Every finding on record at Neighbors - East Neighborhood (The)

Based on observation, interview and record review, the facility did not ensure 3 of 3 residents at risk for elopement received adequate supervision and assistance devices to prevent accidents. R3 is at risk for elopement and did not have a wander guard in place as ordered. R1 eloped out of facility on [DATE]. R1 had wander guard attached to the front bottom metal bar of R1's walker. R2 had wander guard attached to the wheelchair metal frame. Facility staff did not follow recommendations from the manufacturer's instructions. Findings include: Facility policy titled, Wandering Resident and use of Wander Guards/Alarms, states in part, .II. Wander Guard Doors that have activated alarms are: 1. Entry doors 2. Fire exit doors 3. Smoke doors.Wander Guards may be applied per care plan to residents identified as having a risk of wandering (assure it is not too tight) H. Test the Wander Guard by taking the resident to a door area to make sure the alarm system is activated. Wander Guard system manufacturing module titled, Wander Management transmitters user guide manual 0510-1122F, states in part, .Page 4. It is the responsibility of the facility to establish and facilitate a regular inspection schedule for your system. [Name of company] recommends quarterly inspections of your system for safety performance by a qualified [name of company] representative. Page 5. It is the responsibility of the facility to establish and facilitate a regular maintenance schedule for your system. This includes regular inspection, testing, and cleaning. [Name of company] recommends monthly maintenance and testing of your system. It is also recommended facility keep records of maintenance and testing completions. Page 12. The touchpad exit controller receives data from the exit alarm receivers and issues an alarm if a resident wearing a transmitter is detected in the exit alarm zone, and the door is open. Page 24. Signal strength 1. Physically enter an Exit Zone with the transmitter and walk through the door. 2. An alarm must occur when the transmitter is within 4 feet of the monitored door. If applicable, the door also locks. 3. If an alarm does not occur, do not use the transmitter and contact [name of company] for technical support. The following testing is required weekly for transmitters in use on residents. Note: Never take a resident to a door to test their transmitter. Example 1 R3 was admitted to the facility on [DATE] with diagnoses including unspecified dementia. R3's Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 had Brief Interview of Mental Status (BIMS) score of 3/15, indicating R3 has severely impaired cognition. R3's physician treatment orders: Safety devices: Wander guard check function every Wednesday on PM shift. Started on [DATE]. R3's Certified Nurse Assistant (CNA) task care plan, states: -Safety: Wander guard. R3's Treatment Record Administration (TAR) from [DATE]-[DATE]: -Started on [DATE]. Safety devices: Wander guard to body to alert staff related to new environment and cognitive deficits. Check wander guard placement every shift. On [DATE] at 9:41 AM, Surveyor entered R3's room and tried observing for a wander guard located on R3. Surveyor could not find a wander guard on R3. Surveyor exited R3's room to find assistance in locating R3's wander guard. On [DATE] at 10:01 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D and asked CNA D to walk through the unit with Surveyor to identify all residents who use a wander guard including R3. CNA D entered R3's room and asked R3 if CNA D could check R3's body. CNA D reported R3 was not wearing a wander guard. CNA D reported that sometimes nurses will see if a resident has edema and will remove the wander guard but usually staff are to update the resident's care plan indicating the wander guard was moved to another location or wander guard was discontinued. CNA D checked R3's wheelchair and walker for the wander guard. Surveyor asked CNA D why R3's wander guard would be on a walker or wheelchair versus on R3. CNA D reported to Surveyor, sometimes residents don't allow staff to place a wander guard on the resident's body. CNA D reported there was no wander guard on R3's wheelchair or walker. On [DATE] at 10:16 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked if R3 had a wander guard. ADON C entered R3's room with Surveyor and could not find R3's wander guard. ADON C reported to Surveyor that maybe Physical Therapy (PT) changed R3's wheelchair and never replaced the wander guard with the new wheelchair. ADON C reported to Surveyor ADON C would figure out if R3 is supposed to have a wander guard. Surveyor followed ADON C to the system monitor to try and locate R3's wander guard. The software system identified R3's wander guard was still located in R3's room. ADON C reported they would get the wander guard figured out for R3. Surveyor asked ADON C how often the software system is checked. ADON C reported to Surveyor nurses are to check R3's wander guard weekly and document weekly. Maintenance Director H checks the software systems only with updates. Nurses only check the software system computer if the alarm is activated. Example 2 R2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, anemia, and atrial fibrillation. R2's MDS (Minimum Data Set) assessment, dated [DATE], indicated R1 had Brief Interview for Mental Status (BIMS) score of 11/15 indicating R2 had mild impaired cognition. R2's physician treatment orders: -On [DATE], Safety devices; Wander guard check function every Wednesday on PM shift. -On [DATE], Safety devices; Wander guard to (wheelchair, wrist, and ankle) due to exit seeking for safety, check wander guard placement every shift. R2's CNA (Certified Nursing Assistant) task care plan, revised on [DATE], states in part: -Safety: Wander guard. R2's TAR (Treatment Administration Record): -Started on [DATE], Safety devices: Wander guard to (wheelchair, wrist, and ankle) due to exit seeking for safety, check wander guard placement every shift. On [DATE] at 9:58 AM, Surveyor observed R2 to have wander guard on the wheelchair metal handle and not on R2. On [DATE] at 11:08 AM, Surveyor interviewed ADON C and asked ADON C to utilize wander guard tester to test R2's wander guard located on R2's back of wheelchair. Surveyor observed ADON C test R2's wander guard. Surveyor observed the tester beeped green, which indicated R2's wander guard was working at that time. Surveyor requested to review the wander guard tester. Surveyor observed the 9V battery inside the tester, and it expired as of 12/2023. Surveyor asked ADON C who inspects and maintains the wander guard tester. ADON C reported that Maintenance Director H inspects the tester and maintains the working condition of the wander guard tester. On [DATE] at 10:47 AM, Surveyor interviewed Maintenance G and asked about testing the transmitter tester for the wander guard system. Maintenance G reported not knowing anything about the transmitter tester and maybe Maintenance Director H performs this task. On [DATE] at 10:58 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for the alarm report from [DATE]-[DATE]. NHA A reported to Surveyor Maintenance Director H would log into the software and try to generate a report. Example 3 R1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, heart failure, and atrial fibrillation. R1's MDS (Minimum Data Set) assessment, dated [DATE], indicated R1 had BIMS (Brief Interview for Mental Status) score of 99 indicating R1 could not perform BIMS evaluation, and has severe impaired cognition. R1's physician treatment orders: -On [DATE], Safety devices; Wander guard function check every Wednesday on PM shift. -On [DATE], Wander guard to outside aspect of walker for best alarm activation, to monitor whereabouts/exit seeking for safety related to cognitive deficits, check wander guard placement every shift. R1's CNA (Certified Nursing Assistant) task care plan, revised on [DATE], states in part: -Safety: Wander guard to outer side of walker. -Remind R1 to use walker at all times. -30-minute safety checks when in room at nighttime. R1's TAR (Treatment Administration Record): -Started on [DATE]. Safety devices: Wander guard to body to alert staff related to new environment and cognitive deficits. Check wander guard placement every shift. On [DATE] at 9:26 AM, Surveyor observed R1 lying in bed sleeping. Surveyor observed R1's wander guard located on R1's walker on the right metal bar. On [DATE] at 10:27 AM, Surveyor interviewed CNA E and asked CNA E to identify which residents required a wander guard. Surveyor asked CNA E where R1's wander guard was located. CNA E reported R1's wander guard is located on R1's walker. CNA E reported to Surveyor, R1 should have one on their wheelchair too but CNA E did not observe a wander guard on R1's wheelchair. Surveyor asked CNA E if R1 had a wander guard on their body. CNA E stated, no, R1 does not have one on their body. On [DATE] at 11:01 AM, Surveyor interviewed ADON C and asked ADON C to get R1's walker with wander guard and test to see how R1 could exit the building. ADON C reported to Surveyor Maintenance Director H addressed wander guard and sensors and deemed the software to be working. ADON C grabbed R1's walker noting R1's wander guard was attached to the metal bar on the right side of R1's walker. Surveyor asked ADON C if the wander guard on R1's walker was placed appropriately as the wander guard was touching the metal bar. ADON C reported that sometimes residents don't want the wander guard on their person, so facility tries to place wander guard on wheelchair or walker. ADON C stated if the wander guard is moved from person to walker or wheelchair, the resident's progress notes, and care plan is updated to show location of wander guard. Surveyor asked if R1 was to leave their walker and walk out to the common area, then walk to the exit door, how does the alarm trigger to warn staff R1 is trying to elope. ADON C reported to Surveyor, the door would not alarm then if R1 does not have R1's walker with R1. ADON C reported to Surveyor, that staff should implement frequent checks to accommodate R1 venturing without walker since R1 is independent with ambulation. Surveyor observed ADON C walk with R1's walker to the exit door multiple times to test R1's walker. Surveyor observed ADON C going to the exit door with R1's walker and the alarm did not sound. Surveyor observed ADON C approach exit door with R1's walker while walking sideways, and the alarm did not sound until the walker was halfway out the exit door. ADON C reported to Surveyor that the exit door was being difficult as ADON C had never seen that happen. On [DATE] at 12:10 PM, Surveyor interviewed Maintenance Director H and asked if Maintenance Director H performs any audits or checks on the transmitter tester weekly or monthly and did Maintenance Director H know that the 9v battery in the tester expired with expiration date of 12/2023. Maintenance Director reported the transmitter testing was all done by nursing staff and Maintenance Director H did not know the 9V battery expired. Surveyor had Maintenance Director H measure with tape measure sensors on side of entry doors to make sure they were within 4-5 ft of the door to alarm with ample time to prevent further elopement. Surveyor observed inner entry door sensors to units in which the doors were within 4-5 feet of the door. Surveyor observed the exit door sensors on Tender Hearth Haven, which were not 4-5 feet away from the door but directly beside the door frame. Surveyor asked Maintenance Director H if it was a concern the exit door does not alarm until R1 has already exited the door. Maintenance Director H reported that door alarm should be triggering within a couple of feet from the sensors before R1 can even get to the door. Maintenance Director H stated they still do not know why the alarm did not trigger when R1 exited the door. On [DATE] at 12:21 PM, ADON C approached Surveyor and handed Surveyor manufacturing instructions of R1's walker. Surveyor interviewed ADON C and asked how they are preventing the potential frequency interference with the wander guards and metal on R1's walker as well as the wander guard directly touching metal rod on R2's wheelchair. ADON C reported to Surveyor ADON C did not realize wander guards interact with steel or metal. On [DATE] at 1:17 PM, Surveyor interviewed Maintenance Director H, Maintenance Director H showed Surveyor R1's walker. R1's wander guard was attached to the top right metal bar of R1's steel-built walker. Maintenance Director H walked to exit door with R1's walker in front of Maintenance Director H's body. Maintenance Director H body was fully out of the exit door before the wander guard alarm triggered. Maintenance Director H reported that it was odd. Surveyor observed Maintenance Director H trying to readjust the sensors on the side of the exit door. Maintenance Director H stated to Surveyor, that the touch pad exit controller may not be working properly, and they may have to call [name of company] to come in and service the touch pad exit controller so it will set off the alarm. Surveyor asked Maintenance Director H how often the touch pad exit controller is monitored, inspected, and maintained for proper functionality. Maintenance Director H reported to Surveyor they do not monitor or inspect the touch pad exit controller and [name of company] conducts checks every 6 months. Maintenance Director H reported to Surveyor, they were going to call [name of company] right away and get the concern addressed.

Based on interview and record review, the facility did not maintain documentation of screening, education, offering, and current Coronavirus 19 (COVID) vaccination status to staff. This has the potential to affect all 45 residents.The facility did not provide education to all staff for the COVID 19 vaccine.Facility did not develop and implement policies and procedures regarding the COVID 19 vaccine immunization. Findings include:Surveyor was provided separate policies titled Antibiotic Stewardship, Infection Surveillance, Influenza Prevention, Influenza Vaccination, Pneumococcal Vaccine, and the Pandemic Plan. There was no policy for COVID 19 vaccination or mention of COVID 19 vaccination of residents or staff in any of the policies. Code of Federal Regulations S483.80(d)(3) COVID-19 immunizations states in part: The LTC (long term care) facility must develop and implement policies and procedures to ensure all the following(ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine; .(iv) In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff members is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine before requesting consent for administration of any addition doses. (vii) The facility maintains documentation related to staff COVID 19 vaccination that includes at a minimum, the following:(A) That staff were provided with education regarding the benefits and potential risks associated with COVID 19 vaccine: .(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).The facility must maintain documentation that each staff member was educated on the benefits and potential side effects of the COVID-19 vaccine and offered vaccination or provided information on obtaining the vaccine unless medically contraindicated or the staff member has already been immunized. Compliance can be demonstrated by providing a roster of staff that received education (e.g., a sign-in sheet), the date of the education, and samples of the educational materials that were used to educate staff. The facility must document the vaccination status of each staff member (i.e., immunized or not).On 1/6/26 at 7:41 AM, Surveyor interviewed Assistant Clinical Mentor (ACM) C about vaccine clinics. ACM C stated they offer the influenza vaccine to all staff every year and the pharmacy comes and provides the COVID 19 vaccine to those that want it. Surveyor asked if they provide education to all staff and facilitate getting the consents or declinations. ACM C stated they set things up with pharmacy and send out a message to all staff when the COVID 19 vaccine clinic will be. Education is provided when they complete the consent and if they ask. ACM C stated we do not require staff to sign a declination every year if they don't want the vaccine. Surveyor reviewed the background information and most recent COVID 19 consent or declination for Licensed Practical Nurse (LPN) I, Registered Nurse (RN) J and RN K. Surveyor received LPN I's COVID 19 vaccination record with last date received of 6/3/21, RN K's WIR statement showing last COVID 19 vaccine received 3/3/21, and RN J's WIR statement showing last COVID 19 vaccine received was 9/30/21. No declinations since these dates were received. On 1/6/26 at 2:20 PM, Surveyor interviewed RN K regarding COVID 19 vaccinations. RN K thinks she received an email. RN K signed into Matrix (electronic medical record system) and pulled up her messages. On 10/30/25, RN K received a message regarding the pharmacy coming to provide COVID 19 vaccine. No attachments or education regarding the vaccine in the email. RN K stated she didn't receive education regarding immunizations, influenza or COVID 19. RN K stated she declined. Surveyor asked if RN K needed to sign anything that she declined. RN K stated I think I was supposed to. I haven't done that but need to.On 1/6/26 at 2:32 PM, Surveyor interviewed RN J who stated RN J refused the vaccine. RN J stated RN J thinks RN J signed something. RN J stated there was a clinic and we were encouraged to get it. I haven't gotten it since the first booster. Surveyor asked if RN J had received any written or verbal education on the benefits of the COVID 19 vaccine. RN J stated no I didn't get the education; well maybe, we get a lot of stuff. RN J didn't want the vaccine.On 1/6/26 at 3:45 PM, Surveyor asked again if there were any other policies related to the COVID 19 vaccination and for most recent consent or declination of staff for the COVID 19 vaccine.Surveyor reviewed all documentation provided by Clinical Mentor (CM) B. In all the policies provided there is no mention of COVID or COVID 19 vaccination of residents or staff. The facility has a complete listing of all staff that identifies if they had the primary vaccination, an exemption such as religious, and if up to date. Listing does not identify if education was provided or not. Multiple Matrix (electronic medical record system) messages were sent out to staff regarding a COVID 19 vaccine clinic. No consent, declination, or education attached or embedded in these vaccinations. Staff are told in the message that consent forms are available in the Central building and due by 10/24/25.The facility provided an attendance sign-up sheet from the 10/16/25 Monthly CNA/Homemaker Meeting and a copy of the two slides about COVID 19 and the flu season that was presented at the meeting; 35 staff members attended. There are 66 employees and 23 agency/pool staff, or 89 staff, on the staff listing for the facility provided with the NHSN required vaccine listing. Of the 35 staff members in attendance of the 10/16/25 meeting, 17 signatures on the roster work at the facility.On 1/7/26 at 9:45 AM, Surveyor interviewed ACM C regarding the Matrix staff message sent regarding the COVID 19 vaccine clinic. The first message went out on 10/21/25 at 4:33 PM letting staff know the vaccine would be available on 10/30/25. Consent forms were available at the front desk in the Central building. Surveyor asked if the message included an attachment of the COVID 19 vaccine education. ACM C stated there were no attachments to the messages. Surveyor asked when do staff receive the education about COVID 19 vaccine. ACM C gave Surveyor a blank consent form and the COVID 19 vaccine information sheets and stated they get this when they fill out the consent form. Surveyor asked if at any time leading up to the vaccine clinic does everyone get the education. ACM C stated she would have to check with CM B, but this can happen anytime if they want to know. ACM C stated typically everyone has not gotten the education.On 1/7/26 at 7:43 AM, Surveyor interviewed CM B who stated. CM B does not get a signed form from staff if they decline. CM B stated some staff went outside to get the vaccine and bring documentation to me. I do not have them sign a declination. They are told about it and offered it. If they complete the consent and are vaccinated here, then we provide them the written education. A roster is sent to NHSN of those that receive the vaccine. Surveyor asked, so if they do not sign a consent, do they automatically go on roster as declined. CM B stated yes, unless they bring me proof of vaccination somewhere else. On 1/7/26 at 8:05 AM, Surveyor interviewed ACM C and CM B regarding infection control. ACM C stated there is no specific COVID 19 vaccination policy. The Pandemic Plan includes COVID 19, and the Infection Control Plan is all the policies together. ACM C stated the Pandemic Plan is supposed to cover everything. On 1/7/26 at 1:10 PM, Surveyor interviewed Homemaker (HM) L who stated yes, I am offered the influenza and COVID vaccine every year. HM L stated HM L works at Health and Human Services (HHS) also, so HM L gets her vaccines there. HM L stated that she told ACM C she was vaccinated, and ACM C looked it up somewhere online for their records. HM L stated HM L received education at HHS. I got the email it was being offered, but I didn't get education here.On 1/7/26 at 1:16 PM, Surveyor interviewed LPN I who stated they are told vaccines are available every year and where to get them. Surveyor asked LPN I if they receive education about the vaccine with the information. LPN I stated no we do not. LPN I stated LPN I got the influenza vaccine this year. I haven't gotten the COVID 19 vaccine since the first booster. LPN I stated they don't ask me every year about COVID 19, but let us know it's available. I can get it if I want, but I haven't. Surveyor asked if they have to sign anything that you decline the COVID 19 vaccine. LPN I stated no I haven't signed anything. On 1/7/26 at 2:00 PM, Surveyor interviewed CM B who stated only the staff on the roster received formal education before receiving the vaccine. Surveyor clarified that unless staff were at this meeting they only received the email about the COVID 19 clinic and not the education. CM B stated, yes that is correct.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection.Housekeeping did not use any type of clothing barrier (e.g., apron) when sorting and washing dirty laundry. This practice had the potential to affect all 16 residents residing in the same household.Improper hand hygiene was observed during catheter care and personal care for R5 and R29.The facility policy, titled Laundry Duties, last reviewed 2/5/25, states in part: Policy: The Neighbors of [NAME] County provides laundry services to its residents. This includes both personal clothing and facility linens. Purpose: The purpose of the Laundry is to collect, launder, and return linens and clothing to maintain adequate supplies of clean, sanitary linens for Health Center use. Procedure: Resident Laundry is completed on bath day or as needed. AM/PM staff and homemakers should do all personal clothes and lines [sic] in their household. Transfer soiled laundry to the core soiled linen room in the 3 bagged wheeled cart. Before washing badly soiled clothing/lines [sic] they must be rinsed thoroughly in the hopper in your households soiled linen room. There is no mention of infection control related to laundry beyond what is listed above. There is no mention of personal protective equipment (PPE) to be used during Laundry Duties. Per the Centers for Medicare and Medicaid Services Appendix PP of the Standard Operating Manual, requirements at 42 CFR 483.65(c) Infection Control, Linens, state, Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. According to the CDC Infection Control Environmental Infection Control Guidelines, Section G Laundry and Bedding, laundry areas should have handwashing facilities readily available to workers. Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. Example 1 On 1/6/26 at 8:22 AM, Surveyor observed Certified Nursing Assistant (CNA) E collect R37's laundry. CNA E was standing in the doorway of R37's room with a large black garbage bag in hand. CNA E opened the hamper lid, dumped the garbage bag into one of the 3 compartments in the 3-compartment hamper cart and shut the lid. The garbage bag was taken back into R37's room. CNA E did not have on gloves, gown, or any form of PPE. CNA E pulled cart down the hall to the laundry room, unlocked the door, and pulled cart into the laundry room. The room had 3 washing machines, 2 dryers in room towards the back, a sink for handwashing when you walk in, and disposable plastic gown/apron hanging on the wall. CNA E pulled cart to the back by the 3rd washing machine and put on gloves. CNA E, without a gown or some protective barrier, leaned into the soiled linen cart to pull out soiled whites. CNA E's scrub top was touching the soiled linen cart during task. CNA E transferred white washcloths and towels to the washer which were from doing morning peri care and personal cares of all residents in the unit. CNA E closed lid of washer and pushed button on machine to start the load. CNA E showed Surveyor the room, pointing out the door opposite the dryers that goes into a separate room with an exit door to the corridor. CNA E stated this our clean laundry area. During observation, CNA E stated facility has this dirty linen cart (touched the 3-compartment cart) that goes around and gets resident dirty laundry, one room at a time. Resident laundry is done on bath day or when someone's hamper is full. There is a daily load of whites from all the shift peri cares and showers completed during the shift or day. We do not do resident's whites with unit towels. CNA E stated usually CNA E just does all their clothes at once. CNA E took off her gloves and pulled the cart back down to the unit, leaving through the door for soiled linen. The soiled cart did not enter the clean room. The cart was placed back in the soiled utility room on the unit. CNA E stated I do one load at a time; it'll take about 30 minutes. CNA E showed Surveyor the hopper they use if they need to rinse linens first. At end of the observation, Surveyor interviewed CNA E who stated she does not use any other PPE besides gloves when she does laundry. CNA E started to state, We don't have anything, then paused. CNA E stated, Well if we rinse something out, we should wear an apron and face shield. There is a hopper on the unit and apron and shield there. We don't use any bleach. With same soiled scrubs on, CNA E answered a call light assisting R37 with going to the bathroom. Hand hygiene was completed before entering the room. On 1/6/26 at 9:29 AM, Surveyor observed CNA E transfer the clean whites from the washer to the dryer wearing the same soiled scrub top. CNA E was wearing gloves only, no barrier covering her soiled scrub top. Surveyor observed CNA E reach into the soiled hamper cart and pull out resident's personal items and place them into the wash machine. CNA E only had gloves on, no protective barrier in place, and scrubs touched soiled linen cart while pulling the clothing. CNA E stated this will probably take another 30 minutes. At end of the observation, Surveyor interviewed CNA E who stated there is a gown on the wall CNA E could wear but only does when CNA E is dealing with really soiled clothing. Surveyor told CNA E what was observed. CNA E stated CNA E probably should have had the gown on. Surveyor asked if CNA E is done for the day. CNA E stated CNA E is not done for the day and will be caring for residents on the unit; CNA E will not be changing clothes. CNA E shrugged her shoulders and looked away. On 1/6/26 at 2:36 PM, Surveyor observed CNA E wearing same dirty scrubs. On 1/6/26 at 3:45 PM, Surveyor asked Assistant Clinical Mentor (ACM) C what PPE staff should be wearing during laundry. ACM C stated they should be wearing gloves when transferring dirty linen to machine. ACM C stated the laundry area has a clean side for folding, and hands should be washed before folding clothes. Surveyor told ACM C the observation of no gown and leaning into cart to get laundry, soiling scrubs and working shift with soiled scrubs. ACM C stated Oh, she shouldn't have done that. She should have used a gown. Most of the girls pick up the bag and just dump it in the machine. Example 2 Facility policy titled, Hand Washing, Hand Hygiene, last reviewed 09/19/25, states, This facility will outline the appropriate steps to be taken when performing hand hygiene. Hand antisepsis reduces the incidence of health-care-associated infections. Policy further states examples of hand hygiene moments in part as .after body fluid exposure risk, after touching a resident, after touching a resident's surroundings, before and after utilizing gloves. On 01/06/2026 at 8:48 AM, Surveyor observed CNA E conduct morning cares that included incontinence care on R5 who has an indwelling urinary catheter. CNA E conducted hand hygiene and donned clean gloves. After completing upper body cleansing, CNA E unfastened incontinent product and conducted front peri care which included urinary catheter cleansing. CNA E walked into R5's bathroom, and without removing gloves and completing hand hygiene, proceeded to do the following. CNA E: Obtained R5's urinary leg bag from bathroom, opened up an alcohol swab, removed cap from urinary leg bag, and using alcohol wipe, cleansed tip of urinary leg bag tubing. Disconnected nighttime catheter bag tubing from catheter, wiped area with alcohol and connected leg bag to indwelling catheter. Capped nighttime urinary bag and took nighttime urinary bag with and hung on railing in R5's bathroom. Attached urinary leg bag onto right leg. Placed R5's socks on R5's feet. Walked into R5's bathroom to obtain peri cleansing wipes, walked back to R5's bedside and picked up a towel off floor, picked up a clean incontinent product and positioned R5 to turn onto left side and conducted cleansing of R5's rectal area. Without removing original gloves and conducting hand hygiene, CNA E continued to proceed to do the following tasks: Touched and positioned R5 onto right side to position and fasten clean incontinent product. Disposed of dirty incontinent product and put on clean pants. Touched bed controller, raised R5's bed and proceeded to roll R5 side to side to pull up pants and picked up bed controller to lower R5's bed. Placed vinegar in a graduate and filled a flushing syringe. Picked up nighttime urinary bag, opened port to empty urine in toilet and flushed out urinary bag with vinegar. On 01/06/2026 at 9:08 AM, Surveyor interviewed CNA E regarding facility's expectations on when to remove gloves. Surveyor shared observation of no removal of gloves or conducting hand hygiene during entire observation which included cleansing front and back peri care, before the exchange from urinary bag to leg bag, and dressing and touching clean clothing items. CNA E stated the expectation is remove gloves and conduct hand hygiene after conducting peri care. On 01/06/2026 at 4:02 PM, Surveyor interviewed Assistant Clinical Mentor (ACM) C regarding observation of CNA E conducting R5's entire AM cares without removing gloves and conducting hand hygiene. ACM C stated expectation that CNA E should remove gloves and conduct hand hygiene after conducting peri care. Example 3 On 01/07/2026 at 6:43 AM, Surveyor observed CNA F transfer R29 from bed to wheelchair. CNA F ambulated R29 to bathroom. CNA F donned gloves and began providing cares to R29. CNA F washed R29's face, back, and arms. CNA F then placed gait belt on R29 and instructed R29 to stand up to provide peri cares. Surveyor observed CNA F wash R29's peri area around penis and then washed R29's buttocks. Surveyor observed CNA F grab gait belt with contaminated gloves and instruct R29 to sit down in wheelchair. R29 sat down, then CNA F grabbed the wheelchair brakes and unlocked wheelchair to pull R29 back out of bathroom with contaminated gloves. CNA F wheeled R29 over to bedside table, grabbed R29's glasses with contaminated gloves and wiped down the glasses with towel then placed glasses on R29's face. CNA F then grabbed wheelchair handles with contaminated gloves, wheeled R29 to the door, then took off contaminated gloves and threw in trash. CNA F then wheeled R29 out of R29's room without completing hand hygiene and brought R29 to the table in dining room. On 01/07/2026 at 7:03 AM, Surveyor interviewed CNA F and asked what CNA F's process is for providing cares and then completing hand hygiene. CNA F reported to Surveyor that CNA F should have taken off gloves and sanitized hands before R29 transferred to wheelchair but did not.

Based on observation, interview and record review, the facility did not ensure follow up dental care for 1 (R7) of 1 resident reviewed for dental care. R7 complained of tooth pain and requested to see a dentist to have remaining teeth pulled due to broken teeth causing pain during eating. The facility did not document the follow up or extenuating circumstances that led to the delay.Evidenced by: R7 was admitted to the facility on [DATE]. R7's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 11/11/25, indicates R7's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Surveyor reviewed R7's dental progress notes, physician orders, and an email chain pertaining to dental needs: On 07/18/23, progress note states, Specialty care referral form completed to VA for [R7]. [R7] asking to have the rest of his teeth pulled. [R7] doesn't want to work toward dentures.On 08/08/23, a physician order for R7 requesting a dental appointment. On 10/18/23, date of service assessment states: R7 requesting teeth extracted and to get mandibular/max dentures, oral cancer exam completed with negative results for cancer. Class right side cross bite with 3 occlusions. Options: 1: to save as much teeth as possible, Option 2: would be to consider different options including implant retained. R7 wants to go forward with affordable dentures and wanted to go with the acceptable referral to affordable dentures. On 10/13/25, dietary progress notes states, .received a referral for nutritional assessment from recent visit to VA. Recent weight is 162.4 # on 10/08/25 which has been a slow decrease over past years due to his poor intakes. He also cited his poor dental status. Writer noted his preferences state dietary profile and has been taking Ensure three times a day. This provides just under half of both his calorie and protein needs, with his stated oral intake he is most likely falling short of his estimated needs. On 11/25/25, email from Social Worker (SW) D to Unit Clerk G that states, [R7] would like to see a dental provider to get his remaining teeth pulled and then new teeth. Not sure what VA would cover but would imagine dentures? Sounds like from [R7] he went through the VA to see a dentist when he was in St. Cloud. On 12/09/25, progress note, states in part, Resident stated to cancel eye appointment and would like a dental appt at the dental appt at VA for possible extraction of his teeth and possible implants. Unit clerk will reach out to the VA to schedule appointment. Surveyor requested valid documentation of follow up on recommendations from dental provider from the dental assessment on 10/18/23. Facility did not have any follow up documentation. On 01/05/2026 at 10:16 AM, Surveyor interviewed R7 and asked R7 how R7 feels about his dental care. R7 reported that R7 had asked SW D for assistance in setting up a dental appointment for R7 to have all his teeth pulled so that maybe R7 could eat better. R7 reported that R7 was seen back in 2023 with recommendations from dental provider to have teeth pulled and gain dentures, but facility did not go any further with handling R7's dental needs. Surveyor observed R7 hiding his teeth, worried about his smile. R7 stated, My teeth are broken and hurts when eating sometimes. On 01/06/2026 at 11:19 AM, Surveyor requested grievance logs for the last year pertaining to R7's dental request. Nursing Home Administrator (NHA) A reported that NHA A will go pull the grievance log and try to discuss R7's request about dental matters. On 01/06/2026 at 11:56 AM, Surveyor interviewed NHA A and NHA A reported to Surveyor that NHA A found a progress note related to R7's request for VA dental. NHA A reported to Surveyor that Unit Clerk G has already submitted the request for dental services from the VA and awaiting approval. Surveyor asked for verification of the VA referral request for dental services. NHA A reported that Unit Clerk G made a phone call to VA, so it is all verbal. Surveyor asked if Unit Clerk G documents this information anywhere, and NHA A reported that NHA A was unsure. Surveyor let NHA A know that R7 requested that if R7 cannot receive coverage from the VA that R7 can pay out of pocket. Surveyor let NHA A know that could be an option to meet R7's needs. NHA A reported that NHA A will let unit clerk know of the out-of-pocket request as well if VA does not approve. On 01/07/2026 at 11:59 AM, Surveyor interviewed Assistant Clinical Mentor (ACM) C and asked if ACM C is aware of R7 complaining about R7's teeth in pain, hard to eat sometimes, and broken teeth. ACM C reported that ACM C is aware that R7 is requesting to have his teeth pulled and asked back in December of 2025. Surveyor asked ACM C for documentation of progress notes stating how the facility is handling R7's dental needs. ACM C reported to Surveyor that there is only one progress note in December 2025 that states Unit Clerk G will call VA for a referral. Surveyor asked ACM C if Unit Clerk G has made this phone call to VA. ACM C reported that Unit Clerk G made a phone call to the VA and communicated this with ACM C. Surveyor asked ACM C how the phone call to VA was communicated to ACM C. ACM C reported to Surveyor that Unit Clerk G , ACM C, and SW D communicate together usually verbally or through email. Surveyor asked ACM C how the floor nurses are to receive the updated information about specialty services for continuity of care. ACM C reported to Surveyor that the nurse on the floor just comes and asks ACM C or Unit Clerk G. Surveyor asked ACM C when R7 reported R7's dental needs in August of 2023 and a referral was sent out for a comprehensive dental exam, then R7 had the comprehensive assessment in the clinic from specialty on 10/18/23 with a referral to provide R7 with affordable dentures, then why did R7 not receive the recommended services of affordable dentures. ACM C reported that the recommendations from R7's referral visit to dental specialist was never brought back to the facility when R7 returned. Surveyor asked ACM C is it the expectation that R7 needs to bring back any recommendations/orders from an outside provider or is it the obligation of the facility to always follow up with specialty appointments for continuity of care. ACM C stated, It is kind of both, the facility's responsibility and the resident to bring the information back. Surveyor asked ACM C if the facility followed up with the recommendations from the dental specialist for R7 to have teeth pulled and receive dentures. ACM C reported to Surveyor that R7 receiving dentures from affordable dentures was never handled in 2023 but will be now. On 01/07/25 at 12:10 PM, Surveyor requested dental services and management policy. Surveyor received policy titled Resident Dental Care/Dentures but only entailed denture management and dental services for dentures. On 01/07/2026 at 1:15 PM, Dietician H approached Surveyor and gave Surveyor Dietary note dated back to 10/13/25 that states, [R7] also cited his poor dental status and some difficulty managing silverware as factors impacting his eating. Surveyor interviewed Dietician H and asked if Dietician H did anything about the complaint from R7 about poor dental status. Dietician H reported to Surveyor that Dietician H should have reported this concern to a nurse or someone and that Dietician H did not specify R7's poor dental status and what that meant. Dietician H stated, I should have offered ground meat or something as an alternative, but I did not. Surveyor asked Dietician H if R7's weight loss over the last couple years has been related to poor dental health. Dietician H reported to Surveyor that Dietician H could not answer that accurately as R7 has other factors indicating weight loss as well. On 01/07/2026 at 1:38 PM, Surveyor interviewed SW D and asked when SW D was notified that R7 was having some dental concerns and would like specialty to assess R7. SW D reported that originally the complaint from R7 came from a nurse sometime in November and so SW D interviewed R7 who confirmed that if VA won't pay R7 will pay out of pocket. SW D reported that she immediately emailed Unit Clerk G that R7 wanted dental services outside the facility. On 01/07/2026 1:41 PM, Surveyor interviewed Unit Clerk G and asked when Unit Clerk G knew about R7's complaint. Unit Clerk G reported that she received an email in November from SW D and called the VA. Unit Clerk G stated, It is so hard to get a hold of them. Unit Clerk G then received another request for referral of dental services in December, so Unit Clerk G decided to try VA again. Unit Clerk G has a call out presently confirming if R7 needs to be evaluated at the VA or can go to an outside provider. Unit Clerk G stated, I do not have that answer yet, but will be calling again. Surveyor asked Unit Clerk G if Unit Clerk G keeps in records of the steps Unit Clerk G completes for referrals and handling R7's request for dental services. Unit Clerk G reported to Surveyor that Unit Clerk G does not have access to the Electronic Health Record (EHR) to document and therefore Unit Clerk G does not keep a paper trail. On 01/07/2026 at 1:45 PM, Surveyor interviewed ACM C and relayed Surveyor's concerns with facility not providing dental services or following up on recommendations from an outside dental provider. ACM C reported to Surveyor that ACM C understood and will be handling R7's dental needs right away.

Based on record review and interview, the facility did not ensure residents/representatives received notice of bed-hold policy indicating specific reason for transfer or discharge, received notice before transfer or discharge indicating reserve payment, and/or did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman Notification for 2 of 3 residents (R8 and R16).-Facility did not provide a transfer notice form for R16's hospitalizations on 07/09/25, 07/19/25, and 07/23/25.-Facility did not provide specific reason for transfer for R8's hospitalization on 12/06/25.-Facility did not have notification of the daily bed rate on the bed hold policy forms for R8's hospitalization on 12/06/25 or R16's hospitalizations on 07/09/25, 07/19/25, and 07/23/25.-Facility did not notify Ombudsman of R16's hospitalization on 07/19/25.The facility policy titled, Bed Hold Policy for Medical Assistance Residents, last reviewed on 10/25/25 states in part, Beds shall be held for fifteen (15) days for the residents receiving Medical Assistance (MA) while on a hospital or therapeutic leave. There is an option to make payment privately for days beyond the Medicaid bed hold limit at 100% of the current private rate for the level of care determined at the time of discharge. Purpose: To assure the resident and family/legal representative that the bed will be held for fifteen (15) days without replacement while on a hospital or therapeutic leave and/or privately pay to hold the bed under MA program provisions. Procedure: 1. Before a resident is transferred to a hospital or is allowed to go on a therapeutic leave, written information must be given to the resident and/or family member or legal representative specifying the bed hold policy at the facility.The facility was unable to provide a policy regarding Notice of Transfer/Discharge. Example 1 On 12/06/25, R8 was transferred to the emergency room and was provided a bed hold with no reserve payment identified and a discharge notice that did not indicate specific reason for transfer/discharge. Example 2 Surveyor reviewed R16's Electronic Health Record (EHR) that indicated R16 was hospitalized : -07/09/25-07/09/25: For shortness of breath, coughing, and resident request to transfer to ER. -07/19/25-07/20/25: For a fall in room unwitnessed. -07/23-07/26/25: For tachycardia. On 01/06/2026 at 1:27 PM, Surveyor received a bed hold policy notice for R16 from 07/19/25 from Nursing Home Administrator (NHA) A. Surveyor requested the notice of transfer as well for R16 from 07/19/25. NHA A reported to Surveyor that NHA A would try to find the notice. On 01/07/26 at 8:48 AM, Assistant Clinical Mentor (ACM) C approached Surveyor and stated, We do not have a Notice of Transfer for [R16's] transfer on 7/19/25. It was a travel nurse who transferred [R16], and I cannot reach her to follow up. Surveyor asked why ACM C thinks it was not completed and what the process is. ACM C reported to Surveyor that ACM C's expectation is that nurses obtain a copy before they transfer out but that nurses are sometimes in a hurry, and it doesn't always happen. On 01/07/2026 at 9:52 AM, Surveyor requested remaining bed holds and notice of transfers for hospitalizations on 07/09/25 and 07/23/25. On 01/07/2026 at 10:01 AM, Surveyor received bed hold notice for R16 from hospitalization 07/23/25 but Social Worker (SW) D reported there was no bed hold or notice of transfer for 07/09/25. On 01/07/2026 at 10:12 AM, Surveyor interviewed SW D and asked about the bed hold notice for 07/19/25 and 07/23/25 not having the daily payment rate on notice to properly inform R16 or R16's POA of the bed hold payment amount. SW D reported that SW D did not know of the updated regulation. Surveyor asked SW D why R16 did not have a bed hold or transfer notice for 07/09/25. SW D reported there was no need for a bed hold policy or notice of transfer for 07/09/25 since R16 came back within 4 hours. Surveyor indicated to SW D that regardless of how long R16 spent in the ER the facility still did not know when R16 would return so R16 would need to be informed and educated on bed hold and reason R16 is going to the hospital. SW D reported to Surveyor that SW D understood. On 01/07/2026 at 1:38 PM, Surveyor interviewed SW D and asked if Ombudsman was notified for R16's hospitalization on 07/19/25. SW D reported that she did not know she should have reported this since R16 was in hospital only for 4 hours. Surveyor indicated to SW D that state regulation states to update Ombudsman with all admission, transfers, and discharges. SW D reported to Surveyor that SW D understood going forward.

Based on interview and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 1 of 3 residents (R) reviewed. (R1)On 10/01/25, R1 alleged was sexually assaulted by a man. The facility nursing staff did not complete a full body skin assessment to thoroughly investigate the allegation.Facility's policy titled Reporting & Investigating Resident Rights Violations with revised date of 12/15/24, read in part: Assess the Effect on the Resident: Nursing supervisor immediately completes a body assessment and documents findings.R1 was admitted to the facility on [DATE]. R1's current diagnoses include dementia with anxiety, generalized anxiety disorder, dementia with mood disturbance, type 2 diabetes mellitus, chronic kidney disease, and restless legs syndrome.Minimum Data Set (MDS) dated [DATE] a quarterly assessment documented a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe impaired cognition. R1 has fluctuating behaviors of delirium with inattention and disorganized thinking. Verbal behaviors directed toward others.Review of facility reported incident that occurred on 10/01/25, documented R1 reported to staff that a man had sexually assaulted him in the past few days. The man was tall and had light hair. R1 was not able to describe the person and not able to say specifically when this happened. The male Certified Nursing Assistant (CNA) C was placed on leave. CNA C did not meet R1's description of the alleged male. Local law enforcement and R1's Power of Attorney (POA) were notified. R1 was assessed by the rounding provider the day he voiced the concern. Social Worker completed an interview with R1 stating a tall guy sexually assaulted R1 and stating, I'm guessing in bed. Of note, R1 sleeps in recliner in the den next to the nurse's station. The facility interviewed other residents and staff.Of note, the facility's investigation did not document a full body including peri area skin assessment being completed on R1 to assess for any skin abrasions, redness, bruising, or trauma.Review of Nurse Practitioner's (NP) E progress note dated 10/01/25 documented, [R1] is reporting an incident that occurred with another resident, where he was either struck or grabbed on the right arm. This story appears to be different from that of what he told to other staff members earlier today. The exact details of what had occurred remains unclear, and given his advanced dementia, it is unclear the accuracy of what he is recalling. There does not appear to be any obvious injury, or physical abnormalities noted to the site he is referring to.On 10/20/25 at 11:42 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D asking if a full body skin assessment including peri area was completed. LPN D stated no assessment of R1's body was completed. Director of Nursing (DON) B and physician checked R1 and only stated R1's arm being hurt.On 10/20/25 at 1:24 PM, Surveyor interviewed DON B asking if R1's skin was assessed. DON B stated NP asked R1 if he was hurt. R1 stated arm and DON B and NP E assessed R1's arm. Surveyor asked if a full body skin assessment was completed. DON B stated will check to see if a skin assessment was completed.On 10/20/25 at 2:30 PM, Surveyor interviewed DON B asking if expectation to have a full body skin assessment including peri area be completed with allegations of sexual abuse. DON B stated in hindsight a full assessment should have been completed.

Based on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 43 residents in the facility. The facility did not have an adequate surveillance and infection control program in place for tracking and monitoring infection and communicable disease for staff and residents. Staff did not sanitize lift for R11 after resident use. Staff did not sanitize hands during dressing change for R24. Enhanced Barrier Precautions were not put in place for R24, R18 and R26. This is evidenced by: Example 1 Facility's policy titled Infection Surveillance version 2.2, documented, in part: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated infections, to guide appropriate interventions, and to prevent future infections .5. Nursing Staff will monitor residents for signs and symptoms that my suggest infection, according to current criteria and definitions of infections and will document and report suspected infections to the Charge Nurse as soon as possible . Surveyor reviewed the facility's infection control program. The facility did not utilize a data collection tool for surveillance for early detection of symptomatic residents and staff that will identify, track, and monitor for possible communicable disease and outbreaks. In September 2023 a COVID outbreak line list documents the first resident testing positive on 09/16/23. The outbreak line list had a total of 13 positive residents on the EB unit and 1 positive resident on the MS unit. The line lists did not include staff. The outbreak line lists did not document the start date and type of symptoms, or the date precautions were started. The facility did not have any surveillance monitoring documented for residents and staff having symptoms prior to the outbreak. The 01/24 outbreak line list for the MS unit did not document the type of outbreak, the date of onset, type of symptoms, and resolved date for the two residents listed. The line list only marked as positive, but did not specify positive for any specific disease or infection. The outbreak line list did not include staff. Surveyor is unable to determine if the facility meets the criteria for an outbreak. The facility did not have surveillance monitoring of residents and staff having any symptoms prior to the outbreak. The 04/24 Covid outbreak line list for the MS unit did not include positive staff or the resolved date for the three residents listed. The facility did not have surveillance monitoring of residents and staff having any symptoms prior to the outbreak. Surveyor reviewed the facility's monthly infection control logs from 09/23 - 08/24. The infection control logs were not completely filled out to include the room number, date resolved, symptoms, diagnostic results including organism, the date started and type of cautionary measures, and if health care or community acquired. On 09/26/24 at 11:13 a.m., Surveyor interviewed Assistant Clinical Mentor (ACM) D, who is the infection preventionist, about the infection control surveillance and infection control logs. ACM D stated there is no documentation of daily surveillance; we do rounds daily with nurses and notify if any change of condition during morning meeting. ACM D and nursing staff are watching residents and if changes of conditions occur we notify providers for orders for testing. Based on the test results and orders for treatment, then we look for potentially more residents that may be sick. Surveyor asked if residents are having signs or symptoms that don't meet the definition of an infection are they put on a surveillance log to monitor for additional symptoms and prevent the spread to other residents. ACM D stated only if identified as an infection then the resident is put on the line list for that household. Surveyor asked if staff are placed on a surveillance log to assist with the identification of a possible acute respiratory illness or gastrointestinal outbreak on a unit. ACM D indicated the scheduler notifies Nursing Home Administrator (NHA) A and campus Director of Nursing (DON) B when staff are sick and positive then NHA A and DON B say when the staff can return to work. If Covid, staff are tracked where they worked in the last 24 hours, then we would test the residents that they were in contact with. Surveyor reviewed the incomplete infection control logs and lack of surveillance of residents and staff with ACM D. Surveyor shared concern that the surveillance in place will not identify, prevent, or control the spread of infections and communicable disease for all residents and staff in a timely manner. ACM D indicated understanding more detailed surveillance is needed. 46693 Example 2 Policy and procedure titled, Total Lift Mechanical Assist, states, .10. Wipe the lift down after use and in between residents with sanitary wipe or spray. Policy and procedure titled, Hand Washing, Hand Hygiene, states, .Examples of hand hygiene moments: Before touching a resident, before clean/aseptic procedures, after body fluid exposure risk, after touching a resident, after touching a resident's surroundings, before and after utilizing gloves, before and after eating. On 09/25/24 at 7:01 AM, Surveyor observed cares for R11 by Certified Nursing Assistant (CNA) I and Registered Nurse (RN) H. Following care, CNA I and RN H transferred R11 into a wheelchair using a Hoyer lift. After use, RN H brought the Hoyer lift to storage area without sanitizing. Sanitizing wipes are present on a bag connected to the Hoyer lift and readily available. Example 3 On 09/25/24 at 9:30 AM, Surveyor observed wound care for R24 by RN H. During the dressing change, RN H did not sanitize hands after doffing gloves following removal of old dressing and before donning new gloves to finish the wound treatment. RN H did not use a gown during R24's dressing change. Surveyor noted that R24 has an indwelling foley catheter and a chronic wound that would require R24 to be placed on enhanced barrier precautions (EBP). Surveyor reviewed R24's record and it indicates that R24 has a history of MRSA, which would also require the initiation of EBP. Surveyor notes that R24 has no signage on door for EBP and no bins in or outside of room. On 09/25/24 at 9:45 AM, Surveyor asked RN H about sanitizing hands when changing gloves and RN H stated, Oh, I forgot that. Surveyor asked RN H how it is known which residents are on precautions which RN H stated the Infection Control Nurse tracks that and lets us know by telling us and placing signs on residents' doors and carts near their room. On 09/25/24 at 11:45 AM, Surveyor interviewed ACM D and asked what the expectations would be for hand hygiene during dressing changes. ACM D stated, I would expect hand hygiene to be done before the procedure, with any glove changes, after the procedure and anytime as needed in between. Surveyor asked ACM D how often lifts should be sanitized. ACM D said they should be sanitized between residents. Surveyor asked ACM D about incorporating EBP, and ACM D stated they have not revised the policy since they thought it was up to the facility's discretion. Surveyor then reviewed the facility policy and procedure titled, Enhanced Barrier Precautions effective date: 4/1/24. The policy did not include the updates from the CMS memo QSO-24-08-NH, dated March 20, to require Enhanced Barrier Precautions (EBP) in nursing homes. The memo became effective on April 1, 2024. 16692 Example 4 R18 was admitted to the facility with diagnoses that include chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, overactive bladder and history of malignant neoplasm of prostate. R18 requires an indwelling urinary catheter related to urinary retention, and obstruction. Observations of R18 on 09/24-25/24 at varied times revealed no enhanced barrier precautions were in use related to the chronic indwelling catheter use. Example 5 R26 was admitted to the facility with diagnoses that include hypertensive chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine and renovascular hypertension. R26 requires an indwelling urinary catheter related to urinary retention. Observations of R26 on 09/24-25/24 at varied times revealed no enhanced barrier precautions were in use related to the chronic indwelling catheter use.

Based on observation, interview and record review, the facility did not ensure that 1 of 1 resident (R) R3, reviewed for respiratory care was provided care consistent with professional standards of practice. R3 requires continuous oxygen and has a physician's order to change oxygen tubing every 5 days. This was not changed as ordered. This is evidenced by: Facility Policy entitled OXYGEN ADMINISTRATION last revised 03/01/24 states in part 2. Oxygen tubing, masks, etc. c. Are to be changed every 5 days and as needed per the E-MAR/TAR. R3 was admitted to the facility in 2023 and has diagnoses that include chronic obstructive pulmonary disease and atherosclerotic heart disease. R3 utilizes continuous oxygen. On 09/24/24 at 9:14 AM, Surveyor observed R3's oxygen tubing connected to the concentrator in his bedroom. The oxygen tubing is dated 9/1. Surveyor also observed R3's portable oxygen tank on his wheelchair; the tubing connected to the portable oxygen was not dated. R3's physician orders, dated 1/29/24, state in part Oxygen: Change oxygen tubing every 5 days. On 09/25/24 at 10:53 AM, Surveyor interviewed Registered Nurse (RN) E. Surveyor asked RN E to confirm dates of R3's oxygen tubing being changed. RN E could not locate a date on the portable oxygen tubing but stated the tubing on the concentrator in R3's room was dated 09/01. RN E confirmed the date of 9/1 indicates the last date the tubing was changed. RN E confirmed R3 uses continuous oxygen at 2 liters per minute. When asked to look at R3's physician orders, RN E confirmed the physician orders state that oxygen tubing is to be changed every 5 days. RN E confirmed that oxygen tubing should be dated when it is changed on the portable tank.

Based on observation and record review, the facility did not ensure residents (R) were treated with dignity and respect and cared for in a manner to enhance their quality of life. Facility staff used clothing protectors and edge of spoon to wipe resident's face and stood over R32 and R6 while assisting them to eat. Findings: Example 1 R32 was admitted to the facility on [DATE], with diagnoses of Alzheimer's and dementia. Quarterly minimum data set assessment (MDS) dated [DATE] indicated R32 required a mechanically altered diet and is dependent on others for meal assist. On 09/24/24 at 11:44 AM, Surveyor observed Certified Nursing Assistant (CNA) F standing over R32 and using the spoon to clean food from around R32's mouth and then used R32's clothing protector to clean mouth instead of napkin. This observation occurred multiple times during the lunch observation of CNA F with R32. Example 2 R6 was admitted to the facility on [DATE] with diagnoses of Lewy Body dementia and memory deficit following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The annual MDS, dated [DATE], indicated R6 requires setup or clean up assistance while eating. On 09/24/24 at 12:20 PM, Surveyor observed CNA G assist R6 while standing over R6. R32 and R6 have dementia and are unable to speak for themselves. A reasonable person would feel inferior, vulnerable or fear having someone stand over them while being assisted with their meal. The resident would experience a lack of dignity with the use of a spoon or clothing protector to wipe their mouth as opposed to a reasonable person using a napkin.

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessment for 1 of 1 residents (R) reviewed for Preadmission Screening and Resident Review (PASARR) screen (R37). R37's MDS assessment is coded in error stating that a PASARR level 2 screen had not been completed when it was. This is evidenced by: R37 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia and anxiety. Review of R37's medical record found a PASARR level 2 screen was completed, dated 05/06/24. R37's admission MDS assessment, dated 05/14/24, and significant change MDS assessment, dated 07/26/24, indicated for question A1500 that no PASARR level 2 had been completed. On 09/26/24 at 11:00 AM, Surveyor interviewed Social Worker (SW) C, who completed the MDS Section A1500 on R37's admission and significant change MDS. Surveyor asked about the error in MDS coding stating the PASARR level 2 was not completed, when Surveyor observed that it was completed. SW C stated, It must have been an error on my end. SW C acknowledged that a PASARR level 2 screen was completed and is in the records.

Based on record review and interview, the facility did not provide adequate supervision to prevent accidents for 1 of 5 residents (R1) reviewed for supervision with showers and monitoring of water temperatures. R1 had a known history of taking long showers independently, when assessed to require maximum assistance with showers. The facility did not address this behavior in a plan of care. The facility was aware of fluctuating water temperatures on R1's household. The water temperatures were not monitored. R1 entered the shower independently. without assistance, on 1/30/24 and suffered actual harm sustaining second and third degree burns. Findings include: Facility Water Management Plan approval date of 07/17/23 and effective date of 07/17/23. 1. DESCRIPTION OF THE WATER SYSTEM: C. Water heaters are located in the core of each building and in each of the individual households. Central building has 2 water heaters in the core, one supplying the core and the other supplying the main kitchen. Water is heated at each location above 140 degrees and enters a mixing valve and distributes water at a minimum of 140 degrees and runs through a circulation pump at each individual water heater. 2. MONITORING: A. Facilities maintenance technicians are to determine areas in the water system that are vulnerable to legionella. Each household will be monitored on a monthly basis. Records will be kept. in the Life Safety Book including: 1) Temperatures of the incoming cold water and hot water supply. 2) Operation of the water circulation pumps. 3) Ensuring the water heater maintains a temperature 140 degrees F, periodically increasing temperature on the water heater to 150 degrees F. There is no indication that water temperatures should be monitored at the point of resident usage to ensure the temperatures are safe as a part of the water management policy. A policy to direct monitoring of water temperatures in the resident's bathroom sink or shower was not provided. According to Understanding Potential Water Heater Scald Hazards, a white paper developed by the ASSE International Scald Awareness Task Group, hot water scalding can occur in the following time frames at the following temperatures: 154 F / 68 C Scald Injury - Immediate 149 F / 65 C Scald Injury - 1 second 140 F / 60 C Scald Injury - 2 seconds 131 F / 55 C Scald Injury - 5 seconds 126 F / 52 C Scald Injury - 30 seconds 122 F / 50 C Scald Injury - 1 minute 120 F / 49 C Scald Injury - 3 minutes 116 F / 47 C Scald Injury - 35 minutes 110 F / 43 C Shower Temperature Maximum https://www.asse-plumbing.org/media/5213/asse_water_heater_scald_hazards.pdf On 02/07/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE]. R1 is [AGE] years of age. R1's diagnoses included but not limited to unspecified dementia-unspecified severity with mood disturbance, type 2 diabetes mellitus with chronic kidney disease, and history of falling. R1 has an advance directive with an Activated Power of Attorney (POA), who is R1's son. R1 has a certification for incapacity signed 07/18/22, and letter of impairment signed by the physician on 07/18/22, which states R1 is Unable to manage property, finances, or business affairs because of impairment in ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance. R1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/27/24, states R1 is independent with eating, mobility with wheelchair, toilet transfer, requires substantial max assist with shower/bathing, supervision/touch assist with tub/shower transfers. R1's Brief Interview for Mental Status (BIMS) score is 11 out of 15, which indicates moderate cognitive impairment. R1's care plan dated 08/02/23 includes but is not limited to the following: R1 has self-care deficit in ADLs (Activities of Daily Living) in mobility related to impaired skin integrity, antidepressant medication, insulin use, antihypertensive medication, history of falls, bowel and bladder incontinence/assist needed with toileting; requires stand by assist for toileting, dementia, forgetfulness, POA in place, limited or decrease in mobility related weakness, and arthritic pain. R1's goals with short term start date of 11/02/23 and updated short term target date of 01/31/24 and 04/31/24 states: R1 will perform ADLS tasks with 0-1 staff assistance. R1's interventions dated 08/02/23 includes but is not limited to: Provide assist with ADLs utilizing sub-tasking techniques as appropriate (i.e.: set-up, supervision, cueing, and physical assistance) as needed. Encourage participation and independence with cares as R1 is able and safe to perform. Encourage participation and independence with cares as R1 is able and safe to perform-bath per R1's preference. R1's Certified Nursing Assistant (CNA) care plan with no date states: ADLS-Assist: set-up-supervision. Toileting: stand by assist. Do not leave on toilet alone. R1 had a safety assessment conducted on 07/19/22 by therapy. The therapy assessment stated R1 required supervision with transfers, independent with bed mobility, ambulation with assist of 1, ADLs assist of 1 and use of front-wheeled walker, and toileting with stand-by assist. No further safety assessments were completed. On 02/07/24, Surveyor reviewed the Facility Reported Incident (FRI) submitted to the Wisconsin Department of Health Services. The facility identified R1 as being found in the shower on the floor. R1 had gotten self into the shower and turned the water on high. When staff found R1, R1's skin was red and was burned from the water of the shower and beginning to peel off R1's body. EMTs (Emergency Medical Technicians) were called and shortly thereafter to transfer R1 to the emergency room for evaluation. R1's Power of Attorney (POA) was notified, and the facility immediately started an investigation. Facility established a timeline on 01/30/24 regarding R1. The timeline indicates a staff member was in R1's room every hour on 01/30/24 starting at 7:00 a.m. until 11:00 a.m. At this time CNA F provided incontinence care to R1 and R1 stated R1 wanted a shower and was told CNA F would assist R1 with the shower after lunch. The timeline states at 11:45 a.m. when R1's lunch tray was brought into R1's room, R1 was found on the shower floor. The facility report states maintenance staff had been working the prior week on the water in R1's household due to concerns about the water not staying warm. Maintenance worked on the showers the week of 01/22/24 through 01/26/24 and on 01/29/24. Maintenance resolved the issues during that time and the showers in the household that had been having issues were temping out appropriately as of 01/26/24. Report states maintenance was asked to check the temperature of R1's shower after the incident and the shower temped out a couple degrees higher than what it had been set at. The shower valve was taken apart and there were marks on the mechanism as though the handle had been forced past its limits. Report indicates it could not be concluded when this force happened; if it was over time or if occurred on 01/30/24 where enough force was placed on the valve that it displaced the screw that sets the temperature. The facility report stated the facility could not definitively conclude what occurred on 01/30/24 with R1's incident in the shower following their investigation. On 02/07/24, Surveyor reviewed R1's vital signs on 01/30/24 following R1 being found on the floor of the shower. On 01/30/24 at 12:05 p.m., facility documentation states R1's vital signs were Blood Pressure (B/P) 168/76, Respirations (R) 24, Pulse (P) 116, Temperature (T) 97.7, and oxygen (O2) saturation was 94%. Burn injuries leaded to a marked increase in heart rate, increase in heart oxygen demand, and decreased contractility which is the pumping action of the heart. A decreased temperature with burns is due to the inability of the body to control temperature because the blood vessels and sweat glands have been damaged. There is also not the same surface area on the skin to release heat because of the burn damage. On 02/08/24, Surveyor reviewed the ambulance report during transport of R1's status. The ambulance report stated R1 was conscious upon arrival to the facility. It is unknown how long R1 was in the shower. A trauma assessment revealed second-degree burns to the right side of R1's face, the right shoulder, and along the right flank. R1 had sloughed skin along with the burns. R1 rated R1's pain 8 out of 10. R1's pupils were equal and reactive. During ambulance transport to the hospital, R1's vital signs ranges were the following: B/P 144/79 to 174/74, P 90 to 99, R 20-27. R1 received low concentration of oxygen during transport of 1-6 liters per minute. On 02/08/24, Surveyor reviewed the hospital emergency room (ER) report. The report states R1 knows what city R1 is in, does not know why, and does not remember falling. R1's vital signs in theER on [DATE] at 1:16 p.m. were B/P 117/73, P 88, R 18, T 35.8 degrees Celsius (96.44 degrees Fahrenheit), and O2 saturation 93%. The ER report states R1 has first and 2nd degree burns extending down entire right side of R1's back with sloughing towards the lower portion of the back, and over the right side of the buttocks. Also has extensive burns over the right side of the anterior lateral ribcage, underneath the right arm, and partially over the right cheat. Estimate burn surface coverage of about 15-20%. Consistent 2nd degree partial thickness burns with skin sloughing and blistering. Blistering and burns to the right side the forehead, extending down to the chin. Computerized Thermography (CT) of R1's head showed large scalp hematoma (pool of clotted blood) and laceration (deep cut) with no acute intracranial trauma or calvaria fracture (bones of the scalp). R1 was stabilized in ER and transferred to a higher level of care in another hospital burn unit. Surveyor reviewed hospital burn unit medical record for R1. Burn unit report dated 1/30/2024, states R1 has 15% of body surface partial thickness scald burns to the face, head, neck, right upper extremity, torso, and right buttock with third degree burn of less than 10%. Edema noted over right side of face and scalp, with no bruising. R1's vital signs on 01/30/24 were B/P 107/55, P 84, R 16, and O2 saturation 95%. R1's diagnosis per hospital burn unit: agitation, malaise and fatigue, muscle weakness, pain, palliative care encounter, shortness of breath, second degree burn of chest wall, second degree burn of right shoulder, burn involving 10-19% of body surface with third degree burn of less than 10%. Surveyor reviewed facility shower temperature audits conducted by the maintenance department. Room E101 shower temperature 112 degrees F corrective action taken: none (Unknown date of when water temp taken). Room E102 shower temperature 112 degrees F corrective action taken: none (Unknown date of when water temp taken). Room E103 shower temperature 110 degrees F corrective action taken: replaced shower valve 01/30/24-temperature not adjusted correctly. (Water temp prior to adjustment was 119 degrees F, this is R1's room). Room E104 shower temperature 111 degrees F corrective action taken: new valve 01/19/24. Temperature adjusted down 3 degrees F. (Water temp prior to adjustment was 114 degrees F). Room E105 shower temperature 111 degrees F corrective action taken: new valve 01/19/24. Temperature adjusted down 3 degrees F. (Water temp prior to adjustment was 114 degrees F). Room E106 shower temperature 111 degrees F corrective action taken: none (Unknown date of when water temp taken). Room E107 shower temperature 112 degrees F corrective action taken: replaced shower valve-temperature not adjusting correctly. (Water temp unknown prior to adjustment). Room E108 shower temperature 111 degrees F corrective action taken: adjusted temperature down 4 degrees F. (Water temp prior to adjustment was 116 degrees F). Room E109 shower temperature 111 degrees F corrective action taken: adjusted temperature down 5 degrees F. (Water temp prior to adjustment was 116 degrees F). Room E110 shower temperature 111 degrees F corrective action taken: none (Unknown date of when water temp taken). Room E111 shower temperature 111 degrees F corrective action taken: valve replaced 01/24/24. (Water temp prior to valve replacement unknown). Room E112 shower temperature 111 degrees F corrective action taken: temperature adjusted down 4 degrees F. (Water temp prior to adjustment was 115 degrees F). Room E113 shower temperature 112 degrees F corrective action taken: valve replaced 01/24/24. Temperature adjusted down 3 degrees F. (Water temp prior to adjustment was 115 degrees F). Room E114 shower temperature 111 degrees F corrective action taken: valve replaced 01/19/24. Temperature adjusted down 3 degrees F. (Water temp prior to adjustment was 114 degrees F). Room E115 shower temperature 110 degrees F corrective action taken: none (Unknown date of when water temp taken). Room E116 shower temperature 109 degrees F corrective action taken: valve replaced 02/06/24. (Water temp prior to valve replacement unknown). Of note, 4 shower valves on R1's household had been replaced from 1/19 - 1/24/24 ( E104, E105, E113, E114) These rooms needed the temperature adjusted downward. On 02/07/24 at 12:11 p.m., Surveyor and Maintenance Specialist (MS) I checked water temperatures. In room [ROOM NUMBER], which was R1's room, the shower temperature was 115.6 degrees Fahrenheit (F), and in room [ROOM NUMBER] at 12:23 p.m., the shower temperature was 110.3 degrees Fahrenheit. On 02/07/24, Surveyor interviewed R2, R3, R4, and R5 and asked if the residents had any issues with water temperatures or receiving assistance with cares, such as showers. The residents stated the water temperatures were cold and if they did get warm, the water would not stay warm for any length of time. R2, R3, R4, and R5 stated the facility fixed the issue right away and they have no further concerns. Residents R2, R3, R4, and R5 stated they receive assist by staff for their cares. On 02/07/24 at 10:26 a.m., Surveyor interviewed CNA D and asked for CNA D to explain any knowledge of R1's incident in the shower on 01/30/24. CNA D stated CNA D worked in R1's household on 01/30/24 and at 11:47 a.m. was passing out lunch trays and another CNA had brought R1's lunch tray into the room and called out for help because R1 was on the floor of the shower. CNA D stated Registered Nurse (RN) G and CNA E were in R1's room, so CNA D stayed in the dining room with the other residents so they wouldn't go down the hallway to see what was going on and to avoid that area of the hallway. Surveyor asked if there were any issues with water temperatures. CNA D stated the water had been cold and wouldn't stay warm. On 02/07/24 at 10:35 a.m., Surveyor interviewed CNA E and asked if CNA E had any knowledge of R1's incident in the shower on 01/30/24. CNA E stated all residents in the household were checked on at 6:30 a.m. At 7:00 a.m., CNA E stated R1 was checked on and refused cares and did not want to get out of bed. At 9:00 a.m., CNA E brought R1 breakfast. At 10:00 a.m., CNA E stated CNA E checked on R1 and R1 did not want to get out of bed yet. At 11:00 a.m., CNA E stated CNA F went into R1's room and provided incontinence care and changed R1's brief and R1 didn't want to get up. At 11:47 a.m., CNA E stated CNA E brought R1's lunch tray into the room and it was steamy in the room, and the floor had moisture on it. CNA E stated CNA E set R1's tray down, opened the window to clear the steam, and noticed the bathroom door was open. CNA E went into the bathroom, and R1 was lying on the floor in the shower with the water still running on R1's body. CNA E stated CNA E turned the water off, went to the doorway of the room and called for RN G to come into the room. CNA E stated RN G brought the Hoyer lift and CNA E pulled R1's wheelchair and shower chair out of the way in the shower. As RN G was assessing R1, CNA E stated CNA E went to get Assistant Director of Nursing (ADON) C. ADON C came to R1's room. CNA E draped blankets over and under R1, and R1 was placed into the sling. CNA E stated R1's skin was red on the right side of R1's body and was peeling on the right arm, under the right arm, on the right side of R1's body, and R1 had a blister on the forehead. CNA E stated staff assisted R1 back to bed with the Hoyer lift, and R1 was moving around in the bed, and it caused more of the skin to peel. CNA E stated R1 was confused and didn't know what happened and asked if it was bad. Surveyor asked CNA E if R1 requires assist with ADLs such as showers and transfers. CNA E stated R1 is independent with cares and the CNAs will check on R1 when R1 is showering or dressing and will usually make the bed while R1 is doing so. CNA E stated R1 likes to take long showers. Surveyor asked if there were any issues with water temperatures. CNA E stated the water in the rooms had been cold and wouldn't get very hot. On 02/07/24 at 10:53 a.m., Surveyor interviewed R1's POA/Family Member (FM) H via telephone and asked about R1's incident in the shower on 01/30/24. FM H stated the injury is shocking and should not have happened. FM H stated it is understandable if R1 had a fall, especially with R1's stubbornness and wanting to do everything per self, but not R1 getting burned. FM H stated no one in the facility knows exactly how long R1 was in the shower. FM H stated FM H heard there was an issue in the facility with water regulation problems, but FM H does not know the details. FM H stated FM H and spouse came to the facility on [DATE] and looked at the shower and noticed that the only emergency cord in the bathroom was by the toilet and there was not one in the shower. Surveyor asked FM H if there was an update on R1's condition. FM H stated R1 has second and third degrees burns on the right side of R1's body and face. FM H stated the hospital talked to the family regarding surgery (skin grafts) and stated R1 may not survive the surgery, and if R1 did survive the surgery, R1 would probably be on a ventilator. FM H stated hospital staff stated R1 may not come off the ventilator. FM H stated the family decided not to proceed with any surgery and they are looking into hospice care for R1. On 02/07/24 at 11:27 a.m., Surveyor interviewed RN G and asked about R1's incident in the shower on 01/30/24. RN G stated RN G worked on 01/30/24 in the household. RN G stated between 8:30 a.m. and 8:40 a.m. RN G gave R1 medications that were scheduled. RN G stated the CNA was asked to get R1's breakfast so R1 could eat and then receive R1's insulin. RN G stated after giving R1 the medications, RN G stated RN G had to go to another household because RN G was covering two households. RN G stated about an hour later around 9:30 a.m. to 9:40 a.m., RN G went to R1's room and administered insulin to R1 and then left the room to do other things. RN G stated around 11:30 a.m. to 11:40 a.m., a CNA called for help in R1's room and so RN G went to R1's room and R1 was on the floor of the shower. RN G stated the CNA turned the water off because it was still running on R1's body. RN G stated the room was full of steam. RN G stated the CNA was told to go and get ADON C. ADON C came to the room. RN G stated ADON C called the nurse practitioner (NP) and explained the burns on R1. RN G stated R1 had burns on the right side of the face right shoulder, back, right side of chest and a blister on the forehead. RN G stated the skin was starting to peel off. RN G stated R1 was assisted to a Hoyer sling and transferred to bed. RN G stated R1 moved around in the bed and more skin was peeling off R1's body. RN G stated R1 could not state what happened. RN G stated R1 did complain of face burning and cold compresses were applied to R1's face. Surveyor asked RN G if R1 required assistance with cares such as showers and transfers. RN G stated that staff tell R1 to wait for assistance but R1 will do what R1 wants per self anyway and has gone in the shower without assist. On 02/07/24 at 11:46 a.m., Surveyor interviewed MS I about R1's incident in the shower on 01/30/24 and the water temperatures. MS I stated the facility had water issues in R1's household beginning on 01/12/24 but they involved cold water. MS I stated on 01/12/24 the sink was running cold water for the hot and cold water in room [ROOM NUMBER]. MS I stated the mixing valve needed to be replaced in the ceiling because it was putting out too much cold water into the hot water system. MS I stated that starting on 01/19/24 each room in the R1's household was looked at and the shower valves were replaced because the rooms were not adjusting the water temperature correctly. On 01/29/24, MS I stated the solenoid of the emergency shut off for the hot water loop in the system did not open all the way, so it was not creating enough water pressure and limiting the hot water. Surveyor asked when the solenoid was replaced. MS I stated the solenoid was replaced on 02/05/24. Surveyor reviewed documents provided that show the last shower valve was replaced on 2/6/2024. MS I stated on 01/30/24 MS I was called to R1's room around 12:30 p.m. after the incident occurred and R1 had already been transported to the hospital. MS I stated the water temperature in the shower was tested and the temperature was 119 degrees Fahrenheit. (R1 was in shower for possibly 45 minutes and the water temperature was taken another 45 minutes later. Actual water temperature during R1's shower is unknown). MS I stated the shower valve was taken apart and by the condition of it, it looked as though it had been overpowered. MS I stated the on/off shower valve was pushed excessively beyond where it should stop on the hot water side. Surveyor asked if this overpowering could increase the water temperature beyond the maximum temperature the water is supposed to reach. MS I stated it was possible for the water temperature to have increased beyond the 115-degree Fahrenheit maximum temperature it is normally regulated to. Surveyor asked about anti-scald valves for the showers. MS I stated the valves were ordered on 02/05/24 but won't be delivered to the facility until 02/20/24. On 02/07/24 at 2:10 p.m., Surveyor interviewed ADON C and asked about R1's incident in the shower on 01/30/24 and if ADON C could walk Surveyor through the incident. ADON C stated staff came to ADON C's office around 11:58 a.m. or so on 01/30/24 and stated they needed help and R1 was on the shower floor. ADON C stated R1 was lying on the floor of the shower but was trying to prop self-up with R1's right arm. ADON C stated R1's right arm was red, had a blister on the forehead, back was red, and right arm was peeling. ADON C stated R1 was assessed, and the NP was called and updated about R1's status with burns and the skin peeling. ADON C stated NP was told it was unknown how long R1 was in the shower. ADON C stated facility staff got R1 lifted off the floor with a Hoyer lift and transferred R1 to the bed. ADON C stated RN G took R1's vital signs and ADON C needed to check in the record as to what they were. ADON C stated R1's blood sugar was tested , and it was 70mg/dl, which is in the normal range. ADON C stated R1's son, who is the POA was called, the ambulance was called and R1 went to local hospital and was then transferred to the burn unit in another hospital. ADON C stated R1 did not know what happened. Surveyor asked ADON C what interventions were put into place since R1 is known to go into the shower unassisted/unsupervised. ADON C stated a shower chair was placed in the shower in case R1 would need to sit down when going in the shower without assist. Surveyor asked ADON C if R1 requires assist with showers and shower transfers. ADON C stated R1 does require assist by staff. Surveyor asked if any interventions were put into place to prevent this from occurring again. ADON C stated all the residents in the household were assessed by therapies for safety measures with showers. On 02/07/24 at 3:30 p.m., Surveyor interviewed NHA A and asked for NHA A to walk Surveyor through R1's shower incident on 01/30/24. NHA A stated NHA A was made aware of the incident by ADON C. NHA A stated R1 does not always allow assistance with cares. NHA A stated maintenance was called to check the temperature of the water in the R1's shower. NHA A stated a report was submitted to the State Agency, the facility conducted staff interviews, police were notified. NHA A stated the police came to the facility and took pictures of R1's room/shower, interviewed staff, and interviewed NHA A. NHA A stated ADON C notified R1's POA of the incident. NHA A stated interventions were updated for R1's return: sign in room to call for help, therapy order for evaluation, R1 to have 30-minute checks, and staff to keep a log on the times when R1 takes showers. NHA A stated the entire building (3 households) will receive therapy evaluations for shower safety. NHA A stated on 02/01/24 NHA A notified Adult Protective Services (APS) of the incident. Surveyor asked NHA A if interventions were in place because the facility knew R1 tried to perform ADLs per self and especially went into the shower unassisted. NHA A stated a shower chair was placed in R1's shower. NHA A stated R1 was difficult, and the facility couldn't put a lock on the bathroom door or restrain R1 from using the shower by himself. Surveyor asked if R1 was able to use a call light. NHA A stated R1 was capable but refused to use it. On 02/07/24 at 3:46 p.m., Surveyor received a return call from CNA F and asked about R1's shower incident on 01/30/24. CNA F stated on 01/30/24 at 11:00 a.m., CNA F changed R1's brief due to incontinence. R1 stated R1 wanted a shower on 01/30/24. CNA F stated R1 was told CNA F would help R1 with the shower right after lunch since the lunch tray would be served shortly. At 11:45 a.m., CNA F stated CNA F was called into R1's room and R1 was on the floor of the shower. Surveyor asked if R1 required assist with showers and transfers. CNA F stated R1 was stand-by assist but R1 would go and take showers independently. CNA F stated R1 likes to take long showers up to 1.5 hours long. Surveyor asked if there had been any issues with water temperatures. CNA F stated the water in the rooms was cold and wouldn't stay hot very long. On 02/08/24 at 11:55 a.m., Surveyor interviewed facility Medical Director and R1's physician (MD) K about R1's shower incident on 01/30/24. MD K stated MD K did not know any detail of what exactly transpired, but MD K was shocked about the severity of the burns R1 sustained with the incident. According to Nature Reviews Disease Primers ([NAME], M.G., van [NAME], M.E., [NAME], M.A. et al. Burn injury. Nat Rev Dis Primers 6, 11 (2020). https://doi.org/10.1038/s41572-020-0145-5), Burns that affect the uppermost layer of the skin (epidermis only) are classed as superficial (first-degree) burns; the skin becomes red and the pain experienced is limited in duration. Superficial partial-thickness (second-degree) burns (formerly known as 2A burns) are painful, weep, require dressing and wound care, and may scar, but do not require surgery. Deep partial-thickness (second-degree) burns (formerly known as 2B burns) are less painful owing to partial destruction of the pain receptors, drier, require surgery and will scar. A full-thickness (third-degree) burn extends through the full dermis and is not typically painful owing to damage to the nerve endings, and requires protection from becoming infected and, unless very small, surgical management. Finally, a fourth-degree burn involves injury to deeper tissues, such as muscle or bone, is often blackened and frequently leads to loss of the burned part. Although superficial and superficial partial thickness burns usually heal without surgical intervention, more severe burns need careful management, which includes topical antimicrobial dressings and/or surgery. Importantly, burns are classified as either minor or major. A minor burn is usually a burn that encompasses <10% of the total body surface area (TBSA), with superficial burns predominating. By contrast, the burn size that constitutes a major burn is not commonly well-defined; some guidance to classify severe burn injuries are: >10%TBSA in elderly patients. The uniqueness of a severe or major burn injury is anchored in the body responses to it. After the injury, an immediate systemic and local stress response is triggered that, unlike sepsis or trauma, does not recover quickly. Severe burns cause a complex pattern of responses that can last up to several years after the initial insult. In general, immediately after the insult, an inflammatory response is triggered to promote the healing process. However, in severe burns, this inflammatory process can be extensive and become uncontrolled, leading to an augmented inflammation that does not induce healing but rather causes a generalized catabolic state and delayed healing. This response is almost unique to burns and is referred to as the hypermetabolic response; it is associated with catabolism, increased incidence of organ failure, infections and even death.

Based on observations and interviews, the facility did not implement appropriate infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections. Staff observed with open sores assisting residents with meals and prepping silverware. Staff observed washing hands and turning off the faucet with clean hands. No hand hygiene was offered for residents before meals on 2 of the 3 households. This affected 30 of 46 residents (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31, R14, R1, R12, R43, R27, R25, R14, R25, R36, R8, R6, R41, R16, R24, R197, R30, and R26). Staff touching straws with bare hands. This affected 13 residents (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31). No hand hygiene with glove change during medication pass for R97. Findings include: Example 1 On 08/30/23, Surveyor observed Certified Nursing Assistant (CNA) G wrapping silverware in the Eastbrook dining room. Surveyor also noted CNA G to have 2 open red areas on their top left forearm. One area was about the size of a quarter, the other about the size of a nickel. On 08/30/23 at 8:17 AM, Surveyor observed CNA G assisting 2 residents with eating. On 08/30/23 at 8:31 AM, Surveyor observed CNA G sitting next to R7 assisting him with eating. On 08/30/23, Surveyor interviewed Director of Nursing (DON) B and asked if staff should be working with residents with open wounds. DON B indicated when wounds are open staff should have them covered. On 08/30/23, Surveyor interviewed CNA G and asked which households CNA G worked on today. CNA G indicated they worked on Eastbrook and Morning Song. Surveyor asked CNA G what type of duties they performed. CNA G indicated they folded clothes, visited with the residents, folded silverware and assisted residents with eating. Example 2 On 08/28/23 at 11:58 AM, Surveyor observed CNA I wash their hands prior to serving lunch with soap and water, turn off the faucet then grabbed paper toweling to dry their hands. On 08/30/23, Surveyor interviewed Culinary Mentor (CM) F and asked the proper way to wash hands. CM F indicated turn on the water, lather hands for 15-20 seconds, rinse, dry hands with paper toweling, then turn off faucet with paper towel. Example 3 On 08/28/23, at about 12:00 PM in the Eastbrook dining room, Surveyor was observing lunch being served to the residents (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31). No hand hygiene was offered before lunch to the residents. On 08/29/23, at 11:51 AM in the Eastbrook dining room, Surveyor was observing lunch being served to the residents (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31). No hand hygiene was offered to residents before lunch. On 08/29/23 at 12:02 PM, in the Morning Song Villa dining room, Surveyor observing lunch being served to the residents (R14, R1, R12, R28, R43, R14, R27, R25, R36, R8, R6, R41, R16, R24, R197, R30, R26). No hand hygiene was offered to residents prior to the staff delivering their meals. On 08/30/23 at 7:26 AM, in the Morning Song Villa dining room, Surveyor observing lunch being served to the residents (R14, R1, R12, R28, R43, R14, R27, R25, R36, R8, R6, R41, R16, R24, R197, R30, R26). No hand hygiene was offered to residents prior to the staff delivering their meals. On 08/30/23 at 11:23 AM, in the Morning Song Villa dining room Surveyor observing lunch being served to the residents (R14, R1, R12, R28, R43, R14, R27, R25, R36, R8, R6, R41, R16, R24, R197, R30, R26). No hand hygiene was offered to residents prior to the staff delivering their meals. On 08/30/23 at 11:45 AM, Surveyor interviewed Resident (R) 28 and asked R28 if the staff offer hand hygiene before you eat. R28 replied, No, although I try and wash my hands in my room before I come out to the dining room. On 08/30/23 at 11:49 AM, Surveyor interviewed CNA E and asked if they offer residents hand hygiene before they are served meals. CNA E replied, The short answer is no. I try to give them hand sanitizer at their room door when I take them to the dining area. I put some in my hand and then give it to them. Some of the residents will throw it back at me, so you learn which residents you can and can't give hand sanitizer to. On 08/30/23 at 12:14 PM, Surveyor interviewed DON B about the facility's policy regarding hand hygiene before meals. DON B replied, For breakfast they [residents] would have just received their AM cares and would have just been brought out for breakfast. For lunch, we always offer the bathroom to the residents before we take them to lunch and provide hand hygiene after the bathroom. But if we see that the residents' hands are visibly soiled, we would offer them hand hygiene no matter what. Surveyor asked DON B for a copy of their policy regarding hand hygiene before meals. On 08/30/23 at 12:41 PM, DON B informed this Surveyor that the facility does not have a specific policy regarding resident hand hygiene before meals. Example 4 On 08/28/23 at 12:07 PM, Surveyor observed CNA H getting drinks ready for the residents for lunch. CNA H placed lids on all the cups, removed the straw paper, then using bare hands put a straw in all 13 residents' (R33, R28, R20, R147, R44, R7, R3, R9, R19, R10, R21, R37, R31) beverages. On 08/30/23, Surveyor interviewed CM F and asked how staff should remove the paper from straws. CM F indicated staff should remove the paper from the bottom of the straw, leave paper on the top part of the straw and place in cup. Never touch the straw with bare hands. 46694 Example 5 Facility policy titled, Hand Washing, Hand Hygiene revised 04/05/22, states in part: .Examples of hand hygiene moments: Before touching a resident, before clean/aseptic procedures, after body fluid exposure, after touching a resident, after touching a resident's surroundings, before and after utilizing gloves, before and after eating . On 08/29/23 at 8:24 AM, Surveyor observed Registered Nurse (RN) D administer medications to R97. RN D gathered R97's medications and a pair of gloves from the medication cart; hand hygiene was not observed. RN D entered R97's room and put on the gloves without any hand hygiene. RN D administered medications to R97 which included a nasal spray into each of R97's nostrils. RN D removed gloves without performing hand hygiene. RN D walked back to the medications cart and put away R97's nasal spray. No hand hygiene was observed by Surveyor. On 08/29/23 at 8:30 AM, Surveyor interviewed RN D about the proper hand hygiene before and after glove use. RN D replied, I don't like hand sanitizer so I would rather wash my hands with soap and water, but I should've done that before and after glove use. On 08/30/23 at 10:35 AM, Surveyor interviewed DON B about hand hygiene with glove use. DON B replied, All staff should perform hand hygiene before and after glove use.

Based on observation, staff interview and record review, the facility did not follow proper food handling practice. This practice had the potential to affect 16 of 46 residents (R14, R25, R45, R36, R12, R8, R6, R27, R41, R16, R1, R24, R197, R28, R30, R26) residing in the facility. Certified Nursing Assistant (CNA) E did not wear a hairnet while serving breakfast. Findings include: The FDA Food Code 2022 document 2-402.11 Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 08/30/23 at 7:20 AM, Surveyor observed CNA E serving breakfast to residents in the kitchenette. Surveyor asked CNA E if you are supposed to wear a hairnet when you are serving breakfast from this kitchenette. CNA E replied, Oh yeah, and walked around the counter, opened a drawer, pulled out a hairnet and put it on. On 08/30/23 at 9:30 AM, Surveyor interviewed Culinary Mentor (CM) F regarding the use of hairnets in the kitchenette. CM F replied, Yes, the homemakers need to wear hairnets in the kitchenette. Surveyor asked CM F for a policy regarding hairnet use. On 08/30/23 at 9:49 AM, CM F handed this surveyor a policy titled, Sanitation and Food Safety, revised 04/23/2019, which states in part, .1. Personal Hygiene . b. Hair must be completely restrained with proper hair covering while in food preparation areas .

Based on interview and record review, the facility did not have evidence that alleged violations of abuse were thoroughly investigated, prevent further potential abuse, and report the results of all investigations to the administrator and other officials in accordance with state law, including to the state survey agency for 2 of 5 residents (R), R4 and R5. Staff overheard R4 tell R5 that he kissed her. The facility did not do a thorough investigation, to prevent further potential abuse, and did not report to the administrator or state survey agency. This is evidenced by: The facility's policy, entitled Reporting & Investigating Resident Rights Violations, dated 3/09/07, states in part: .Notify Administrator or designee immediately of the allegation. Even if suspected, the employee should report their suspicions within 2 hours .With Administrator's direction, immediately report such violations via the Department of Quality Assurance electronic reporting system .Document, document, document - including a facility incident/accident report and/or associated decision-tree charts . On 07/03/23, Surveyor reviewed R4 and R5's medical records to find the following: R4 was admitted to the facility on [DATE] and has diagnoses that include, but are not limited to parkinsonism, schizophrenia, and post-traumatic stress disorder. R4's Minimum Data Set (MDS) assessment, dated 4/18/23, indicated that the Brief Interview for Mental Status (BIMS) score was 15. BIMS score ranges from 00-15. 13-15: cognitively intact. 08-12: moderately impaired. 00-07: severe impairment. R5 was admitted to the facility on [DATE] and has diagnoses that include, but are not limited to severe vascular dementia with anxiety, unspecified visual loss, and bilateral sensorineural hearing loss. R5's MDS assessment, dated 4/01/23, indicated that the BIMS score was 10. On 07/03/23 at 9:20 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F concerning abuse/neglect. CNA F stated she heard R4 and R5 had kissed each other, and that nursing and management were made aware of this. Staff are to try to keep the two residents separated. CNA F believed they care planned the kissing but was not sure as this just happened recently. A review of both R4 and R5 care plans and documentation in the chart had nothing noted about this kissing incident. On 07/03/23 at 9:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D concerning kissing between residents. LPN D stated there had been a report of residents kissing, but she had not seen it. She had reported this to the Assistant Clinical Mentor (ACM) C. This recently happened end of last week. On 07/03/23 at 10:15 AM, Surveyor interviewed Social Worker (SW) E concerning kissing between residents this past week. SW E stated she was not aware of any residents kissing each other this past week. On 07/03/23 at 10:45 AM, Surveyor interviewed ACM C concerning kissing between residents this past week. ACM C stated she was not aware of kissing incidents between residents this past week. On 07/03/23 at 10:55 AM, Surveyor interviewed CNA F concerning R4 and R5 kissing. CNA F stated this happened last Thursday or Friday (06/29/23 or 06/30/23). LPN D helped with this incident. Another CNA witnessed this incident. CNA F said she did not directly see/hear kissing between these two residents. On 07/03/23 at 11:00 AM, Surveyor interviewed LPN D concerning R4 and R5 kissing. LPN D said the CNA who reported it to her overheard R4 tell R5 that they had kissed. These residents were not observed kissing. LPN D immediately spoke with R4 about this issue and that it was not to be done as R5 was not aware of what was going on. LPN D said she told staff to keep the two residents separate. LPN D said she reported this incident to ACM C via text. On 07/03/23 at 11:30 AM, Surveyor interviewed ACM C and asked if she was informed by LPN D of the kissing incident with R4 and R5. ACM C said she was told by LPN D about the incident and that it was only hearsay and no witness of them kissing. LPN D spoke with R4 who said he denied it. ACM C said she spoke with staff, and no one witnessed any kissing between the residents. The kissing incident was not care planned because it was not witnessed. ACM C said they did not do an incident report because it was hearsay and not seen. R4 does not have a history of sexual or kissing incidents. ACM C said she did not report this to the state because no one witnessed kissing and the resident denied it. Surveyor asked ACM C to obtain any documentation on this incident. On 07/03/23 at 12:05 PM, ACM C provided Surveyor with the investigation documentation that states the following: LPN D mentioned to writer that CNA G told her that she overheard R4 say to R5 that he kissed her. CNA G reported that R5 didn't respond to R4's comment. LPN D asked the staff working in the house if they witnessed any kissing and they said no. Writer instructed LPN D to educate R4 on nursing home having rules and we discourage kissing etc. Writer instructed LPN D to instruct staff to monitor interactions closely and report any inappropriate interactions. R5 did not acknowledge any kissing to staff or to writer that day. R4 has schizophrenia diagnosis and has hallucinations/delusional thoughts as well. Writer ACM C The investigation did not include documented interviews with other alert residents, or staff to determine if R4 had ever acted this way with others. On 07/03/23 at 12:35 PM, Surveyor asked the Director of Nursing (DON) B if she was aware of this kissing incident. DON B responded she was not aware of any kissing incidents this past week. Surveyor also asked the Nursing Home Administrator (NHA) A if she was aware of this kissing incident. NHA A responded she was not aware of this incident either to complete a full investigatoin into the incident.

Based on interview and record review, the facility did not perform regular inspections of all bed frames, mattresses, and bed rails as a regular part of maintenance program to identify areas of possible entrapment for 4 out of 8 residents (R) with bed rails (R5, R9, R22 and R27). Routine maintenance to ensure proper working order was not provided for beds with rails for cognitively impaired residents at risk for entrapment. Findings include: Example 1 On 08/08/22 during the initial tour of the facility, Surveyor noticed that R5 had a bed rail on right side of the bed. Record review identified R5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia in other disease classified elsewhere without behavioral disturbance, other specified anxiety disorder, history of falling. R5's quarterly Minimum Data Set (MDS) assessment, dated 05/04/22, Brief Interview for Mental Status (BIMS), showed resident severely impaired meaning never/rarely made decisions. Section G: on the MDS indicated Bed Mobility Extensive is assistance and one-person physical help from staff. Transfer/Self-Performance is Extensive assistance with 2 plus Record review of R5's medical record on 08/08/22 did not identify any documentation of regular maintenance or inspection of R5's bed frame, mattress, or bed rails, or assessment for risk of entrapment. Example 2 Record review of R9's medical record on 08/08/22 did not identify any documentation of regular maintenance or inspection of R9's bed frame, mattress, or bed rails, or assessment for risk of entrapment. Example 3 On 08/08/22 during the initial tour of the facility, Surveyor noticed that R22 had bed rail on right side of the bed. Record review identified R22 was admitted to the facility on [DATE] with a diagnosis including Hypertensive chronic kidney disease, unspecified dementia without behaviors. R22's quarterly MDS dated [DATE] showed a BIMS score of 5 which indicates cognitive impairment. Section G: on the MDS indicates Bed Mobility Supervision and one-person physical help from staff. Transfer Limited assistance with one person. Record review of R22's medical record on 08/08/22 did not identify any documentation of regular maintenance or inspection of R22's bed frame, mattress, or bed rails, or assessment for risk of entrapment. Example 4 On 08/08/22 at 2:37 p.m., Surveyor observed R27's bed having a left assist bar. Review of R27's medical record documented current diagnosis of [CONDITION(S)] disease, dementia without behavioral disturbance, [CONDITION(S)], anxiety disorder, [CONDITION(S)] without pathological fracture, chronic pain, [CONDITION(S)], and overactive bladder. Review of the Minimum Data Set (MDS), dated [DATE], a significant change assessment documented R27 requiring extensive assist of one staff for bed mobility and transfers. Review of the care plans did not document assist bars as equipment being used. Review of the medical record did not identify a signed consent for use of the assist bar. The medical record did not contain a bed rail risk assessment for risk of entrapment or other equipment trials before bed rail/assist bars were utilized. Review of the maintenance record of bed rail inspection dated 09/13/21 did not identify assessments of risk for entrapment. On 08/10/22 at 10:59 a.m., Surveyor interviewed the Maintenance Director (MD) C asking about the inspections of the resident's beds and bed rails. MD C indicated the beds are inspected yearly for any type of wear and broken parts. MD C indicated the inspection of the beds have not been completed yet this year. Surveyor asked if the bed rails are able to be removed from the bed. MD C indicated the bed rails are able to be removed. When a resident discharges from the facility the beds are inspected and prior to a new resident occupying the room. If the bed had two bed rails then one would be removed so the bed would only have one bed rail when the new resident arrived. Surveyor asked if the resident and the bed are assessed for risk of entrapment. MD C indicated when the resident is in the room maintenance does not go into the room to check the beds. If there is an issue with the beds the nursing staff will tell maintenance about the problem that needs to be fixed. Surveyor asked if a new or different mattress other than the bed frame manufacturer mattress is installed if there an inspection of measurements for proper fit and for risk of entrapment. MD C indicated he does not take measurements of the beds and has not been asked. At 11:25 a.m., Surveyor and MD C entered a vacant room to review the function and attachment of the bed rail. Surveyor asked if the mattress and the bed rail are the appropriate distance and is there a chance for a person to be entrapped. MD C indicated the distance of the mattress to the bed rail is too large. MD C inspected the installation of the bed rail and found additional hardware was attached to the bed frame and this caused the bed rail to be farther away from the mattress. MD C indicated this bed rail should not be installed this way and will get it fixed. Surveyor asked if routine checks are not being completed and only completed yearly how would this have been corrected before a new resident occupied this bed. MD C indicated understanding the need for frequent inspections. Surveyor reviewed with MD C of the facility's policy of listed resources for proper placement of mattresses to identify risk of entrapment.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 16 out of 42 residents who reside in the facility. Refrigerator, freezer, and dishwasher temperature checks were not completed twice a day. SOM review: Practices to maintain safe refrigerated storage include: Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation; This is evidenced by: On 08/09/2022 at 7:01 a.m., Surveyor conducted a tour of the facility's Tender Hearth kitchenette. The refrigerator held cheeses, juices, milk, lunch meats, and items used during breakfasts that are cooked and served as residents come into the dining room. It also had a drawer of residents' personal items of all varieties that they can access when they want. It is normal to store food in the refrigerator on a regular basis. Review of the kitchenette temperature logs identified: June 2022, 37 out of 60 shift entries for temperatures on the pantry fridge, kitchen fridge, kitchen freezer, and dish machine rinse were not completed. July 2022, 33 out of 62 shift entries for temperatures on the pantry fridge, kitchen fridge, kitchen freezer, and dish machine rinse were not completed. August 2022, 7 out of 17 shift entries for temperatures on the pantry fridge, kitchen fridge, kitchen freezer, and dish machine rinse were not completed. On 8/10/2022 at 2:01 p.m., Surveyor interviewed Maintenance Director (MD) D who stated the temperature logs are to be checked two times a day by a homemaker or whomever is doing that position delegated by the charge nurse. The charge nurse or dietary department are responsible to check and see if it is completed. If a Certified Nursing Assistant is pulled to be the homemaker, the temperatures may get missed. MD D stated that the staff was provided direct education. At times, MD D will double check the temperatures and will also try to track down the staff who missed checking temperatures to provide education. MD D has no documentation on education provided.

Based on observation, interview and record review, the faciity failed to assess the risk of entrapment, obtain informed consent, or attempt alternative interventions before implementing use of side rails, and failed to assess whether the bed rail was still needed for 4 out of 9 residents (R) reviewed for side rail use and risk of entrapment (R5, R9, R22 and R27). R5, R9, R22, and R27 had grab bars on their beds, without an assessment completed to determine their risk for entrapment, without first attempting alternate methods prior to side rail use, and no consent obtained for the use of the side rails. Findings include: The Food and Drug Administration document titled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, states, in part: Many beds currently in use may no longer have the original mattress or bed rails, and may present an entrapment hazard by increasing or creating gaps or spaces between various components of the bed system. Reducing the risk of entrapment involves a multi-faceted approach that includes bed design, clinical assessment, and monitoring, as well as meeting patient, resident, and family needs for vulnerable patient in most health care settings-hospitals, long term care facilities and at home. Therefore, comprehensive bed safety programs in these settings will likely involve input from manufacturers as well as facility staff. Reassessment may be appropriate when (1) there is reason to believe that some components are worn (e.g., rails wobble, rails have been damaged, mattresses are softer) and could cause increased spaces within the bed system, (2) when accessories such as mattress overlays or positioning poles are added or removed, or (3) when components of the bed system are changed or replaced (e.g., new bed rails or mattresses) . Example 1 On 8/08/22 during the initial tour of the facility, Surveyor noticed that R5 had a bed rail on right side of the bed. R5's quarterly Minimum Data Set (MDS) assessment, dated 05/04/22, Brief Interview for Mental Status (BIMS) showed resident severely impaired meaning never/rarely made decisions. Section G: on the MDS indicated Bed Mobility Extensive assistance and one-person physical help from staff. Review of R5's medical record on 08/08-08/10/22 did not reveal any assessment for the risk of entrapment with bed rail use, did not reveal a review of the risk and benefits or consent for the use of bed rails with the resident's representative. Example 2 On 08/08/22 during the initial tour of the facility, Surveyor noticed that R9 had a bed rail on left side of the bed. R9's Admission MDS dated [DATE] showed resident severely impaired, meaning never/rarely made decisions. Section G: on the MDS indicates Bed Mobility is Extensive assistance and one-person physical help from staff. Review of R9's medical record on 08/08-08/10/22 did not reveal any assessment for the risk of entrapment with bed rail use, did not reveal a review of the risk and benefits or consent for the use of bed rails with the resident's representative. Example 3 On 08/08/22 during the initial tour of the facility, Surveyor noticed that R22 had a bed rail on right side of the bed. R22's quarterly MDS dated [DATE] showed a BIMS score of 5 which indicates cognitive impairment. Section G: on the MDS indicates Bed Mobility Supervision and one-person physical help from staff. Review of R22's medical record on 08/08-08/10/22 did not reveal any assessment for the risk of entrapment with bed rail use, did not reveal a review of the risk and benefits or consent for the use of bed rails with the resident's representative. Example 4 On 08/08/22 at 2:37 p.m., Surveyor observed R27's bed having a left assist bar. Review of R27's medical record documented current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], a significant change assessment documented R27 requiring extensive assist of one staff for bed mobility and transfers. Review of the care plans did not document assist bars as equipment being used. Review of the medical record did not identify a signed consent for use of the assist bar. The medical record did not contain a bed rail risk assessment for risk of entrapment or other equipment trials before bed rail/assist bars were utilized. On 08/09/22 at 2:15 p.m., Surveyor interviewed Assistant Director of Nursing (ADON) C asking if the facility completes grab bar/bed rail assessments for risk of entrapment. ADON C indicated they do not do separate grab bar assessments as the grab bar is on the bed. ADON C indicated if a different mattress is placed on the bed they would look to see if it fits and have ordered a bariatric air mattress to fit on the bed frame. Surveyor asked if they conduct a trial of other assistive devices for positioning before using the grab bars. ADON C indicated no they do not as the assist bar is already on the bed from the manufacturer.

Based on observation, interview and record review, the facility did not provide a safe and sanitary enviornment to help prevent the development and transmission of infections. This occurred for 1 of 5 residents (R) reviewed, R5. The facility staff did not follow standard precautions with insulin administration for R5. This is evidenced by: R5's [DIAGNOSES REDACTED]. On 02/10/20 at 7:30 a.m., Surveyor observed Registered Nurse (RN) C administer insulin to R5. RN C was not wearing gloves. R5 was seated at a dining room table. RN C approached the resident, carrying an insulin injection pen and an alcohol wipe. After obtaining permission to administer the medication, RN C cleansed R5's right lower abdominal area using the alcohol wipe. Next, RN C administered the injection. After administering the injection, RN C disposed of the used needle in a needle container located on the medication cart. Next, RN C performed hand hygiene using an alcohol based product. At 11:45 a.m., Surveyor observed RN C administer insulin to R5. RN C performed hand hygiene using an alcohol based product. Next, RN C attached a clean needle to an insulin pen. RN C approached R5 and gained permission to administer the insulin. RN C was not wearing gloves. RN C cleansed R5's left lower abdomen with an alcohol wipe and performed the injection. Next, RN C disposed of the used needle in a container located on the medication cart. After disposing of the needle, RN C performed hand hygiene using an alcohol based product. Surveyor interviewed RN C. RN C stated, I have never worn gloves to administer insulin. At 1:45 p.m., Surveyor interviewed RN D who is the clinical mentor for the unit. RN D stated RN C should have donned gloves while performing the injections. Surveyor reviewed a policy provided by RN D. The policy was entitled Medications. The document read, in part, (prior to injection) .put on clean gloves .gloves help prevent exposure to contaminants.

Based on observation, interview and record review, food temperatures were not maintained during meal service for Tender Hearth and Morning Song units (2 of 3 units). This had the ability to affect 30 of 44 residents. This is evidenced by: On 06/10/19 at 8:45 a.m., Surveyor interviewed R7. R7 stated, in part .the food is cold . R7 stated the food is delivered to his table directly from the steam table. On 06/10/19 at 9:24 a.m., Surveyor interviewed R19. R19 stated, in part, .they have to bring the food over from a another building so sometimes the food is lukewarm or cold . On 06/11/19, R25 and R95 complained the lunch food was cold on 06/10/19. R25 and R95 reside on the Morning Song unit. On 06/10/19 at 11:40 a.m., Surveyor observed meal service on Tender Hearth unit. The following food temperatures were obtained by facility staff and confirmed by Surveyor: Hamburger gravy mixture=150 degrees Fahrenheit. Pureed hamburger/gravy mixture=180 degrees Fahrenheit. Pureed vegetables=150 degrees Fahrenheit. Pureed potatoes=160 degrees Fahrenheit. Mashed potato=140 degrees Fahrenheit Soup=170 degrees Fahrenheit. Whole vegetables=120 degrees Fahrenheit and were reheated in microwave. After reheating, the vegetable temperature was 150 degrees Fahrenheit. At 12:14 p.m., a pureed room tray was delivered to R23. At 12:19 p.m., a test tray was obtained by Surveyor. The test tray temperatures were: Soup 120 degrees Fahrenheit. Tasted lukewarm. Hamburger/gravy over pureed potatoes 112 degrees Fahrenheit. Tasted cold. Vegetables 90 degrees Fahrenheit. Tasted cold. Pureed vegetables 110 degrees Fahrenheit. Tasted cold No mashed potatoes were available to test. At 12:30 p.m., Surveyor interviewed R23. R23 stated she does not like the food, does not like the food texture and the food is cold. She stated she just wanted the pureed pears and coffee. Surveyor reviewed past recorded food temperatures for the month of June. The food temperatures were recorded after the food left the kitchen in the Central building unit, transferred to the main East building unit, then delivered to the separate building neighborhoods. These initial temperatures were within normal limits. At 3:15 p.m., Surveyor interviewed Culinary Manager (CM) I. CM I stated the food temperatures are first obtained in the kitchen to ensure the temperatures reach 140 degrees Fahrenheit, with an internal temperature of 165 degrees Fahrenheit. The food leaves the kitchen, and is transferred manually to other buildings, then distributed to individual units. Once the food reaches the buildings steam tables, the food temperatures are obtained. If the food temperatures are less than 140 degrees Fahrenheit, the food is to be heated either in the unit microwave or in the oven. CM I stated the facility does not have a system for ensuring the food holding temperatures are maintained. Food holding temperatures are not taken during the meal to ensure adequate holding temperatures.

The facility did not accommodate a resident's diet choices nor were these diet choices reflected through adjustments in the plan of care for 1 of 17 residents. Resident (R) 23 was provided a pureed diet which was not updated by the facility when order was changed to as tolerated by hospice. Resident's requests for regular food were denied by the facility despite diet order to provide. This is evidenced by: On 06/10/19 at 12:30 p.m., Surveyor interviewed R23. R23 stated she hated pureed food, she can't eat it and the facility is aware of this. R23 stated she has been eating snacks in her room, which consist of candy and cheese balls. R23 told surveyor the doctor at the hospital told her she did not have to have a pureed diet texture, but the facility staff tell her she has to have a pureed diet. R23 stated. All I want is liver and onions. I'm craving them so bad. Surveyor interviewed Registered Nurse (RN) K and relayed resident request. RN K stated, She can't really have that since she is on a pureed diet, but I will pass it along. When asked if resident was able to have food items she considered important for her quality of life, RN K said, She is on a pureed diet. Surveyor interviewed Licensed Practical Nurse (LPN) M. LPN M stated she had contacted the hospice Nurse on 06/04/19, regarding R23's request for a regular diet. LPN M stated the hospice nurse told her R23 could have a diet as tolerated. Surveyor reviewed R23's clinical record. The record showed on 06/04/19, R23 received a regular tray for the evening meal after LPN M obtained an order from hospice to advance R23's diet as tolerated. However, R23 continued to receive a pureed diet. On 06/09/19, R23's son called and told the facility he wanted to speak to the hospice nurse, because R23 was having confusion regarding her diet. He said R23 asked why she had to receive a pureed diet in the facility, since the doctor told her she could have a regular diet upon hospital discharge. R23 refused dinner stating the pureed food did not look appetizing. On 06/10/19, R23's food texture was upgraded to Mechanical Soft. On 06/10/19, Surveyor observed the breakfast meal. Bacon was served as a breakfast meat. R23 asked CNA M if she could have some bacon. CNA M stated no, but that she would double check with the nurse. CNA M asked LPN P if R23 could have bacon and LPN P said, No. Surveyor interviewed the Culinary Manager (CM) I and Dietician C. Dietician C stated she had received the order from the hospice nurse to increase R23's diet as tolerated on 06/04/19. Dietician C said she did not process this order, since resident was receiving hospice services, and was unsure if Speech Therapy services (for texture recommendations) were covered. Dietician C stated she could have contacted hospice services to set up an appointment for the hospice Speech Therapist to evaluate R23. There was no evidence the facility discussed R23's dietary texture status with her until 06/10/19, when her diet texture was increased to mechanical soft. There was no evidence the facility discussed the risks/benefits with R23 regarding diet textures related to dysphagia. Surveyor interviewed the Director of Nursing (DON) and RN A. Both the DON and RN A agreed R23 should be allowed to determine her own dietary choices, and R23's care plan should include interventions that reflect R23's choices, preferences and tolerance for other diet textures.

Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 3 of 10 sampled residents. (Residents (R) 2, 3 and 4). On 02/02/17, R1 exposed himself to R2 in R2's room. The facility added a sensor alarm on R1's room door and continued 15 minute checks as previously done. On 02/05/17 at 9:00 p.m., R1 exposed himself to R4. Staff found R1's penis in R4's hand. Five minutes later, at 9:05 p.m., R1 exposed himself to R3. The facility did not provide adequate supervision to prevent further possible incidents affecting vulnerable female residents such as R2, R3, R4 and the other five female residents (R7, R8, R9, R11 and R12) who currently reside on the dementia unit. This is evidenced by: 1. On 02/07/17, Surveyor reviewed R1's medical record. Per the face sheet printed on 02/07/17, R1 was diagnosed on [DATE] with dementia without behavioral disturbances. The initial Minimum Data Set ((MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 8 for moderately impaired cognition. The current Certified Nursing Assistant (CNA) care plan states R1 is independent with ambulation, has wandering behavior and wears a wanderguard bracelet and has a motion sensor in doorway to monitor his whereabouts at night. R1 is also on 15 minute checks to monitor his whereabouts. The nurses' notes state the following: ~11/09/16 at 12:45 p.m., Consulted with primary MD regarding sexual advance behaviors noted towards staff; md does not want to make any med changes at this time. MD would like to allow Zoloft to work for a while before considering a different anti-depressant for this. ~11/15/16 at 5:30 p.m., Resident exhibiting exit seeking behaviors tonight with doors and windows. Resident placed on 15 min checks and motion sensor placed in his doorway to monitor his where abouts for safety as well as window limiters applied to windows by maint dept. ~12/01/16 at 2:15 p.m., Res has been exit seeking much of day. He is closely monitored every 15 min. ~12/01/16 at 10:57 p.m., New order for Depakote sprinkles 125 mg. ~12/05/16 at 2:21 p.m., Consulted with Medical Doctor (MD) earlier this am regarding continued exit seeking behaviors; discussed increase behaviors noted to start approx 1400, MD opting to change Depakote to 250 mg in am and 125 mg q (every) pm for his dementia with agitation. On 12/06/16, the physician discontinued the motion sensor at R1's doorway. The nurses' notes documented the following: ~12/14/16 at 12:47 p.m., Consulted with MD regarding continued behaviors of exit seeking/yelling/wandering in the evening hours especially. ~12/14/16 at 2:00 p.m., Depakote 125 mg given @noon per new order. ~12/19/16 at 10:37 p.m., Behavior- Resident noted to making inappropriate comments to staff asking when are you going to go to bed with me. Resident redirected and was effective. ~12/30/16 at 7:59 p.m., Behavior- Resident noted to making sexual comments towards female staff and residents. No inappropriate touching noted. Resident was redirected somewhat effective. Resident then went to room. Upon recheck resting contently. ~01/15/17 at 1:57 p.m., Res has been noted to be paying more attention to female peer. He was overheard inviting this female peer to his previous room and was redirected per staff. In the past he has made inappropriate sexual comments to staff. On 01/30/17, the physician ordered an increase dose of Depakote 250 mg at noon for dementia with sexually aggressive behavior. Incident 1. R1's nurses' notes stated the following: ~02/02/17 at 5:26 a.m., This morning resident wandered into a peer's room and agitated peer. Resident was redirected from peer's room and assisted to the dining room, provided a snack. Motion sensor initiated on resident's doorway for noc shift to alert staff of resident leaving room/wandering. The facility internal nursing communication form, dated 02/02/17, completed and signed by CNA J, stated the incident occurred around 5 a.m. The form stated, As I was checking residents that had not voided for the night on my way to room I noticed (R1) in . (R2's) room. Standing over her with pants down. (R2) was upset but fully clothed. I removed him from the room and he stated to me not to be a crab ass. I sat (R2) at the nurses station and sent (R1) back to his room. On 02/07/17, Surveyor reviewed R2's medical record. Per the face sheet printed on 02/07/17, R2 was diagnosed on [DATE] with dementia with Lewy bodies, dementia with behavioral disturbances and anxiety. The quarterly MDS dated [DATE] documented R2 had a BIMS score of 11 for moderately impaired cognition. R2's nurses' notes stated the following: 02/02/17 at 5:24 a.m., Staff noted resident's peer in her room this morning, standing next to resident's bed. Resident appeared to dislike her peer's presence in her room and was stating, I wish he would leave. Staff quickly redirected peer from resident's room and resident got out of bed and 1:1 was provided. Shortly after resident requested to return to bed to sleep. The facility investigation report completed and signed by Registered Nurse (RN) I stated, 02/02/17 Received a call from nurse (RN K) reporting that (R1) was standing near (R2) next to her bed with his pants down. (R2) was fully clothed and that (R2) was yelling at him to get out of her room. Staff intervened and 1:1 provided and close monitoring as well. Discussed motion sensor on (R1) doorway to alert staff of him leaving his room at night to monitor his where abouts in the house as he is independent and wanders into rooms. (R1) used to have the room next to (R2) in the past. (RN K) instructed to update (DON) regarding this. (R2) was seen by (MD) and myself and full body audit was done with no bruising or skin integrity concerns noted. Resident was calm during MD visit and did not bring up the event. Both POA's were updated by writer early am on 2/2/17 .Discussions held after morning meeting with (DON), (Social Worker (SW) L), (Director of Social Services M) and felt initiated intervention of motion sensor in doorway at night is appropriate at this time and continue to monitor behaviors. No changes noted in either of the residents' behaviors. Both up per their usual routines. On 02/07/17 at 10:45 a.m., Surveyor interviewed R2 who stated one resident was after a woman and wanted to have sex. R2 stated the man touched her between her legs while she was walking about two weeks ago. R2 stated she told head quarters. R2 stated the man came in her room and touched her on top of her clothes between her legs. R2 stated she yelled and staff came in her room. R2 was unable to identify the man and stated it hasn't happened again. On 02/07/17 at 4:50 p.m., Surveyors and interviewed RN K. RN K stated a CNA reported to her that when doing rounds she discovered R1 in R2's room by R2's bed. R2 told the CNA to get R1 out of the room. R1 was pulling his pants down. The CNA told R1 to leave the room and he walked out to the common area. The CNA brought R2 out to the nurses' station and called RN K to come to the unit. The CNA provided R1 with a snack. R2 was put to bed per her request. A motion sensor alarm was added to R1's room door. A motion sensor alarm was put in the hallway outside R2's room. RN K notified RN I and the DON, who was acting administrator at the time. On 02/08/17 at 8:20 a.m., Surveyors and interviewed RN I, the DON and SW L related to the incident on 02/02/17 between R1 and R2. RN I stated R1 was on 15 minute checks prior to the incident and no alarms were utilized. There had been no incidents between R1 and R2 prior to 02/02/17. After the incident on 02/02/17, the facility initiated the door sensor alarm on R1's doorway at night and continued 15 minute checks. Surveyor questioned what the facility had done for training after the incident. RN I and the DON stated the facility did not do staff training after the incident as they did everything they were supposed to do. Nurses' notes in R1's medical record stated the following: ~02/02/17 at 2:01 p.m., He continues to aimlessly wander about unit without purpose. He has been monitored closely and when he is about to enter another res room he is reminded that room is not his. Staff have redirected him and he has been cooperative. ~02/04/17 at 12:16 p.m., Resident noted to making multiple inappropriate sexual comments to staff about other staff members and peers. 1:1, redirection and snack offered, noted somewhat effective. Incident 2 On 02/07/17 at 11:05 a.m., Surveyor reviewed R4's clinical record. The nurses' notes indicated that on 02/05/17 at 9:00 p.m., staff found R1 in R4's room. The nurses' notes said, Male resident found standing over resident's bed exposing himself inappropriately. Male resident redirected out of R4's room. Skin assessed and skin intact. No behavior changes reported by house staff. Upon recheck, resident noted to be resting contently, no signs or symptoms of distress related to incident. Charge nurse updated personal representative. There was no evidence that an interview with the resident was attempted at the time of the incident. On 02/07/17 at 4:00 p.m., Surveyor and Surveyor interviewed CNA G. CNA G stated she was working on the east unit on 02/05/17. At 9:00 p.m., CNA G entered R4's room. Upon entering the room, CNA G stated that R1 .had his pants dropped and (R4) had her hand on (R1's) genitals. A written statement given after the incident by CNA G stated, (R1) had his pants down in (R4's) room. (R4) had his penis in her hand. (R1) said she's busy and old men do it better. CNA G stated she told (R1) to get out. CNA G stated I told him to get out. He pulled up his pants and left. I don't know where he went I think he was walking the halls. I don't know, I stayed with (R4) and put her to bed, that's what we are supposed to do .stay with the resident. R4's [DIAGNOSES REDACTED]. R4's cognition is severely impaired. On 02/08/17 at 8:10 a.m., Surveyor attempted to interview R4. R4 did not respond. Incident 3 CNA G's written statement continued, When I was done helping (R4) at 9:05 p.m., I saw (R1) walking in the hallway. He asked me and the other CNA if we would please him. I saw him walk into (R3's) room . put her call light on. When I went into (R3's) room, he already had his pants down. I think she was kind of scared. I told her he was doing something that he wanted to do and things would be okay. I got him out of there. He pulled up his pants and left the room. After that, he walked around a little bit in areas where we could see him. When I saw him with (R4) I yelled at (CNA E) to contact the nurse. The LPN was at the desk and did not get up. (RN F) went down there. It was already after 9:00 p.m., and I had to leave. R3's [DIAGNOSES REDACTED]. On 01/05/17, R3 had a BIMS of 14, indicating that R3 was cognitively intact. On 02/07/17, Surveyor reviewed R3's clinical record. The nurses' notes indicated that on 02/05/17 at 9:05 p.m., R1 .entered R3's room and exposed himself inappropriately. No physical contact noted. Male resident redirected out of room. Writer spoke with resident and asked if she was ok. Resident stated that she was fine . On 02/06/17, the nurse's note stated, .the physician examined the resident. A groin rash was noted. Resident did not recall event and reported she had a good night. The facility left a message for R3's personal representative to give update regarding incident. On 02/08/17 at 7:40 a.m., Surveyor interviewed R3. R3 told Surveyor that a man comes in here and rummages. The other ladies talk about him touching them, but he hasn't touched me. R3 was not able to give Surveyor any details about any other residents. R3 stated, He came in here once .he rummaged through the stuff on the dresser .and then . Surveyor asked if R1 touched her. R3 stated, No he didn't but he did something I couldn't see. When asked if R1 exposed himself, R3 stated, I don't know. When asked how R3 felt now, R3 stated, Well .it's kind of spooky . When asked if R3 felt afraid, R3 stated, When he's around .I worry about that. I have the call bell that I keep close to my head now. I know that I can yell, 'Get out this is not your room.' R3 stated that she generally feels safe. The nurse's note describing incidents 2 and 3 was written on 02/05/17 at 9:00 p.m., NAR (Nursing Assistant Registered) reported to writer that resident found in another female residents room exposing himself inappropriately. Resident was easily redirected back to room. Writer notified charge nurse right away. Motion sensor placed on female residents door way to help prevent further interaction/resident safety. Aprox 5 minutes later resident found in another female resident's room exposing himself inappropriately. Resident redirected out of resident's room. Charge nurse updated. Motion sensor placed by door way to help prevent further interactions/resident safety. Writer heard resident make sexual advances to other nursing staff working the floor. Resident educated that it was inappropriate and asked to stop. Non-effective. Resident then made comment to writer about you going to please me? Writer told resident that it was inappropriate to speak that way, resident then said will just do it from behind. Resident redirected, somewhat effective. Surveyor asked CNA G if increased monitoring was ordered or initiated by the staff after either the first or the second incident. CNA G stated, Well nobody was with him. He was not monitored 1 on 1. But they (management staff) are talking about it today. On 02/07/17 at 2:45 p.m., Surveyor and Surveyor interviewed RN F, who functions as the afternoon charge nurse. RN F stated, On 02/05/17, I was working on Morning Song (another unit) when I was called to the East unit by (LPN H). I told (LPN H) to get (R1) into a different area, the dining area. I came down and had everybody write statements. RN F stated that he ordered a motion alarm to be placed on R4's door, to alert staff if anyone attempted to enter the room. RN F stated that the staff did not increase monitoring of R1. RN F stated, We just tried to redirect him. We were all watching him after the incident. After the first incident, I thought he was in the dining room .it was only 5 minutes after the first incident that R1 exposed himself again to another female resident. RN F stated that a motion alarm was in place in R1's doorway to alert staff if R1 left his room once in bed. RN F agreed that the motion alarm placed in R1's room would only be effective if R1 was in his room and attempted to leave, and would not prevent him from entering other residents' rooms. RN F indicated R1 was on 15 minute checks. ~Asked if increased supervision was initiated after the first incident with R4, RN F stated no increased supervision or 1:1 no. ~Asked if increased supervision was initiated after the second incident with R3, RN F stated, No. RN F stated he did contact the NHA and DON immediately. After the two incidents, the DON instructed the staff to place motion sensors on each female resident's doorway, to alert staff that someone had entered the rooms. RN F stated that he filled out an incident report and obtained statements from staff involved in the incidents. On 02/08/17, Surveyor interviewed LPN H. LPN H stated, I was on. The CNAs reported that (R1) was sexually exposing himself, and had to be redirected to his room. When I went to get the charge nurse, the CNAs said he was in another resident's room exposing himself. When asked if monitoring of R1 was increased, LPN H stated, No. He was on 15 minute checks. I believe we had a pretty good view of him. We redirected him back to his room after the incidents. When asked if R1 attempted to leave his room, or if any other incidents occurred, LPN H stated, Not on my shift. Subsequent nursing notes indicate: ~02/06/17 at 12:39 p.m., Seen by MD during md rounds this am. Consulted with MD regarding increased behaviors; md reviewed med/vitals and opted to add a 5 pm dose of risperidone daily to help reduce this sexual type behaviors. Discussion held with IDT team this am regarding behaviors and feel that this is behavior r/t dementia progression. Will also explore more activities to keep resident busy in the evening hours as well and will talk to POA (Power of Attorney) regarding the use of pants/jeans with a belt vs sweatpants. ~02/06/17 at 1:19 p.m. Resident wandered throughout the shifts. Did not have any sexual advances towards any other residents. Door alarms effective in alerting staff to redirect resident. ~02/06/17 at 8:08 p.m., Resident noted to attempt to enter other female residents' rooms x 3. No physical contact between resident. Resident easily redirected. Motion sensors on. No noted sexual comments towards residents or staff on this shift at this time.