Every finding on record at Morrison Nursing Home

Based on observation, interview, and record review, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food storage temperatures for 1 out of 2 kitchen refrigerators and 1 of 3 kitchenette refrigerators observed. Findings include:Observation on 1/6/26 at approximately 9:25 a.m. of the [NAME] Wing Kitchenette Resident refrigerator revealed a temperature of 46 degrees F (Fahrenheit).Observation on 1/6/26 at approximately 10:50 a.m. of the Cook's refrigerator in the Main kitchen with Staff A (Dietary Manager) revealed that the temperature of 41.4 degrees F.Interview on 1/6/26 at approximately 10:50 a.m. with Staff A confirmed the above findings. Staff A further revealed that he/she was unaware of the out-of-range temperatures for the [NAME] Wing Kitchenette refrigerator or the Cook's refrigerator.Observation on 1/6/26 at approximately 12:55 p.m. of the Cook's refrigerator in the Main kitchen with Staff C (Dietary Aide) revealed that the temperature was 43.9 degrees F. Interview on 1/6/26 at approximately 12:55 p.m. with Staff C confirmed the above findings.Review on 1/8/26 of refrigerator temperature logs for the [NAME] Wing kitchenette revealed the following temperatures that were outside the acceptable range of 33-41 degrees Fahrenheit:12/1/25 42 degrees, 12/7/25 42 degrees, 12/8/25 44 degrees, 12/9/25 42 degrees, 12/11/25 42 degrees, 12/18/25 42 degrees, 12/19/25 42 degrees, 12/21/25 43 degrees, 12/22/25 42 degrees, 12/23/25 44 degrees, 12/25/25 42 degrees, 12/27/25 48 degrees, 12/28/25 50 degrees, 12/29/25 45 degrees, 12/30/25 48 degrees, 12/31/25 44 degrees, 1/1/26 44 degrees, 1/2/26 44 degrees, and 1/5/26 44 degrees.Interview on 1/8/26 at approximately 10:25 a.m. with Staff A revealed that he/she was not aware of any out-of-range temperatures for the [NAME] Wing Kitchenette refrigerator for December 2025 or January 2026Review on 1/7/26 of the Facility's policy title Preventing Foodborne Illness- Food Handling, revised August 2017, revealed the following: .5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require refrigerated food be stored below 41 degrees F .Review on 1/7/25 of the facility's policy titled Refrigerators and Freezers Policy, undated, revealed the following: . Kitchenettes . If fridge temp is not within proper range (33F-41F), it must be reported to the dietary manager and the maintenance personnel immediately If the fridge is above acceptable range (33F-41F) .Review on 1/8/26 of the Food and Drug Administration (FDA) Food Code, dated 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed the following: Certain foodborne pathogens that are anaerobes or facultative anaerobes are able to multiply under either aerobic or anaerobic conditions. Therefore special controls are necessary to control their growth. Refrigerated storage temperatures of 5 C (41 F) may be adequate to prevent growth and/or toxin production of some pathogenic microorganisms.

Based on observation, interview, and policy review, it was determined that the facility failed to have smoking policies in regards to smoking safety for 1 out of 1 residents reviewed for accidents. (Resident identifier is #29.) Findings include:Interview on 1/7/26 with Resident #29 at approximately 12:00 p.m. revealed that he/she goes across the street with his/her cane several times per day to smoke independently. Interview on 1/7/26 with Staff E (Registered Nurse), at approximately 12:30 p.m. revealed that Resident #29 goes off campus several times per day to smoke and that Resident #29 comes to the nurse to obtain lighter and returns it to the nurse when he/she returns to the facility. Interview on 1/7/26 at approximately 2:15 p.m. with Staff D (Administrator) confirmed that Resident #29 goes off campus to smoke and there was no smoking assessment completed for Resident #29. Review on 1/7/26 of Resident #29's medical record revealed no assessment of residents ability to smoke independently. Observation on 1/7/26 at approximately 2:30 p.m. of Resident #29 revealed Resident #29 obtained cigarette lighter from nurse and exited the unit using cane in one hand and carrying a portable chair in the other. Resident #29 was later observed sitting in the chair across the street on the sidewalk smoking a cigarette. Review on 1/8/26 of facility policy titled Smoking Policy, revised September 2017, revealed no policies for assessing resident safety with smoking, designated areas, or management of smoking materials.

Based on interview and record review, it was determined that the facility failed to provide the resident and/or resident's representative a Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 for 3 of 3 residents reviewed for Beneficiary Notification. (Resident identifiers are #3, #31, and #51).Findings include:Resident #3 Review on 1/7/26 of the Beneficiary Notice-Residents Discharge Within the Last Six Months form, completed by the facility, revealed that Resident # 3's last covered day of Medicare Part A Services was on 7/31/25 and she/he remained in the facility with days remaining. Review on 1/7/26 of Resident #3's SNF (Skilled Nursing Facility) Beneficiary Notification Review for Residents who Received Medicare Part A Services, form CMS-20052, revealed that Resident #3 was not provided with the NOMNC form CMS-10123. Resident #31 Review on 1/7/26 of the Beneficiary Notice-Residents Discharge Within the Last Six Months form, completed by the facility, revealed that Resident # 31's last covered day of Medicare Part A Services was on 7/9/25 and she/he remained in the facility with days remaining. Review on 1/7/26 of Resident #31's SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services, form CMS-20052, revealed that Resident #31 was not provided the NOMNC form CMS-10123. Resident #51 Review on 1/7/26 of the Beneficiary Notice-Residents Discharge Within the Last Six Months form, completed by the facility, revealed that Resident # 51's last covered day of Medicare Part A Services was on 11/18/25 and she/he did not remain in the facility with days remaining. Review on 1/7/26 of Resident #51's SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services, form CMS-20052, revealed that Resident #51 was not provided with the NOMNC form CMS-10123. Interview on 1/7/26 at approximately 11:00 a.m. with Staff G (Physical Therapy Director) confirmed the above findings that Resident #3, #31, and #51 and/or their representatives were not provided a Notice of Medicare Non-Coverage.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that dietary staff used hair restraints when handling food and failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchen observed. Findings include: Observation on 12/8/24 at approximately 9:20 a.m. of Staff C (Dietary Aide) revealed Staff C to be portioning fruit salad into individual cups for meal service with long hair pulled up in a bun with a hair clip. Staff C was not wearing a hair restraint in place. Interview on 12/8/24 at approximately 9:20 a.m. with Staff C revealed that he/she had not been told to use a hair restraint and did not wear a hair net while working with food. Review on 12/10/24 of facility policy titled, [NAME] Nursing Home Hair Net Policy, revealed: .All Food Handlers are required to wear effective hair restraints that cover all exposed body hair . Observation on 12/8/24 at approximately 9:10 a.m. of the Main Kitchen Refrigerator revealed the following food with no use by or preparation date: a chicken salad sandwich wrapped in plastic wrap, a bowl of lobster salad covered in plastic wrap, 2 small portioned containers of cottage cheese, and 3 portioned containers of three bean salad Interview on 12/8/24 at approximately 9:10 a.m. with Staff B (Dietary Manager) confirmed the above finding. Review on 12/10/24 of facility policy titled, Labeling and Dating Procedure-Dietary Kitchen revealed: .All product is to be labeled from the date opened and or prepared . All items prepared for service are to be dated the day they are prepared, and a use by date of the day to be used . Review on 12/10/24 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 2 Management and Personnel .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens .Chapter 3 Food .3-305.11 Food Storage .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .

Based on observation, interview, and record review, it was determined that the facility failed to implement policies for hand hygiene for 1 of 1 resident reviewed for pressure ulcers and the use of appropriate Personal Protective Equipment (PPE) to prevent the potential spread of infection for 1 of 2 residents reviewed for catheter/urinary tract infection (Resident Identifier #1). Findings include: Review on 12/9/24 of Resident #1's medical record revealed that he/she currently had two pressure wounds and an indwelling catheter. Observation on 12/9/2024 of Resident #1's room revealed signage indicating Enhanced Barrier Precautions (EBP) use for Resident #1. Observation on 12/9/24 at 10:15 a.m. of Staff D (Licensed Nursing Assistant) exiting Resident #1's room after providing a shower and dressing Resident #1. Further observation revealed Staff D was not wearing a gown. Interview on 12/9/24 at 10:15 a.m. with Staff D revealed that he/she was unaware that Resident #1 was on EBP and was unaware that he/she needed to wear a gown while providing high-contact care activities. Review on 12/9/24 of facility policy titled, Isolation-Categories of Transmission-Based Precautions, Updated and effective April 1, 2024, revealed: .Enhanced Barrier Precautions 1. In addition to Standard Precautions, implement Enhanced Barrier Precautions (EBP), the use of gown and gloves during high-contact care activities . Observation on 12/9/24 at 10:30 a.m. with Staff E (Licensed Practical Nurse) of Resident #1's dressing change revealed that Staff E removed Resident #1's old dressing, removed his/her gloves and then applied clean gloves without performing hand hygiene. Interview on 12/9/24 at approximately 10:40 a.m. with Staff E confirmed that he/she did not perform hand hygiene when he/she changed his/her gloves. Review on 12/9/24 of facility policy titled, Wound Care, revised December 2023, revealed . 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. 6. Put on gloves . Review on 9/9/24 of the Centers for Disease Control and Prevention (CDC) guideline titled, Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms (MDRO's), updated July 12, 2022 revealed: . Effective implementation of EBP requires .the availability of PPE and hand hygiene supplies at the point of care .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing .MDRO's may be indirectly transferred from resident-to-resident during these high-contact activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated . Review on 9/6/24 of the CDC guideline titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, retrieved from: https://www.cdc.gov/infection-control/hcp/core-practices/index.html, revealed: .Hand Hygiene .Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient .After touching a patient or the patient's immediate environment .Immediately after glove removal . Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material: Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions. Use protective eyewear and a mask, or a face shield, to protect the mucous membranes of the eyes, nose and mouth during procedures and activities that could generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. Remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area. If a respirator is used, it should be removed and discarded (or reprocessed if reusable) after leaving the patient room or care area and closing the door. Do not use the same gown or pair of gloves for care of more than one patient. Remove and discard disposable gloves upon completion of a task or when soiled during the process of care .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were appropriately stored in 2 out of 3 medication carts observed (Resident Identifiers are #15 and #42). Findings include: Observation on 12/8/24 at approximately 9:20 a.m. of the A Wing medication cart revealed an unlabeled medicine cup with a tablet in it. Interview on 12/8/24 at approximately 9:20 a.m. with Staff G (Registered Nurse (RN)) confirmed the above finding and Staff G stated that it was his/her personal medication in the medicine cup. Observation on 12/8/24 at approximately 9:25 a.m. of the [NAME] Wing medication cart revealed 2 unlabeled medicine cups. One cup had pills in it and one cup had pills and a transdermal patch in it. Interview on 12/8/24 at approximately 9:25 a.m. with Staff H (RN) confirmed the above findings and revealed that the medicine cups were Resident #15's and Resident #42's morning medications. Review on 12/8/24 of Resident #15's Medication Administration Record (MAR) revealed the following medications left unlabeled in the medication cup: Aspirin 81 milligrams (mg), Grape Seed Extract 400 mg, Omeprazole Delayed Release (DR) 20 mg, Vitamin D3 25 micrograms (mcg), 2 Levetiracetam 750 mg. Review on 12/8/24 of Resident #42's December 2024's MAR revealed the following medications left unlabeled in the medication cup: Rosuvastin Calcium 5 mg, Liothyronine 5 mcg, Losartan Potassium 25 mg, Myrbetiq 24 hour 25 mg, Pantoprazole Sodium DR 40 mg, Venlafaxine Extended Release (ER) 75 mg, Famciclovir 250 mg, 2 Carbidopa-Levodopa 25-100 mg, Carbidopa 25 mg, and the Rivastifmine Transdermal patch 4.6 mg. Observation on 12/9/24 from approximately 7:15 a.m. to 7:20 a.m. revealed the A Wing medication cart was left unattended with two cups on top of the medication cart with clear liquid and spoons in them. Interview on 12/9/24 at approximately 7:20 a.m. with Staff I (RN) revealed that the two cups on top of the A Wing medication cart had Miralax mixed with water in them. Staff I confirmed that the medication was left unattended on the medication cart. Observation on 12/9/24 from approximately 7:22 a.m. to 7:25 a.m. revealed Staff I left two cups with the Miralax mixed in water on top of the A Wing medication cart unattended and entered a resident's room down the hall. Observation on 12/9/24 from approximately 7:30 a.m. to 7:35 a.m. revealed Staff I left the 2 cups of Miralax mixed in water on top of the A Wing medication cart unattended to go and administer medications to Resident #2. Review on 12/8/24 of the facility policy titled, Medication Administration, General Guidelines, dated 9/18, revealed: .Medication Administration .4. Medications are to be administered at the time they are prepared . Review on 12/8/24 of the facility policy titled, Storage of Medication, dated 9/18, revealed: .Procedures, 1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements .Medications are to remain in these containers .

Based on observation and interview, it was determined that the facility failed to follow their policy for labeling and dating resident food items brought in by visitors for 1 of 3 kitchenettes observed. Observation on 12/8/24 at approximately 9:50 a.m. of the B wing kitchenette revealed food that was not labeled with resident names or dates: two prepackaged pepperoni sticks, one unopened can of Low Sodium V-8 juice, one prepackaged pulled pork mac-n-cheese bowl, and two packages of ice cream sandwiches. Interview on 12/8/24 at approximately 9:50 a.m. with Staff B (Dietary Manager) confirmed that the above items were not provided by the facility and were not labeled with resident names or dates. Review on 12/8/24 of facility policy titled, Foods Brought by Family/Visitors, revised November 2017, revealed: .6. Food brought by family/visitors .will be labeled and stored in manner that is clearly distinguishable from facility-prepared food .

Based on interview and record review it was determined that the facility failed to submit complete and accurate data for Payroll Based Journal for Fiscal Year Quarter 4 (July 1, 2024 - September 30, 2024). Findings include: Review on 12/10/24 of the Payroll Based Journal (PBJ) Staffing Data [NAME] Report for Fiscal Year Quarter 4 2024 revealed that the facility failed to have Registered Nurse hours on the following dates: 7/1-7/13, 7/18-7/27, 8/9-8/18, 8/24, 8/25, 8/29-8/31, 9/4-9/6, 9/12-9/14, 9/22, 9/24, 9/25, 9/29, and 9/30. Further review revealed that the facility failed to have Licensed Nursing coverage 24 hours a day on the following dates: 7/1-7/31, 8/1-8/26, 8/29-8/31, 9/1-9/30. Interview on 12/10/24 at approximately 9:00 a.m. with Staff A (Administrator) confirmed that the PBJ file was submitted timely but was rejected for invalid format. Review on 12/10/24 of Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, effective date June 2022, revealed: .Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline .

Based on interview and record review, the facility failed to adequately administer in a way to ensure that when allegations of abuse were identified, that the facility's policies for reporting and investigating were followed and that appropriate corrective actions were taken to prevent further abuse and ensure the resident's highest practicable physical, mental, and psychosocial wellbeing in a facility. (Census 53 Residents) Findings include: Review on 11/16/23 of the facility's policy titled, Abuse Investigation and Reporting, revised 9/2017, revealed .Role of the Administrator: 1. If an incident or suspected incident of residents abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. 6. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident . Review on 11/16/23 of the facility's policy titled, Abuse Prevention Program, revised 9/2017, revealed .As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals . Identified Abuse/Allegation of Abuse Review on 11/16/23 of Resident #36's nursing behavior notes from 6/1/23 through 11/14/23 revealed that Resident #36 had 18 sexually inappropriate behaviors incidents on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, 9/21/23, 10/29,21, 11/7/23, and 11/13/23. Review on 11/17/23 of Resident #35's nurse's notes from 7/1/23 through 9/30/23 revealed that Resident #35 had 3 sexually inappropriate behaviors incidents on 7/8/23, 7/20/23 and 9/24/23. Review on 11/15/23 of Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I (Licensed Nursing Assistant (LNA)) was extremely rude and was rough during care. Further review of Grievance Report revealed no investigation was completed for the allegations. Review on 11/16/23 of Staff J's (Licensed Practical Nurse (LPN)) written notice to administration dated 2/23/23 regarding Resident # 20's allegations of rough handling and being fearful of Staff I revealed that Staff H (Director of Nursing) had received the handwritten notice on 3/3/23. Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/15/23 during the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M (LPN) was not being nice. Resident #45 was crying and shaking when describing the alleged incident. Reporting of Alleged Violations of Abuse Interview on 11/16/23 at 8:43 a.m. with Staff A (Registered Nurse (RN)) revealed that the 18 sexually inappropriate incidents identified for Resident #36 on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, 9/21/23, 10/29/23, 11/7/23 and 11/13/23 were not reported to the State Survey Agency (SSA), physician or resident representatives of the affected residents. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that the incidents identified for Resident #35 on 9/24/23 and 7/8/23 were not reported to the SSA or resident representatives. Interview on 11/16/23 at 8:30 a.m. with Staff A revealed that the report of alleged abuse on 2/8/23 involving Resident #10 and Resident #29 by Staff I was not reported to the SSA as required. Interview on 11/16/23 at 9:00 a.m. with Staff B (Administrator) revealed that the allegations of abuse by Staff I involving Resident #9 and Resident #10 on 11/14/23 had not been reported to the SSA until after 26 hours of being notified. Review on 11/16/23 of the facility's policy titled, Abuse Investigation and Reporting, revised 9/2017, revealed .Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care; e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily harm; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . Investigation of Alleged Violations of Abuse Review on 11/16/23 of Resident #36's behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had 18 sexually inappropriate behaviors with residents (11/13/23, 11/7/23, 10/29/23, 9/21/23, 8/8/23, 8/6/23, 7/30/23, 7/21/23, 7/16/23, 7/14/23, 7/12/23, 7/11/23, 7/10/23, 7/3/23, 6/29/23, 6/27/23, 6/6/23, and 6/5/23). Interview on 11/16/23 at 8:43 a.m. with Staff A revealed that the above incidents were not investigated by staff at the facility. Review on 11/17/23 of Resident #35's nurse's notes from 7/1/23 through 9/30/23 revealed that Resident #35 had 3 sexually inappropriate behavior incidents on 7/8/23, 7/20/23, and 9/24/23. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that the incidents on 9/24/23 and 7/8/23 were not investigated by staff at the facility. Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/15/23 during the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M was not being nice. Review further revealed that Resident #45 was crying and shaking when describing the alleged incident. Interview on 11/17/23 at 10:40 a.m. with Staff A confirmed the above allegation of abuse. Interview further revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 and a thorough investigation was not completed. Interview on 11/15/23 at approximately 10:15 a.m. with Staff B revealed that no one had started the investigation regarding Resident #9 and Resident #10's allegation of abuse on 11/14/23. Review on 11/15/23 of Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Further review of Grievance Report indicated no investigation for allegations. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A revealed that no other residents or staff were interviewed regarding the treatment from Staff I for the allegation of abuse on 2/8/23. Review on 11/16/23 of the facility's policy titled, Abuse Prevention Program, revised 9/2017, revealed .7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. 8. Protect residents during investigations. Review on 11/16/23 of the facility's policy titled, Abuse Investigation and Reporting, revised 9/2017, revealed All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management . Review on 11/16/23 of the facility's policy titled, Abuse Policy and Procedures, revised 8/2011, revealed . Identification: Incident reports are reviewed by members of the Interdisciplinary Team to identify events, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation . Corrective Actions to Prevent Further Abuse Review on 11/16/23 of Resident #36's nursing behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had documented incidents of inappropriate sexual behaviors on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, 9/21/23, 10/29/23, 11/7/23 and 11/13/23. Review on 11/16/23 of Resident #36's comprehensive care plan revealed that there were no interventions in place that addressed Resident #35's inappropriate sexual behaviors towards other residents. Interview on 11/16/23 at 1:01 p.m. with Staff A confirmed the above finding. Review on 11/17/23 of Resident #35's electronic medical record revealed that Resident #35 had inappropriate sexual behaviors with other residents on 7/8/23, 7/20/23, and 9/24/23. Review on 11/17/23 of Resident #35's comprehensive care plan revealed that there were no interventions in place that addressed Resident #35's inappropriate sexual behaviors towards other residents. Interview on 11/17/23 at 12:48 p.m. with Staff A confirmed the above finding. Interview on 11/17/23 at 10:40 a.m. with Staff A revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 while an investigation was ongoing. Review on 11/16/23 of the facility's policy titled, Abuse Policy and Procedures, revised 8/2011, revealed . Prevention . The Inter Disciplinary Team (IDT) will analyze incidents/occurrences to determine what changes are needed, if any, to Policies and Procedures to prevent further occurrences .Supervision of staff to identify inappropriate behaviors .The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff . Refer to F600: Freedom from Abuse and Neglect, F607 Develop/Implement Abuse/Neglect Policies, F609 Reporting of Alleged Violations, and F610 Investigate/Prevent/Correct Alleged Violations

Based on interviews and record reviews, it was determined that the facility failed to ensure that residents remained free from resident to resident sexual abuse or from staff to resident physical and verbal abuse (Resident identifiers are #35 and #36). Finding include: Resident #36 Interview on 11/14/23 at 11:14 a.m. with Staff K (Registered Nurse (RN)) revealed that Resident #36 had incidents involving inappropriate sexual behavior towards other residents. Review on 11/16/23 of Resident #36's medical record revealed that he/she was admitted to the facility on [DATE] and had a primary diagnosis of a traumatic subdural hemorrhage and a secondary diagnosis of unspecified dementia. Resident #36 resides in the Memory Care Unit on the B-Wing. Review on 11/16/23 of Resident #36's quarterly Minimum Data Set (MDS) with an assessment reference date of 10/16/23 revealed that Resident #36 had a Brief Interview of Mental Status (BIMS) of 2, indicating severe cognitive impairment. Review on 11/16/23 of Resident #36's nurse's notes revealed the following: On 10/29/23 at 6:53 p.m., it was noted that . [pronoun omitted] was also found with his/her hand down a [gender omitted] resident's shirt. [Name omitted] was redirected away from this resident. [Pronoun omitted] went right into another [gender omitted] room . On 11/7/23 at 7:01 p.m., it was noted that .Later in the evening this writer heard a [gender omitted] resident yelling for help. When this writer came around the corner this writer saw [name omitted] trying to put [pronoun omitted] hands down the [gender omitted] resident's shirt .; On 11/13/23 at 9:06 p.m., it was noted that .Resident having had inappropriate/intrusive behavior this evening. In [gender omitted] resident's room attempting to kiss [gender omitted] .; Interview on 11/16/23 at 8:43 a.m. with Staff A (RN) revealed that there were no investigations into the above incidents of the non-consensual sexual contact behaviors of Resident #36. Interview on 11/16/23 at 10:31 a.m. with Staff L (RN) confirmed that Staff L witnessed Resident #36 put his/her hands down Resident #17's shirt on 10/29/23 and 11/7/23. Staff L stated that both incidents were reported in writing to either Staff A or Staff H (Director of Nursing) and that Staff L did not report either incident to a medical provider. Review on 11/16/23 of Resident #17's quarterly MDS with an assessment reference date of 10/10/23 revealed that Resident #17 had a BIMS of 00, meaning severely cognitively impaired. Interview on 11/16/23 at 11:56 a.m. with Staff A revealed that Staff A was not aware of the incidents on 10/29/23 and 11/7/23. Staff A stated that the medical provider was not notified on 10/29/23, 11/7/23, or 11/13/23. Review on 11/16/23 of Resident #36's provider note dated 11/10/23 revealed, Behaviors are manageable and no acute issues per nursing. There was no mention of the incidents with Resident #36 on 10/29/23 or 11/7/23. Review on 11/16/23 of Resident #36's care plan revealed that there were no interventions in place for Resident #36's sexual or intrusive behaviors with other residents. Interview on 11/16/23 at 1:01 p.m. with Staff A confirmed that there was no care plan for Resident #36's sexual or intrusive behaviors. Review on 11/16/23 of Resident #36's nursing behavior notes from 6/1/23 through 10/31/23 revealed that Resident #36 had 15 sexually inappropriate behaviors incidents on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, and 9/21/23. Resident #35 Review on 11/17/23 of Resident #35's nurse's notes revealed the following: On 7/8/23 at 5:36 p.m., it was noted that .the resident was witnessed making a sexual advance, reaches for a [gender omitted] areola (breast) .'. On 7/20/23 at 3:13 p.m., it was noted that .the LNA [Licensed Nursing Assistant] on duty reported seeing resident grope a [gender omitted] resident while he/she was in another resident room .; On 9/24/23 at 8:14 p.m., it was noted that .the resident had inappropriate behaviors towards a [gender omitted] .; Review on 11/17/23 of Resident #35's medical record revealed that he/she was admitted to the facility on [DATE]. Resident #35 resides on the B-Wing. Review on 11/17/23 of Resident #35's quarterly MDS with an assessment reference date of 9/6/23 revealed that Resident #35 had a BIMS of 15, meaning cognitively intact. Interview on 11/17/23 at 12:11 p.m. with Staff J (Licensed Practical Nurse (LPN)) confirmed that Resident #35 had inappropriate sexual behavior towards other residents. Staff J revealed that Resident #35 had touched another resident's breast and made other inappropriate sexual advances towards other residents. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that there were no interventions in place for Resident #35's known inappropriate sexual behaviors. Staff M (LPN) Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/16/23 between the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M was not being nice. Resident #45 was crying and shaking when describing the alleged incident. Resident #45 reported feeling unsafe. Interview on 11/17/23 at 10:40 a.m. with Staff A confirmed the above allegation of abuse. Interview further revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 during the investigation of the above incident. Staff M was not assigned to Resident #45. 43408 Staff I (LNA) Interview on 11/14/23 at approximately 2:30 p.m. during a Resident Council meeting Resident #9 and Resident #10 had reported that Staff I was very rough during care and rude. Review on 11/14/23 of Resident #9's medical record revealed an admitted [DATE] and a primary diagnosis of fusion of the spine. Further review of Resident #9's medical record revealed a quarterly MDS dated [DATE] with a BIMS score of 15 out of 15. Review on 11/14/23 of Resident #10's medical record revealed an admitted [DATE] and a primary diagnosis of unspecified dementia. Further review of Resident #10's medical record revealed a quarterly MDS dated [DATE] with a BIMS score of 15 out of 15. Interview on 11/15/23 at approximately 10:15 a.m. with Staff B (Administrator) revealed that no one had started the investigation regarding Resident #9 and Resident #10's allegation of abuse that was reported on 11/14/23. Review on 11/15/23 of the Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Further review of the Grievance Report revealed no investigation was completed for the allegations. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A confirmed the above information. Staff A stated that no other residents or staff were interviewed regarding treatment and interactions with Staff I for the allegation of abuse on 2/8/23. Review on 11/16/23 of Staff J's written notice to administration dated 2/23/23 regarding Resident #20's allegations of rough handling and being fearful of Staff I revealed that Staff H had received the handwritten notice on 3/3/23. Further review of the written notice revealed no physical assessment of Resident #20 for potential injuries from rough handling. Review on 11/16/23 of the administration notes attached to Staff J's handwritten notice of abuse allegation revealed a typed document that stated there was a meeting with Resident #20 and their family member regarding a complaint about Staff I. Further review revealed a statement that read Staff I would be assigned to a different unit. Further review of the document revealed no physical assessment completed of Resident #20 for potential injuries from rough handling. Interview on 11/16/23 at approximately 9:00 a.m. with Staff B confirmed that the above report of alleged abuse on 2/23/23 was not received by the administration until 3/3/23. Interview on 11/16/23 at approximately 11:50 a.m. with Staff J stated that Staff I was allowed to keep working but was moved to another unit after the allegation from Resident #20 on 2/23/23. Review on 11/17/23 of Staff I's time clock punches for 2/23/23 through 3/3/23 revealed that Staff I worked shifts on 2/23/23, 2/24/23, 2/28/23, 3/1/23, and 3/3/23. Interview on 11/17/23 with Staff B confirmed the above working shifts for Staff I. Staff B stated that Staff I had been allowed to work in the facility but had been moved to another unit. Staff B confirmed that no investigation could be found for an allegation of abuse on 2/23/23.

Based on interviews and record reviews it was determined that the facility failed to ensure that alleged violations of abuse were thoroughly investigated for 5 out of 5 residents and 2 out of 3 staff members reviewed for abuse (Resident Identifiers are #9, #10, #20, #35 and #36) and (Staff Identifiers are I and M ). Findings include: Resident #35 Review on 11/17/23 of Resident #35's nurse's notes revealed the following: On 9/24/23 at 8:14 p.m. revealed that .the resident had inappropriate behaviors towards a [gender omitted] . On 7/8/23 at 5:36 p.m. revealed that .the resident was witnessed making sexual advance, reaches for a [gender omitted] areola .' Interview on 11/17/23 at 12:48 p.m. with Staff A (Registered Nurse (RN)) revealed that the incidents on 9/24/23 and 7/8/23 were not investigated by staff at the facility. Resident #36 Review on 11/16/23 of Resident #36's behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had 18 sexually inappropriate behaviors with residents (11/13/23, 11/7/23, 10/29/23, 9/21/23, 8/8/23, 8/6/23, 7/30/23, 7/21/23, 7/16/23, 7/14/23, 7/12/23, 7/11/23, 7/10/23, 7/3/23, 6/29/23, 6/27/23, 6/6/23 and 6/5/23). Interview on 11/16/23 at 8:43 a.m. with Staff A revealed that none of the above incidents were investigated by staff at the facility. Staff M (Licensed Practical Nurse (LPN)) Review on 11/17/23 of the facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/15/23 during the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M was not being nice. Review further revealed that Resident #45 was crying and shaking when describing the alleged incident. Interview on 11/17/23 at 10:40 a.m. with Staff A confirmed the above allegation of abuse. Interview further revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 and a thorough investigation was not completed. Review on 11/16/23 of the facility's policy titled, Abuse Investigating and Reporting, revised date of 09/2017, revealed .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management. Findings of abuse investigations will also be reported .Role of the Administrator: 1. If an incident or suspected incident of reside abuse, mistreatment, neglect, or injury of an unknown source is reported, the Administrator will assign the investigation to an appropriate individual . 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation . 5. The Administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented . 43408 Staff I (LNA) Interview on 11/14/23 at approximately 2:30 p.m. during a Resident Council meeting Resident #9 and Resident #10 had reported Staff I was very rough during care and rude. Interview on 11/15/23 at approximately 10:15 a.m. with Staff B (Administrator) revealed that no one had started the investigation regarding Resident #9 and Resident #10's allegation of abuse on 11/14/23. Review on 11/15/23 of the Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Further review of the Grievance Report indicated no investigation for allegations. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A revealed that no other residents or staff were interviewed regarding the treatment from Staff I for the allegation of abuse on 2/8/23. Review on 11/16/23 of Staff J's (LPN) written notice to administration dated 2/23/23 regarding Resident #20's allegations of rough handling and being fearful of Staff I revealed that Staff H (Director of Nursing) had received the hand written notice on 3/3/23. Interview on 11/16/23 at approximately 9:00 a.m. with Staff B confirmed that the above report of alleged abuse on 2/23/23 was not received by administration until 3/3/23 and that Staff I had been allowed to work in the facility but had been moved to another unit. Staff B confirmed that no investigation could be found for an allegation of abuse on 2/23/23.

Based on interviews, record reviews, and policy review, it was determined that the facility failed to implement the facility's abuse policy for 5 out of 5 residents and 2 out of 3 staff reviewed for abuse (Resident Identifiers are #9, #10, #20, #35 and #36). Findings include: Review on 11/16/23 of the facility policy titled, Abuse Policy and Procedure, with a revised date of 9/2019, revealed .Identification: Incident reports are reviewed by members of the Interdisciplinary Team to identify events, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation .Resident to Resident Contact/Abuse: Every attempt to foresee/prevent incident will be made by observing the following: Identify resident with potential behavior problems . Identify the precipitating situation . Closely supervise . Document interventions in Resident Care Plans .Reporting Resident Abuse or Neglect: Observation or suspicion of alleged resident abuse, neglect, or misappropriation of resident property must be reported and investigated IMMEDIATELY . Instructions for Reporting Alleged Resident Abuse: 4. Complete the Notice of Alleged Resident Abuse form . These documents are faced to the following agencies within 24 hours of the incident . Resident #36 Interview on 11/14/23 at 11:14 a.m. with Staff K (Registered Nurse (RN)) revealed that Resident #36 had inappropriate sexual behavior towards other residents. Review on 11/16/23 of Resident #36's behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had multiple documented (11/13/23, 11/7/23, 10/29/23, 9/21/23, 8/22/23, 9/11/23, 8/8/23, 8/6/23, 7/30/23, 7/21/23, 7/16/23, 7/14/23, 7/12/23, 7/11/23, 7/10/23, 7/3/23, 6/29/23, 6/27/23, 6/22/23, 6/6/23 and 6/5/23) behaviors of being sexually inappropriate and intrusive with residents. Interview on 11/16/23 at 8:43 a.m. with Staff A (RN) confirmed that Resident #36 had a known history of sexual abuse towards other residents. Interview further revealed that the facility did not do any investigations for any of the above incidents, did not report to state agencies, and no interventions were put in place to prevent further incidents from occurring. Resident #35 Review on 11/17/23 of Resident #35's nurse's notes revealed the following: On 9/24/23 at 8:14 p.m. revealed that .the resident had inappropriate behaviors towards a [gender omitted] . On 7/20/23 at 3:13 p.m. revealed that .the LNA on duty reported seeing resident grope a [gender omitted] resident while he/she was in another resident's room . On 7/8/23 at 5:36 p.m. revealed that .the resident was witnessed making a sexual advance, reaches for a [gender omitted] areola .' Interview on 11/17/23 at 12:11 p.m. with Staff J (Licensed Practical Nurse (LPN)) confirmed the above. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that there were no interventions in place for Resident #35's known inappropriate sexual behaviors. Interview further revealed that the incidents on 9/24/23 and 7/8/23 were not investigated or reported. Staff M (LPN) Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/15/23 during the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M was not being nice. Review further revealed that Resident #45 was crying and shaking when describing the alleged incident. Interview on 11/17/23 at 10:40 a.m. with Staff A confirmed the above allegation of abuse. Interview further revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23. 43408 Staff I (LNA) Interview on 11/14/23 at approximately 2:30 p.m. during a Resident Council meeting Resident #9 and Resident #10 had reported Staff I was very rough during care and rude. Interview on 11/15/23 at approximately 10:15 a.m. with Staff B (Administrator) revealed that they had not reported to the State Agencies nor had they started the investigation regarding Resident #9 and Resident #10's allegation of abuse on 11/14/23. Review on 11/15/23 of the Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Further review of the Grievance Report indicated no investigation for allegations. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A revealed that no report had been made to the State Agencies and no other residents or staff were interviewed regarding the treatment from Staff I for the allegation of abuse on 2/8/23. Review on 11/16/23 of Staff J's written notice to administration dated 2/23/23 regarding Resident # 20's allegations of rough handling and being fearful of Staff I revealed that Staff H (Director of Nursing) had received the hand written notice on 3/3/23. Interview on 11/16/23 at approximately 9:00 a.m. with Staff B confirmed that the above report of alleged abuse on 2/23/23 was not received by the administration until 3/3/23 and that Staff I had been allowed to work in the facility but had been moved to another unit. Staff B confirmed that no report had been made to the State Agencies and no investigation could be found for allegation of abuse on 2/23/23.

Based on interviews and record reviews, it was determined that the facility failed to report an allegation of abuse immediately, but no later than 24 hours, to the State Survey Agency (SSA) and the results of the investigation to the SSA within 5 working days of the incident for 5 of 5 residents reviewed for alleged abuse (Resident Identifiers are #9, #10, #20, #35 and #36). Findings include: Resident #35 Review on 11/17/23 of Resident #35's nurse's notes revealed the following: On 9/24/23 at 8:14 p.m. revealed that .the resident had inappropriate behaviors towards a [gender omitted] . On 7/8/23 at 5:36 p.m. revealed that .the resident was witnessed making sexual advance, reaches for a [gender omitted] areola .' Interview on 11/17/23 at 12:11 a.m. with Staff J (Licensed Practical Nurse (LPN)) revealed that Staff J reported the incident on 9/24/23 to the Director of Nursing. Interview on 11/17/23 at 12:48 p.m. with Staff A (Register Nurse (RN)) revealed that the incidents on 9/24/23 and 7/8/23 were not reported to the SSA. Resident #36 Review on 11/16/23 of Resident #36's behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had 19 sexually inappropriate behaviors with residents (11/13/23, 11/7/23, 10/29/23, 9/21/23, 8/8/23, 8/6/23, 7/30/23, 7/21/23, 7/16/23, 7/14/23, 7/12/23, 7/11/23, 7/10/23, 7/3/23, 6/29/23, 6/27/23, 6/22/23, 6/6/23 and 6/5/23). Interview on 11/16/23 at 8:43 a.m. with Staff A revealed that none of the above incidents were reported to the SSA. Review on 11/16/23 of the facility policy titled, Abuse Investigating and Reporting, revised date of 09/2017, revealed .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulation) . Findings of abuse investigations will also be reported .Reporting: 2. An alleged violation of abuse . will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse . 43408 Staff I (Licensed Nursing Assistant (LNA)) Interview on 11/14/23 at approximately 2:30 p.m. during a Resident Council meeting Resident #9 and Resident #10 had reported Staff I was very rough during care and rude. Interview on 11/16/23 at approximately 9:00 a.m. with Staff B (Administrator) confirmed that the above reported allegations of abuse by Resident #9 and Resident #10 on 11/14/23 had not been reported to the SSA until after 26 hours of them being notified. Review on 11/15/23 of the Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A confirmed that the above report of alleged abuse on 2/8/23 was not reported to the SSA. Review on 11/16/23 of Staff J's written notice to administration dated 2/23/23 regarding Resident #20's allegations of rough handling and being fearful of Staff I revealed that Staff H (Director of Nursing) had received Staff J's written notice on 3/3/23. Interview on 11/16/23 at approximately 9:00 a.m. with Staff B confirmed that the above report of alleged abuse on 2/23/23 was not reported to the administration of the facility immediately. Staff B also confirmed that the above allegation of abuse on 2/23/23 was not reported to the SSA.

Based on interview and record review, it was determined that the facility failed to ensure that a resident with pressure ulcers had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcers for 1 out of 1 resident reviewed for pressure ulcers in a final sample of 23 residents (Resident identifier is #12). Findings include: Review on 11/17/23 of Resident #12's Wound Notes revealed the following: Right heel 5/18/23 Resident #12 developed a Deep Tissue Injury (DTI) to right heel. Wound measurements and descriptions were completed on the following dates: 5/18/23, 5/26/23, 6/26/23, 7/4/23, 7/11/23, 7/17/23, 7/31/23, 8/14/23, 8/16/23, 8/24/23, 8/28/23, 9/2/23, 9/10/23, 9/23/23, 10/2/23, 10/8/23, 10/9/23, 10/14/23, 11/2/23, and 11/5/23. Outer aspect of the right foot 9/1/23 Resident #12 developed a reddened pressure area to right outer aspect of right foot. Wound measurements and descriptions were completed on the following dates: 9/2/23, 9/10/23, 9/23/23, 10/8/23, 10/14/23, and 11/5/23. Right buttocks 10/7/23 Resident #12 developed a pressure ulcer on his/her right buttocks. Wound measurements and descriptions were completed on the following dates: 10/7/23, 10/14/23, 11/2/23, 11/5/23 and 11/16/23. Coccyx 11/5/23 Resident #12 developed a pressure ulcer to his/her coccyx. Wound measurements and descriptions were completed on the following dates: 11/5/23 and 11/16/23. Interview on 11/17/23 at approximately 1:15 p.m. with Staff A (Registered Nurse) confirmed the above findings and that wound measurements and descriptions had not been performed weekly. Review on 11/16/23 of the facility policy titled, Pressure Ulcers/Injuries Overview, Revision Date 6/2018 did not indicate how often the facility would monitor pressure ulcers or how pressure ulcers would be described.

Based on interviews and record reviews, it was determined that the facility failed to develop and implement a comprehensive care plan for 2 of 53 residents reviewed for care plans (Resident Identifiers are #35 and #36). Findings include: Resident #36 Interview on 11/14/23 at 11:14 a.m. with Staff K (Registered Nurse (RN)) revealed that Resident #36 had inappropriate sexual behavior towards other residents. Review on 11/16/23 of Resident #36's behavior notes from 5/1/23 through 11/13/23 revealed that Resident #36 had a behavior problem of hypersexuality towards staff and residents and being intrusive with residents on 11/13/23, 11/7/23, 10/29/23, 9/21/23, 8/8/23, 8/6/23, 7/30/23, 7/21/23, 7/16/23, 7/14/23, 7/12/23, 7/11/23, 7/10/23, 7/3/23, 6/29/23, 6/27/23, 6/22/23, 6/6/23 and 6/5/23. Review on 11/16/23 of Resident #36's psych nursing home visit note dated 8/3/23 and 8/17/23 revealed that Resident #36 was seen due to increased hypersexual behaviors. Review on 11/16/23 of Resident #36's comprehensive care plan revealed that there was no focus, goals, or interventions in place for Resident #36's sexual or intrusive behaviors with other residents. Interview on 11/16/23 at 1:01 p.m. with Staff A (RN) confirmed that there was no care plan for Resident #36's sexual or intrusive behaviors. 38218 Resident #35 Review on 11/17/23 of Resident #35's electronic medical record revealed that Resident #35 had documented inappropriate sexual behaviors with other residents on 7/8/23, 7/20/23, and 9/24/23. Review on 11/17/23 of Resident #35's comprehensive care plan revealed that there was no focus, goals, or interventions that addressed Resident #35's inappropriate sexual behaviors. Interview on 11/17/23 at 12:48 p.m. with Staff A confirmed that Resident #35's inappropriate sexual behaviors should have been addressed in Resident #36's care plan and were not.

Based on interview and record review, it was determined that the facility failed to identify indicators of trauma in order to provide trauma informed care for 1 out of 5 residents reviewed for behavioral/emotional in a final sample of 23 residents (Resident identifier is #24). Findings include: Review on 11/16/23 of Resident #24's Psychiarty Nursing Home Visit, dated 7/6/23 revealed: .Social History .Previous Occupational History: nurse . Lost license d/t [due to] narcotic abuse. Disabled d/t back pain and psych Substance Use .Type-opiates . previously incarcerated, . incarcerated from 2003-2007 Review on 11/16/23 of Social Service Assessment, dated 8/30/23 revealed no history of trauma identified. Interview on 11/17/23 at approximately 9:00 a.m. with Staff C (Administrator in Training) and Staff D (Activities Director) both revealed they began doing the assessments in July of 2023 and they were not aware that Resident #24 had a history of trauma. Staff C and D also revealed that they have had no specialized training or experience to screen for a history of trauma or triggers of trauma to ensure that trauma informed care is delivered. Review on 11/17/23 of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, Revision Date 2/2018 revealed: . Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a care plan accordingly.7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities

Based on observation, interview, and record review it was determined that the facility failed to provide services to a resident with a limited range of motion for 1 of 1 resident reviewed for position/mobility in a final sample of 23 residents (Resident identifier is #20). Findings include: Observation on 11/14/23 at approximately 11:00 a.m. of Resident #20's left hand appeared that his/her hand was contracted. Observation on 11/15/23 at approximately 1:00 p.m. of Resident #20's left hand appeared that his/her hand was contracted. Review on 11/15/23 of Resident #20's medical record revealed that there were no physician orders for a splint for Resident #20's left hand. Review on 11/15/23 of Resident #20's care plans revealed the following: Status Post Chronic Physical Disability L [left] side weakness post CVA [cerebral vascular accident], further review of Resident #20's care plan revealed that there was no mention of Resident #20 requiring a splint for his/her left hand to prevent further contracture. Review on 11/15/23 of Resident #20's Occupational Therapy Discharge Summary, dated 5/16/23 revealed: . Discharge Recommendations: RA [Restorative Aide] program followed by nursing and care plan for splint use. . Interview on 11/15/23 at approximately 1:15 p.m. with Staff F (Registered Nurse) revealed that there is a hand splint that the resident has in his/her dresser and that he/she is unaware of an order for removal or application of the hand splint. Interview on 11/15/23 at approximately 2:00 p.m. with Staff E (Physical Therapist) revealed that Occupational Therapy was discontinued on 5/16/23 and it was recommended for the resident to use a splint with nursing. Staff E also revealed that this is usually communicated with Staff G (Minimum Data Set Nurse) and Staff G would transcribe the order and ensure that it was entered into a care plan as well. Interview on 11/15/23 at approximately 2:05 p.m. with Staff G revealed that he/she was never notified of the above recommendation and did not initiate a care plan or order for the splint.

Based on interview and record review it was determined that the facility failed to ensure that the physician was involved in a resident's referral to hospice on 1 of 3 residents reviewed for hospice in a final sample of 23 residents (Resident identifier is #2). Findings include: Review on 11/14/23 of the facility matrix revealed that Resident #2 was receiving hospice services. Review on 11/14/23 of Resident #2's medical record revealed that he/she was admitted to receive hospice services on 11/4/23. Further review of Resident #2's medical record revealed that there was no physician's referral/order obtained for a hospice evaluation. Interview on 11/17/23 at approximately 9:00 a.m. with Staff C (Administrator in Training) confirmed that there was no referral/order for Resident #2 to be evaluated by hospice.

Based on interview and record review, it was determined that the facility failed to ensure confidentiality of medical records was maintained for 1 of 23 residents (Resident identifier is #2). Findings include: Review on 11/14/23 of Resident #2's medical record revealed that he/she was admitted to receive hospice services on 11/4/23 without a physician referral. Interview on 11/17/23 at approximately 9:00 a.m. with Staff C (Administrator in Training) confirmed that there was not a physician referral for Resident #2 for hospice services and no signed consent from the resident or resident's representative for the release of medical records to the hospice. Further interview with Staff C revealed that he/she released a copy of Resident #2's medication list to the hospice facility for review. Review on 11/17/23 of the facility policy titled, Confidentiality of Information, Revision Date 10/2017 revealed: .1. The facility will safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information. 2. Access to resident medical records will be limited to authorized staff and business associates 6. Residents may initiate a request to release information contained in their records and charts to themselves or anyone they wish. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor)

Based on interview and record review it was determined that the facility failed to follow physician orders for 1 of 5 residents reviewed for unnecessary medications in a final sample of 23 residents (Resident Identifier is #40). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 11/14/23 of Resident #40's October 2023 and November 2023 Medication Administration Record (MAR) revealed the following physician's order: Isosorbide Mononitrate ER [extended release] Oral Tablet Extended Release 24 hour 30 mg [milligram] Give 1 tablet by mouth one time a day related to essential [Primary] hypertension, hold for SBP [Systolic Blood Pressure] < [less than] 110, Start Date 10/14/23. Further review of Resident #40's MAR revealed that the medication was administered daily from 10/14/23 through 11/15/23. Review on 11/16/23 of Resident #40's blood pressures revealed the following blood pressures obtained with medication administration: October 2023 10/14, 10/18, 10/19, 10/20, 10/24, and 10/25 Further review of October 2023's blood pressures revealed the following SBP's <110 10/19 SBP 98 10/24 SBP 105 10/25 SBP 98 November 2023 11/2, 11/3, 11/4, 11/6, 11/11 and 11/12 Further review of November 2023's blood pressures revealed the following SBP's <110 11/2 SBP 94 11/11 102/60 Interview on 11/16/23 at approximately 7:45 a.m. with Staff A (Registered Nurse) confirmed the above findings and confirmed that the Isosorbide Monitrate should not have been administered when the SBP was less than 110.

Based on interview and record review, it was determined that the facility failed to follow accepted national standards for the return to work guidelines for health care personnel who were positive for COVID-19 illness for 21 of 21 staff reviewed. Non-complaince with return to work guidelines potenitally increased the exposure to pathogens for the facility's census of 52 residents, as well as staff and visitors (Staff identifiers are A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, and U). Findings include: Review on 7/6/23 of the facily COVID-19 line list of positive staff and the June 2023 staff time clock entries revealed the following: Staff A (Registered Nurse (RN)) was asymptomatic, tested positive for COVID-19 on 6/5/23 and returned to work with no retesting for COVID-19 on 6/12/23 (Day 7); Staff B (RN) was symptomatic, tested positive for COVID-19 on 6/11/23 and returned to work on 6/15/23 (Day 4); Staff C (Housekeeper) was symptomatic, tested positive for COVID-19 on 6/11/23 and returned to work on 6/14/23 (Day 3); Staff D (Licensed Nursing Assistant (LNA)) was asymptomatic, tested positive for COVID-19 on 6/12/23 and returned to work on 6/13/23 (Day 1); Staff E (LNA) was symptomatic, tested positive for COVID-19 on 6/12/23 and returned to work on 6/16/23 (Day 4); Staff F (Licensed Practical Nurse (LPN)) was symptomatic, tested positive for COVID-19 on 6/12/23 and returned to work on 6/17/23 (Day 5); Staff T (housekeeper) was symptomatic, tested positive for COVID-19 on 6/12/23 and returned to work with no retesting for COVID-19 on 6/19/23 (Day 7); Staff G (RN) was symptomatic, tested positive for COVID-19 on 6/13/23 and returned to work on 6/19/23 (Day 6); Staff H (Administrative staff), was symptomatic, tested positive for COVID-19 on 6/13/23 and returned to work on 6/15/23 (Day 2); Staff I (LNA) was symptomatic, tested positive for COVID-19 on 6/13/23 and returned to work on 6/15/23 (Day 2); Staff J (LNA) was symptomatic, tested positive for COVID-19 on 6/13/23 and returned to work on 6/15/23 (Day 2); Staff K (Administrative staff) was symptomatic, tested positive for COVID-19 on 6/14/23 and returned on 6/19/23 (Day 5); Staff P (Administrative staff) was symptomatic, tested positive for COVID-19 on 6/14/23 and returned to work on 6/20/23 (Day 6); Staff L (LPN) was symptomatic, tested positive for COVID-19 on 6/15/23 and returned to work on 6/18/23 (Day 3); Staff M (RN) was symptomatic, tested positive for COVID-19 on 6/15/23 and returned to work on 6/19/23 (Day 4); Staff N (LNA) was symptomatic, tested positive for COVID-19 on 6/15/23 and returned to work on 6/19/23 (Day 4); Staff O (LNA) was symptomatic, tested positive for COVID-19 on 6/15/23 and returned to work with no retesting for COVID-19 on 6/24/23 (Day 9); Staff Q (LNA) was symptomatic, tested positive for COVID-19 on 6/15/23 and returned to work on 6/20/23 (Day 5); Staff R (Unit Clerk) was symptomatic, tested positive for COVID-19 on 6/19/23 and returned to work on 6/21/23 (Day 2); Staff S (LPN) was symptomatic, tested positive for COVID-19 on 6/19/23 and returned to work on 6/21/23 (Day 2); Staff U (Activities) was asymptomatic, tested positive for COVID-19 on 6/26/23 and returned to work with no retesting for COVID-19 on 7/5/23 (Day 9). Interview on 7/6/23 at approximately 11:30 a.m. with Staff V (Director of Nursing) and Staff B confirmed the above return to work dates for COVID-19 positive staff. Staff V and Staff B revealed that staff were allowed to return to work if they were asymptomatic or symptoms had improved. Staff V and Staff B also revealed that during the facility COVID-19 outbreak, staffing maintained above the facility determined staffing levels. Staff V and Staff B revealed that they did not have a policy for when staff could return to work and stated that they would follow the Centers for Disease Control and Prevention guidelines (CDC). Interview on 7/6/23 at approximately 11:30 a.m. with Staff B confirmed they were symptomatic, tested positive for COVID-19 on 6/11/23 and returned to work on 6/15/23. Interview on 7/6/23 at approximately 12:17 p.m. with Staff D confirmed they were asymptomatic and tested while at work on 6/12/23. Staff D stated they returned to work on 6/13/23 and resumed all work duties with COVID-19 positive and negative residents. Review on 7/6/23 of the Centers for Disease Control (CDC) Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposed to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection. The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. After returning to work, HCP should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen. If symptoms recur (e.g. [for example], rebound) these HCP should be restricted from work and follow recommended practices to prevent transmission to others (e.g., use of well-fitting source control) until they again meet the healthcare criteria below to return to work unless an alternative diagnosis is identified. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT [Nucleic Acid Amplification Test] (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later .