10:25 AM, he stated .I was in the dish room, the residents were in the dining room, we [myself and Dietary Aide #3] saw him [Resident #3] have her [Resident #2's] shirt up over her breast. He was groping and sucking on her breast. I went and told [Dietary Cook] she went and told [RN#2] . During an interview with RN #2 on 9/12/2022 at 1:40 PM, he stated the Dietary Cook reported to him that two residents needed to be separated. RN #2 stated he went to the dining room and observed Resident #2 and Resident #3 and stated Resident #3 was .about 10 feet away . from Resident #2. RN #2 stated he did not observe Resident #2's shirt up or that her breast was exposed. RN #2 stated the Dietary Cook did report a second incident to him and denied he was informed there was observed sexual contact between the residents. During an interview with the Administrator on 9/12/2022 at 3:35 PM, he stated, .on the morning of the 15th the Dietary Supervisor called me and reported an allegation of abuse that a dietary aide had reported to him. The incident occurred on 8/14/2022 at approximately 9:45 AM, in the dining room . During an interview with the Dietary Supervisor on 9/12/2022 at 5:15 PM, he stated .I didn't know the day of the incident but when [Dietary Cook] reported it to the nurse she thought it was taken care of. At 6:00 AM on 8/15/2022 [Dietary Cook] reported to me [Resident #2] and [Resident #3] were in the dining room and her shirt was up and he was touching her breast. The second time was close to the nurses' station, and he took her hand and put it on his genitals. She said she reported to the nurse, but it didn't seem like it got anywhere but the nurse and stopped, so she felt like I should call the Administrator to ensure he knew, so I did . During an interview with the Administrator on 9/13/2022 at 2:00 PM, he stated .I have an all staff meeting every month and go over who is the Abuse Coordinator, what do when you see abuse or think abuse has occurred. We did specific abuse education in May .As soon as I was made aware we started our investigation, but unfortunately if I don't know something I can't do anything about it .I received a phone call from .the Dietary Supervisor on 8/15/2022 he informed me of what the Dietary Cook told him . During the interview the Administrator confirmed the facility had not reported the incident timely as required but stated the investigation had been started immediately when he was made aware of the allegation.

Based on review of a facility policy, medical record review, interview and observation, the facility failed to provide showers as scheduled for 3 residents (#4, #5 and #1) of 7 residents reviewed for Activities of Daily Living. The findings included: Review of a facility policy Bath, Shower not dated showed .The purposes of this procedure are to promote cleanliness . Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's shower schedule showed Resident #4 was to receive a shower on Tuesday, Thursday and Saturday on day shift. Review of Resident #4's Shower Look Back Report dated 1/10/2022-2/7/2022 showed the resident did not receive a shower on 1/11/2022, 1/25/2022, 1/27/2022, and 1/29/2022, missing 4 of 13 scheduled showers. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's shower schedule showed Resident #5 was to receive a shower on Tuesday, Thursday and Saturday on day shift. Review of Resident #5's Shower Look Back Report dated 1/10/2022-2/7/2022 showed Resident #5 did not receive a shower on 1/11/2022, 1/25/2022, 1/27/2022, and on 1/29/2022, missing 4 of 13 scheduled showers. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's shower schedule showed Resident #1 was to receive a shower on Tuesday, Thursday and Saturday on day shift. Review of Resident #1's Shower Look Back Report dated 1/10/2022-2/7/2022 showed Resident #5 did not receive a shower on 1/11/2022, 1/27/2022, 2/3/2022, and on 2/5/2022, missing 5 of 13 scheduled showers. During an interview with Registered Nurse (RN) #1 on 2/8/2022 at 8:45 AM, she stated .I work the 400 hall and we are able to meet resident needs timely. Showers are a challenge, but we are able to get them done most of the time. If not ,we offer bed baths or pass it on to the next shift . During an interview with Certified Nursing Assistant (CNA) #1 on 2/8/2022 at 9:33 AM .I am to answer to call lights timely unless you get tied up with a resident .I got a complaint yesterday 2 ladies [Resident #4, #5] stated they had not gotten their shower in about a week. I got one of them this morning and I will do the other after breakfast. That is the only complaint I've had . During an interview with RN #2 on 2/8/2022 at 10:10 AM she stated .I do work the floor on nights and weekends as needed .we do have staffing challenges, the facility does try to fill those slots .but showers are sometimes not done . Observation of Resident #4 on 2/8/2022 at 10:35 AM, in the hallway outside of her room door, showed the resident to be seated in a wheelchair she was well groomed, dressed appropriately for location and temperature. No odors or signs of incontinence were observed. During an interview with Resident #4 on 2/8/2022 at 10:35 AM, in the hallway outside of her room door, she stated she had missed some of her showers during the last month, but she had received a shower earlier this morning. Observation of Resident #5 on 2/8/2022 at 10:45 AM, in her room, showed the resident to be seated in a wheelchair she was awake and alert, well groomed, and no odors or signs of incontinence were identified. During an interview with Resident #5 on 2/8/2022 at 10:45 AM, in her room, she stated .I hadn't received a shower in a week. They are doing better but it does get missed sometimes .Actually, showers have been pretty good up until this week . Observation of Resident #1 on 2/8/2022 at 11:10 AM, in the hallway right outside of her room, showed the resident to be seated in a wheelchair she was awake, alert, and well groomed. No odors or signs of incontinence were observed. During an interview with Resident #1 on 2/8/2022 at 11:10 AM, in the hallway right outside of her room, she grinned at this surveyor and stated, I was doing fine until I had to answer all of your questions During the interview she stated she received good care and she had no concerns. During an interview with Certified Nursing Assistant (CNA) #3 on 2/8/2022 at 11:15 AM, she stated .as a whole I can meet my resident needs within a timely manner, there are times when something slows you down and puts you behind, showers do get pushed toward the end of the shift, but I can usually get them done if I don't get the shower done I at least do a bed bath, if I absolutely can't get it done I pass it on to night shift and they let you know in report the next day if they were able to do it or not . During an interview with the Director of Nursing (DON) on 2/9/2022 at 11:30 AM, she stated .I have received concerns about showers not being completed as scheduled, there is a shower schedule when we identify a staffing concern, we look at the showers scheduled and what showers could be moved to the following shift, but the resident is included in the decision, also no showers are scheduled on Sunday, and we utilize it for a make-up day. We also have recently offered shorter shifts for CNAs on their off day to come in and focus only on providing showers. If the CNA is unable to complete shower, she is to report it to the nurse, and it is communicated to the oncoming shift. CNAs are to report any refusal of shower. My expectation is that residents receive a minimum of 3 showers or bed baths weekly . During the interview the DON confirmed 3 residents #1, #4 and #5 had not received their showers as scheduled during the last 30 days.

Based on facility policy review, observation, and interview, the facility failed to follow infection control practices on 2 of 5 hallways observed which had the potential to result in Coronavirus (COVID-19) transmission. The findings include: Review of the facility's policy titled, COVID-19, dated 6/11/2020, showed .adhere to Federal and State/Local recommendations to include .Precautions: Standard, Contact, Droplet including the use of Personal Protective Equipment (PPE) . Yellow Zones are comprised of new admissions, symptomatic, suspected positive and potentially exposed residents. Required PPE for Yellow Zone staff includes .N-95 Mask .Eye Protection .Gloves for care .Gown for direct care workers . Observation of the 500 Hallway entrance signage on 1/5/2021 at 9:18 AM, showed .Yellow Zone .Contact Precautions .Put on gloves upon room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person .Droplet Precautions .Make sure .eyes, nose and mouth are fully covered before room entry . Observation on the 500 Hall on 1/5/2021 at 9:23 AM, showed Physical Therapy Assistant (PTA) #1 assisting a resident with positioning and ambulation. PTA #1 exited the resident's room without removing gown and gloves, sanitized the walker, entered an empty resident room to store the walker, and returned to the resident's room to discard gown and gloves. During an interview on 1/5/2021 at 9:25 AM, PTA #1 confirmed she had not discarded her gown and gloves before exiting the resident's room. Observation of the 200 Hallway entrance signage on 1/5/2021 at 9:40 AM, showed .Yellow Zone .Contact Precautions .Put on gloves upon room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person .Droplet Precautions .Make sure .eyes, nose and mouth are fully covered before room entry . Observation on the 200 Hall on 1/5/2021 at 9:42 AM, showed Physical Therapist (PT) #1 assisting a resident with positioning and ambulation without eye protection. During an interview on 1/5/2021 at 9:50 AM, PT #1 stated that N-95 mask, eye protection, gown and gloves should be worn for direct contact with residents in the Yellow Zone. PT #1 confirmed she was not wearing facility provided eye protection during direct contact with a resident. During an interview on 1/5/2021 at 12:10 PM, the Director of Nursing confirmed the observations were breaches in Yellow Zone infection control practices. PTA #1 was to discard gown and gloves before exiting the resident's room and PT #1 was to wear eye protection during direct contact with the resident.

Based on facility policy review, medical record review, grievance report review, and interviews, the facility failed to immediately report an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse. The findings include: Review of the facility policy FREEDOM OF ABUSE, NEGLECT AND EXPLOITATION STANDARD revised 11/2017, revealed .Report allegations or suspected abuse .immediately to: Administrator, Other Officials in accordance with State Law .Reporting-All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation .of resident abuse .investigation can be undertaken promptly .The Director of Nursing Services, Administrator, or designee will .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed Resident #33's Brief Interview for Mental Status score was 11 of 15, indicating the resident had moderate cognitive impairment. Review of a GRIEVANCE/CONCERN/COMMENT REPORT dated 8/5/19, not timed, revealed .(Resident #33) .Person Reporting: Dtr (Daughter) .I have witnessed tech, (Certified Nurse Assistant (CNA) #2) .talk ugly to my Dad. He has verbalized that he is scared of her. She is hateful . Continued review revealed the grievance form was signed by the Social Service Director. Interview with the Social Service Director on 8/7/19 at 9:00 AM, in the conference room, revealed on 8/5/19 a grievance was turned in by Resident #33's daughter. Continued interview revealed the Resident's daughter reported to the Social Service Director that CNA #2 had been hateful and the resident was scared of CNA #2. Further interview confirmed the Social Service Director reported the grievance to the Director of Nursing (DON) the morning of 8/6/19 (1 day later). Interview with the Administrator on 8/7/19 at 12:15 PM, in the Administrator's office, confirmed the facility failed to report an allegation of abuse to the Administrator and the State Survey Agency within 2 hours.

Based on facility policy review, medical record review, grievance report review, and interviews, the facility failed to initiate an immediate investigation of an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse. The findings include: Review of the facility policy FREEDOM OF ABUSE, NEGLECT AND EXPLOITATION STANDARDS, revised 11/2017, revealed .This facility will conduct a comprehensive investigation of any employee suspected of abuse .of residents and will implement disciplinary action according to company policy. Any employee, who is accused of resident abuse .will be suspended at the time of allegation, pending further investigation .INVESTIGATION: OF ALLEGED ABUSE .When .reports of abuse .occur, an investigation is immediately warranted .All alleged violations involving .abuse .will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed Resident #33's Brief Interview for Mental Status score was 11 of 15, indicating the resident had moderate cognitive impairment. Review of a GRIEVANCE/CONCERN/COMMENT REPORT dated 8/5/19 revealed .(Resident #33) .Person Reporting: Dtr (Daughter) .I have witnessed tech, (Certified Nurse Assistant (CNA) #2) .talk ugly to my Dad. He has verbalized that he is scared of her. She is hateful . Continued review revealed the grievance form was signed by the Social Service Director. Interview with the Administrator on 8/6/19 at 5:17 PM, outside the conference room, confirmed he had been made aware of the allegation of abuse to Resident #33 reported by the resident's daughter on 8/5/19. Interview with the Social Service Director on 8/7/19 at 9:00 AM, in the conference room, confirmed the grievance was turned in by Resident #33's daughter on 8/5/19. Further interview confirmed an investigation was not initiated by the facility at time the grievance was reported on 8/5/19. Interview with the Administrator and Director of Nursing (DON) on 8/7/19 at 12:15 PM, in the Administrator's office, revealed the DON was made aware of the grievance the morning of 8/6/19. Continued interview revealed an investigation was not initiated until the evening (unknown time) of 8/6/19 (1 day later). Further interview revealed the facility did not initiate an immediate investigation and the facility failed to follow the facility policy.

Based on facility policy review, observation, and interview, the facility failed to perform proper hand hygiene after providing direct resident care for 1 resident (#32) of 3 residents during resident care of 17 sampled residents. The findings include: Review of the facility policy Hand Hygiene, revised 2011, revealed .Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections .waterless handwashing products. If hands are not visibly soiled, use an alcohol based hand tub for routinely decontaminating hands in all clinical situations . Observation of Certified Nursing Assistant (CNA) #3 on 8/6/19 at 2:58 PM, in the resident's room, revealed after CNA #3 donned gloves to provide peri-care (personal hygiene care) to Resident #32. Continued observation revealed the CNA then assisted the resident to bed, adjusted the resident's call light, removed the contaminated gloves, and without washing the hands, took a lift device out of the resident's room, and placed it into the 200 hall bathroom. Interview with CNA #3 on 8/6/19 at 3:10 PM, in the 200 Hall bathroom, confirmed she did not perform hand hygiene after removing the gloves. Interview with the Infection Prevention Nurse on 8/07/19 at 7:30 AM, on the 100 Hall, confirmed staff was expected to perform hand hygiene after removing gloves. Continued interview confirmed the facility failed to follow facility policy.

Based on facility policy review, observation, and interview the facility failed to ensure expired foods were not available for resident use in 2 of 2 refrigerators, 1 of 1 stock rooms, and 1 of 1 nourishment refrigerators, and failed to ensure kitchen equipment and floors were maintained in a clean and sanitary manner in 2 of 3 kitchen observations potentially affecting 66 of 66 residents in the facility. The findings included: Review of the facility policy FOOD STORAGE LABELING revised ,[DATE] revealed .The facility will ensure the safety and quality of food by following good storage labeling procedures .All temperature controlled foods and ready to eat foods .will be labeled .Name of the Food .Date of storage .Date by which it should be eaten or discarded (USE BY DATE) . Review of the facility policy SANITARY CONDITIONS OF THE DINING SERVICE DEPARTMENT undated revealed .Facilities equipment used .are safe and sanitary .Cleaning Program .The dietary manager develops a master cleaning schedule that includes .What should be cleaned .when it should be cleaned .The dietary manager supervises the daily cleaning .conducts periodic spot inspections .A sanitation checklist of the dining service will be conducted at least monthly .areas monitored for appropriate sanitation will include .Equipment . Review of the facility policy USE AND STORAGE OF FOOD BROUGHT IN BY FAMILY OR VISITOR revised ,[DATE] revealed .The facility may refrigerate label and dated prepared times in the nourishment refrigerator .If not consumed within 3 days, food will be thrown away . Observation on [DATE] at 10:30 AM, in the facility's produce and milk refrigerator and dry stock room, with the Interim Dietary Manager, revealed the following: - A 4 quart container ¼ full of sliced turkey in the produce refigerator with a prepare date of [DATE] and no used by date. - 1 pound of butter in a silver container covered with aluminum foil in the milk refrigerator with a prepared date of [DATE] and a use by date of [DATE], 9 days past use by date. - A 5 gallon bucket of flour ¼ full in the dry stock room with a use by date of [DATE], 31 days past use by date. Interview with the Interim Dietary Manager on [DATE] at 11:00 AM, in the dining room, confirmed food was stored in 2 refrigerators and 1 stock room with expired use by dates. Further interview revealed the food items were available for resident use. Observation on [DATE] at 8:35 AM, in the milk refrigerator and stock room, revealed the following: - A gallon of vitamin D milk ½ full in the milk refrigerator with a best by date of [DATE], 1 day past best buy date. - A 5 gallon container of corn meal ¾ full in the stock room with a use by date of [DATE], 26 days past use by date. Observation [DATE] at 10:30 AM and [DATE] at 8:45 AM, in the kitchen, revealed the following: - The oven had a greasy, sticky substance on the front door and knobs and a dark brown dry crusty debris covering the interior bottom of the oven. - The convection oven had brown debris on the interior bottom of the oven and a white substance splattered on the door. - Thick, greasy brown/black debris observed on the floor and wall between the 2 ovens. Interview with the Interim Dietary Manager on [DATE] at 8:55 AM, in the kitchen, confirmed the vitamin D milk was out of date and the corn meal had a use by date of [DATE] and both were available for resident use. Further interview confirmed the 2 ovens are to be deep cleaned weekly and the floors are to be swept & mopped daily. Continued interview confirmed the facility had no documentation the cleaning had been done. Interview with the Administrator on [DATE] at 9:35 AM, in the kitchen, confirmed .I recognize we need to make improvements and my expectation is for the new Dietary Manager to deep clean . Interview with the Certified Dietary Manager on [DATE] at 12:20 PM, in the kitchen, confirmed the ovens and floor needed a deep cleaning. Observation on [DATE] at 7:45 AM, in the nourishment room, with the Director of Nursing (DON) revealed a nourishment refrigerator for resident use with the following: - A sandwich sized container ¾ full of fruit salad for Resident #58 with no use by date. - A 1.1 liter container ¾ full of watermelon dated ,[DATE] and no use by date. - A plastic divided container with lettuce and tomatoes dated [DATE] with no use by date. - A medium size plastic container ½ full of a meat mixture for Resident #316 with no use by date. - A small container of pudding with an expiration date of [DATE] and a 4 oz (ounce) container of greek yougurt with an expiration date of [DATE] for Resident #416. - A 1.4 quart plastic container ¼ full of watermelon for Resident #29 with no use by date. - A small plastic container ½ full of watermelon dated [DATE] with no use by date. - 2 small plastic bags with 1 roll in each bag dated [DATE] with no use by date. - 3 dozen brown eggs with no use by or expiration date. Interview with the DON on [DATE] at 8:05 AM, in the nourishment room, confirmed food had either expired or had no use by dates in the resident's nourishment refrigerator and was available for resident use.

Based on facility policy review, medical record review, Pharmacy Recommendation review, and interview, the facility failed to perform lab tests ordered by the Physician for 1 resident (#24) of 5 residents reviewed for unnecessary medications. The findings included, Review of the facility policy LABORATORY PR[NAME]EDURES/OTHER DIAGNOSTIC SERVICES revised 2010 revealed .All tests will be completed as ordered . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with a re-admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #24's current Physician Recapitulation Orders dated 6/20/18 revealed .HA1C (a blood test that gives a 3 month average glucose level) every 6 months . Further review revealed a HA1C had been done on 8/22/17. Continued review revealed no documentation a HA1C had been done in (MONTH) (YEAR). Review of a Pharmacist Recommendation form dated 5/28/18 revealed .Please locate the following ORDERED LAB .A1c(HA1C) q (every) 6 months, .Last located A1c (HA1C) = 8/22/17 . Interview with Registered Nurse #1 on 6/20/18 at 8:55 AM, at the nurse's station confirmed, .(HA1C) not done in (MONTH) (YEAR) and not sure why . Interview with the Director of Nursing on 6/20/18 at 9:52 AM, in the conference room, confirmed the facility failed to follow the Physician orders to obtain a HA1C for Resident #24.