Every finding on record at Pecan Valley Rehabilitation and Healthcare

Based on interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 3 residents (Residents #1 and #2) reviewed for pharmacy services. 1.The facility failed to ensure Resident #1's prescribed medications of Insulin Glargine Subcutaneous Solution and NovoLOG Injection Solution 100 UNIT/ML were administered according to physician orders for the months of February 2026 - April 2026.2.The facility failed to ensure Resident #2's prescribed medications of Insulin Glargine and NovoLOG FlexPen Subcutaneous were administered according to physician orders for the month of April 2026. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings included:1. Record review of Resident #1's admission Record dated 04/28/2026 revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was listed as his own financial responsible party, with his [family member] listed as Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed on 04/28/2026 at 1:14 p.m., revealed diagnoses including Diabetes Mellitus (DM) (chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels), Cerebrovascular Accident (CVA) (medical term for a stroke), blindness right eye, legal blindness, and absence of left leg below knee. Record review of Resident #1's quarterly MDS, dated [DATE] and signed on 03/17/2026 as completed, reflected a BIMS score of 15, indicating cognition intact. Resident #1 was documented as having verbal behavioral symptoms directed toward others and as having not exhibited any physical behavioral symptoms. Resident #1 was documented as requiring insulin injection. Resident #1's functional abilities were documented as having functional limitation in range of motion with impairment to lower extremity requiring mobility device (wheelchair) and supervision or touching assistance to independent. Record review of Resident #1's Care Plan, undated and accessed on 04/28/2026 at 1:26 p.m., reflected Resident #1 had a history of Type 2 Diabetes Mellitus. Record review of Resident #1's Medication Administration Record, printed 04/29/2026 and revealing medication administrations from 4/1/2026 - 4/30/2026, reflected the order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 22 unit subcutaneously at bedtime related TYPE 2 DIABETES MELLITUS and 'Scheduled Time 2000 [8:00 p.m.]. Order noted as Active with Order Date, 03/03/2026 and start date, 03/03/2026. Record review of Resident #1's Medication Administration Record, printed 04/29/2026 and revealing medication administrations from 4/1/2026 - 4/30/2026, reflected the order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 22 unit subcutaneously at bedtime was administered as follows:Scheduled Time Administered Time Administered By04/22/26 20:00 [8:00 p.m.] 04/22/26 21:02 [9:02 p.m.] LVN A04/23/26 20:00 [8:00 p.m.] 04/23/26 21:01 [9:01 p.m.] LVN A Record review of Resident #1 Medication Administration Record printed 04/29/2026 and revealing medication administration from 4/1/2026 - 4/30/2026, reflected the order: NovoLOG Injection Solution 100 UNIT/ML (Insulin As part) Inject as per sliding scale:if 0 - 149 = 0 units;150 - 199 = 2 units;200 - 249 = 4 units;250 - 299 = 6 units;300 - 349 = 8 units;351 - 400 = 10 unitsBS [blood sugar] over 400 give 10 units and notify MD/NP, subcutaneously before meals related to TYPE 2 DIABETES MELLITUS. Hours Ordered 0630 (6:30 a.m.), 1130 [11:30 a.m.], and 1630 [4:30 p.m.]. Order noted as Active with order Date, 03/19/2026 and start date, 03/19/2026. Record review of Resident #1's Medication Administration Record, printed 04/29/2026 and revealing medication administration from 3/1/2026 - 3/31/2026, reflected the order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 22 unit subcutaneously at bedtime was administered as follows:Scheduled Time Administered Time Administered By03/16/26 20:00 [8:00 p.m.] 03/16/26 21:22 [9:22 p.m.] LVN A03/20/26 20:00 [8:00 p.m.] 03/20/26 21:42 [9:42 p.m.] LVN B Record review of Resident #1 Medication Administration Record, printed 04/29/2026 and revealing medication administrations from 2/1/2026 - 2/28/2026, reflected the order: NovoLOG Injection Solution 100 UNIT/ML (Insulin As part) Inject as per sliding scale:if 0 - 150 = 0 units;151 - 200 = 2 units;201 - 250 = 4 units;251 - 300 = 6 units;301 - 350 = 8 units;351 - 400 = 10 units BS [blood sugar] over 400 give 10 units and notify MD/NP, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS.Hours Ordered 0630 (6:30 a.m.), 1130 [11:30 a.m.], 630 [4:30 p.m.] and 2000 [8:00 p.m.]. Order noted as Active with order Date, 05/22/2025, start date, 05/22/2025 and D/C [discontinued] Date 03/18/2026. Record review of Resident #1 Medication Administration Record undated and accessed 04/29/2026 and revealing medication administrations from 2/1/2026 - 2/28/2026, reflected the order: Insulin Glargine Solution 100 UNIT/MLInject 25 unit subcutaneously at bedtime for diabetes related to TYPE 2 DIABETES MELLITUS and Scheduled Time 18:00 [6:00 p.m.]. Order noted as Active with Order Date, 06/27/2025 and D/C [Discontinued] Date 03/03/2026. Record review of Resident #1 Medication Administration Record, printed 04/29/2026 and revealing medication administrations from 2/1/2026 - 2/28/2026, reflected the order: NovoLOG Injection Solution 100 UNIT/ML was administered as follows:Scheduled Time Administered Time Administered By02/16/26 20:00 [8:00 p.m.] 02/16/26 21:41 [9:41 p.m.] LVN A02/23/26 20:00 [8:00 p.m.] 02/23/26 21:19 [9:19 p.m.] LVN A Record review of Resident #1's progress notes dated 02/01/2026 - 04/30/2026 did not reveal a progress note identifying medication administration errors or notification to the provider and facility management. 2. Record review of Resident #2's admission Record dated 04/29/226 revealed a [AGE] year-old female admitted on [DATE]. Resident #2 was listed as her own financial responsible party, with her [family member] listed as Emergency Contact #1. Record review of Resident #2's Medical Diagnoses, undated and accessed on 04/29/2026 at 12:01 p.m., revealed diagnoses including Diabetes Mellitus (DM) (chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels), major depressive disorder (condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and bipolar disorder (mental health condition characterized by significant mood swings). Record review of Resident #2's quarterly MDS, dated [DATE] and signed 02/23/2026 as completed, reflected a BIMS score of 11, indicating cognition intact. Resident #2 was documented as requiring insulin injection. Resident #2's functional abilities were documented as primarily dependent and requiring mobility device (wheelchair). Record review of Resident #2's Care Plan, undated and accessed on 04/29/2026 at 12:09 p.m., reflected Resident #2 had a history of Type 2 Diabetes Mellitus. Record review of Resident #2's Order Summary Report dated 04/29/2026, reflected the order: Insulin Glargine-yfgn Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine-yfgn) Inject 20 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED (E11.40) hold is [if] bs less than 150. Order noted as Active with Order Date, 01/29/2026 and start date, 01/29/2026. Record review of Resident #2's Medication Administration Record, printed 04/29/2026 and revealing medication administration from 4/1/2026 - 4/30/2026, reflected the order: Insulin Glargine-yfgn Subcutaneous Solution Pen-injector 100 UNIT/ML was administered as follows:Scheduled Time Administered Time Administered By04/02/26 18:00 [6:00 p.m.] 04/02/26 21:09 [9:09 p.m.] LVN A04/13/26 18:00 [6:00 p.m.] 04/13/26 21:04 [9:04 p.m.] LVN A04/20/26 18:00 [6:00 p.m.] 04/20/26 21:01 [9:01 p.m.] LVN A04/21/26 18:00 [6:00 p.m.] 04/21/26 21:22 [9:22 p.m.] LVN A04/22/26 18:00 [6:00 p.m.] 04/22/26 21:05 [9:05 p.m.] LVN A Record review of Resident #2's Order Summary Report dated 04/29/2026, reflected the order: NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 2 u; 201 - 250 = 4 u; 251 - 300 = 6 u; 301 - 350 = 8 u; 351 - 399 = 10 u <400 Give 10 units and Notify MD/NP, subcutaneously before meals and at bedtime for Diabetes HOLD IF BS LESS THAN 150. Order noted as Active with Order Date 01/05/2026 and start date, 01/05/2026. Record review of Resident #2's Medication Administration Record, printed 04/29/2026 and revealing medication administration from 4/1/2026 - 4/30/2026, reflected the order: NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML was administered as follows:Scheduled Time Administered Time Administered By04/02/26 20:00 [8:00 p.m.] 04/02/26 21:09 [9:09 p.m.] LVN C04/13/26 20:00 [8:00 p.m.] 04/13/26 21:04 [9:04 p.m.] LVN A04/21/26 20:00 [8:00 p.m.] 04/21/26 21:21 [9:21 p.m.] LVN A Record review of Resident #2's progress notes dated 03/30/2026 - 04/30/2026 did not reveal a progress note identifying medication administration errors or notification to the provider and facility management. During an interview on 04/29/2026 at 1:20 p.m., MA D revealed the medication administration protocol is to give scheduled dose one hour before or one hour after the prescribed time before going into violation. She stated the DON took medication administration seriously and the protocol was to notify the DON if dose was missed or late. MA D stated medication aides were to document the missed or late dose in the resident's progress notes and notify the charge nurse. MA D stated the medication aides are required to follow medication orders as missed or late dose could be harmful to the resident. During an interview on 04/29/2026 at 1:36 p.m., MA E revealed that medication aides were required to follow physician orders and their specific times and to stay within the one hour before or one hour after the prescribed time. MA E stated a medication error would be reported to the DON immediately, she would be required to document error in progress notes. She stated the DON checks medication administration daily and would let her know if an error was made. She stated the impact of medication errors could be harmful to residents. During an interview on 04/29/2026 at 1:58 p.m., RN F revealed that medication administration protocol times were one hour before and one hour after the medication wasdue and making sure the right medication, right person, right time were followed. RN F stated if administered outside of the one-hour window the staff were to administer it to the resident as soon as possible, and were to inform the resident why it happened, and if late would be considered a medication error. RN F stated if a medication error was identified staff were required to notify the ADON and make a progress note stating what occurred. She stated the impact of administering medication outside of the one-hour window could make residents worry if the staff were providing the proper care, they could lose trust in the staff. During an interview on 04/29/2026 at 2:42 p.m., ADON G revealed that most medications were set up with a 6-10 window, if scheduled then it was one hour before or one hour after. ADON G stated if outside of the one-hour time staff were required to contact the physician and provide reason as to why medication was administered late. ADON G stated staff should be documenting progress notes as to why it was administered late and depending on the medication there could be negative effects if given late. She stated the management staff could pull a report and see the times medications were administered and could identify if out of range and would prompt staff to investigate what was going on and there would be follow-up with staff. ADON stated she had not counseled LVN A on late medication administration and she was not aware of the medication errors. During an interview on 04/29/2026 at 3:10 p.m., ADON H revealed the medication administration protocol/times follows RIGHTS-right person, right time, right dose, right medication. She stated if staff deviated from the scheduled dose, they needed to notify the doctor to see if okay with this and if anything needed to be done differently on their end. ADON H stated doses that were out of range meaning hour after it was order, anything out of range will trigger was late and identified as a medication error. She stated medication aides were required to notify the charge nurse, the charge nurse would then notify the provider, make a progress note and document the 24-hour report, which the management team reviewed daily in morning meetings. She stated all (3) ADONs could pull a report to determine if medication administration were outside of range. ADON H said depending on the medication there could be negative side effects on the resident if administering medication late. ADON H stated she had not seen late medication administration entries, and staff did not notify her of late entries. During an interview on 04/29/2026 at 4:29 p.m., the DON revealed medication administration times are based on physician orders. She noted medication administration outside of an hour before and an hour after need to be documented in the progress note, the reason it was administered late, would require notification to the doctor. The DON stated she was aware of late medication entries by LVN A. The DON stated if residents want to talk, LVN A would not interrupt them, and this could potentially cause her to document medication administration later than time it was administered, and this would cause a medication error. The DON stated she had not counseled LVN A on medication administration late entries. Attempted interview with LVN A, on 04/29/2026 at 5:06 p.m., no return call received. During an interview on 04/29/2026 at 5:22 p.m., the Administrator revealed staff were to follow physician orders. She stated there could be an adverse reaction depending on type of medication if medication was administered outside of physician's orders. During an interview on 04/29/2026 at 5:58 p.m., Human Resources revealed LVN A had not been counseled on the numerous medication administration late entries identified during the investigation. Record review of In-Service Acknowledgement titled Rights of Medication Administration, dated 04/3/2026 revealed ADON was the instructor and staff education included: Right Time: Administer at the prescribed frequency and time. Right Documentation: Record medication given, time, dose, and route immediately. Record review of In-Service Acknowledgement titled Insulin Administration, dated 03/24/2026, revealed ADON was the instructor and staff education included: Always read the order completely The Six Rights of Safe Medication Administration. 4. Right Time. Does the administration time match the order? . 6. Right Documentation. Document immediately after the medication is administered. Record review of policy titled, Your Rights in a Nursing Facility dated January 2025, revealed .You have the right to: Receive all care necessary to have the highest possible level of health. Record review of policy titled, Charting and Documentation, dated 05/2007, revealed .The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under current law and regulations at the time of admission.[Importance And Use of the Record] 1.To the resident is saves time if needed at a future date. 2. To the institution it reflects the quality of care given to the resident. 3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care.6. To the nurse, it provides a multidisciplinary record of the physical and mental status of the resident. [Rules for Charting] 1. Notes are to be written on all long-term residents by day, evening and night shifts; frequency is determined by the individual nursing service. 2. Daily notes are required as the necessary arises.

Based on interviews and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 3 residents (Residents #1 and #2) reviewed for medical records. 1.The facility failed to maintain progress notes and documentation of notification to physician when medication errors were identified for Resident #1's prescribed medications, Insulin Glargine Subcutaneous Solution and NovoLOG Injection Solution 100 UNIT/ML for the months April 2026.2.The facility failed to maintain progress notes and documentation of notification to physician and management team when medication errors were identified for Resident #2's prescribed medications, Insulin Glargine and NovoLOG FlexPen Subcutaneous for the month of April 2026. These failures placed residents at risk for missed treatment and medications which could result in decline in health and well-being.The findings included: 1. Resident Record review of Resident #1's admission Record dated 04/28/2026 revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was listed as his own financial responsible party, with his [family member] listed as Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed on 04/28/2026 at 1:14 p.m., revealed diagnoses including Diabetes Mellitus. Record review of Resident #1's quarterly MDS, dated [DATE] and signed on 03/17/2026 as completed, reflected a BIMS score of 15, indicating cognition intact. Resident #1 was documented as requiring insulin injection. Record review of Resident #1's Care Plan, undated and accessed on 04/28/2026 at 1:26 p.m., reflected Resident #1 had a history of Type 2 Diabetes Mellitus. Record review of Resident #1's Medication Administration Record, printed 04/29/2026 and revealing medication administrations from 4/1/2026 - 4/30/2026, reflected the order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 22 unit subcutaneously at bedtime related TYPE 2 DIABETES MELLITUS and 'Scheduled Time 2000 [8:00 p.m.]. Order noted as Active with Order Date, 03/03/2026 and start date, 03/03/2026. Record review of Resident #1's Medication Administration Record, printed 04/29/2026 and revealing medication administrations from 4/1/2026 - 4/30/2026, reflected the order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 22 unit subcutaneously at bedtime was administered as follows:Scheduled Time Administered Time Administered By04/22/26 20:00 [8:00 p.m.] 04/22/26 21:02 [9:02 p.m.] LVN A04/23/26 20:00 [8:00 p.m.] 04/23/26 21:01 [9:01 p.m.] LVN A Record review of Resident #1's progress notes dated 02/01/2026 - 04/30/2026 did not reveal a progress note identifying medication administration errors or notification to the provider and facility management. 2. Record review of Resident #2's admission Record dated 04/29/226 revealed a [AGE] year-old female admitted on [DATE]. Resident #2 was listed as her own financial responsible party, with her [family member] listed as Emergency Contact #1. Record review of Resident #2's Medical Diagnoses, undated and accessed on 04/29/2026 at 12:01 p.m., revealed diagnoses including Diabetes Mellitus (DM) {chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels}, major depressive disorder {condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and bipolar disorder (mental health condition characterized by significant mood swings). Record review of Resident #2's quarterly MDS, dated [DATE] and signed 02/23/2026 as completed, reflected a BIMS score of 11, indicating cognition intact. Resident #2 was documented as requiring insulin injection. Record review of Resident #2's Care Plan, undated and accessed on 04/29/2026 at 12:09 p.m., reflected Resident #2 had a history of Type 2 Diabetes Mellitus. Record review of Resident #2's Order Summary Report dated 04/29/2026, reflected the order: Insulin Glargine-yfgn Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine-yfgn) Inject 20 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED (E11.40) hold is [if] bs less than 150. Order noted as Active with Order Date, 01/29/2026 and start date, 01/29/2026. Record review of Resident #2's Medication Administration Record, printed 04/29/2026 and revealing medication administration from 4/1/2026 - 4/30/2026, reflected the order: Insulin Glargine-yfgn Subcutaneous Solution Pen-injector 100 UNIT/ML was administered as follows:Scheduled Time Administered Time Administered By04/02/26 18:00 [6:00 p.m.] 04/02/26 21:09 [9:09 p.m.] LVN A04/13/26 18:00 [6:00 p.m.] 04/13/26 21:04 [9:04 p.m.] LVN A04/20/26 18:00 [6:00 p.m.] 04/20/26 21:01 [9:01 p.m.] LVN A04/21/26 18:00 [6:00 p.m.] 04/21/26 21:22 [9:22 p.m.] LVN A04/22/26 18:00 [6:00 p.m.] 04/22/26 21:05 [9:05 p.m.] LVN A Record review of Resident #2's progress notes dated 03/30/2026 - 04/30/2026 did not reveal a progress note identifying medication administration errors or notification to the provider and facility management. During an interview on 04/29/2026 at 2:42 p.m., ADON G revealed all medication errors and notification to the physician and management team were to be documented in the resident's electronic medical record immediately. ADON G further stated failure to do so could negatively impact a residents' care. During an interview on 04/29/2026 at 3:10 p.m., ADON H revealed medication errors are required to be documented in the resident's electronic medical record. She stated this process will help staff recall reasons for late medication administration entries. During an interview on 04/29/2026 at 4:29 p.m., the DON revealed all staff who identify a medication administration error need to document the electronic medical record immediately. She stated the documentation in progress notes would help management understand why there was a late entry for medication administration. The DON stated failure to document medication errors could have an impact on the residents by not having accurate medical records. Record review of In-Service Acknowledgement titled Rights of Medication Administration, dated 04/3/2026 revealed ADON was the instructor and staff education included: Right Documentation: Record medication given, time, dose, and route immediately. Record review of In-Service Acknowledgement titled Insulin Administration, dated 03/24/2026, revealed ADON was the instructor and staff education included: The Six Rights of Safe Medication Administration. 6. Right Documentation. Document immediately after the medication is administered. Record review of policy titled, Charting and Documentation, dated 05/2007, revealed .The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. [Rules for Charting] 1. Notes are to be written on all long-term residents by day, evening and night shifts; frequency is determined by the individual nursing service. 2. Daily notes are required as the necessary arises.

Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators reviewed. The personal refrigerator in the resident's room [ROOM NUMBER]A contained unlabeled, undated food items. This failure could place residents at risk of foodborne illness from consuming spoiled food. The findings were: Observations on 1/27/2026 at 9:35 a.m. revealed that the personal refrigerator in RM [ROOM NUMBER] A contained cooked beef and white pasta in an unlabeled, undated storage container. Further observations on 1/27/2026 at 11:30 a.m. of the personal refrigerator in RM [ROOM NUMBER] A revealed that the cooked beef and white pasta in an unlabeled, undated storage container were still present. An interview with Resident # 104 on 01/27/2026 at 9:40 a.m. revealed that she could not recall how long the cooked beef and white pasta had been in her personal refrigerator, but recalls that her daughter, who visits often, leaves food in her personal refrigerator to eat when she visits. Interview on 01/27/2026 at 9:50 a.m., with CNA E stated she was assigned to Resident #104 and confirmed that the personal refrigerator in Resident #104's room contained cooked beef and white pasta, which were undated and unlabeled. She did not know who was responsible for checking the president's personal refrigerator for expired food, but would check with the charge nurse. Interview with LVN F on 1/27/2026 at 10:00 a.m. revealed she was the assigned nurse for Resident # 104 and confirmed there was cooked beef and white pasta in an unlabeled and undated storage container in the personal refrigerator. She added that nursing was responsible for removing undated and unlabeled food items from residents' personal refrigerators. LVN F stated that resident # 104's family member at times, brings in food to consume for herself during her visit and leaves leftovers in resident # 104's personal refrigerator. Resident # 104 risked some form of food-borne illness by possibly consuming food that was unlabeled and undated. Phone interview with Residents #104's family member on 01/27/2025 at 11:24 a.m. She confirmed that she leaves leftover food in the family's personal refrigerator to eat when she visits. She recalls DON instructing her to notify the nursing staff when she leaves food in the personal refrigerator so it can be labeled and dated, but she forgets. During an interview with the DON on 01/28/26, at 1:37 p.m., the DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. The DON stated that nursing was responsible for removing undated, unlabeled food items from residents' refrigerators daily, including assisting families in labeling and dating food items brought in. The DON stated that families sometimes bring food for residents without notifying the nursing staff. She said she would send a memo to all family members instructing them to notify the nursing staff when they bring food to residents and place it in their refrigerators. She added that her charge nurses were responsible for overseeing this task, and her ADONs would be monitoring at random. Record review of the facility policy, Residents Personal Food Storage, 11/2016, revised, 1/2022, revealed: Residents and individuals bringing in food from outside sources will be educated on safe food handling and storage techniques by designated facility staff a

Based on interview and record review, the facility failed to conduct an initial comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity for one of 32 residents (Resident #45) reviewed for comprehensive assessments.The facility failed to complete and transmit an admission assessment for Resident #45 within 14 days of the resident's admission.This failure placed residents at risk of not having their needs, strengths, goals, life history and preferences assessed to ensure they received appropriate care.The findings included:Record review of Resident #45's electronic face sheet dated 01/28/2026 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including open would on lower left leg, Type 2 diabetes with hyperglycemia (high blood sugar levels), bipolar disorder (a mental health condition that causes extreme mood swings) and morbid obesity (an excess of 80 to 100 pounds above ideal body weight). No previous admission date was indicated.Record review of Resident #45's electronic health record revealed an admission MDS assessment was initiated but the only section completed was Section F, Preferences for Routine & Activities. All the other sections were noted In Progress. The Complete By date for this assessment was 01/21/2026. Record review of a BIMS evaluation completed by the facility's speech therapist on 01/09/2026 revealed the resident scored 15/15, indicating intact cognition.Record review of the resident's EHR revealed the facility initiated a comprehensive care plan for Resident #45 on 01/09/2026 that included the resident's code status, medications, cognitive function, self-care deficits, pain, and activity preferences. During an interview on 01/28/2026 at 10:30 AM, MDS LVN A stated she was responsible for completing the admission MDS for Resident #45, it was due on 01/21/2026, and she failed to complete the admission MDS in a timely manner. MDS LVN A stated she would have to check her schedule to see what other duties she was assigned the day it was due, and with her supervisor to verify why it was not completed in a timely manner.During an interview on 01/28/2026 at 10:55 AM, the administrator stated the facility had two MDS LVNs who were responsible for completing MDS assessments but they were occasionally assigned other duties. The administrator stated it was important MDS assessments were completed in a timely manner so the facility knew how to care for the residents.During an interview on 01/28/2026 at 11:05 AM, the DON stated the MDS LVN was responsible for completing MDS assessments, but the facility's census had increased recently and it was difficult for the two MDS LVNs on staff to keep up with the assessments in a timely manner. The facility had placed advertisements to hire another full-time employee and prn MDS LVN to help keep up with the workload. The DON said completing assessments in a timely manner was important so the facility was familiar with the residents' needs and were able to formulate comprehensive care plans.Record review of the facility's policy Resident Assessment and Associated Processes revised 12/2023 revealed, Policy: It is the policy of this facility that residents will be assessed and the findings documented i their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. Procedure: Comprehensive MDS assessment include Admission, Annual, significant Change in Status Assessment and Significant Correction Prior to Comprehensive Assessment. 3. Comprehensive assessments will be conducted within 14 days of admission .Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 October 2025, 2.6 Required OBRA Assessments for the MDS, Comprehensive Assessments, 01. admission Assessment, revealed, The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the day of admission to the nursing home as day 1, if: this is the resident's first time in this facility, ORthe resident has been admitted to this facility and was discharged return not anticipated, ORthe resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one resident (Resident #53) reviewed for range of motion. The facility failed to ensure Resident #53's right hand splint (medical device used to treat hand contractures, permanent tightening of the muscles, tendons, skin and surrounding tissues that causes stiffness, placed in the hands to help improve range of motion) was in place to her right hand. This failure could place the resident at risk for decrease in mobility and range of motion and contribute to worsening of contractures. Record review of Resident #53's Face Sheet dated 01/29/26, documented a [AGE] year-old female originally admitted to the facility on [DATE] with her last admission date of 07/30/25. Resident #53's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (neurological conditions causing one-sided body impairment, from a stroke), aphasia following cerebral infarction (language disorder resulting from damage to brain regions responsible for language comprehension and formulation, often following a stroke), dysphagia following cerebral infarction (difficulty swallowing after a stroke) and frontal lobe and executive function deficit following cerebral infarction (a stroke that causes executive function deficits, affecting planning, decision-making, problem-solving, and impulse control leading to difficulty with daily tasks). Record review of Resident #53's Annual MDS dated [DATE] revealed a severe cognitive impairment for daily decision making. Section O - Special Treatments, Procedures and Programs did not indicate any therapy, including restorative nursing, in the last 7 days. Record review of Resident #53's Care Plan with the last revision date of 12/18/25 indicated a focus of Alteration in musculoskeletal status r/t impaired ROM to R hand. The intervention included FYI: Resident has a right-hand splint per restorative and or therapy. Monitor Right hand every shift for any s/sx of breakdown, redness, open areas, blistering, bruising, unusual skin appearance, every shift. The date initiated was 12/18/25. Record review of Resident #53's active orders as of 01/29/26 revealed an order dated 12/18/25 that stated FYI: Resident has a right hand splint per restorative and or therapy. Monitor Right hand every shift for any s/sx of breakdown, redness, open areas, blistering, bruising, unusual skin appearance, every shift. During an interview and observation with a family member on 01/29/26 at 1:40 pm, she said the splint on Resident #53's hand was paused when therapy stopped a few months ago. Resident #53 was observed with a rubber hand spacer with fingers in holes of a rubber device on her left hand but her right hand appeared to be curled under her shirt hem. During an interview on 01/29/26 at 1:53 pm with PT C who worked with Resident #53 stated the resident was discharged from PT and OT on 11/11/25 due to reaching her potential. PT C stated the Restorative Aide should have taken over the splint and nursing and therapy should have monitored it since there was an order to have it monitored. During an interview with RA E on 01/29/26 at 2:02 pm, RA E stated, We are doing lower extremities on Resident #53 like stretching her legs. We don't have program set up to do hand therapy. We see her 3 times per week. During an interview with the DON on 01/29/26 at 3:59 pm, the DON stated therapy was managing Resident #53's PT, OT and SLP but they were supposed to roll a restorative plan over to the RA after the resident no longer qualified for skilled therapy. Resident #53 already had a contracture and it could worsen without further interventions. The Director of Rehabilitation was the one who was supposed to set up restorative plans. The MDS Nurse wrote the care plan based on a splint management meeting. The RA plan was never set up. The Director of Rehabilitation was no longer employed so nursing was monitoring therapy and RA plans until a new Director was hired. Record review of the Weekly LTC Clinical Review Policy dated November 2025 revealed the following:Procedures:3. IDT members will review clinical documentation (therapy documentation, nursing documentation, Care Plans, MDS, etc.) and discuss progress and/or barriers to goal achievement on regular intervals of at least once per claim month. Areas of review to assist the IDT in this process to support the need for skilled therapy interventions will include, but not be limited to:c. Discuss and review documentation of any patient who has a barrier to the treatment plan to determine next steps in patient care. For example:i. Any medical complications and/or other reasons for limited progress.ii. Nursing or other IDT services that are addressing the barriers relevant to the medical condition.iii. Determine what information needs to be shared with the IDT/nursing team such as transfer status, pain management, dietary changes, new orders, need for transition to RNA, etc. Update Care Plan and MDS accordingly.

Based on interviews and record reviews, the facility failed to ensure an encoded, accurate and complete discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #20) reviewed for discharge MDS assessments.The facility failed to ensure a discharge MDS was completed and transmitted for Resident #20's within 14 days of his discharge to the hospital.This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.The findings included:Record review of Resident #20's electronic face sheet, accessed on 01/27/2026, revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnoses that included epilepsy (seizures), Type II diabetes (a problem in the way the body regulates and uses blood sugar), acute respiratory failure (a life-threatening condition that occurs when fluid leaks from small blood vessels in the lungs and builds up in the air sacs) and cerebral infarction due to occlusion of left middle cerebral artery (stroke that may result in paralysis on one side of the face or body or loss of coordination). The resident's payer source was Medicare A.Record review of Resident #20's EHR revealed a progress note by LVN B dated 01/07/2026 at 5:40 PM stating the resident experienced a sudden loss of consciousness in the dining room with hypotension (a decrease in blood pressure) and agonal breathing (involuntary respirations caused by low oxygen in the blood). The resident's MD was notified immediately, who gave the order to send the resident to the ER. Emergency services were notified, arrived at 5:52 PM, and transported the resident to the hospital.Record review of Resident #20's EHR revealed a progress note by NP D dated 01/09/2026 at 8:00 PM stating she was unable to round with the resident due to his transfer to the hospital for loss of consciousness and an increase in oxygen demand.Record review of Resident #20s electronic MDS assessments revealed an admission MDS Assessment with an ARD of 11/01/2025. There was no evidence of a discharge MDS completed or transmitted to CMS.During an interview on 01/27/2026 at 2:30 PM, MDS LVN A stated when residents were discharged to the hospital they were generally anticipated to return to the facility, and Resident #20's discharge MDS should have been initiated the day the resident left or the day after. It was her responsibility to complete and transmit the discharge MDS and she missed it. She was occasionally assigned other duties besides the completion of MDS assessments and could not explain specifically why this discharge MDS was missed, but understood timely completion of discharge assessments was important.During an interview on 01/28/2026 at 10:55 AM, the administrator stated the facility had two MDS LVNs who were responsible for completing MDS assessments but they were occasionally assigned other duties. The administrator stated it was important MDS assessments were completed in a timely manner so the facility knew how to care for the residents.During an interview on 01/28/2026 at 11:05 AM, the DON stated the MDS LVN was responsible for completing MDS assessments, but the facility's census had increased recently and it was difficult for the two MDS LVNs on staff to keep up with the assessments in a timely manner. The facility had placed advertisements to hire another full-time employee and prn MDS LVN to help keep up with the workload. The DON said completing assessments in a timely manner was important so the facility was familiar with resident needs and were able to formulate comprehensive care plans.Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 October 2025, 2.5 Assessment Types and Definitions, revealed, Discharge refers to the date a resident leaves the facility or the date the resident's Medicare Part A stay ends but the resident remains in the facility. A day begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether discharge occurs at 12:00 a.m. or 11:59 p.m., this date is considered the actual date of discharge. There are three types of discharges: two are OBRA required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS Discharge. A Discharge assessment is required with all three types of discharges.Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. OBRA Discharge assessments consist of discharge return anticipated and discharge return not anticipated. [ .] Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days).

Based on observation, interview, and record review, the facility failed to ensure the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure the Dietary Manager used hair restraints properly while working in the kitchen. This failure could place residents who received meals or snacks from the kitchen at risk for food borne illness.The findings included: During an observation of the facility kitchen on 10/14/25 at 11:30 AM, the Dietary Manager (DM) was observed wearing a hair restraint over only part of her hair during meal preparation. The dietary manager wore a hair restraint over her ponytail but did not have a hair restraint covering the rest of her head. During an interview with the DM on 10/14/25 at 11:35 AM, the DM stated her expectation is for staff to always be wearing hair restraints in the kitchen. The DM further stated it was important for hair to be completely covered to ensure no hair gets in the food being prepared. The DM stated if hair fell into the food, there could be cross contamination, and the food would have to be remade. The DM stated the hair restraint was too small to cover her entire head and ponytail, but she would fix the issue immediately with an additional hair restraint. During an interview with the DON on 10/14/25 at 4:07 PM, the DON stated her expectation regarding hair restraints was that everyone in the kitchen should have a hairnet or hat on to prevent hair from falling into the food. The DON further stated if hair restraints are not worn properly, hair could fall into the food during preparation and result in contamination. During an interview with the Administrator on 10/16/25 at 12:45 PM, the Administrator stated his expectation regarding hair restraints was for hair to be fully covered by the restraint to prevent hair from falling into food. The Administrator further stated if hair fell into food, the food would have to be tossed out for sanitation. Review of the facility policy titled Dietary Services, with a revision date of 10/2007, noted It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards: The facility failed to ensure Resident #1's environment was free of choking hazards when Resident #1 expired on 6/24/2025 as a result of asphyxiation by choking[PH1] [SA2] . An Immediate Jeopardy (IJ) was identified as past non-compliance on 7/07/2025. The Noncompliance began on 6/24/2025 and ended on 6/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health and or death. The findings included: Record review of Resident #1's face sheet dated 6/24/2025 revealed a 72- year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and/or anxiety, unspecified pain and primary osteoarthritis left hand. Record review of Resident #1's significant change MDS dated [DATE] revealed a BIMs score could not be determined due to both long-term and short-term memory loss and severely impaired cognitive skills and inattention. The assessment indicated no behaviors exhibited with maximum to total dependance on staff for ADL care. Record review of Resident #1's care plan initialed on 10/21/2021 revealed the resident was full code status with interventions: in the event of cardiac or respiratory arrest, staff will perform cardiopulmonary resuscitation. ADL self-care performance deficit related to dementia, debility and muscle wasting with interventions which included maximal assistance to full dependance on ADL care of one staff person for all ADLs. A potential for pain related to dementia, impaired mobility and stiffness with an intervention of administer medications as ordered by physician. Record review of Resident #1's physician order summary for June 2025 revealed an order with a start date of 10/04/2021 for Lidoderm Patch 5% (Lidocaine) apply to left leg and right shoulder for pain, apply one patch to left leg and one patch to right shoulder, off at HS (bedtime). Record review of Resident #1's June 2025 MAR revealed Lidoderm Patch 5% (Lidocaine) was last documented as administered on the morning of 6/23/2025 by CMA A and last documented as removed by LVN C (time unknown). Record review of Resident #1's Lidoderm Patch 5% time/date CMA Administration Record audit report dated 7/03/2025 revealed: CMA A documented application of Lidoderm Patch 5% to right front shoulder on 6/23/2025 at 11:10 a.m. and LVN C documented handling (unknown handling) of the patch on 6/23/2025 at 7:46 p.m. Record review of Resident #1's nurse progress notes, LVN C documented she made rounds on Resident #1 at 12:57 a.m. and gave the resident acetaminophen. At 2:30 a.m., she documented she was summoned by a CNA, that the resident was not breathing. The residents code status was verified, CPR was initiated, checked the airway and AED was applied. EMS pronounced time of death at 2:49 a.m. and the ME office came to retrieve the body. Record review of form 3613-A Provider Incident Report dated 7/01/2025 revealed a facility self-reported incident that occurred on 6/24/2025 at 2:30 pm resulting in Resident #1's death, signed by the Executive Director. The supporting documents indicated an allegation was confirmed after investigation. The summary stated Resident #1 did not exhibit behaviors of putting foreign items or non-edible foods in her mouth. The report indicated the medical examiner's office verbally informed the facility that Resident #1 expired from accidental asphyxiation choking on 6/24/2025[PH3] . Record review of a witness statement by CMA A dated 6/24/2025, CMA A wrote on 6/23/2025 she administered Resident #1's routine medications and applied two patches to her left leg and to her right shoulder. She wrote Resident #1 appeared to be her normal state of condition. She also wrote she had never witnessed the resident put any object in her mouth. Record review of a written statement by CNA B dated 6/24/2025 revealed he last saw Resident #1 alive and breathing at 1:15 a.m[PH4] [SA5] .(6/24/25). At 2:15 a.m., he noticed the resident was unresponsive, called for a nurse and code and confirmed CPR was initiated and 911 was called. Record review of a written statement by LVN D dated 6/24/2025, LVN D wrote she saw LVN C running up the hallway asking for Resident #1's code status, which was full code. LVN C ran back to the resident room and CPR was initiated. She wrote when she got to the room, Resident #1 was already placed on the floor with a back board and AED in place. She (LVN D) got the ambu bag and connected to the oxygen tank and started breath resuscitation. Upon placing the mask to the resident's face, she noticed a white substance in the resident mouth. She wrote she did a finger sweep of the mouth but was unable to get the white substance out with glove. She wrote EMS arrived and took over. She wrote she assumed the white substance was thrush on her tongue. She wrote she was able to see the chest rise and fall with each breath resuscitation provided. Record review of a written statement by LVN C dated (undated), LVN C wrote on 6/24/2025 at 12:57 a.m. Resident #1 received acetaminophen and then at 2:30 a.m. she was summoned by a CNA (not named) for a change of condition. CPR initiated. She wrote she was doing chest compressions; the AED was initiated and LVN D began using the ambu bag and provided a finger sweep. LVN C wrote LVN D felt it looked like thrush. EMS arrived and took over. They used a suction machine and obtained a Lidoderm patch from Resident #1's mouth. EMS pronounced death at 2:49 a.m. and the medical examiners office came to retrieve her body. Record review of a written statement by LVN C dated 6/25/2025 revealed she was working as a CMA on 6/23/2025 and she took the patch (Lidoderm) to the knee but not to her shoulder. She wrote she did not see a patch on her shoulder. During an interview on 7/03/2025 at 10:37 a.m. CMA A stated she was the medication aide that applied the Lidocaine patch to Resident #1's right shoulder and left leg at approximately 11:00 a.m. on 6/23/2025. She stated she dated the patches with her initials. She stated she was not the same person who removes the patches, she only applies them. CMA A stated Resident #1 used the patches for pain on a routine schedule. She stated when she applied the patches, she looked for old ones and did not see any. CMA A stated she remembers physically putting the patches on the resident. She stated the right shoulder patch was placed on the top right shoulder in the front of the body. CMA A stated she was not working when Resident #1 died. She stated the resident could answer simple yes/no questions but could not make her needs known. She was wheelchair dependent and required staff to move the wheelchair for her. She stated she was not aware of any behaviors other than occasional yelling out. CMA A stated since the incident had occurred, she had completed multiple trainings. She stated the trainings included application of patch, removal and disposal of the patch. She stated now when a patch was removed the new training was for two staff the med aide and the nurse to go together to witness the removal and both have to document the removal. She stated she had also received training on CPR, what to do when they see someone choking which included the Heimlich maneuver. She stated she practiced in person the skills. She stated she had training about resident choking hazards and putting objects in their mouths. She stated they are to keep out of reach and if they see a resident with something that was a choking hazard she should first attempt to take it away and then report immediately to the DON. She stated there were no residents with that behavior currently with known behaviors of putting objects in their mouth. CMA A stated she had received abuse and neglect training which included definitions. She stated neglect was not providing a resident with care, not feeding, or changing them or not answering the call light. She stated she was trained to report any abuse or neglect immediately and within 2 hours to the Abuse Coordinator who was the ED. During an interview on 7/03/2025 at 11:09 a.m., CNA B stated he worked on 6/23/2025-6/24/2025 on night shift. He stated his shift started at 10:00 p.m. He stated at the start of the shift he made rounds and Resident #1 was okay. CNA B stated at approximately 12:00 p.m., he changed her, and she was doing good. He stated she has dementia and would talk to herself at night but was not verbal and could not communicate. He stated the next round was at approximately 2:00-2:15 a.m. He stated he first changed Resident #1's roommate. He stated then he approached Resident #1 and saw she was unresponsive. He stated she was not breathing, and he could just tell she was not ok. He stated her body was warm and he did not notice anything visible outside of her mouth. He stated he immediately notified the nurse, LVN C and called a Code Blue. CNA B stated he stayed in the room with LVN C and LVN D to help with CPR until EMS arrived. He stated the nurses saw something in her mouth and thought it was thrush, he said they knew something was there. He said he could not really describe it. LVN D was using the bag (ambu bag used to provide ventilations during CPR) and he was performing chest compressions. He stated he did not know if Resident #1's chest had a rise and fall with respirations because he was doing compressions. He stated after EMS arrived while EMS was doing CPR, they found something in Resident #1's mouth and pulled it out with a Yanker (suction). He stated he did not know what it was. He stated he left the room at that point with EMS still working on the resident. CNA B stated he did not notice anything wrong or any change in Resident #1 prior to finding her unresponsive. He stated she required full staff assistance for all care. He stated this included feeding. CNA B stated Resident #1 was able to move her hands to her head and touch her hair, scratch her face, etc. but she did not have the cognitive status to be able to feed herself. He stated she was bedbound unless someone moved her or transferred her out of bed. CNA B stated Resident #1 was unable to use the call light and was unable to make her needs known. He stated to meet her needs they had to check on her and make rounds every two hours. CNA B stated Resident #1 did not have any behaviors of putting things in her mouth other than food on a plate in front of her. He stated she would pick up a cup in front of her and chew on it and he has seen her chew on her tongue. CNA B stated he had noticed patches on her body during the daytime but not at night. He stated he did not know what time the patches were normally taken off. CNA B stated before Resident #1 was found unresponsive he had noticed a patch on her inner shoulder. He stated he thought that patch wasn't where it normally goes but he did not say anything to anyone because he thought maybe somebody was going to come back and get it. CNA B stated after she was found unresponsive, he was not paying attention to patches and does not remember if the patch was still there or not. CNA B stated after the incident the facility did an investigation and he was asked the same questions he was asked today. He stated they received a lot of training. He stated the training was what to do in an emergency. He stated as a CNA they told him he could do CPR after notifying the nurse and verifying code status. He stated any staff could perform CPR until EMS arrived. He stated the in-service training included compressions, respirations, oxygen use, emergency procedures, how to use the bubble thing (ambu bag). He stated he received a choking and small object in-service. He stated they were told to immediately perform the Heimlich maneuver until the object was removed and CPR if necessary. Trained to keep small objects out of the reach of dementia residents. He stated he received training on notifying the nurse of small objects including patches. He stated he received abuse/neglect training. He stated he learned about the definition of neglect which was refusing to give care to a resident or not rendering aide. He stated he was not aware of any neglect at the facility. He stated he was trained to notify the Executive Director immediately. During an interview on 7/03/2025 at 1:43 p.m., LVN C stated on 6/24/2025 between 2:00-3:00 a.m., she was summoned by CNA B from the door of the resident room while she was near the nurse's station. She stated she was told it looked like Resident #1 had passed. LVN C stated she immediately asked LVN D to look up the resident's code status which was verified full code and immediately went to the room with CNA B. She stated Resident #1 was warm, was not breathing and had no signs of life. She stated they pulled Resident #1 to the floor and noted she was warm and began CPR. LVN C stated LVN D called 911 and then came to assist with CPR until EMS arrived. LVN C stated LVN D did the ambu bag. LVN C stated she noted something that looked like bubbles in Resident #1's mouth. She stated LVN D did a finger sweep and could not get anything out of the mouth. LVN C stated she did not suction the bubbles because they were able to get air through and into her and she had no color change, was not blue. LVN C stated the resident was pale. LVN C stated the resident had a rise and fall of the chest with ambu bag. She stated the reason a finger sweep was done because they saw the bubbles, they could see something, and they thought what was that? LVN C stated the had brought the crash cart and AED which was applied but did not suction because they were able to get the rise and fall of her chest. LVN C ended the interview at this time and stated she would continue later in the day. During an interview on 7/03/2025 at 3:25 p.m., LVN D stated she was seated at the desk on 6/24/2025 (time unknown) when LVN C came running up to her and asked her to look up code status for Resident #1. She stated she confirmed full code. LVN D stated she called 911 and then went to the room to assist. LVN D stated when she got to the room Resident #1 was on the floor and CNA A and LVN C were doing compressions. She stated she connected the ambu bag (to oxygen). She stated when she tilted Resident #1's head back to use the ambu bag she saw something white in her mouth. She stated she tried to remove it with her finger but could not get it out because it was so slippery. LVN D stated she gave Resident #1 breaths with the ambu bag and got a rise and fall of the chest. She stated she then again tried to remove the substance. She stated the substance was too slippery and she could not grab it. She stated at the same time EMS arrived and took over. LVN D stated she told EMS about the substance in her mouth. She stated EMS asked her for tweezers which she did not have. She stated EMS used the suction from the crash cart with a yanker (type of suction catheter). LVN D stated EMS tried to maneuver the white substance out of her mouth with the suction. She stated the EMS tech finally stuck his whole hand in her mouth and pulled out a white substance that was really gooey and slimy. LVN D stated she thought it looked like a mucous plug. LVN D stated EMS said this was what was in her throat but did not say what it was. LVN D stated she left the room after EMS took over to print paperwork for EMS. LVN D stated she did not normally work that hallway and was unfamiliar with Resident #1. LVN D stated she thought the facility emergency procedures weren't well. She stated they followed facility policy, worked together to notify 911, and do CPR. She stated someone (unknown name) went and held open the front door for EMS personnel who arrived very fast. LVN D stated after the incident she received multiple trainings. She stated she had to perform a demonstration and check off of how to properly put on and take off a patch, how to dispose of it in a trash can with stick sides pressed together and outside of the resident room. She stated she was trained that if they see any object in a residents mouth, they are to notify the DON right away, keep objects out of reach. She stated received CPR, Heimlich training and abuse training. She stated she was instructed where the Abuse Coordinator number was located which was all over the place and to notify him (ED) immediately. During an interview on 7/03/2025 at 3:40 p.m., CMA E stated Resident #1 normally had her shoulder Lidoderm in the front and not in the back. She stated she was not working on the date of the incident. She stated she was not aware of any behaviors of putting objects in the mouth by Resident #1 or any other resident. She stated while working she had never had an incident where one of Resident #1's patches was missing. She described Resident #1 as very confused and unable to say what she needed. CMA E stated following the incident she had received in-service training which included patches, how to put on and take off. She stated two people, one being a nurse had to witness removal of patches. She stated all patches had to be disposed of in the medication cart and not in a resident room and had to be signed off with the nurse. She stated she also received training on CPR, first aide, small objects. She stated she was trained to notify the nurse of objects. And if a resident was choking to initiate the choking protocol, CPR and call 911. She stated during CPR she was trained to call 911, get the crash cared, open doors for EMS and to assist wherever was needed. She stated she did a demonstration for CPR and choking. She stated she had received abuse/neglect training, had no knowledge of any resident abuse or neglect and new to tell the ED immediately. During an interview on 7/03/2025 at 4:02 p.m. LVN C stated Resident #1's Lidoderm patches were applied in the morning and taken off in the evening by the medication aides. She stated she worked the medication aide cart on 6/23/2025 and acknowledged she signed off that the patches in the evening. LVN C stated she removed the one from the left knee but did not see a patch on Resident #1's shoulder to remove. She stated this occurred at approximately 7:00 pm. She stated she looked for the patch on the back of the shoulder and on the arm and did not see it. She stated she did not know where the patch was normally placed on Resident #1 because she normally did not pass the medications. She stated she looked on the resident back but not on her from and not on her chest. She stated she did look on the front of the shoulder but not the chest area. LVN C stated she assumed the Lidoderm patch fell off. She stated Again, I don't know. I don't normally pass the medications when asked how she trained to respond when a patch could not be located. LVN C stated all she knew was that the patch would normally be taken off in the evening. LVN C stated Resident #1 did not have behaviors. She stated the resident would babble to herself until she fell asleep, and night and she never saw her chew on anything or put anything in her mouth. LVN C stated Resident #1 never tried to get up, was not able to use her call light and did not have the ability to make her needs know. LVN C stated no special supervision was required other than meeting all of the residents needs. LVN C stated prior to the incident Resident #1 did not have a change of condition. LVN C stated she last saw Resident #1 well at midnight, when she gave Resident #1 Tylenol. She stated she was supposed to check on the resident every 2 hours. She stated they were doing CPR between 2:00-3:00 a.m. LVN C stated EMS personnel told her they removed a Lidoderm Patch from Resident #1 during CPR. She stated they put it on the bed. LVN C stated she looked at it and agreed with EMS that it was a Lidoderm patch. She stated she could not see the working of the patch, but you could see remnant of the marker and date which were illegible. LVN C stated the patch had turned into a ball of goo and was very sticky. She described it as a blob. She stated when the Medical Examiner arrived, they took the blab with them. LVN C stated she was suspended from working pending the investigation. She stated she was required to complete all the in-services before being allowed to come back to work the next day. She stated she received hands on training for CPR, Heimlich maneuver, patch removal, medication administration, and AED and small objects and abuse. She stated she could not remember the others but had completed them all[PH6] . During an interview on 7/03/2025 at 4:18 p.m., CNA F stated she had no knowledge of the incident. She stated after the situation she had received training on patches. She stated she was trained to notify the nurse if the patch wasn't where it was supposed to be or if they saw a patch off the resident. She stated she would go to the nurse if a patch needed to be removed. CNA F stated she received training on CPR and the Heimlich maneuver. She stated she was trained to look for small objects, look in resident mouths and do the Heimlich maneuver if someone is choking and to continue to do it until the object comes out and notify nurse. She stated she also received training on abuse neglect and definitions and would notify the ED immediately. During an interview on 7/06/2025 at 12:16 p.m. ADON G stated staff should document when the patch was put on and when it was taken off, usually in the evening. She stated Resident #1 was verbal but not understood and not able to make her needs known. She stated the resident spoke in word salad. ADON G stated the staff were trained to use the resident's non-verbal cues, monitor the resident, and look for any change of condition when caring for her. She stated monitoring at night would include ensuring the resident was observed every two hours during the night. She stated the resident herself did not have complaints and had no behaviors she was aware of. A ADON G stated she was not working when the choking incident occurred. She stated she found out about it the next morning when the DON called and asked to have a manager meeting to discuss the incident. ADON G stated she was told staff found a Lidocaine patch in Resident #1's throat. She stated the management pulled all resident orders, specifically residents who had orders for lidocaine patches. She stated the physicians came to the facility and reviewed their orders for residents and changed any orders for patches to creams if the resident allowed. ADON G stated she then assisted with in-serving staff. She stated staff had to actually perform CPR, use the AED. She stated they received training on abuse and neglect, what to do is someone was choking and what to do if they saw a resident put something in their mouth that wasn't supposed to be there. She stated the facility changed their policy for Lidocaine patches for two personnel to do the removals. She stated aides were instructed that while giving showers, if a patch comes off they are to take the patch to the nurse for documentation. ADON G stated the pharmacist came in and did education to the staff on patch use. ADON G stated only one resident remained on a Aspercream patch and was cognitively intact, all others had been changed to cream only. ADON G stated she did not participate in the investigation, just in staff in-services and education. ADON G stated a CPR drill was run, a actual simulation code. She stated each staff member received feedback and anyone who struggled repeated the drill until their response was adequate. ADON G stated each staff had to participate in using the AED, CPR training, crash cart review and assembly. She stated they had a choking vest, and a choking simulation was completed to assess staff on their choking skills. She stated she watched staff put on and properly remove a patch and a medication pass review was completed with staff. She stated all staff participated in the Heimlich skills. ADON G stated the abuse and neglect training was for all staff, who to contact, when and forms of abuse. She stated staff was instructed to report immediately, facility protocol and where the number for the Administrator (ED) was located. She stated this training was completed on 6/25/2025. She stated a few stranglers of staff who were on vacation were completed in the following days. She stated 99% of staff was completed on 6/25/2025. She stated it was important for staff to know and monitor the location of a patch, so staff knows where the patch is, in case it comes off so the facility does not experience a repeated incident. She stated the risk of a loose patch was choking. During an interview on 7/6/2025 at 1:33 p.m., CNA J stated they had completed multiple trainings post incident. He stated about CPR and how to help out in any way he could, preventing choking and what to do in the event of choking, which was to immediately help the resident, do the Heimlich maneuver, get help from the nurse if available, check their airway and start CPR if not breathing. He stated he was trained to look for small objects and keep them out of reach so confused residents could not put them in their mouth. He stated if he saw a resident put something in their mouth, he would check their mouth and let the ADON or DON know immediately. He stated he learned about patches He stated he was trained on abuse and neglect he was instructed to notify the abuse coordinator right away and he would also notify his supervisor. During an interview on 7/06/2025 at 1:47 p.m,. the MDS Coordinator stated she was not in the facility during the incident and did not participate in the investigation or training. She stated she had received training herself which included adding monitoring of patch locations to residents' care plans who used a patch. She stated she also received training on monitoring new admissions for patch use and notification of the DON. She stated she was not aware of any oral behaviors exhibited by Resident #1 and was not aware of any resident in the facility who had oral fixation or oral behaviors. She stated her training also included CPR, code training, choking new patch process with two people as a witness, patch destruction out of the resident room, training of new staff and what to do if someone puts an small object in their mouth. She stated she would notify the ADON and DON so the resident could be assessed. She stated she received abuse/neglect training. She state any allegation or suspicious activity should be reported immediately to the Administrator (ED). She stated she would try to resolve/investigate immediately. She stated CPR training showed how to identify vital signs, initial assessment, rate of breaths/compressions, calling for help, AED, calling 911, teamwork, and Heimlich maneuver. During an interview on 7/06/2025 at 1:57 p.m., ADON H stated she was not at the facility when the incident occurred. She stated she received a call from the DON and came to the facility to assist. She stated she was told Resident #1 had coded and at the time they were not sure what happened. She stated later they learned she had choked on a Lidoderm patch. She stated she was not a witness and did not participate in the investigation. She stated she participated in education to staff post incident. She stated education included abuse neglect, a new system for patch monitoring, choking, CPR, monitoring patches, monitoring patch orders. She stated she taught the call right away to the Abuse Coordinator (ED) for abuse or neglect. She stated reviewed types of abuse, including the definition of neglect which was failure to provide essential care. She stated she told the staff all the multiple placed the ED number was located. ADON H stated choking hazards, Heimlich, CPR, code status, AED skills were all taught and reviewed as skills check off. She stated they reviewed how all departments could help in an emergency like calling 911, holding the doors, showing EMS where to co. She stated the skills check off included a return demonstration of skills by staff. She stated they taught the new procedure for logging of patches. Signing off their removal. She stated CNAs who see a patch off should notify the nurse. She stated if a resident had an altered mental status the nurse should see if they could obtain a different order and keep patches and small objects out of reach. During an interview on 7/06/2025 at 3:38 p.m., the DON stated on 6/24/2025 at 5:00 am she was notified about the incident involving Resident #1 and came to the facility. She stated she began the investigation, found out who the med-aide was which was LVN C and suspended her pending investigation. The DON stated began conducting interviews and notified the Administrator. The DON stated later that same day, they were updated from the Medical Examiner that the cause of death was accidental asphyxiation. She stated they were not told from what. The DON stated one nurse LVN C stated it was a Lidoderm Patch and LVN D stated it was a white substance. She stated the do not have confirmation from the ME that it was a Lidoderm patch. The DON stated the investigation revealed Resident #1 had no known behaviors of putting things in her mouth and had no change in behavior. She also had no change of condition prior to the event. The DON stated she asked staff and got input from therapy and even housekeeping if there was anyone, any resident who put items in their mouth. She stated no residents were identified. She stated they did safe surveys of residents and staff, and no abuse was identified. The DON stated from interviews she believed the facility handled the code appropriately. She stated she did not believe there was deficient practice. She stated they notified the pharmacist and she came to the facility to assist with training on patches and medication administration. The DON stated they reviewed their policy for patch administration and changed their protocols for how patches are handled. She stated they reviewed all orders and got rid of any patch orders that could be changed with the physicians. She stated they adjusted patch removal times on the MARS and included an entry for monitoring placement of the patches during the shifts. She stated all patches need to be disposed of outside of the resident rooms. The DON stated the Medical Director was notified and she informed him of the facilities plan. She stated he reviewed the plan and did not give any instruction, just said they were doing a good job. She stated the education of staff included what staff should do if they see a resident put a foreign object in their mouth. She stated they should notify the nurse and she should also be notified immediately to make sure the patient was safe. She stated someone should stay with the resident to keep them safe. The DON stated now everyone knows if a patch can not be located a through sear of the bedding and a head-to-toe assessment should be completed to try to locate the patch. She stated she protected residents from harm by reviewing charts and staff education. She stated she talks to residents and families about their concerns. She stated this was important for accountability. She stated the risk of an unaccounted for patch was possible choking. The DON stated from that point she proceeded with education of staff which included: -medication pass and observation, disposal of patches, patch protocol 40 of 41 staff completed. -patch protocols with two people as a witness, training CNA to question any patch they see in the room and to pick it up and bring it out of the room, CPR and ensuring everyone knows their part 83/83 nursing staff educated. -Following physician orders, new admission checklist in which any new admission with orders for a patch will be sent to her (DON) for review 32/32 licensed nurses completed. -choking and foreign object/small object in-service all 148/148 staff completed -Abuse/Neglect and Resident Rights- all 148/148 staff completedThe DON stated the training was mandatory and was completed on 6/24/2025-6/25/2025. During an interview on 7/06/2025 at 5:00 p.m., the Executive Director stated at the time of the incident he was out of state for a military obligation. He stated he was notified around

Based on interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 2 of 8 residents (Residents #1 and #2) reviewed for grievances. On 11/9/2024 Resident #1 made a grievance to Medication Aide A (MA A) which she did not document or report to the DON. The grievance alleged he did not receive medications on 11/8/2024. On 11/19/2024 Resident #2 made a grievance to Case Manager D (CM D) which she did not document or report to the DON. Resident #2 alleged he was left at the doctor's office for hours without return home transportation. These failures could place residents at risk for harm by leaving residents with frustration and demoralization. The findings included: 1. A record review of Resident #1's admission record dated 5/7/2025 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included blindness, diabetes (high blood sugar concentration which impairs the body functions and could cause blindness and kidney injuries), and chronic kidney disease. A record review of Resident #1's medication administration records for 11/1/2024 through 11/30/2024 revealed Resident #1 received all medications prescribed to him throughout November 2024. A record review of the state regulatory agency's complaint intake dated Wednesday 11/13/2024 revealed Resident called the state regulatory agency to allege he did not receive his medications on Saturday 11/9/2024. A record review of the facility's grievance reports for the month of November 2024 revealed no grievances for Resident #1 regarding not receiving medications. During an interview on 5/7/2025 at 9:20 AM Resident #1 stated he has had many grievances against the facility and does not recall the specific grievance he reported in November 2024 but did recall he did not receive medications during a weekend in November 2024. Resident #1 stated he usually received his medications from MA A but she did not work the weekends and most likely MA A and the nurses would have been the staff who would have heard his grievances concerning the staff on the weekends. Resident #1 stated no one has addressed his concerns for the weekend staff. During an interview on 5/7/2025 at 11:20 AM MA A stated she recalled Resident #1 sometime in November 2024, on a Monday, had made a complaint that the weekend nurse had not administered his medications over the weekend. MA A stated she believed she had not documented a grievance report but had reported the complaint to the weekday nurse she usually worked with, LVN B. During an interview on 5/7/2025 at 4:20 PM LVN B stated she had a good rapport with Resident #1 and MA A. LVN B stated she could not recall if she had received a report from Resident #1 or MA A related to Resident #1 not receiving his medications. LVN B stated had she heard a report of Resident #1 not receiving his medications she would investigate and report the concern to the DON and would have documented a grievance report. 2. A record review of Resident #2's admission record dated 5/9/2025 revealed Resident #2 was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (a hardening of the arteries from plaque buildup), dementia (a group of symptoms affecting memory, thinking and social abilities which interfere with activities of daily life), and difficulty walking. A record review of the facility's grievance reports for the month of November 2024 revealed no grievances for Resident #2 regarding being left at the doctor's office for hours. A record review of Resident #2's nursing note dated 11/19/2024 revealed LVN G documented at 2:16 PM, Resident returned from cardiology appointment During an interview on 5/6/2025 at 1:41 PM, Resident #2's representative stated, on 11/19/2024 Resident #2 went to the cardiologist's physician's assistant office for an early morning appointment and after the appointment was confused by the doctor's staff as to where to await the return to home transport and consequently waited for hours within the clinic and missed his transport. Resident #2's representative stated Resident #2 used his cell phone to call family and the family coordinated a pickup and transported Resident #2 back to the facility that afternoon. Resident #2's representative stated she and Resident #2 made a grievance to CM D concerning Resident #2's missed transportation and lack of assistance for hours. Resident #2's representative stated the facility had not responded to the grievance. During an interview on 5/7/2025 at 11:29 AM CM D stated she recalled Resident #2 was upset because his Family member was late to pick him up after a doctor's appointment. CM D stated she could not recall if she received a complaint from Resident #2's representative. CM D stated she did not document Resident #2's complaint on a grievance report but she recalled speaking to Resident #2's representative about the late return to the facility. CM D stated, I don't remember what month, but the incident was around fall 2024. During an interview on 5/9/2025 at 9:23 AM the Administrator and the DON stated they had not received a report on behalf of Resident #1 from November 2024 alleging he did not receive medications nor Resident #2's complaint of missing his return to the facility transport after his cardiology appointment. The Administrator and the DON stated the expectation was all residents who communicated grievances had their grievances heard and for staff to follow the grievance process and at a minimum document a grievance report which would have been reviewed and investigated by the facility leadership. The Administrator and the DON stated the potential risk to residents was their grievances would go unrecognized and unresolved. A record review of the facility's Grievance policy dated June 2023, revealed, It is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have.

Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 8 residents (Resident #3) reviewed for quality of care. Resident #3 had a cardiology appointment on 11/13/2024, for an echocardiogram (an exam which uses sound waves to make pictures of the heart), and the facility failed to attempt to provide a chaperone to the appointment when her representative was late; subsequently Resident #3 missed her appointment. This failure could place residents at risk for decreased quality of care due to delayed health status reports to the physicians. The findings included: A record review of Resident #3's admission record dated 5/7/2025 revealed Resident #3 was a [AGE] year-old female admitted [DATE] with diagnoses which included heart failure, cardiomegaly (enlarged heart), and need for assistance with personal care. A record review of Resident #3's physicians order dated 10/28/2024 revealed Resident #3 was scheduled to see her cardiologist on 11/13/2024 at 1:00 PM. Further review revealed the scheduled ambulance pick up was scheduled for noon and Resident #3 was to be escorted by her representative. A record review of Resident #3's nursing notes dated 11/13/2024 at 2:43 PM, revealed LVN F documented Resident #3 missed her cardiology appointment due to Resident #3's representative did not arrive to accompany Resident #3 to her cardiology appointment, The patient had an appointment today. Transportation arrived at the facility one hour prior to the appointment. The patient was cleaned and positioned in her wheelchair and sat by the nursing station awaiting on her [Resident #3's Representative] who was going to escort the patient to the appointment. Writer called the [Resident #3's Representative] several of times, to see if she was going to meet [Resident #3] here or at the doctor's office, but she did not answer. The [Resident #3's Representative] arrived at the facility at 1:40 pm. Requested the number to the Transportation service she was given the number then walked away to [Resident #3's] room. During an interview on 5/7/2025 at 3:01 PM Resident #3 Representative stated she usually accompanies Resident #3 to all her medical appointments. However, on 11/19/2024 she was delayed and arrived at the facility to accompany Resident #3 to her cardiologist appointment and discovered LVN F had dismissed the ambulance and cancelled the cardiologist appointment without attempting to support Resident #3 to attend her cardiologist appointment and did not attempt to send a staff member with Resident #1. During an interview on 5/8/2025 at 11:28 AM ADON E stated the facility's system for appointment coordination had multiple data input points to include appointment information from residents, representatives, doctors, nurses, staff, and the data was recorded on a worksheet and entered into the medical record as an order to be populated on the medication administration record. ADON E stated she was informed Resident #3 missed her cardiology appointment on 11/13/2024 after the missed appointment. ADON E stated had she been given a report she would have tried to organize a chaperone for Resident #3 to attend her appointment. During an interview on 5/8/2025 at 11:40 AM LVN F stated the usual routine for resident's appointments was coordinated by the facility to have transportation take residents to the appointments and if needed the Resident would be chaperoned by a staff member, usually CNA C. LVN F stated all nursing staff could coordinate transportation for residents, but CNA C also assisted to plan transportation for residents. LVN F stated she recalled the incident when Resident #3's representative had not arrived on time to accompany Resident #3 to her cardiologist's appointment. LVN F stated, I don't remember what month, but it was a couple of months ago. LVN F stated Resident #3 could not attend any appointment by herself and needed supervision for safety. LVN F stated the contracted ambulance service waited for Resident #3's representative to arrive to accompany Resident #3 to her appointment but could not wait for an extended time due to scheduling conflicts. LVN F stated she was unsuccessful in contacting Resident #3's representative with phone calls and after 20 to 40 minutes of waiting for Resident #3's representative to arrive she dismissed the ambulance. LVN stated she had not reported the incident to her supervisors and had not attempted to coordinate any staff member to accompany Resident #3 to her appointment because she decided that no staff member was available to accompany Resident #3 to her appointment. LVN F stated, I decided we did not have staff to send with her. I knew CNA C was already going to an appointment with another Resident. During an interview on 5/8/2025 at 3:53 PM the Medical Director stated he consulted with Resident #3's cardiologist and in their professional opinions the missed cardiology appointment on 11/13/2024 was for an echocardiogram and Resident would not have seen the physician. The MD stated the ideal would have been for Resident #3 to have had her images completed sooner rather than later but the delay did not impede her healthcare. During an interview on 5/9/2025 at 9:23 AM, the Administrator and the DON, stated the expectation was for all residents who had a need to attend a medical appointment were supported with their needs to attend their appointment. The DON stated she and her ADONs were not included in the decision to dismiss the ambulance service transportation for Resident #3 on 11/13/2024 and if they had been given a report the facility would have made attempts to chaperone Resident #3 to her appointment. The DON stated the risk to residents missing their appointments was varied and she could not speculate other than residents should be supported in attending their appointments. A record review of the facility's Prevention of Abuse, Neglect and Exploitation policy dated August 2024 revealed, The facility will implement policies and procedures to prevent and prohibit all types of . neglect, . that achieves: . Identifying, correcting and intervening in situations in which . neglect, . is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs

Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #3) reviewed for resident records. The facility failed to ensure the wound administration records (WAR) for Resident #3 accurately reflected the wound care that was provided to her sacrum (large triangular bone at base of the spine) wound and ischium (the curved bone forming the base of the pelvis) wound on 5 different treatment days in November and December 2024. This failure could put residents at risk of inaccurate documentation. The findings were: Record review of Resident #3's Admission Record (face sheet), dated 02/12/2025, revealed she was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney failure), high blood pressure, diabetes (long-term condition in which the blood sugar level is too high which can result in damage to many of the body's systems especially the nerves and blood vessels), anemia (low iron stores), Von Willebrand Disease (an inherited blood disorder that keeps the blood from clotting), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), severe protein-calorie malnutrition (inadequate intake of protein and calories resulting in depleted body stores of protein), pressure ulcer (bed sore) of sacral region, and pressure ulcer of other site. Record review of Resident #3's electronic clinical record revealed she was discharged to the hospital on 10/21/2024, readmitted on [DATE], discharged to the hospital on 11/21/2024, readmitted on [DATE] and discharged to the hospital on 01/28/2025. Record review of Resident #3's MD Quarterly assessment dated [DATE], revealed a BIMS score of 12 out of 15, which indicated her cognitive skills for daily decision making were intact; and she was admitted with two stage 4 pressure ulcers (the most severe type where the skin is severely damaged and underlying muscles or bone may also be damaged). Record review of Resident #3's care plans for impairment to the skin integrity related to the stage 4 pressure ulcer to the right ischium (the curved bone forming the base of the pelvis on the right side) and sacrum (large triangular bone at base of the spine), revealed under interventions was to Administer treatment as ordered by MD/NP with a start date of 06/24/2024 and was revised on 09/20/2024. Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 6 cm length x 3.5 cm width x 2.7 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5 cm length x 3 cm width x 1.6 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 7 cm length x 4 cm width x 3.2 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5.2 cm length x 4.2 cm width x 1.5 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 7.5 cm length x 4 cm width x 2.5 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5.3 cm length x 5 cm width x 3.1 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 5.5 cm length x 4.2 cm width x 2 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5.5 cm length x 3.5 cm width x 1.5 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Physician Order Listing Report, dated 02/15/2025, revealed the following orders: -Wound Care: Stage 4 Pressure Sacrum: Cleanser with wound cleanser, pat dry, skin pre peri-wound, Collagen particles to entire wound bed ., pack entire wound with calcium alginate or gel fiber ribbon and secure with dry absorbent dressing every day shift every other day with a start date of 11/01/2024 and a discontinue date of 11/12/2024. -Wound Care: Stage 4 Pressure Sacrum: Cleanser with wound cleanser, pat dry, skin prep peri-wound, Collagen particles to entire wound bed .pack entire wound with calcium alginate or gel fiber ribbon and secure dry with absorbent dressing every day shift . with a start date of 11/12/2024 and a discontinue date of 12/17/2024. -Wound Care: Stage 4 Pressure Sacrum: Cleanser with wound cleanser, pat dry, skin prep peri-wound, Collagen Sheet to entire wound bed ., pack entire wound with calcium alginate or gel fiber ribbon and secure with dry absorbent dressing every day shift . with a start date of 12/17/2024 and a discontinue date of 01/29/2025. -Wound Care: Stage 4 Pressure RT [right] Ischium: Cleanse with wound cleanser, pat dry, skin prep peri-wound, place collagen particles to entire wound bed and cover with gel fiber ribbon or calcium alginate and secure with dry dressing every day shift every other day . with a start date of 11/01/2024 and a discontinue date of 11/12/2024. -Wound Care: Stage 4 Pressure RT Ischium: Cleanse with wound cleanser, pat dry, skin prep peri-wound, place collagen particles to entire .wound bed and cover with gel fiber ribbon or calcium alginate and secure with dry dressing every day shift . with a start date of 11/12/2024 and a discontinue date of 12/17/2024. -Wound Care: Stage 4 Pressure RT Ischium: Cleanse with wound cleanser, pat dry, skin prep peri-wound, place collagen sheet to entire .wound bed and cover with gel fiber ribbon or calcium alginate and secure with dry dressing every day shift . with a start date of 12/17/2024 and a discontinue date of 01/29/2025. Record review of Resident #3's November 2024 WAR revealed wound care for the stage 4 pressure ulcers on the right ischium and sacrum were not documented as provided on 11/02/2024 and 11/04/2024. Record review of Resident #3's December 2024 WAR revealed wound care for the stage 4 pressure ulcers on the right ischium and sacrum were not documented as provided on 12/11/2024, 12/12/2024, and 12/30/2024. In an interview on 02/15/2025 from 10:14 a.m. to 10:37 a.m., Wound Care Nurse LVN A stated she would provide wound care to residents Monday through Friday and the weekend supervisor or floor nurse would provide wound care on the weekends. Wound Care Nurse LVN A stated she provided wound care for Resident #3 on 11/04/2024 since it was a Monday and she probably forgot to check off that she had provided the wound care. LVN A said the wound care provided to Resident #3 on 11/02/2024 would have been done by the nurse or weekend supervisor since it was a Saturday. LVN A stated she provided wound care to Resident #3 on 12/11/2024, 12/12/2024, and 12/30/2024 and she probably forgot to document it was completed. Wound Care Nurse LVN A stated the harm of not documenting the wound care was provided is that it would not show the treatment was done. LVN A said she thought the reasons why it was not documented were because she was moving too fast and because she had clicked it was done and did not sign off in the electronic clinical record before she closed her computer. In an interview on 02/15/2025 at 12:22 p.m., the DON stated RN B was Resident #3's nurse on 11/02/2024. In a telephone interview on 02/15/2025 at 2:33 p.m., RN B stated she was Resident #3's nurse on 11/02/2024 and she provided wound care to the resident but was not certain if she had documented the wound care was completed. RN B said the harm of not documenting that wound care was completed was that it would not show the wound care was completed and it would look like the wound care was not done. In an interview on 02/15/2025 at 3:06 p.m. to 3:18 p.m., the DON stated wound care should be documented in the clinical record after it was provided to the resident and the harm of not documenting could result in other staff not knowing the wound care had been provided. In an interview on 02/15/2025 at 3:21 p.m., the Administrator stated he could not think of any harm that could result from wound care not being documented in the resident's clinical record. Record review of the facility's policy Charting and Documentation, revised 05/2007, revealed The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition .IMPORTANCE AND USE OF THE RECORD .2. To the institution it reflects the quality of care given to the resident. 3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care. 4. In legal defense, it serves as valid information .6. To the nurse, it provides a multidisciplinary record of the physical and mental status of the resident.

Based on interview and record review, the facility failed to ensure the governing body appointed an administrator who was licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body for 1 of 1 facility reviewed for the governing body, in that: The governing body failed to appoint an administrator who was responsible for the management of the facility. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. The findings include: During an interview on 10/28/2024 at 9:05 AM, OM L introduced himself to the survey team as the OM of the facility and stated he did not have an administrator license but was in the process of obtaining one. The facility had an administrator who did not work at the facility full-time. He was at the facility full-time and was responsible for the daily management of the facility. During an interview on 10/30/2024 at 12:35 PM, the Administrator stated she assumed the position of administrator for the facility sometime the end of February 2024 but was unsure of the exact date. She had not been in the facility on a daily basis, did not spend 40 consecutive hours per week at the facility, and visited the facility as needed. She was available at home if the facility needed her. During a telephonic interview on 10/30/2024 at 1:47 PM, OM M stated he had taken over leadership of the facility from the previous administrator. He was not a licensed administrator, but in the process of becoming an administrator. He remained the OM when the administrator assumed the position in February 2024, was at the facility daily, and was responsible for the daily operation and management of the facility. The administrator was not at the facility daily. Record review of hire dates provided by the facility revealed the following: - Previous licensed administrator was employed by the facility from 12/27/2022 - 01/16/2024. - OM M became the OM of the facility on 02/11/2024 - 10/01/2024. - OM L became the OM of the facility on 10/08/2024. - The facility's current administrator's hire date was 03/01/2024. During an interview on 10/31/2024 at 1:26 PM, OM L stated the facility did not have a specific policy regarding the administration of the facility, they just followed the regulation.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Resident #67) of 6 residents reviewed for clinical records. The facility failed to ensure CNA F documented oral hygiene care that was offered, performed or refused by Resident #67 on 10/4/2024, 10/7/2024, 10/11/2024, 10/15/2024, 10/25/2024, 10/28/2024 and 10/29/2024. This deficient practice could place residents at risk of improper care due to inaccurate medical records. The findings were: Record review of Resident #67's face sheet, dated 10/28/2024, revealed a [AGE] year-old female with an admitted [DATE], and diagnoses which included: Dysphagia (trouble swallowing) following Cerebral Infarction (stroke resulting from blood flow to brain being blocked); Non-Traumatic Intracerebral Hemorrhage in Hemisphere (bleeding in the brain); Seizures (uncontrolled jerking, loss of consciousness, blank stares or other symptoms caused by abnormal electrical activity in brain); Type 2 Diabetes mellitus (a long-term condition in which the body has trouble regulating blood sugar); Contracture (fixed tightening of muscle and tissue that prevents normal movement) right hand; Age-Related physical debility (physical weakness) and Need for Assistance with Personal Care. Record review of Resident #67's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 4, indicating severe cognitive impairment. Further review under Section GG - Functional Abilities and Goals, shows Resident #67 was assessed as needing partial to moderate assist in oral hygiene. Record review of Resident #67's care plan dated 09/22/2024 reflected a focus area for ADL Self Care Performance Deficit r/t CVA [cerebrovascular accident], impaired mobility, with interventions that include Oral Hygiene: Dependent x 1 staff member. Record review of Resident #67's oral hygiene log for October 2024 revealed there was no oral hygiene documented as being done on the following days: 10/4/2024, 10/7/2024, 10/11/2024, 10/15/2024, 10/25/2024, 10/28/2024 and 10/29/2024. Interview on 10/28/2024 at 9:41 a.m. with Resident #67's RP revealed she visited often, and was concerned because it did not appear that Resident #67's teeth were being brush daily, noting her teeth did not appear clean sometimes when she visited. During an interview with LVN H on 10/31/2024 at 9:37 a.m., LVN H stated she also was one of the MDS Nurses and helps with training of staff. She reviewed the oral hygiene log for Resident #67 for October 2024 and confirmed that n/a ,(non-applicable), was recorded on the 7 days with no oral hygiene recorded as being completed. LVN H was not able to explain why n/a would be documented for oral hygiene, unless there was a medical reason the resident could not brush her teeth, and stated that oral hygiene should be conducted at least daily, and documented in POC (Point of Care). LVN H reviewed the record and stated the CNA who documented the n/a on Resident #67's on the dates in question on the oral hygiene log was CNA F. Interview with CNA F on 10/31/2024 at 10:00 a.m. revealed he had been working at the facility for about 3 years and stated he did brush Resident #67's teeth every day, but instead of using a toothbrush, he used a sponge stick, because the toothbrush seemed to hurt her, and she would pull away. He stated he used a sponge stick to swab Resident #67's teeth every day when he was on duty, but he documented it as n/a because he did not use a toothbrush. He stated that the log they document tasks performed changed a few months back and he realized now he entered the completed oral hygiene task in wrong section of the log. During an interview with the DON on 10/30/2024, the DON stated oral hygiene should be done at least daily, but ideally both am & pm. She stated staff should be documenting all tasks completed and any refusals. She stated that if not documented, the task could be considered as not being done. Record review of facility policy titled Charting and Documentation revised 5/2007 revealed that The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 15 residents (Residents #67, #49 and #6) reviewed for infection control, in that: 1. While providing incontinent care for Resident #67, CNA D did not change her gloves or wash her hands after touching the privacy curtain before starting to provide care. 2. While observing LVN I perform an accu-check test on Resident #49, a used lancet (a sharp pointed medical instrument used to puncture the skin to obtain a small amount of blood for testing) was observed on Resident #49's bedside table that was parallel next to her bed, within her reach and lying next to some candy wrappers. 3. While preparing to administer eye drops to Resident #6, MA J took off the lid to the eye dropper, obtained a tissue from the box next to the resident's bed and wiped the top of the eye dropper in a back and forth turning motion, rubbing the tissue across the tip of the eye dropper several times These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: 1. Record review of Resident #67's face sheet, dated 10/31/2024, revealed an admitted [DATE] with diagnoses which included: Dysphagia (difficulty swallowing), Hypertension (High blood pressure), Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism (under active thyroid), Cerebral infraction (Stroke). Record review of Resident #67's MDS Annual assessment, dated 09/25/2024, revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #67 required extensive assistance to total care, had an indwelling catheter and, was always incontinent of bowel. Record review of Resident #67's care plan revealed a care plan initiated 11/12/2022 with a problem of has an indwelling Foley catheter 16F (French) with 30cc balloon related to obstructive uropathy and a goal of Will remain free from catheter related trauma/UTI through review date. Observation on 10/30/24 10:12 a.m., revealed while providing catheter/incontinent care for Resident #67, CNA D touched the privacy curtain with her gloved hands. She did not change her gloves or wash her hands, then, started to provide care for Resident #67. During an interview on 10/30/2024 at 10:40 a.m., CNA D verbally confirmed the privacy curtain was considered dirty as part of the environment around the resident and she should have changed gloves and sanitize her hands. She revealed she forgot. She confirmed receiving training on infection control within the year During an interview on 10/31/2024 at 9:20 a.m., the DON verbally confirmed the staff should have changed her gloves and sanitize her hands prior to start providing care for the resident. She confirmed it could cause a risk of cross contamination and infection for the resident. She confirmed they provided training on infection control at least once a year and as needed. She confirmed they checked the skills of the staff annually and as needed with the assistance of her ADONS. Record review of the facility's incontinent care evaluation, undated, revealed wash hands before care, after each gloves change, before reapplying gloves. 33866 2. Record review of Resident #49's face sheet, dated 10/31/2024, revealed an admitted [DATE] with diagnosis which included: cerebral infarction (stroke); Hemiplegia and Hemiparesis (paralysis or weakness on one-side of the body) following cerebral infarction affecting left non-dominant side; Type 2 diabetes mellitus (high level of sugar in the blood); and glaucoma (disease that damage the eye's optic nerve). Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Resident #49 was assessed as having diabetes Mellitus, and glaucoma. Record review of Resident #49's Care Plan initiated 6/20/2020 with a focus area for Diabetes Mellitus, and a goal to have no complications related to diabetes through the review date. Record review of Resident #49's Order Summary dated 10/31/2024 revealed an order for Humalog Kwik Pen Subcutaneous solution Pen-Injection 100 unit/ml (Insulin Lispro) as per sliding scale .subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with other circulatory complications. Observation on 10/30/2024 at 07:05 a.m. revealed that after LVN I administered an accu-check test on Resident #49, she picked up with her gloved hands the used lancet she had just used, and then reached over to pick up another used lancet that was located on Resident #49's bedside table, next to some candy wrappers and within Resident #49's reach. During an interview on 10/30/2024 at 7:09a.m., LVN I stated the lancet should not have been left out on Resident #49's bedside table, and it appeared to have been left out by someone conducting an earlier accu-check. She stated a lancet is considered a sharps, and should be disposed of correctly in sharps container, not left out in open and that is why she picked it up. Interview with Medical Records Specialist K who was also monitoring the accu-check being performed, confirmed that the used lancet should not have been left out on the bedside table, and without proper disposal posed a safety and infection control concern. Review of facility policy titled Infection Control - Sharps Disposal dated 6/2016, revealed under Procedure: 1. Contaminated sharps shall be discarded immediately or as soon as feasible into designated containers. 3. Record review of Resident #6's face sheet dated 10/31/2024 revealed an initial admitted [DATE] with re-admission on 10/10/2024 and diagnoses which included: Congestive Heart Failure (condition where heart does not pump as it should); Primary open-angle glaucoma bilateral (condition causing increased pressure in eye); Glaucomatous Optic Atrophy (damage to optic nerve affecting vision) bilateral and dementia (loss of cognitive functioning). Record review of Resident #6's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #6's Care Plan Initiated 11/11/2020 revealed a focus area of impaired vision r/t glaucoma, wears prescription glasses and a goal to have no indications of acute eye problems through review date and interventions which I included Administer medications as ordered by physician. Record review of Resident #6's Order Summary dated 10/31/2024 revealed an order for Ofloxacin Ophthalmic Solution 0.3%. Instill 1 drop in both eyes three times a day related to Glaucomatous Optic Atrophy Bilateral. Observation on 10/30/2024 at 3:51p.m. revealed that while administering medications to Resident #6, MA J opened the top of the eye drops (Ofloxacin Ophthalmic Solution 0.3%) and then obtained a tissue from a box next to Resident #6's bed, and wiped the top of the eye dropper in a back and forth turning motion, rubbing the tissue across the tip of the eye dropper several times. During an interview with MA J on 10/30/2024 at 3:51p.m., MA J stated she did not know why she wiped the top of the eye dropper with a tissue, explaining she was nervous and just did it. MA J stated she knows she is not supposed to touch the tip of the eye dropper to any surface, as this may contaminate the eye drops. Interview with the DON on 10/30/2024 at 4:32p.m. revealed that she confirmed that the surface of the eye dropper should not touch any surface, as this may contaminate the eye drops. Further interview with DON revealed that MA J had been trained on medication administration of eye drops and infection control, and she provided Competency Testing with MA J completed 10/07/2024 which showed MA J showed competency with medication administration to include administration of eye drops. Record review of American Academy of ophthalmology article titled How to Put in Eye Drops dated 05/05/2023, revealed instructions which included: Remove the cap of the eye drop medication but do not touch the dropper tip. Further review reveals the dropper tip could pick up bacteria from fingers or other surfaces and contaminate the bottle of medication.

Based on observations, interviews, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 6 residents (Resident # 67) observed for resident rights. The facility failed to ensure CNA F sat down while feeding Resident #67 in her room on 10/29/2024. This failure could place residents at risk of not being treated with dignity and respect. Findings included: Record review of Resident #67's face sheet dated 10/28/2024, revealed a [AGE] year-old female with an admitted [DATE], and diagnoses which included: Dysphagia (difficulty swallowing) following cerebral infarction (stroke); and gastrostomy status (has g-tube to bring nutrition directly into the stomach) Record review of Resident #67's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 4, indicating severe cognitive impairment. Further review under Section GG - Functional Abilities and Goals, shows Resident #67 was assessed as needing Supervision or touching assistance for eating. Record review of Resident #67's Care Plan dated 09/22/2024 reflected a focus area for potential nutritional problem r/t PEG tube, mechanically/therapeutically altered diet, and dysphagia (difficulty swallowing) post CVA (stroke), with interventions that included Patient to be up in chair for all meals. Observation on 10/29/2024 at 12:55 p.m. revealed Resident #67 was lying in her bed, and the bed was in the lowest position closest to floor, the head of bed was elevated, and her lunch tray was in front of her on an overbed table. She was observed to be only picking at her dessert (a square of cake) with her fingers, not eating. CNA F came into her room at 1:02pm and asked Resident #67 if she would like some assistance eating her food, and proceeded to stand next to her bed, bending over at the waist to reach down to her utensils and food and proceeded to feed her. After a few bites, Resident #67 pushed her tray away. During an interview on 10/29/2024 at 1:05 p.m., CNA F stated he had worked at the facility for about 3 years, and they always tried to give Resident #67 time to eat on her own at beginning of meal to encourage independence, but will check on her and if she was not eating, they will offer her assistance. He stated I'm used to standing up when feeding Resident #67, but also stated that he knew he should sit down, to get closer to her level to feed her, and indicated he had received training in feeding residents. CNA F proceeded to obtain a chair from the corner of the room, placed it next to Resident #67's bed and asked her if she wanted to try to eat some more of her meal. She indicated yes, and CNA F proceeded to feed her more of her meal while sitting next to her in a chair. During an interview on10/31/2024 at 12:17 p.m., the DON stated that when staff were assisting a resident with feeding, they should sit, not stand over the resident, because it would make them feel like the staff were towering over the resident, and that all staff should have received training and competency checks on this. Record review of Competency Skill Assist with Meal dated 10/7/2024 indicated CNA F met requirements in this skill area, which included Sits in a chair facing the resident. Record review of facility policy titled Nursing Administration - Resident Rights (undated) indicated, .The resident has the right: 1. To be treated with consideration, respect and full recognition of his or her dignity and individuality.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Resident #351) reviewed for privacy, in that: 1. LVN A and LVN B failed to provide privacy to Resident #351 while providing wound care by not closing completely Resident #351's privacy curtain. 2. LVN A failed to protect Resident #351's record by not locking the screen of her laptop. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #351's face sheet, dated 10/31/2024, reflected an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Osteomyelitis (infection of bone), Hydronephrosis (kidney swelling), Colostomy status (opening in the large intestine created by surgery), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Chronic kidney disease (gradual loss of kidney function), Type 2 diabetes mellitus (high level of sugar in the blood), Pressure ulcer of sacral region stage 4 (damage of skin and/or underlying tissue over a bony prominence). Record review of Resident #351's Quarterly MDS assessment, dated 10/09/2024, reflected the resident had a BIMS score of 14, indicating he was mildly cognitively impaired. Resident #351 required extensive assistance to total care with his ADLs and, had an ostomy and indwelling catheter. Record review of Resident #351's care plan, dated 06/30/2023, reflected a problem of has a stage 4 pressure ulcer to sacrum, admitted with related to immobility., with an intervention of Administer treatments as ordered and monitor for effectiveness. 1. Observation on 10/29/2024 at 3:25 p.m. reflected LVN A and LVN B did not completely close the privacy curtains while they provided wound care for Resident #351 because the privacy curtain was too short to cover the end of the bed. The resident's roommate was in the room and the resident's buttock was exposed. During an interview with LVN A on 10/29/2024 at 4:40 p.m., LVN A verbally confirmed the privacy curtains was not completely closed while she provided care for Resident #351, but it should have been. She stated she received resident rights training within the year. During an interview on 10/29/2024 at 3:45 p.m., Resident #351 confirmed the privacy curtain had been too short for awhile and he had received care multiple time without the privacy of a full curtain. 2. Observation on 10/29/2024 at 4 p.m. revealed after care was provided, this surveyor walked out of the room and noticed LVN A's laptop's screen was not locked and was showing residents' information. During an interview with LVN A on 10/29/2024 at 4:02 p.m., she verbally confirmed her laptop's screen should have been locked when she was not using it to protect the privacy of information of the residents. During an interview with the DON on 10/31/24 at 9:20 a.m., the DON stated privacy must be provided during nursing care and Resident #351's privacy curtains should have been closed completely. She confirmed Laptop screens should always been locked when not in used to protect residents' information. She stated the staff had received training on resident rights within the year and the training was provided by the DON and ADONs. They also checked the staff skills annually and as needed. Review of the facility's policy titled HIPAA, undated, reflected, Do not leave computers screens open with patient/resident information. Review of facility's care evaluation, undated, revealed provide privacy - pull curtain, shut door and/or window curtain.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #48) whose assessments were reviewed, in that: Resident #48's quarterly MDS assessment incorrectly documented the resident as not receiving an anticoagulant medication. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #48's face sheet, dated 10/28/2024, revealed an admitted [DATE] and, a readmitted [DATE] with diagnoses that included: Cerebral infarction (stroke), Deep vein thrombosis (blood clot). Record review of Resident #48's Physician orders and Medication administration record for October 2024 revealed an order for: Eliquis (an anticoagulant) Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT [deep vein thrombosis right popliteal (back of the knee) vein]. Resident #48 had received Eliquis in the month of September 2024. Record review of Resident #48's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #48 did not receive an anticoagulant. During an interview with MDS nurse C on 10/31/2024 at 6:50 a.m., the MDS nurse verbally confirmed she had completed the MDS. MDS nurse C confirmed Resident #48's quarterly MDS was coded as the resident not receiving an anticoagulant when Resident #48 had received Eliquis (an anticoagulant). MDS nurse C revealed she did not know why she had not coded Eliquis as an anticoagulant. She verbally confirmed Eliquis was an anticoagulant and should have been coded as an anticoagulant. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Based on observations, interview and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 6 residents (Resident #67) reviewed for hygiene, in that. The facility failed to ensure Resident #67 received a shower or bath as scheduled on 10/12/2024 and 10/14/2024. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life. The findings were: Record review of Resident #67's face sheet, dated 10/28/2024, revealed a [AGE] year-old female with an admitted [DATE], and diagnoses which included: Dysphagia (trouble swallowing) following Cerebral Infarction (stroke resulting from blood flow to brain being blocked); Seizures (uncontrolled jerking, loss of consciousness, blank stares or other symptoms caused by abnormal electrical activity in brain); Contracture (fixed tightening of muscle and tissue that prevents normal movement) right hand; Age-Related physical Debility (physical weakness) and Need for Assistance with Personal Care. Record review of Resident #67's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 4, indicating severe cognitive impairment. Further review under Section GG - Functional Abilities and Goals, shows Resident #67 was assessed as being totally dependent in bathing. Record review of Resident #67's Care Plan dated 09/22/2024 reflected a focus area for ADL Self Care Performance Deficit r/t CVA, impaired mobility, with interventions that include Shower/Bathe Self: Dependent x1-2 staff members. Record review of Resident #67's shower and bathing log for October 2024 revealed no showers or full baths were documented as having been given between 10/11/2024 and 10/16/2024. During an interview with LVN H on 10/31/2024 at 9:37a.m., LVN H stated Resident #67 was scheduled to receive showers 3 days a week, and after reviewing the shower/bathing log confirmed Resident #67 did not receive a shower or bath on scheduled days of 10/12 and 10/15 and had not received any bath or shower on non-scheduled days between 10/11/2024 and 10/16/2024. LVN H stated that Resident #67 does not want to get out of bed at times and will refuse her shower, but also stated that refusals should be documented in the POC. Observation and interview on 10/29/2024 at 12:55pm with Resident #67 revealed she was lying in bed, wearing clean clothes and no body odor noted, but was not able to answer questions regarding bathing. Interview on 10/28/2024 at 09:41a.m. with Resident #67's Responsible Party (RP) revealed that Resident #67 was supposed to be bathed three times a week, on Tuesday, Thursday and Saturdays, but she sometimes sees Resident #67 wearing the same clothes with bad body odor and does not believe she is getting showered/bathed as scheduled. During an interview with CNA G on 10/30/2024 at 2:05p.m., CNA G stated that residents on left side of hall where Resident #67's room was located were to receive showers on Tuesday, Thursday, and Saturdays. If resident refused, they were supposed to give resident some time and offer a shower a little later or other option such as a bed bath if they were not feeling well. If resident continued to refuse, they were to notify the Charge Nurse and document in POC (Point of Care electronic record). CNA G stated that Resident #67 did refuse showers and hygiene at times, but she would document the refusal in POC. CNA G stated it was important to document all showers given and any refusals, to make sure care is being provided. During an interview with the DON on 10/30/2024 at 1:30pm, the DON stated that staff should be documenting all hygiene activities, including bathing and oral hygiene and any refusals in the resident's record, and that if not documented, could be considered not done. The DON stated that not showering residents as scheduled could result in residents developing body odor or skin problems. Record review of ADL Policy (undated) revealed under Procedures #6 Nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. These interventions will be on the Kardex, which is accessed in Point of Care (POC). Any changes noted in the resident's performance or abilities will be reported to the licensed Nurse. Record review of facility Policy titled Charting and Documentation revised 5/2007, revealed the following: The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition and Notes to be written on all long-term residents by day, evening and night shifts.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to store, label and date two containers of milk properly in the walk-in cooler. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 10/28/2024 at 10:52 AM in the walk-in cooler revealed a one-gallon container of whole milk and a one-gallon container of Lactose-Free whole milk. The container of whole milk was opened, there was approximately 1 cup remaining in the container, and labeled 10/25. The container of Lactose-Free milk was opened, there was approximately one quart of milk remaining in the container and labeled 10/15. During an interview on 10/28/2024 at 10:53 AM, the DS stated the dates on the containers of milk were the dates they were received by the facility and stored in the cooler. They did not indicate the date they were opened or the use-by date. They should have both been labeled with the use-by date. Staff storing opened food in the coolers were responsible for properly labeling and dating all food items in the cooler with the date opened and use-by date; failure to do so could cause proliferation of bacteria that could lead to food borne illness. All staff was trained upon hire and during monthly inservices. All staff had current food-handler certificates. The facility used the TFER as their policy manual. Record review of the TFER, 2015, revealed, S228.75(g)(1) (g) Ready-to-eat, time/temperature controlled for safety food, date marking. (2) Except as specified in paragraphs (5) - (7) of this subsection, refrigerated, ready-to-eat, time/temperature controlled for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and held at a temperature of 41 degrees Fahrenheit (5 degrees Celsius) or less if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (I) of this paragraph: A) the day the original container is opened in the food establishment shall be counted as Day 1; and (B) the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 2 of 2 dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. 1. The facility failed to ensure the waste in dumpster #1 was removed to allow the top lid to close 2. The facility failed to ensure dumpster #2 had a drainage plug and the right door was completely shut These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: 1. Observation on 10/30/2024 at 11:59 AM revealed there was overflowing trash at the top of the dumpster, preventing the lid from closing and leaving a gap approximately 18 in length. There was a piece of cardboard approximately 2' x 3' on the ground in front of dumpster #1, and there were flies circulating between the two dumpsters. During an interview on 10/30/2024 at 12:00 PM, the DS stated the top lid should have been closed, the facility's trash was supposed to be picked up daily, and it did not appear the trash had been picked up recently. She told the maintenance department to contact the local waste management and request two large dumpsters to better manage the amount of trash generated by the facility. The dumpsters were used by both the dietary and nursing departments. 2. Observation on 10/30/2024 at 12:01 PM revealed the sliding door on the right side of dumpster #2 was open approximately 12. There was also a drainage plug missing from right side of the dumpster. During an interview on 10/30/2024 at 12:02 PM, the DS stated the door to the dumpster should not have been open, as it presented an unsanitary condition and an opportunity for the proliferation of rodents. This dumpster had recently been replaced, and the previous one had a drainage plug. During an interview on 10/30/2024 at 12:05 PM, OM L stated the facility's trash was supposed to be picked up daily and it did not appear the trash had been picked up for over a day. Failure to remove trash in a timely manner could attract pests which carry disease. During an interview on 10/31/2024 at 12:50 PM, the DS stated the facility used the Texas Food Establishment Rules as their policy manual. Record review of the Texas Food Establishment Rules, 2015, S228.152(n)(2), revealed: Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (2) with tight-fitting lids or doors if kept outside the food establishment. (o) Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 4 of 6 residents (Resident #1, #2, #3, and #4) reviewed for abuse, in that: The facility failed to supervise and protect Resident #1, who did not have the ability to consent, from harm when Resident #2 was observed performing a sex act on Resident #1 on 10/24/2022, and failed to develop/implement interventions to prevent additional residents from harm when Resident #2 (who had dementia) had physical contact with multiple female residents including Resident #3, who did not have the ability to consent and Resident #4 who stated she did not like male attention. An IJ was identified on 4/11/2023. The IJ template was provided to the facility on [DATE] at 4:26 p.m. While the IJ was removed on 4/16/2023 at 7:00 p.m., the facility remained out of compliance at a scope of pattern and severity of no actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. These deficient practices placed residents at risk of psychosocial harm and continued abuse. The findings were: Record review of the facility Investigative Summary (undated) revealed: Investigative Summary: Oral sex was occurring. [Resident #1's RP] decided to take her home after this incident occurred. When was the Allegation made? 10/24/2022. Action Post Investigation: Educate resident on the safety of sexual activity. Provide condoms if necessary. Incident Category: other Action to Prevent Recurrence: Made sure they were safe and have a private area. Both patients have dementia with a BIMS of 1. Family and Medical Director notified. Record review of Resident #1's face sheet dated 4/06/2023 revealed an admitted [DATE], a discharge date of [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety [a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life], major depressive disorder [depression], and cerebral infarction [stroke] Record review of Resident #1's Physician Notes (History and Physical), dated 10/02/2022, revealed: Resident was referred for dementia .Difficulty communicating, reverted to Thai (native language), on memantine [also known as Namenda, a medication used to treat symptoms of Alzheimer's disease, which is a progressive disease that affects memory and other important mental functions] and risperidone [a medication used to treat the symptoms of schizophrenia, which is a chronic mental illness characterized by delusions, hallucinations, and disordered thinking] for hallucinations. Rapid dementia progression since 3/2020 . (family member) reported Resident #1 had no short-term memory, getting lost, constantly losing things. Her normal day consists of sitting next to her (family member), talks to him in Thai, seems to have forgotten English. There is very little meaningful communication. She stays mostly silent. She used to watch Thai TV, but more recently lost interest. Mental status: untestable, affect euthymic [a normal, tranquil mental state or mood], Judgement/Insight: untestable. Speech comprehension: poor-would follow some pantomimes [exaggerated gestures] only, no speech produced. PET of brain 9/2020: marked bilateral medial temporal atrophy [a loss of volume in the brain typically seen in people with Alzheimer's disease.] Likely a combination of Alzheimer and Lewy Body disease [a form of dementia associated with abnormal deposits of a protein called Lewy bodies in the brain] given hallucinations, staring spells, resident tremor. Record review of Resident #1's Care Plan dated 10/11/2023 revealed Resident #1 had impaired cognition related to dementia with interventions which included: identify yourself at each interaction, face when speaking and make eye contact .use simple, directive sentences. Provide with necessary cues, stop and return if agitated. Record review of Resident #1's admission MDS, dated [DATE] revealed: a BIMS score of 1 (scale 0-15) which indicated a severe cognitive impairment. Delirium with fluctuating behaviors which included inattention. Wandering 1-3 days which placed the resident at significant risk. Functional status included supervision of one staff person for walking and assistance of one staff person for dressing, toileting, and bathing. Record review of Resident #1's Care Plan dated 10/18/2022 revealed Resident #1 was an elopement risk; wanderer related to dementia and had a wander guard [a monitoring bracelet worn by a resident that alerts staff when a resident attempts to leave a safe area] with interventions which included: Demographic sheet located in binder at nurses' station and front desk in case of elopement. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Document wandering behavior and attempted diversional interventions. Identify pattern of wandering .intervene as appropriate. Record review of Resident #1's Order Summary for October 2022 revealed: -Order for Wander Guard to prevent resident from wandering outside unattended due to poor safety awareness, secondary to dementia with an order date of 10/10/2022. -Aricept [a medication used to treat Alzheimer's disease] tablet 10 mg, give 2 tablets one time a day for dementia with an order date of 10/10/2022. -Memantine tablet 10 mg, give 1 tablet by mouth one time a day for dementia with an order date of 10/10/2022. -Risperidone tablet 0.5 mg, give 1 tablet at bedtime for hallucinations/dementia with an order date of 10/10/2022. Record review of Resident #1's progress notes revealed: -10/11/2022: Behavior: wandering. Alert x 1 (to self only). Education/teaching provided. Resident #1 unable to verbalize understanding of any teachings. Patient unable to be assessed with questioning, patient unable to respond at this time. Documented by LVN I. -10/12/2022: Resident #1 noted constantly wandering. Found in another resident's room earlier during 1st shift. No injuries or interactions noted but resident needs to be closely followed. Resident noted follows commands but just smiles and will go around, following other residents and nurses. Documented by LVN O (no longer employed at facility). -10/14/2023: MDS notes: Resident #1 responds in English and will speak in English to staff but sometimes due to cognition does not respond appropriately. Documented by MDS Coordinator N. -10/16/2022: Resident noted to wander halls and will follow other residents around. Noted to go into others room and had to be redirected constantly. Documented by LVN O. -10/17/2022: Due to dementia, Resident #1 was up walking constantly. Documented by former SW P (no longer employed at facility). -10/17/2022: Resident is alert and oriented x 1 (oriented to person/herself only). Resident noted to wander halls and will follow other residents around. Noted to go into other rooms and has to be redirected constantly. Documented by LVN O. -10/24/2022 Resident discharged at the request of family. Documented by LVN J Record review of Resident #1's medical record revealed no documentation of sexual contact incident with Resident #2 on 10/24/2022. Record review of Resident #1's medical record revealed there was no evidence Resident #1 had an assessment of skin and body following sexual contact with Resident #2. Record review of Resident #2's face sheet dated 4/06/2023 revealed an admitted [DATE] with diagnoses which included: unspecified dementia unspecified severity with other behavioral disturbance [a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life and include changes in behavior], major depressive disorder recurrent mild [mild depression], and metabolic encephalopathy [abnormalities in the chemical balances of the brain which affect brain function]. Record review of Resident #2's progress notes dated 9/16/2022 revealed: Resident (#2) observed engaging in displays of affection with another patient (unknown name). The patient involved is alert and oriented x 3 (oriented to person, place, and time) and has also been seen initiating affection with this resident. Both parties involved are cognitively aware of behaviors taking place. Contact between the two is consensual. RP notified and aware of situation. RP stated, 'I am happy he has a companion, thank you for letting me know.' Documented by ADON B. Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed: Resident #2 had an impaired cognitive function related to dementia with history of metabolic encephalopathy with interventions which included: monitor, document, report to MD any changes in cognitive function, especially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Social Services to provide psychosocial, psychological support as needed/ordered. Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed there was no plan of care to address Resident #2's behaviors related to flirtations, PDA or sexual behaviors or sexual contact with residents. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 1 (scale of 0-15) with no documented behaviors. He required supervision with walking and person hygiene and was independent the other ADL's. Record review of Resident #2's Social Worker notes dated 9/21/2022 by former SW P revealed: Resident has engaged in some displays of affection with another resident from a different hall. Resident is alert and seems to know what he is doing and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Record review of Resident #2's psychiatric services note dated 9/26/2022 revealed a BIMS was conducted with resulting score of 1 which indicated a severe cognitive impairment. There was no mention of sexualized behaviors or affections with another resident. Record review of Resident #2's quarterly IDT Care Plan Review dated 10/06/2022 revealed: Resident has engaged in some display of affection with another resident from a different hall. Resident is alert and seems to know what he is going and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Psych Services patient. The review indicated DON, CNA R, the Director of Rehabilitation, former SW P, the Activity Directory, Resident #2's physician, former ADON C, former ADON D and the Resident #2's RP all participated in the review. The document was signed by former ADON C. Record review of a written witness statement, dated 10/24/2022, signed by Housekeeper V read: I . knocked on the room of [resident room] and I said 'hello housekeeping' .The Door was already cracked open. No one said anything, no answer, so I went into [Resident #2's room] to do house cleaning. That's when I saw Resident #2 on his knees, with Resident #1 lying flat on her back .Resident #2 was on his knees, his head was between Resident #1's legs, giving her oral sex .I walked out of the room fast [and] notified LVN W of what I just saw immediately [sic]. Record review of Resident #2's psychiatric services note dated 10/24/2022 revealed the resident was seen for management of psychotropic medications and side effects and to monitor the effect of medication. The report stated staff reported Resident #2 was more confused. The report indicated Resident #2 had moderate dementia. The report indicated Resident #2 was at little to no risk of aggression. There was no documentation or mention of sexual behaviors. The document was signed by NP U. Record review of a typed facility document (untitled) dated 10/24/2022 revealed: At 11:30 a.m., [former Administrator] was notified of an incident that happened .A housekeeper knocked on the room of [Resident #2's room] and announced herself. No one answered so she entered. When she entered, she saw [Resident #2] on his knees between the legs of [Resident #1.] [Resident #1] was lying on the bed with her pants down and feet on the floor. [Resident #2] was performing oral sex on [Resident #1.] [Housekeeper V] immediately exited the room and went and told the nurse, [LVN W.] [LVN W] then notified myself (sic) [presumed to be former Administrator.] [Former SW P] called [RP] of [Resident #1] at 11:45 and left a message. [Resident #1's RP] showed up at noon, so [former SW P] informed [Resident #1's RP] at that time. Both residents have a BIMS of 1 [which indicated a severe cognitive impairment.] Medical Director notified. An in-service is being scheduled with a physician off-site to do training on handling difficult situations with people with dementia. In-service being completed on resident rights. Record review of Resident #2's Visit Note Psychotherapy Treatment Plan dated 10/24/2022 revealed: The purpose of psychotherapy is to alleviate emotional disturbance. Spoke with nurse: patient refuses to talk only gestures, he can speak. She stated patient was observed having oral sex with a resident. Resident was able to consent. Mental Status Exam: Behavior was uncooperative. Patient was oriented to person. Remote and recent memory was moderately impaired. Moderate dementia. Treatment Goals: cognitive deficits, lack of insight into consequences of behavior or impaired judgement. Documented signed by the Behavioral Health SW. Record review of Resident #2's Initial Psychiatric Diagnostic Interview dated 10/27/2022 revealed Patient was referred due to medication management. Patient evaluated via telemetric using secure video and audio. Patient was irritable and refused to answer the provider's questions at this time. Unit nurse denies any AVH/SI/HI, sadness, depression, or anxiety at this time. No delusions noted. No behaviors or rejection of care reported. No other concerns were addressed. Diagnoses: major depressive disorder, dementia in other diseases without behavioral disturbance. Record review of Resident #2's Physician/NP/PA Progress Note dated 11/01/2022 revealed Resident #2 seen for monthly PCP assessment for acute and chronic conditions .info obtained via medical records, patient poor historian. Patient currently seeing alert x 2, Spanish speaking, nods head to simple yes/no questions, forgetful .followed by psychological services .There was no documentation of sexual behaviors. Document signed by NP T. Record review of Resident #2's Psychiatry Visit Note dated 11/11/2022 revealed Resident #2 was seen for dementia, depression/sadness and management of psychotropic medications via telemedicine (video or telephone visit). Staff reports the patient has not displayed worsening behaviors, depression, or insomnia. Nurse denies any concerns with depression or anxiety. No disruptive or aggressive behaviors at time of visit. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Cognition: Patient was oriented to person. Moderate dementia. Counseling/Coordination of Care: The following sources were used to gather information: reviewed chart including relevant labs, other provider notes, medications, consulted with nursing staff on duty. Provider reviewed .progress notes and MARS. Staff was consulted about any behavioral concerns or changes. Documented signed by Behavioral Health MD. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 00 (scale of 0-15) with no documented behaviors. He required supervision with walking and personal hygiene and was independent with the other ADL's. Record review of Resident #2's Order Summary for April 2023 revealed physician orders for: -May refer to psychological service to evaluate and treat with an order date of 7/01/2022 -Namenda tablet 5 mg by mouth two times a day for dementia with other behavioral disturbance with an order date of 10/03/2022 -There were no orders to monitor sexual behaviors Record review of 24-hour nurses notes (used for shift change between staff, not part of resident medical record) dated 3/24/2023 revealed for Resident #2: 6 am-2 p.m. shift: inappropriate behaviors with female residents. Documented by unknown staff. 2 p.m.-10 p.m. shift: inappropriate behaviors n/c (no change). Documented by unknown staff. Record review of Resident #2's progress notes revealed: -4/01/2023: Resident was redirected-pushing a female resident (unknown name) to her room. Resident redirected back to his hall. Documented by LVN Q -4/02/23: Resident redirected several times during this shift for inappropriate behavior with female residents. (unknown names) Resident was sitting in the TV room, rubbing a female residents legs. When redirected resident became agitated but went back to his room. Documented by LVN Q -4/03/2023: No noted inappropriate behavior with female residents this shift documented by LVN I There was no other documented monitoring of sexual behaviors or of sexual encounter with Resident #1. Record review of 24-hour nurses notes dated 4/01/2023 revealed for Resident #2: Monitor behavior PDA. 2 p.m.-10 p.m. shift: redirect-pushing 300 hall female resident to her room, monitor behaviors. Documented by unknown staff. Record review of 24-hour nurses notes dated 4/03/2023 revealed for Resident #2: Monitor behavior PDA. Documented by unknown staff. Record review of 24-hour nurses notes dated 4/04/2023 revealed for Resident #2: monitor behavior PDA. Documented by unknown staff. Record review of Resident #2's Kardex dated 4/06/2023 revealed the document did not address sexual behaviors, flirtations or PDA. Record review of Resident #2's medical record from admission to 4/06/2023 revealed no documentation of the sexual act between Resident #2 and Resident #1 on 10/24/2022. Record review of the facility Incident/Accident log from September 2022 to current revealed no documented incidents for Resident #1 or Resident #2. During an interview on 4/05/2023 at 8:04 p.m., Resident #1's RP stated Resident #1 was placed in the nursing home on 10/10/2022 with the intention of long-term care. The RP stated Resident #1 had been at the nursing facility for 2 weeks when he received a call one morning (date unknown) from the HR Coordinator (identified as the Admissions Coordinator) asking him to come to the facility. The RP stated the coordinator stated a male resident with dementia went into a room and locked the door and when staff got in the room, the male resident was on top of Resident #1. The RP stated he asked if Resident #1 was raped and was told by the facility that residents were allowed to have consensual sex. The RP stated he told the staff at the facility (unknown name) that Resident #1 could not consent to sex because she had dementia. The RP stated he spoke to the head honcho (female, unknown name) at the facility about the incident who stated she was very sorry the incident occurred. The RP stated he immediately removed Resident #1 from the facility on 10/24/2022. The RP stated Resident #1 required complete care with eating, bathing, and other personal care, except toileting. The RP stated, due to dementia, Resident #1 was not able to communicate what happened to her. The RP stated the event was very upsetting to him at the time and remains very upsetting to this date. During an observation/interview on 4/06/2023 at 10:20 a.m. Resident #2's room was observed to be at the end of the hallway, directly beside the exit door. Resident #2 was observed walking around his room. He had a large wet stain on the front of his pants. Resident #2 was unable to answer questions due to cognitive status. During an observation/interview on 4/06/2023 at 12:42 p.m., Resident #2 was observed in his room, moving items around in his room/closet. Resident #2 did not respond to questions. When asked his name, Resident #2 shrugged his shoulders and presented his hands in response on two separate attempts. During an observation/interview on 4/07/2023 at approximately 10:45 a.m., Resident #2 was observed laying in the opposite direction of the headboard. He was awake and looking out into the hallway. Resident #2 did not respond to questions. During an interview on 4/06/2023 at 12:47 p.m., LVN I stated Resident #2 had speech that could not be understood and was only able to communicate his name by saying his name and pointing to his chest. LVN I stated Resident #2 was ambulatory (able to walk), and would walk to the dining room and back for meals but spent the rest of his time in his room. LVN I stated Resident #1 had behaviors of being flirtatious with other residents. She stated he liked to sit by females. LVN I stated she was told about the behaviors in report and they were documented in the 24-hour report. She stated the staff had to keep an eye on Resident #2. LVN I stated last week (date unknown) he had some flirtations with a female resident. LVN I stated she was told to monitor his behaviors (unknown staff). LVN I stated monitoring behaviors meant keeping an eye on the resident and making sure he does not do anything inappropriate to another resident. LVN I stated behaviors were documented in nurse progress notes, or as a change of condition for behaviors and also as an incident report. During an interview on 4/06/2023 at 2:15 p.m., the DON stated she was unable to provide 24-hour records from September 2022 to March 2023. She stated they had been shredded. The DON stated the 24-hour books were cleared of 24-hour noted one time a week. The DON stated the 24-hour notes were not part of the resident medical record and were just a way for staff to communicate. During an interview on 4/10/2023 at 9:17 a.m., CNA Y stated Resident #2 had a history of being friendly with the ladies, although he had never witnessed any of these behaviors. CNA Y stated he had been told to watch Resident #2 and keep him away from other residents. He stated he did not remember who told him to watch Resident #2 or when he was told. CNA Y stated he was trained to report abuse to the Administrator immediately. During an interview on 4/10/2023 at 9:26 a.m., CNA F stated there were several residents with behaviors on the hallway. She stated Resident #2 liked to mess with other residents, the women and he liked to rub them and touch their feet. CNA F stated staff try to keep Resident #2 away from certain people (unknown). CNA F stated some of the female residents are friendly and go along with Resident #2's actions, but she tried to keep an eye on Resident #2. CNA F stated one resident (Identified as Resident #1) was taken out of the facility by her family. CNA F stated Resident #1 had dementia and went into everybody's room. She stated the staff had to keep up with her. CNA F stated one morning around shift change (date unknown) she was looking for Resident #1 and found her in the room with Resident #2. CNA F stated Resident #2 was pulling up his pants and Resident #1 did now know what was going on. CNA F stated she got Resident #1 out of Resident #2's room and brushed Resident #1's hair. CNA F stated Resident #1's family came. CNA F stated she reported it to the DON. CNA F stated the DON responded by saying What? and then said something like, they are doing some stuff that they do. CNA F stated she could not remember the date, but remembered it occurred last year during 2022. CNA F stated Resident #2 also liked to talk to Resident #3, although she had not heard Resident #3 complain about the attention. CNA F stated Resident #3 was very outspoken. CNA F stated she was trained to respond to sexual behaviors by separating residents, calming them down, offering a distraction and then reporting to the nurse, ADON and Administrator. CNA F stated she did write a statement about Resident #2's contact with Resident #1. CNA F stated an example of sexual abuse was someone touching inappropriate when the resident says no, and they continue to do it. Record review of Resident #3's face sheet dated 4/10/2023 revealed an admitted [DATE] with diagnoses which included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life), expressive language disorder (learning disability affecting communication of thoughts using spoken language) and cognitive communication deficit (difficulty with communication that has an underlying cause in a cognitive deficit which affects one or more cognitive processes such as attention, memory, reasoning, problem-solving, planning, organization and social skills). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment. Record review of Resident #3's Care Plan dated 7/21/2022 for impaired cognitive function related to dementia. The care plan did not address any sexual behaviors or PDA. Record review of Resident #3's medical record revealed no notes or references to sexualized contact or PDA with Resident #2. During an interview on 4/10/2023 at 9:40 a.m., LVN I stated she had only worked with Resident #2 for 3 weeks and she had not seen any sexual behaviors herself. She stated she was told to watch for PDA around female residents, but she had not seen anything. She stated she does not know the specifics or why she was told to watch for PDA. She stated she was told Resident #2 had flirtations and was very flirtatious and tried to hit on female residents. LVN I stated she thought it was weird because Resident #2 did not talk and mostly slept, and she had not seen him interact with any residents. LVN I stated she just knew it came up recently because he sat too close to a female resident and made someone feel uncomfortable. She stated it happened over the weekend, but it did not involve a resident on her hallway. She stated it might have been in activities. LVN I confirmed Resident #2 did not have a care plan for sexual behavior or PDA prior to surveyor intervention. During an interview on 4/10/2023 at 9:56 a.m. LVN J stated Resident #2 had dementia, had a mental decline, and did not talk very much. She stated he was known to have displays of affection with other female residents. She stated staff would catch him massaging or touching other female residents (location unknown, date unknown, resident unknown). LVN J stated she had witnessed him massaging the leg and caressing the hand of Resident #3 during lunch in dining hall last month (date unknown). LVN J stated she redirected Resident #2 and moved him to another table away from Resident #3. LVN J Stated Resident #3 let him massage her but was fine being separated and started eating her lunch after they were separated. LVN J stated she asked Resident #3 if she felt uncomfortable, and she said no. LVN J stated she documented it in the chart and reported it but could not remember who she reported it to. She stated she also asked Resident #3 if she was in pain, and she replied to no. LVN J stated she did not know of any other incidents but had heard of a previous incident that occurred sometime last year. LVN J stated former ADON C (no longer works at facility) told her to keep an eye on Resident #2 around other female residents. LVN J stated former ADON C told her an aide (unknown name) caught Resident #2 having performed oral sex on another resident (female resident, unknown name, unknown date). When asked how she was trained to respond to an inappropriate act of sexual conduct, LVN J stated to her knowledge the resident had the right to those types of activities as long as it was consented. If it was not consented, the staff separate the residents. She stated if the resident was cognitively intact, they have the right to engage, and staff close the door and let them be. She stated if the resident was not cognitively intact to consent the staff separate the residents and let her superior, the ADON know, write an incident report and document in the medical record a brief description of what was observed in a progress note. LVN J stated Resident #2 was not cognitively intact and the other female resident he performed oral sex on was also not cognitively intact. LVN J stated she did not know how the facility responded to the sexual contact. She stated she believes both families of the residents were notified and that was why the female resident left the facility because the family was not happy about it. LVN J stated to monitor behavior means to keep an eye on him. She stated they are only documenting the monitoring if something was out of the norm but otherwise it was not documented. LVN J stated she had not been trained on behaviors of dementia residents but had received several in-service trainings on abuse, with the last one approximately 3 weeks ago. She stated she was trained to report abuse to the Administrator. She stated sexual abuse meant no consent. During an interview on 4/10/2023 at 10:45 a.m., Resident #2's RP stated Resident #2 was at the facility for rehab because he had trouble with his balance and walking. She stated she was notified by the facility of a situation of inappropriate things that were happening with another resident. She stated the facility had a psychiatrist speak with Resident #2 and put him on some medication. The RP stated this behavior was new and he had not been that way before that she was aware of. She stated prior to coming to the facility he had lived independently at his own house, and she was not aware of his sexual behaviors or contacts at that time. She stated she was shocked at the current behavior. The RP stated she could not remember when this occurred, but it was sometime last year. She stated she was told that a nurse walked in and he was performing oral sex with another resident. The RP stated she had not received any other notification of inappropriate behaviors. During an interview on 4/10/2023 at 11:40 a.m., the Activity Director stated Resident #2 was quiet but had sexual behaviors. She stated he mostly came to activities in the afternoon. She stated he liked activities with food and music and liked bingo. The Activity Director stated on Friday, 3/31/2023 during Happy Hour, she turned her back for just a few minutes and when she turned back to the residents, she saw Resident #3 sitting on Resident #2's lap. The Activity Director stated she was surprised and had to look twice. She stated she does not know how it happened. She stated Resident #3 used a wheelchair, but somehow, she was out of her wheelchair and on Resident #2's lap. The Activity Director stated she told LVN Z who came and separated the residents and moved Resident #3 two tables away. She stated Resident #3 did not want to be separated and was trying to hold on the table. She stated it looked like Resident #3 was the aggressor because she kept going back over to Resident #2. The Activity Director stated when Resident #3 went back over to Resident #2 she put her leg in his lap. She stated Resident #2 began rubbing Resident #3's legs, picking up her pants leg and rubbing at first the lower leg and then working his way up the leg. The Activity Director stated she interviewed, and another resident (unknown name) told Resident #2 to stop it because it was not right. The Activity Director stated she notified ADON B and the ADON B came and removed Resident #3 from activities. She stated shortly after ADON B removed Resident #3; Resident #2 left on his own. She stated she had never seen Resident #3 act that way before. She described Resident #3 as normally very reserved with a flat affect who does not like to visit with others. The Activity Director stated she had heard of other sexual behavior involving Resident #2 and another female resident (name unknown) who was no longer at the facility. The Activity Director stated she did not know the details of [TRUNCATED]

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and establish policies and procedures to include notification of law enforcement for 5 of 6 residents (Resident #1, #2, #3, #4 and #12) reviewed for complaints of abuse, in that: The facility failed to develop and implement written policies and procedures for abuse to include written definition of sexual abuse including a resident with dementia or impaired cognition or who was not able to give consent, defining how consent was determined in a resident with dementia or impaired cognition and notification of law enforcement for abuse. An IJ was identified on 4/13/2023. The IJ template was provided to the facility on [DATE] at 9:31 a.m. While the IJ was removed on 4/14/2023 at 7:07 p.m. the facility remained out of compliance with a scope identified as a pattern and severity of no actual harm with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for unidentified sexual abuse in a resident with impaired cognition and at risk for law enforcement not being notified of abuse and could result in continued or sustained harm and continued abuse. The findings were: Record review of a facility policy, titled Abuse Prevention (undated) revealed: it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Definitions: Sexual Abuse: is non-consensual sexual contact of any type with a resident. The policy did not address sexual abuse of a resident with dementia/impaired cognitive status or with a resident who was not able to give consent and the policy did not establish how the facility determined the ability to give consent. The abuse policy did not address notification of law enforcement for abuse. Record review of the facility Investigative Summary (undated) revealed: Investigative Summary: Oral sex was occurring. Resident #1's RP decided to take her home after this incident occurred. When was the Allegation made? 10/24/2022. Action Post Investigation: Educate resident on the safety of sexual activity. Provide condoms if necessary. Incident Category: other Action to Prevent Recurrence: Made sure they were safe and have a private area. Both patients have dementia with a BIMS of 1. Family and Medical Director notified. Record review of Resident #1's face sheet dated 4/06/2023 revealed an admitted [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), major depressive disorder (depression), and cerebral infarction (stroke). Record review of Resident #1's Care Plan dated 10/11/2023 revealed Resident #1 had impaired cognition related to dementia with interventions which included: identify yourself at each interaction, face when speaking and make eye contact .use simple, directive sentences. Provide with necessary cues, stop, and return if agitated. Record review of Resident #1's admission MDS, dated [DATE] revealed: revealed a BIMS score of 1 (scale 0-15) which indicated a severe cognitive impairment. Delirium with fluctuating behaviors which included inattention. Wandering 1-3 days which placed the resident at significant risk. Functional status included supervision of one staff person for walking and assistance of one staff person for dressing, toileting, and bathing. Record review of Resident #1's progress notes revealed: -10/10/2022: .High risk (elopement) due to exit seeking, statements, and ability to walk unassisted. Resident expressing desire to leave facility. Wander guard placed on right wrist .staff made aware of elopement risk. Documented by MDS Coordinator N. -10/11/2022: Behavior: wandering. Alert x 1 (to self only). Education/teaching provided. Resident #1 unable to verbalize understanding of any teachings. Patient unable to be assessed with questioning, patient unable to respond at this time. Documented by LVN I. -10/12/2022: Resident #1 noted constantly wandering. Found in another resident's room earlier during 1st shift. No injuries or interactions noted but resident needs to be closely followed. Resident noted follows commands but just smiles and will go around, following other residents and nurses. Documented by LVN O (no longer employed at facility). -10/14/2023: MDS notes: Resident #1 responds in English and will speak in English to staff but sometimes due to cognition does not respond appropriately. Documented by MDS Coordinator N. -10/16/2022: Resident noted to wander halls and will follow other residents around. Noted to go into others room and had to be redirected constantly. Documented by LVN O. -10/17/2022: Due to dementia, Resident #1 was up walking constantly. Documented by former SW P (no longer employed at facility). -10/17/2022: Resident is alert and oriented x 1 (oriented to person/herself only). Resident noted to wander halls and will follow other residents around. Noted to go into other rooms and has to be redirected constantly. Documented by LVN O. -10/24/2022 Resident discharged at the request of family. Documented by LVN J There is no documentation in the nurse progress notes of sexual encounter with Resident #2. Record review of Resident #2's face sheet dated 4/06/2023 revealed an admitted [DATE] with diagnoses which included: unspecified dementia unspecified severity with other behavioral disturbance (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life and include changes in behavior), major depressive disorder recurrent mild (mild depression), and metabolic encephalopathy (abnormalities in the chemical balances of the brain which affect brain function). Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed: Resident #2 had an impaired cognitive function related to dementia with history of metabolic encephalopathy with interventions which included: monitor, document, report to MD any changes in cognitive function, especially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Social Services to provide psychosocial, psychological support as needed/ordered. Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed there was no plan of care to address Resident #2's behaviors related to flirtations, PDA or inappropriate sexual behaviors or sexual contact with residents. Record review of Resident #2's progress notes dated 9/16/2022 revealed: Resident (#2) observed engaging in displays of affection with another patient (unknown name). The patient involved is alert and oriented x 3 (oriented to person, place, and time) and has also been seen initiating affection with this resident. Both parties involved are cognitively aware of behaviors taking place. Contact between the two is consensual. RP notified and aware of situation. RP stated, 'I am happy he has a companion, thank you for letting me know.' Documented by ADON B. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 1 (scale of 0-15) with no documented behaviors. He required supervision with walking and person hygiene and was independent the other ADL's. Record review of Resident #2's Social Worker notes dated 9/21/2022 by former SW P revealed: Resident has engaged in some displays of affection with another resident from a different hall. Resident is alert and seems to know what he is doing and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Record review of Resident #2's psychiatric services note dated 9/26/2022 revealed a BIMS was conducted with resulting score of 1 which indicated a severe cognitive impairment. There was no mention of sexualized behaviors or affections with another resident. Record review of Resident #2's quarterly IDT Care Plan Review dated 10/06/2022 revealed: Resident has engaged in some display of affection with another resident from a different hall. Resident is alert and seems to know what he is going and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Psych Services patient. The review indicated DON CNA R, the Director of Rehabilitation, former SW P, the Activity Directory, Resident #2's physician, former ADON C, former ADON D and the Resident #2's RP all participated in the review. The document was signed by former ADON C. Record review of a written witness statement, dated 10/24/2022, signed by Housekeeper V stated: I . knocked on the room of [resident room] and I said 'hello housekeeping' .The Door was already cracked open. No one said anything, no answer, so I went into {Resident #2's room] to do house cleaning. That is when I saw Resident #2 on his knees, with Resident #1 lying flat on her back .Resident #2' was on his knees, his head was between Resident #1's legs, giving her oral sex .I walked out of the room fast [and] notified LVN W of what I just saw immediately (sic). Record review of Resident #2's psychiatric services note dated 10/24/2022 revealed the resident was seen for management of psychotropic medications and side effects and to monitor the effect of medication. The report stated staff reported Resident #2 more confused. The report indicated Resident #2 had moderate dementia. The report indicated Resident #2 was at little to no risk of aggression. There was no documentation or mention of sexual behaviors. The document was signed by NP U. Record review of a typed facility document (untitled) dated 10/24/2022 revealed: At 11:30 a.m., former Administrator was notified of an incident that happened .A housekeeper knocked on the room of [Resident #2's room] and announced herself. No one answered so she entered. When she entered, she saw Resident #2 on his knees between the legs of Resident #1. Resident #1 was lying on the bed with her pants down and feet on the floor. Resident #2 was performing oral sex on Resident #1. Housekeeper V immediately exited the room and went and told the nurse, LVN W. LVN W then notified myself (sic) (presumed to be former Administrator). Former SW P called RP of Resident #1 at 11:45 and left a message. RP showed up at noon, so former SW P informed RP at that time. Both residents have a BIMS of 1 (which indicated a severe cognitive impairment). Medical Director notified. An in-service is being scheduled with a physician off-site to do training on handling difficult situations with people with dementia. In-service being completed on resident rights. Record review of Resident #2's Visit Note Psychotherapy Treatment Plan dated 10/24/2022 revealed: The purpose of psychotherapy is to alleviate emotional disturbance. Spoke with nurse: patient refuses to talk only gestures, he can speak. She stated patient was observed having oral sex with a resident. Resident was able to consent. Mental Status Exam: Behavior was uncooperative. Patient was oriented to person. Remote and recent memory was moderately impaired. Moderate dementia. Treatment Goals: cognitive deficits, lack of insight into consequences of behavior or impaired judgement. Documented signed by the Behavioral Health SW. Record review of Resident #2's Physician/NP/PA Progress Note dated 11/01/2022 revealed resident #2 seen for monthly PCP assessment for acute and chronic conditions .info obtained via medical records, patient poor historian. Patient currently seeing alert x 2, Spanish speaking, nods head to simple yes/no questions, forgetful .followed by psychological services .There was no documentation of inappropriate sexual behaviors. Document signed by NP T. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 00 (scale of 0-15) which revealed a severe cognitive impairment with no documented behaviors. He required supervision with walking and person hygiene and was independent the other ADL's. Record review of Resident #2's Order Summary for April 2023 revealed physician orders for: -May refer to psychological service to evaluate and teat with an order date of 7/01/2022 -Namenda tablet 5 mg by mouth two times a day for dementia with other behavioral disturbance with an order date of 10/03/2022 -There were no orders to monitor inappropriate sexual behaviors Record review of 24-hour notes (used for shift change between staff, not part of resident medical record) dated 3/24/2023 revealed for Resident #2: 6 am-2 p.m. shift: inappropriate behaviors with female residents. Documented by unknown staff. 2 p.m.-10 p.m. shift: inappropriate behaviors n/c (no change). Documented by unknown staff. Record review of Resident #2's progress notes revealed: -4/01/2023: Resident was redirected-pushing a female resident (unknown name) to her room. Resident redirected back to his hall. Documented by LVN Q -4/02/23: Resident redirected several times during this shift for inappropriate behavior with female residents. (Unknown names) Resident was sitting in the TV room, rubbing a female resident's legs. When redirected resident became agitated but went back to his room. Documented by LVN Q -4/03/2023: No noted inappropriate behavior with female residents this shift documented by LVN I There was no other documented monitoring of sexual behaviors or of sexual encounter with Resident #1. Record review of 24-hour nurses notes dated 4/01/2023 revealed for Resident #2: Monitor behavior PDA. 2 p.m.-10 p.m. shift: redirect-pushing 300 hall female resident to her room, monitor behaviors. Documented by unknown staff. Record review of 24-hour nurses notes dated 4/03/2023 revealed for Resident #2: Monitor behavior PDA. Documented by unknown staff. Record review of Resident #2's medical record from admission to 4/06/2023 revealed no documentation of the sexual act between Resident #2 and Resident #1 on 10/24/2022. Record review of Resident #3's face sheet dated 4/10/2023 revealed an admitted [DATE] with diagnoses which included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life) , expressive language disorder (learning disability affecting communication of thoughts using spoken language) and cognitive communication deficit (difficulty with communication that has an underlying cause in a cognitive deficit which affects one or more cognitive processes such as attention, memory, reasoning, problem-solving, planning, organization and social skills). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment. Record review of Resident #3's Care Plan dated 7/21/2022 for impaired cognitive function related to dementia. The care plan did not address any sexual behaviors or PDA. Record review of Resident #3's medical record revealed no notes or references to sexualized contact or PDA with Resident #2. Record review of Resident #4's face sheet dated 4/10/2023 revealed an admitted [DATE] with a readmitted ,d+[DATE] with diagnoses which included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life), mood disorder due to known physiological condition (depression symptoms that develop during or soon after substance use or withdrawal or after exposure to a medication), and heart failure. Record review of Resident #4's quarterly MDS dated [DATE] (near time of incident) revealed a BIMS score of 10 which indicated a moderate cognitive impairment. Record review of Resident #4's quarterly MDS dated [DATE] (most recent) revealed a BIMS score of 5 which indicated a severe cognitive impairment. Record review of Resident #4's care plan last revised on 4/23/2020 revealed the resident had impaired cognitive function related to dementia. Record review of Resident #4's nurse progress note revealed: Resident #4 found kissing male Resident #2 on the lips. Resident #4 stated Resident #2 was her boyfriend and they have been together for years. Resident alert to self, place, and situation .will continue to monitor. Record review of Resident #12's face sheet dated 4/11/2023 revealed an admitted [DATE] with a readmitted [DATE] and a discharge date of [DATE] with diagnoses which included: paranoid personality disorder, cognitive communication deficit and pedestrian injured in unspecified traffic accident subsequent encounter. Record review of Resident #12's admission MDS dated [DATE] revealed a BIMS of 14 which indicated the resident was cognitively intact. Record review of Resident #12's Care Plan dated 2/14/2023 revealed the resident had behaviors which included refusing medication, hoarding, bringing in unsafe items such as clothing dye, irons, tools, steamers, paints with interventions which included intervene as necessary to protect the right and safety of others. There was no mention in the care plan of sexual behaviors. During an interview on 4/05/2023 at 8:04 p.m., Resident #1's RP stated Resident #1 was placed in the nursing home on 10/10/2022 with the intention of long-term care. The RP stated Resident #1 had been at the nursing facility for 2 weeks when he received a call one morning (date unknown) from the HR Coordinator (identified as the Admissions Coordinator) asking him to come to the facility. The RP stated the coordinator stated a male resident with dementia went into a room and locked the door and when staff got in the room, the male resident was on top of Resident #1. The RP stated he asked if Resident #1 was raped and was told by the facility that residents were allowed to have consensual sex. The RP stated he told the staff at the facility (unknown name) that Resident #1 could not consent to sex because she had dementia. The RP stated he spoke to the head honcho (female, unknown name) at the facility about the incident who stated she was very sorry the incident occurred. The RP stated he immediately removed Resident #1 from the facility. The RP stated Resident #1 required complete care with eating, bathing, and other personal care, except toileting. The RP stated, due to dementia, Resident #1 was not able to communicate what happened to her. The RP stated the event was very upsetting to him at the time and remains very upsetting to this date. During an observation/interview on 4/06/2023 at 10:20 a.m. Resident #2's room was observed to be at the end of the hallway, directly beside the exit door. Resident #2 was observed walking around his room. He had a large wet stain on the front of his pants. Resident #2 was unable to answer questions due to cognitive status. During an observation/interview on 4/06/2023 at 12:42 p.m., Resident #2 was observed in his room, moving items around in his room/closet. Resident #2 did not respond to questions. When asked his name, Resident #2 shrugged his shoulders and presented his hands in response on two separate attempts. During an observation/interview on 4/07/2023 at approximately 10:45 a.m., Resident #2 was observed laying in the opposite direction of the headboard. He was awake and looking out into the hallway. Resident #2 did not respond to questions. During an interview on 4/06/2023 at 12:47 p.m., LVN I stated Resident #2 had speech that could not be understood and was only able to communicate his name by saying his name and pointing to his chest. LVN I stated Resident #2 was ambulatory (able to walk), and would walk to the dining room and back for meals but spent the rest of his time in his room. LVN I stated Resident #1 had behaviors of being flirtatious with other residents. She stated he liked to sit by females. LVN I stated she was told about the behaviors in report and they were documented in the 24-hour report. She stated the staff had to keep an eye on Resident #2. LVN I stated last week (date unknown) he had some flirtations with a female resident. LVN I stated she was told to monitor his behaviors (unknown staff). LVN I stated monitoring behaviors meant keeping an eye on the resident and making sure he does not do anything inappropriate to another resident. LVN I stated behaviors were documented in nurse progress notes, or as a change of condition for behaviors and also as an incident report. During an interview on 4/10/2023 at 9:26 a.m., CNA F stated Resident #2 liked to mess with other residents, the women and he liked to rub them and touch their feet. CNA F stated some of the female residents are friendly and go along with Resident #2's actions, but she tried to keep an eye on Resident #2. CNA F stated Resident #1 had dementia and went into everybody's room. CNA F stated one morning around shift change (date unknown) she was looking for Resident #1 and found him in the room with Resident #2. CNA F stated Resident #2 was pulling up his pants and Resident #1 did now know what was going on. CNA F stated she got Resident #1 out of Resident #2's room and brushed Resident #1's hair. CNA F stated she reported it to the DON. CNA F stated the DON responded by saying What? and then said something like, they are doing some stuff that they do. CNA F stated Resident #2 also liked to talk to Resident #3, although she had not heard Resident #3 complain about the attention. CNA F stated Resident #3 was very outspoken. CNA F stated she was trained to respond to sexual behaviors by separating residents, calming them down, offering a distraction and then reporting to the nurse, ADON and Administrator. CNA F stated she did write a statement about Resident #2's contact with Resident #1. CNA F stated an example of sexual abuse was someone touching inappropriate when the resident says no, and they continue to do it. During an interview on 4/10/2023 at 9:40 a.m., LVN I stated she was told to watch for PDA around female residents, but she had not seen anything. She stated she does not know the specifics or why she was told to watch for PDA. She stated she was told Resident #2 had flirtations and was very flirtatious and tried to hit on female residents. LVN I stated she thought it was weird because Resident #2 did not talk and mostly slept, and she had not seen him interact with any residents. LVN I stated she just knew it came up recently because he sat too close to a female resident and made someone feel uncomfortable. She stated it happened over the weekend, but it did not involve a resident on her hallway. She stated it might have been in activities. LVN I confirmed Resident #2 did not have a care plan for sexually inappropriate behavior of PDA prior to surveyor intervention. During an interview on 4/20/2023 at 9:56 a.m. LVN J stated Resident #2 had dementia, had a mental decline, and did not talk very much. She stated he was known to have inappropriate displays of affection with other female residents. She stated staff would catch him messaging or touching other female residents (location unknown, date unknown, resident unknown). LVN J stated she had witnessed him messaging the leg and caressing the hand of Resident #3 during lunch in dining hall last month (date unknown). LVN J stated she redirected Resident #2 and moved him to another table away from Resident #3. LVN J Stated Resident #3 let him message her but was fine being separated and started eating her lunch after they were separated. LVN J stated she asked Resident #3 if she felt uncomfortable, and she said no. LVN J stated she documented it in the chart and reported it (unknown). She stated she also asked Resident #3 if she was in pain, and she replied to no. LVN J stated she did not know of any other incidents but had heard of a previous incident that occurred sometime last year. LVN J stated former ADON C (no longer works at facility) told her to keep an eye on Resident #2 around other female residents. LVN J stated former ADON C told her an aide (unknown name) caught Resident #2 performing oral sex on another resident (female resident, unknown name, unknown date). When asked how she was trained to respond to an act of sexual conduct, LVN J stated to her knowledge the resident had the right to those types of activities if it was consented. If it was not consented, the staff separate the residents. She stated if the resident was cognitively intact, they have the right to engage, and staff close the door and let them be. She stated if the resident was not cognitively intact to consent the staff separate the residents and let her superior, the ADON know, write an incident report and document in the medical record a brief description of what was observed in a progress note. LVN J stated Resident #2 was not cognitively intact and the other female resident he performed oral sex on was also not cognitively intact. LVN J stated she did not know how the facility responded to the sexual contact. She stated she believes both families of the residents were notified and that was why the female resident left the facility because the family was not happy about it. LVN J stated to monitor behavior means to keep an eye on him. She stated they are only documenting the monitoring if something was out of the norm but otherwise no, it was not documented. LVN J stated she had not been trained on behaviors of dementia residents but had received several in-service trainings on abuse, with the last one approximately 3 weeks ago. She stated she was trained to report abuse to the Administrator. She stated sexual abuse meant no consent. During an interview on 4/10/2023 at 11:40 a.m., the Activity Director stated Resident #2 was quiet but had sexual behaviors. She stated he mostly came to activities in the afternoon. She stated he liked activities with food and music and liked bingo. The Activity Director stated on Friday, 3/31/2023 during Happy Hour, she turned her back for just a few minutes and when she turned back to the residents, she saw Resident #3 sitting on Resident #2's lap. The Activity Director stated she was surprised and had to look twice. She stated she does not know how it happened. She stated Resident #3 used a wheelchair, but somehow, she was out of her wheelchair and on Resident #2's lap. The Activity Director stated she told LVN Z who came and separated the residents and moved Resident #3 two tables away. She stated Resident #3 did not want to be separated and was trying to hold on the table. She stated it looked like Resident #3 was the aggressor became she kept going back over to Resident #2. The Activity Director stated when Resident #3 went back over to Resident #2 she put her leg in his lap. She stated Resident #2 began rubbing Resident #3's legs, picking up her pants leg and rubbing at first the lower leg and then working his way up the leg. The Activity Director stated she intervened, and another resident (unknown name) told Resident #2 to stop it because it was not right. The Activity Director stated she notified ADON B and the ADON came and removed Resident #3 from activities. She stated shortly after ADON N removed Resident #3, resident #2 left on his own. She stated she had never seen Resident #3 act that way before. She described Resident #3 as normally very reserved with a flat affect who does not like to visit with others. The Activity Director stated she had heard of other sexual behavior with Resident #2 with a female resident (name unknown) who was no longer at the facility. The Activity Director stated she did not know the details of the encounter. She stated she had not received any instruction from nursing staff prior to 3/31/2023 on behavior monitoring for Resident #2. She stated after the 3/31/2023 incident she was told by nursing staff to monitor his behaviors. The Activity Director stated Resident #3 was able to make simple yes/no decisions for herself but had dementia. She stated she did not know if Resident #3 was ablet to consent to sexual activities. The Activity Director stated Resident #3 had cognitive fluctuations. Sometimes she was on the low side and sometimes he was not acclimated to day or activity. She stated Resident #2 was mostly Spanish speaking and followed directions. She stated she thought Resident #2 knew what he was doing but there was a language barrier and prevented him from answering questions. She stated she had received abuse training and was trained to report allegations of abuse to the Administrator. She stated she reported the incident on 3/31/2023 to LVN Z, ADON B and the Administrator because he walked into the area right after it occurred. She stated the Administrator told her to call nursing for assistance and to keep the residents separated. During an interview on 4/10/2023 at 12:11 p.m., Staff V (former Housekeeper V, now Activity Aide V) stated she became the assistant Activity Assistant in October 2022, prior to becoming the assistant she was a housekeeper at the facility. Staff V stated in October 2022 between breakfast and lunch service, she knocked on Resident #2's door and did not receive an answer. She stated the door was cracked and she entered the room. Upon entering the room, she saw Resident #2 on his knees between Resident #1's legs. She stated Resident #1 was lying on her back. Staff V stated Resident #2 was using both hands to hold Resident #1's legs apart and he had his mouth on her vaginal area. Staff V stated she had never seen that type of behavior before, and she ran out of the room. Staff V stated she was shocked when she saw it. She stated Resident #2 froze. She stated she went got CNA F and told her what she saw. Staff V stated CNA F went into the room and told Resident #2 to stop it and told him to get up. She stated Resident #2 was fussing at CNA F and he told her to move and get away. Staff V stated Resident #1's pants and undergarments were complete off the resident and Resident #2 was fully clothed. She stated the sexual act looked like oral sex. She stated Resident #1 was just looking up at the ceiling and looked spaced out like she was in another world. She did not seem to be in any distress. She stated CNA F made Resident #2 leave his room and she stayed in the room with Resident #1. Staff V stated she does not know what happened after because she left and reported the incident immediately to the former SW P, the former Administrator, and a nurse (unknown name, no longer works at facility). The assistant stated the nurse told her to write everything down on a piece of paper. She stated she did and gave it to the SW. She stated the former Administrator interviewed her and asked her to write everything down. During an interview on 4/10/2023 at 12:38 p.m., former ADON C stated she was aware of an act of sexual conduct by Resident #2 when on an unknown date the activity assistant (identified as Staff V) entered a resident room and witnessed a sex act performed on Resident #1. She stated she found out when the DON notified her. The former ADON stated she was shocked. She stated another ADON (unknown name) gave an in-service to staff about Resident Rights. She stated it was a thin line about allowing residents privacy. She stated the resident rights in-service included sex intimacy was part of resident rights. Former ADON C stated they were taught that staff should notify management but allow residents their privacy and advocate for the residents to allow them to participate in things that they wanted, inc [TRUNCATED]

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 28 residents (Resident #8 and #7) reviewed for accidents and hazards in that: 1. CNA G utilized a Hoyer lift by herself when transferring Resident #8 from bed to chair and chair to bed. 2. CNA G and CNA H did not utilize a Hoyer lift when transferring Resident #7 from the shower chair to the bed resulting in an unsuccessful transfer and Resident #7 fracturing her right leg. These deficient practices could place the residents at risk for pain, and serious injury. The findings were: 1. Record review of Resident #8's face sheet, dated 4/10/23, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension, mild protein-calorie malnutrition, muscle weakness (generalized), and muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites. Record review of Resident #8's quarterly MDS, dated [DATE], revealed Resident #8 had a BIMS score of 8, signifying moderate cognitive impairment. During an interview on 4/10/23 at 2:51 p.m., CNA G stated, If it's a Hoyer, we have to use two people. CNA G stated she thought she used the Hoyer lift on Resident #8 either on 3/30/23 or 3/31/23. CNA G stated she used a Hoyer for Resident #8 one day to transfer her out of bed for dinner and back into bed once dinner was finished because she's extremely heavy for me . I asked permission from therapy and I asked permission from the office and everyone thought it would be best because I can't transfer her myself. [Resident #8] was scared. CNA G stated she used the Hoyer by herself because she worked alone. During an interview on 4/11/23 at 1:56 p.m., Resident #8 stated she was assisted out of bed by one of the staff members. Resident #8 stated a staff member used a Hoyer lift with her once, but could not recall the exact date or time. Resident #8 stated, I got scared once. They [the staff] were right there with me, but I felt like I was slipping. During an interview on 4/11/23 at 2:52 p.m., the DON stated the facility did not have a manufacturer's instruction for use for the Hoyer lifts used within the facility. The DON stated the facility used their Hydraulic Lift policy in place of a manufacturer's instructions for use. When asked how the staff ensure safety when using a Hoyer lift, the DON stated, It's supposed to be a two-person transfer. When asked how the facility ensured two staff members utilize the Hoyer lift, the DON stated, It's part of their skills check off and during our rounds we always make sure there's two people. I do morning rounds as soon as I get here. I check the staff, check the things routinely. And throughout the day, I walk around the building. When asked what sort of negative effects could occur if one staff member used a Hoyer lift instead of two staff members, the DON stated, the resident could get hurt. The DON stated Resident #8 was not a Hoyer lift transfer. The DON stated, I'm not sure if [CNA G] used the Hoyer by herself or not. I'm not sure why she used it. 2. Record review of Resident #7's demographics, dated 4/13/23, revealed Resident #7 was admitted to the facility on [DATE]. Record review of Resident #7's care plan, dated 4/17/23, revealed Resident #7 had the following diagnoses: vascular dementia [brain damage typically caused by multiple strokes], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and other chronic pain, muscle wasting and atrophy not elsewhere classified, unspecified site, and peripheral vascular disease [a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs], unspecified. Further record review of this care plan revealed the following Focus area: [Resident #7] has an ADL self care deficit r/t [related to] muscle weakness/wasting, impaired mobility. This Focus area had the following intervention: TRANSFER: requires total assistance via hoyer, x2 staff members. Record review of Resident #7's quarterly MDS, dated [DATE], revealed Resident #7 had a BIMS score of 4, signifying severe cognitive impairment. Record review of Resident #7's incident report, dated 8/31/22 and written by LVN K, revealed the following verbiage: CNA notified nurse that resident had a witnessed fall in shower room was assisted to floor by CNAs. Record review of Resident #7's X-ray results of right femur [the bone that runs from the hip to the knee], dated 9/1/22, revealed the following: HISTORY: post fall/pain . IMPRESSION: Acute fracture of the right distal femur. Record review of a statement written by CNA H, dated 9/2/22, revealed After [Resident #7] was done showering I assisted [CNA G] again in transferring [Resident #7] back to her wheelchair but had a harder time transferring [Resident #7] back into her wheelchair and she couldn't bear any weight so we slowly eased her to the ground. Record review of a statement written by CNA G, not dated, revealed I transfer [Resident #7] back to her chair. As doing that [Resident #7] was holding onto shower chair therefore cause her chair to move with nothing close to sit her on as both chairs were out of reach we calmly and as gentle as possible sat her to the floor. A phone interview was attempted with CNA H on 4/17/23 at 11:49 a.m. No return call was received prior to the end of the investigation. During an interview on 4/17/23 at 12:49 a.m., Resident #7's RP stated [Resident #7] was dropped . on 8/31/22 . At that point it was my understanding that she complained about her knee hurting and x-rays were going to be done. During an interview on 4/17/23 at 2:06 p.m., the DON stated When they [the CNAs] got her in the shower they didn't use the Hoyer. They started to lose the grip, that's when they eased her to the floor . They said they thought it would be faster to self-transfer her. The DON stated Resident #7 typically required a Hoyer lift to transfer. During an interview on 4/17/23 at 2:59 p.m., when asked how she knew which residents required a one-person, two-person, or Hoyer lift transfer, CNA G stated, we go to the little care plan. When asked about Resident #7, CNA G stated, They said it was a Hoyer, but at that time [of the incident], I didn't know. She didn't have a [hoyer] sling underneath her, and that usually is the telltale sign if [the resident is] a hoyer lift. When asked about the incident involving Resident #7, CNA G stated, [Resident #7] was already bathed and [CNA H and I] were putting her back into her chair. [Resident #7] was in the shower chair and finished, dressed, and the wheels of both the wheelchair and the shower chair were locked . The gait belt was under the waist, [CNA H] had one side and I had one side. We lifted her up and transferred her. That's when she [Resident #7] grabbed the wheelchair and the other one [the shower chair] moved away and we couldn't hold her weight any longer because the chair was out of reach. We eased her to the floor and I sat with her and waited until the nurse got there. During an interview on 4/18/23 at 11:02 a.m., LVN K stated, I remember that day it was [Resident #7's] shower day . [CNA G and CNA H] went in and they gave her a shower. While transferring her back to the wheelchair, she had a fall and both of them let her down to the floor, due to the fall I believe she had a fracture to one of her hips or her leg . The thing that happened was that they didn't use a Hoyer. I believe she was a Hoyer lift. During an interview on 4/18/23 at 3:54 p.m., the DON stated CNAs are able to find a resident's transfer status using a Kardex (a type of document summarizing the resident and certain types of care the resident required.) The DON stated the facility had done in-services to educate the staff on how to find the Kardex. The DON stated the facility ensured staff are performing transfers safely during the staff members' skills check-offs. Record review of an educational in-service, dated 9/2/22, revealed the facility educated their staff on a list of residents who required a Hoyer lift. Resident #7 was one of the residents listed. This educational in-service also included the following verbiage: REMEMBER: ALL HOYER TRANSFERS REQUIRE 2 STAFF MEMBERS AT ALL TIMES. Record review of an educational in-service, dated 4/4/23, revealed the following verbiage: CNA to check transfer status, check with nurse if unsure. CNA G's signature was not seen on this sign-in sheet of this educational in-service. Record review of a facility policy titled, Hydraulic Lift, not dated, revealed the following: Hydraulic Lift: 2 person at all times.