Every finding on record at Pleasant Manor Nursing & Rehab

Based on observation, record review and interview, the facility failed to ensure the ice machine and ice scoop were maintained in a clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the refrigerator, freezer and storage room were covered, sealed and dated to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to potential cross contamination of food and clean dishes, failed to ensure hot food item was maintained at the required temperature on the stove and serving line to prevent potential foodborne illness. This failed practice had the potential to affect 69 residents who received meals from the kitchen. The findings are: 1. On 07/15/2024 at 9:17 AM, the area in the ice machine where ice forms before dropping into the ice collector had wet sage and brown colors on it. The Surveyor asked the Dietary Manager (DM) to wipe the area. The wet sage and brown residue easily transferred to the tissue. She stated, It was sage and brown residue. The Surveyor asked the DM, Who uses the ice from the ice machine and how often do you clean it? She stated, We clean it every month. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the resident's rooms and we use it in the kitchen to fill beverages served to the residents at mealtimes. 2. The scoop holder on top of the hand washing on the wall by the food preparation sink had accumulation of wet black/gray residue all around the corner and the area where ice scoop was resting. The surveyor asked Dietary Manager to wipe the wet yellowish/brown residue. She did so, wet yellowish/brown residue easily transferred to the tissue. The surveyor asked Dietary Manager How often do you clean the ice machine and who uses the ice from the ice machine? stated, We clean it once a week. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and we use it in the kitchen to fill beverages served to the residents at mealtimes. 3. On 07/15/2024 at 9:35 AM, the Dietary Manager asked the Maintenance Supervisor to wipe the area where ice forms before dropping into the ice collector. Wet yellowish/brown residue easily transferred to the tissue. The surveyor asked the Maintenance Supervisor to describe what was observed on the tissue. He stated, It's kind of slimy and moldy. 4. On 07/15/2024 at 9:42 AM, the following observations were made in the kitchen: a. An opened box of salt was under food preparation close to the hand washing sink. The box was not covered. b. A gallon of liquid margarine with an opening date of 07/07/2024 was stored on a shelf below the food preparation counter. 5. On 07/15/2024 at 9:46 AM, Dietary Aide (DA)#1 turned on the 3-compartment sink and washed her hands. She dried her hands with a tissue. As the tissue got saturated with water, she pulled another tissue covering the saturated tissue with it, she then, used the same tissue to dry her hands, contaminating her hands. She removed gloves from the glove box, placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she picked up clean dishes and stacked them on a rack with her fingers inside the dishes. 6. On 07/16/2024 at 8:22 AM, the surveyor asked DA#1 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have removed gloves and washed my hands. 7. On 07/15/2024 at 10:11 AM, the following observations were made in the walk-in freezer. a. An opened box of burritos. The box was not covered. b. An opened box of egg rolls. The box was not covered, the bag inside that held egg rolls was not sealed. c. An opened box of chocolate chip cookies. The box was not covered or sealed. d. An opened box of garlic. The box was not covered or sealed. 8. On 07/15/2024 at 10:15 AM, an opened box of fish fryer crumbs was on a rack in the storage room and had no opening date on it. 9. On 07/15/2024 at 10:55 AM, the following observations were made in the freezer in the unit: a. A box of popsicles containing 12 were mushy to touch with a used by date of 04/27/2024. b. A box of popsicles with 9 pops that were mushy to touch. c. A carton of chocolate ice cream was soft to touch. Dietary Manager stated, The popsicles were mushy and chocolate ice cream was soft to touch. A bottle of water and other food package in the freezer were frozen solid. 10. On 07/15/2024 at 10:58 AM, the following observations were made on a shelf in the unit refrigerator: a. A bowl of chili covered with plastic wrap had fuzzy, white, green, and black residue on it. There was no name to identify who it belongs to, and the storage date was not marked on the bowl. The Dietary Manager stated, It's molded. b. A crock pot that contained smokey sausage links with sauce. The was no name to aid in identifying whom it belongs to, and the storage date was not on the pot. c. On 07/15/2024 at 11:06 AM, Licensed Practical Nurse #3 stated, the popsicles were melted, and chili was molded and nasty. d. On 07/16/2024 at 10:48 AM, the Administrator in training stated, The ice cream in the unit freezer came from hospice care. They were having an ice cream social on 06/19./2024 and whatever was left, they said to give it to the residents in the memory unit. 11. On 07/15/2024 at 11:42 AM, DA #4 was wearing gloves on her hands when she turned on the 3-compartment sink and washed the blender bowl, the blade and the lid that goes over the bowl. She then turned off the faucet with her gloved hand. Without changing gloves and washing her hands, she used her contaminated gloved hand to pick up a blade and attached it to the base of the blender. When DC #1 was preparing to use it for pureeing foods to be served to the residents on pureed diets, the surveyor pointed out leftover food stuck in the corners that hadn't been properly cleaned, and immediately asked DA #4 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 12. On 07/15/2024 at 12:58 PM, the temperature of tomato soup in a bowl on the stove checked by the Dietary manager before it was served to the residents was 101-degree Fahrenheit. Tomato soup was not reheated before served to the resident who requested for it. 13. A facility policy titled Handwashing/Hand Hygiene provided by the Dietary Manager on 07/16/2024 at 1:41 PM, showed under general instructions wash hands before, during after food preparation.

49688 Based on record review, and interview the facility failed to notify the resident and/or resident representative of the facility policy for bed holds including reserve bed hold payments when the resident was transferred/ discharged to the hospital for 4 (Residents #15, #38, #61 and #67) sampled residents. The findings are: 1. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2024 indicated that Resident #15 had diagnoses of end-stage renal disease (ESRD), Viral Hepatitis, and Non-Alzheimer's Dementia and scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A review of a Hospital Discharge Summary dated 06/25/2024 indicated Resident #15 was admitted to the hospital on 06/20/2024 with the principal problem of acute renal failure and discharged back to the facility on [DATE]. b. On 07/17/2024 at 12:15 PM, the Administrator was asked for a copy of the bed hold notification that was given to Resident #15 and the resident's representative when the resident went to the hospital on 06/20/2024. c. On 07/17/2024 at 12:20 PM, the Administrator stated, We do not send out a bed hold notice when the resident's go to the hospital. We give them the bed hold agreement when they are first admitted , but we do not give them a notice when they go to the hospital. d. On 07/17/2024 at 2:05 PM, the Administrator was asked if the facility had a bed hold policy and the Administrator stated, We do not. 2. Resident #38 had diagnoses of chronic obstructive pulmonary disease, depression, schizophrenia and bipolar as noted on the face sheet 07/18/2024 and hospital note on 07/09/2024. a. A review of Resident # 38's hospital admission and discharge documentation indicated the hospital admitted Resident # 38 with a diagnosis of pneumonia on 07/08/2024. b. On 07/18/2024 at 1:39 PM, the Surveyor asked the Administrator for a copy of the notification to Resident #38 and or the resident's representative of the facility policy for bed hold, including reserve bed payment. The Administrator stated she didn't realize that was supposed to be done. 3. Resident #61 had diagnoses listed on the Order Summary of 07/19/2024 of pneumonia, major depressive disorder, and lymphedema. a. A review of Resident #61's Progress Note indicated the resident was sent to the emergency room and admitted the hospital 11/23/2023 related to low 02 (Oxygen) and altered mental status. Resident was discharged home on hospice 01/02/2024 then readmitted back to nursing home on 01/12/2024. b. On 07/18/2024 at 1:39 PM, the Surveyor asked the administrator for a copy of the notification to resident # 61 and or the resident's representative of the facility policy for bed hold, including reserve bed payment. The Administrator stated she didn't realize that was supposed to be done. c. On 07/18/2024 at 1:39 PM, the Administrator stated they did not have a policy for bed hold they did not know they had to have one. 4. Resident #67 had diagnoses from the Significant Change MDS with Assessment Reference Data (ARD) of 06/25/2024 of sepsis due to streptococcus pneumonia, anxiety disorder, acute embolism, and heart failure. a. A review of Resident #67's hospital admission and discharge documentation indicated the hospital admitted Resident # 67 with a diagnosis of pneumonia on 06/16/2024. b. On 07/18/2024 at 1:39 PM, the Surveyor asked the Administrator for a copy of the notification to Resident # 67 and the resident's representative of the facility policy for bed hold, including reserve bed payment. The Administrator stated she didn't realize that was supposed to be done.

Based on observation, record review and interview, the facility failed to maintain an effective pest control program to ensure the kitchen service areas and the main dining room were free of pests. This failed practice had the potential to affect all residents who resided in the facility. The findings are: 1. Pest control invoices were reviewed and showed the following: a. An invoice dated 5/1/2024 showed target pests none. b. An Invoice dated 06/03/2024 showed general pest control service. c. An Invoice dated 06/14/2024 showed re-service inside flies. d. An Invoice dated 06/24/2024 showed re-service inside flies. 2. A Quality Assurance Action Plan provided by the Administrator in training on 07/16/2024 at 10:18 AM under intervention documented, Fly control. I. (Named) pest control x 2 fly spray for 1/5, 2/1, 3/4, 4/1, 5/1, 5/23, 5/25/5/29, 6/1, 6/3, and 7/2. An Invoice dated 07/04/2024 showed re-service inside flies. 3. An Invoice dated 5/29/2024 showed 6 feet lights installed results: ongoing fly treatment. 4. On 07/15/24 at 9:33 AM, the following observations were made in the kitchen area: a. A fly on the ceiling by the air vent. b. Two flies on the metal wall above the food preparation sink. c. One fly on the metal wall above the counter where the drink machine was located. d. One fly on the floor in front of the food preparation counter. e. One fly on the tong, one at the back a saucepan, and one at the back of colander hanging on the metal bar above the food preparation counter. f. One fly at the edge of the tray cover located on the counter that contained snacks. g. One fly on the wall by the hand washing sink. i. Two flies on the rack by the deep fryer where plate covers where kept. j. One fly was on the vent hood. k. One fly on top of the ice chest lid located by the ice machine. l. Two flies in the dishwashing machine room. m. One fly on the wall by the fly trap. n. One fly at the edge of a pan on the steam table. The Dietary Manager stated, That's a lot of files. The surveyor asked the Dietary Manager to count the flies in the kitchen and in the dish washing machine room. She stated, I counted 18 flies. 4. On 07/16/24 11:05 AM, the following observations were made in the kitchen. a. Two flies on the rack where tray covers were kept. b. One fly on the counter where the tea machine was kept. c. One fly on the cod attached to a socket above the food preparation counter. d. Two flies on the tray on the counter. e. 0ne fly on the wall by the fly tray. f. One fly on dish rack where clean dishes were kept uncovered. g. Two flies on a rack leading to the outside. h. Two flies were crawling on top of the potholder on the counter by the steam table. i. One fly was on the metal wall leading to the kitchen. The Dietary Manager stated, We killed some of the flies last night. The surveyor asked the Dietary Manager to count the flies that were in the kitchen now. She stated, There were 13 flies, we have been having problems with flies for few months now. 9. On 07/16/2024 at 12:05 PM, the surveyor interviewed the pest control representative with the pest control company. He stated the flies have been bad for several months, and he noticed they were early this year. He shared photos of the ultraviolet sticky fly traps. The photo of the trap in the kitchen showed there were only 12 flies adhered to the trap since 7/01/2024. He advised the traps were the only intervention they are using at this time inside the building. Other interventions such as chemicals are used outside the building, especially at the entrances.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 3 residents who received pureed diet, and only resident who received pureed meat only. The findings are: 1. On 07/15/2024 at 11:38 AM, Dietary [NAME] (DC) #1 used a spatula to place 5 servings of beef enchilada into a blender and pureed. At 11:39 AM, DC #1 poured the pureed beef enchilada into a pan and placed it on the steam table. The consistency of the pureed beef enchilada was lumpy and not smooth. 2. On 07/15/2024 at 11:47 AM, DC #1 used a #6 scoop to place 5 servings of Spanish rice into a blender and pureed. At 11:49 AM, DC #1 poured the pureed rice into a pan that had some loose rice in it. The consistency of the pureed Spanish rice was lumpy and was not smooth. The were rice grains visible in the mixture. 3. On 07/15/2024 at 12:21 PM, the surveyor asked the Dietary Manager (DM) to describe the consistency of the pureed Spanish rice and pureed beef enchilada served to the residents on pureed diets. She, stated, Pureed rice had some chunks in it still and beef enchilada has lumps in it. I will puree them over. 4. On 07/16/2024 at 12:44 PM, the following food items were served to the residents on the pureed chicken diets: a. Pureed chicken: The consistency was thick and lumpy and was not smooth. b. Pureed bread: The consistency was too thick. 5. On 07/16/2024 at 12:45 PM, the surveyor asked Certified Nursing Assistant (CNA) #5 who was assisting residents in the unit dining room to describe the consistency of the pureed barbeque chicken and pureed bread to the residents on pureed diets. She stated, they were both pretty thick. 6. On 07/16/2024 1at 2:58 PM, the surveyor asked CNA #6 who was assisting residents in the dining room to describe the consistency of the pureed barbeque chicken and pureed bread to the residents on pureed diets. She stated, they were both thick. 7. On 07/16/2024 at 1:15 PM, the surveyor asked the DM to describe the consistency of the pureed foods served to the residents for lunch. She stated, they were thick. She should have added more milk. The surveyor asked the DM what should have been done when food items are not hot enough to serve the to the residents. She stated, Reheat them.

Based on interview, and record review the facility failed to ensure the minimum data set [MDS] accurately reflected on section A1500 the preadmission screening and assessment resident record [PASARR] a serious mental illness and/or intellectual disability affecting 2 Resident (Resident #14 and #45) with a level II PASRR. The findings are: 1. Review of the Medical Diagnosis portion of Resident #14's electronic health record revealed diagnoses of bipolar disorder, anxiety disorder, and major depressive disorder. a. The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/04/2024 documented no in Section A1500 if the resident was currently considered by the Level 11 PASARR process to have serious mental illness. b. A letter from the State Designated Professional Associates dated 08/17/2022 states, The above-named client will require a PASRR/Level II Screening to be completed at your nursing facility per the Office of Long-Term Care. An Assessor from the State Designated Professional Associates will contact your facility to make arrangements for this appointment. c. A letter from the State Designated Professional Associates dated 08/23/2022 with results of the Level II states, You DO NOT require specialized services for your mental illness (MI). intellectual disability, and/or developmental disability (ID/DD) beyond the capabilities of a nursing facility. Specialized services for ID/DD are services provided outside the nursing facility such as Sheltered Workshop or Adult Education. d. A review of Resident #14's Care Plan showed the resident had a diagnosis of bipolar disorder. e. On 07/18/2024 at 1:38 PM, the Minimum Data Set (MDS) Coordinator was interviewed regarding Resident #14. The Surveyor asked the MDS Coordinator if the Resident had a PASARR II diagnosis. The MDS Coordinator indicated yes. The surveyor asked if the Resident doesn't require services, does the MDS have to be coded showing a PASARR II. The MDS Coordinator indicated yes. The Surveyor asked the MDS Coordinator to look up the MDS for Resident #15 and see how it is marked and tell this surveyor how it is supposed to be coded. The MDS Coordinator looked in the electronic record and stated, PASARR level II but doesn't require services. The Surveyor asked, how is the MDS marked? The MDS Coordinator stated, The MDS under section A1500 is marked NO, it should be marked yes. f. On 07/18/2024 at 3:20 PM, a Resident Assessment Instrument Process (RAI/MDS) was provided to this surveyor by the Administrator and showed Procedure: 1. The MDS Coordinator or designee will open/initiate the appropriate MDS 3.0 item Set either on a paper copy of the item Set or in the facility's electronic medical record (EMR)within the allowable ARD window (Includes grace day for PPS assessments) and complete Section A. 2. Review of the Medical Diagnosis portion of Resident #45's electronic health record revealed diagnoses of depression, anxiety disorder, manic episode, and bipolar disorder. a. A review of Resident #45's MDS with an ARD of 10/23/2023 shows that Section A1500 is marked no for needed a Level II PASRR. b. A review of Resident #45's Care Plan shows, The resident is/has potential to be physically and/or verbally aggressive r/t Bipolar disorder Noted to frequently cry or be emotional Short tempered. c. A letter from the State Designated Professional Associates dated 03/03/2022 states The above-named client will require a PASRR/Level II Screening to be completed at your nursing facility per the Office of Long Term Care. An Assessor from the State Designated Professional Associates will contact your facility to make arrangements for this appointment. d. A letter from the State Designated Professional Associates dated 3/09/2022 indicated results of the Level II that included You DO NOT require specialized services for your mental illness (MI), intellectual disability, and/or developmental disability (ID/DD) beyond the capabilities of a nursing facility. Specialized services for MI are services such as inpatient psychiatric hospitalization . Specialized services for ID/DD are services provided outside the nursing facility such as [Named local workshop] or adult Education. e. On 07/18/2024 at 1:45 PM, the MDS Coordinator was interviewed regarding Resident #14. The Surveyor asked the MDS Coordinator if the resident had a PASARR II diagnosis? The MDS Coordinator indicated yes. The surveyor asked if the Resident doesn't require services, does the MDS have to be coded showing a PASARR II. The MDS Coordinator indicated yes. The Surveyor asked the MDS Coordinator to look up the MDS for this resident and see how it is marked and tell this surveyor how it is supposed to be coded. The MDS Coordinator looked in the electronic record and stated, PASARR level II but doesn't require services. The Surveyor asked, how is the MDS marked? The MDS Coordinator stated, The MDS under section A1500 is marked NO, it should be marked yes. The MDS Coordinator stated, I just missed that one too.

Based on interviews and record review, it was determined the facility failed to ensure resident was provided with the opportunity to formulate advance directives other than code status, to enable resident to make advance decisions regarding which measures should be provided or withheld in the event of their incapacitation for 1 resident (Resident #54). The findings are: 1. Review of the Care Plan indicated the facility admitted Resident #54 with diagnoses that included Alzheimer's disease, chronic fatigue, hypertension, dementia, and anxiety a. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/11/2024 revealed Resident #54 had a Brief Interview for Mental Status [BIMS] score of 0, which indicated the resident has severe cognitive impairment. b. The clinical records for Resident #54 did not indicate the resident was provided with the opportunity to formulate an Advance Directive. c. On 07/16/2024 at 3:33 PM, the Administrator in Training (AIT) provided a copy of the Physician Orders for Life-Sustaining Treatment (POLST) for Resident #54 dated 01/31/2024. d. On 07/18/2024 at 2:14 PM, the Surveyor interviewed the Administrator regarding Advance Directives. The Administrator was asked what the difference was between an Advance Directive and a POLST. The Administrator stated, Aren't they the same thing? The Surveyor asked if they had an Advance Directive other than the POLST for Resident #54. The Administrator was unable to locate or provide an Advance Directive for Resident #54. e. On 07/18/2024 at 2:18 PM, the Surveyor requested a policy on Advance Directives from the Administrator. At 3:20 PM, the Administrator provided a DNR (Do Not Resuscitate) - No Extraordinary Life-Saving Measures policy. The Do Not Resuscitate Policy indicated, Purpose: Ensure that resident rights are protected in the presence of a DNR order or Advance Directive; when the resident wishes for no extraordinary measures to be taken at his/her end of life.

Based on observation and interview, the facility failed to ensure eggs were stored below other foods and cooked food items were maintained the proper temperatures to reduce the chances of food borne illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; 1 of 1 ice machine was maintained in clean condition; foods stored in the storage area refrigerator and freezer were sealed, labeled, and dated. These failed practices had the potential to 73 affect residents who received meals from the kitchen (Total Census:76), as documented on a list provided by the Dietary Supervisor on 09/20/23 at 2:15 PM. The findings are: 1. On 09/18/23 at 11:02 AM, in the refrigerator there was an opened carton of eggs on the third shelf from the bottom. Two eggs remained in the carton. Sealed containers of cooked food were immediately below the carton on the second shelf. 2. On 09/20/23 at 9:33 AM, Dietary Employee (DE) #1 pushed her glasses to her face. Without washing her hands, she picked up clean plates and stacked them on the racks on the clean side of the machine with her fingers inside the plates. 3. On 09/20/23 at 9:56 AM, the area in the ice machine where ice forms before dropping into the ice collector had wet sage and brown colors on it. The Surveyor asked DE #1 to wipe the area. The wet sage and brown residue easily transferred to the tissue. She stated, It was sage and brown residue. The Surveyor asked the Dietary Supervisor, Who uses the ice from the ice machine and how often do you clean it? She stated, We clean it every month. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and we use it in the kitchen to fill beverages served to the residents at mealtimes. 4. On 09/20/23 at 10:06 AM, the following observations were made on a shelf in the walk-in refrigerator: a. An opened box of sausage. The box was not covered or sealed. b. An opened box of bacon. The box was not covered or sealed. 5. On 09/20/23 at 10:11 AM, the following observations were made on a shelf in the walk-in freezer: a. An opened box of hamburger patties. The box was not covered or sealed. b. An opened box of biscuits. The box was not covered or sealed. c. An opened box of beef fritters. The box was covered or sealed. 6. On 09/20/23 at 11:41 AM, DE #3 took a dirty pot from the Dietary Supervisor and took it to the dish washing machine. She placed it on a rack and pushed it inside the machine to wash. Without washing her hands, she picked up clean dishes and stacked them on a cart on the clean side of the machine with her fingers inside the dishes. 7. On 09/20/23 at 11:43 AM, the temperatures of the food items in the baskets on the deep fryer were checked and read by DE #2, the temperatures were: a. Tartar tots - 127 degrees Fahrenheit. b. Pork egg rolls - 120 degrees Fahrenheit. The deep fryer was not on. The above food items were not reheated before being served to the residents. 8. On 09/20/23 at 11:49 AM, DE #2 pushed a cart containing bags of hamburger buns towards the oven and pushed a plate warmer towards the steam table. She then placed gloves on her hands, contaminating the gloves. She opened the bags of buns and then turned off the stove. She removed gloves from the glove box and placed them on her hands, contaminating the gloves in process. She then picked up plates to be used in portioning food items to be served to the residents for lunch and placed them on the trays with her fingers inside the plates. She also picked bowls with her gloved fingers inside the bowls as she placed them on the trays to be used in serving food to the residents for lunch. 9. On 09/19/23 at 12:33 PM, DE #2 turned off the stove after serving cut green beans from a pot on the stove. Without changing gloves and washing her hands, she removed slices of cheese from foil on a pan of ice and placed them on the hamburger patties to be served to two residents who requested cheese with their hamburger. 10. A facility policy titled, Handwashing and Glove Usage in Food Service, provided by the Dietary Supervisor on 09/20/23 at 2:15 PM documented, .When Food Handler's must wash their hands: Before starting work . After leaving and returning to the kitchen/prep area After touching anything else such as dirty equipment, work surfaces or cloths . 11. A facility policy titled, Proper Food Storage, provided by the Dietary Supervisor on 09/22/23 at 10:24 PM documented, .the wrong order of food on shelves could potentially promote the growth of pathogens, increasing the risk of foodborne illness.Fourth Shelf . It is important that meat that has been ground, injected, or tenderized be kept on a lower shelf. This category also includes eggs that will be hot held .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 1 resident who received a pureed diet and 17 residents who received a mechanical soft diet, and 55 residents who received a regular diet from 1 of 1 kitchen, (Total Census:76), according to a list provided by the Dietary Supervisor on 09/20/23 at 2:15 PM. The findings are: 1. On 09/20/23, the menu for the lunch meal documented the resident who received a puree diet was to receive two #8 scoops (1 Cup) of pureed cheeseburger, 1/2 cup of vegetable juice, and residents on mechanical soft and regular diets were to receive one cheeseburger each. 2. On 09/20/23 at 11:22 AM, Dietary Employee (DE) #2 placed 5 servings of hamburger patties into a blender, ground and poured into a pan. At 11:24 AM, she placed 7 more servings of hamburger patties into a blender, ground and poured in the same pan total of 12 servings without cheese. She then placed the pan in the oven to be served to 17 residents who received mechanical soft diets. At 12:20 PM, DE #2 used a #16 scoop (2 ounces) to serve a single portion of ground hamburger patties to the residents who received mechanical soft diets, instead of 3 ounces of cheeseburger. 3. On 09/20/23 at 11:26 AM, DE #2 placed 2 servings of hamburger patties with gravy into a blender and pureed. At 11:28 AM, she poured the pureed contents into a pan and placed it in the oven. At 12:32 PM, DE #2 used a #16 scoop to serve a single portion of pureed beef patties to the resident who received a puree diet, instead of two #8 scoops. She also used a #16 scoop (1/2 cup) to serve a single portion of pureed cut green beans, instead of 1/2 cup of pureed vegetable. The resident was not served pureed bread or cheese with her lunch meal. 4. On 09/20/23 at 2:12 PM, the Surveyor asked DE #2 what scoop size she used to serve pureed food items to the resident on a pureed diet and how many servings she gave. She stated, I used a blue scoop (#16) which is equivalent to 1/4 cup or 2 ounces. I gave a serving of pureed beef patties and a single portion of pureed green beans. The Surveyor asked the reason bread and/or bun and cheese were not served to the resident. She stated, I forgot to puree them. The Surveyor asked the reason cheese was not served to the residents on regular and on mechanical soft diets. She stated, Only two people asked for cheese, and I forgot to give it to every resident.

Based on observation and interview, the facility failed to ensure that refrigerated scheduled II-V controlled medications were maintained within a locked permanently affixed compartment in the Medication Storage Room. The finding are: On 09/21/23 at 1:15 PM, during observation of the Medication Room with Licensed Practical Nurse (LPN) #1, the Surveyor asked LPN #1 to see the refrigerated controlled medications. LPN #1 removed a small black medal box from the unlocked refrigerator and unlocked the box containing controlled medications. On 09/22/23 at 8:45 AM, in the Medication Storage Room the small black box containing controlled medications continued to not be permanently affixed to the unlocked refrigerator. On 09/22/23 at 9:10 AM, the Surveyor accompanied LPN #2 to the Medication Storage Room. In the unlocked refrigerator was the small black medal box containing controlled medications in the door. The Surveyor asked if she had ever been told that the box should be permanently affixed to the refrigerator. LPN #2 stated, No. During an interview on 09/22/23 at 9:15 AM, the Director of Nursing (DON) said she was not aware of the requirement.

Based on record review and interview, the facility failed to ensure all controlled medications were maintained in a secured location and failed to ensure all controlled medications had a detailed record of receipt for medications belonging to 1 (Resident #2) of 2 (Residents #2 and #3) sampled residents who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an Opioid 7 days of the 7 day look back period. a. The Care Plan with a revision date of 04/12/22 documented, .The resident has a terminal prognosis r/t [related to] [CONDITION(S)] .The resident's comfort will be maintained through the review date .Work with the nursing staff to provide maximum comfort for the resident . b. The August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 04/02/2022 . c. The Incident Report dated 8/23/22 documented, .On 08/22/2022, 1530 [3:30 PM] [Director of Nursing (DON)] was notified by Pharmacy Consultant that [Resident #2] was out of [MEDICATION(S)] but when the Charge Nurse tried to reorder the medication, she was told by the Pharmacy that the medication was not due for a refill because 84 pills had been delivered on 08/12/2022 . By 08/22/2022, 1600 [4:00 PM] the Pharmacy Consultant immediately audited the Pharmacy Delivery manifest for 08/12/2022 and found [MEDICATION(S)] 84 pills listed for [Resident #2] and signed as received by LPN [Licensed Practical Nurse #2] at 1555 [3:55 PM]. On 08/22/2022, DON [Name] conducted a phone interview with [LPN #2] and she affirmed that she checked the [MEDICATION(S)] received was 84 tablets which was 42 tablets on 2 different cards and then handed the medication to [LPN #1] who was the Charge Nurse for [Resident #2]. [LPN #1] placed the medications in an unlocked file drawer at the nurses station . d. The form titled, Report of Loss of Controlled Substance Form documented, .Type of Loss: Pharmacy Consultant auditing and noted medications were not present in facility. Charge nurse signed verifying 84 tablets. Medication handed to nurse of resident. When 2nd [second] nurse logged medication onto controlled log 42 were added. Nurse #2 states she was only handed 42 tablets on blister pack . e. The form titled, List of Controlled Substances Lost or Stolen documented, .[MEDICATION(S)]/APAP . 10/325mg tablets, Total Quantity Lost or Stolen 42 . f. The August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A H indicating the medication was held was documented on 08/23/22 at 8:00 PM, 08/24/22 and 08/25/22 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM and 08/26/22 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM and 4:00 PM. g. On 11/02/22 at 9:38 AM, the Surveyor asked the DON, Do you know of any nurses that don't log the [MEDICATION(S)]'s in the narcotic book when they are received from the pharmacy? The DON stated, The way it went about, we watched the camera. She put the medicine in a drawer. I can't verify that [LPN #2] gave her [MEDICATION(S)]. We did verify she gave [LPN #1] [MEDICATION(S)]. We gave the [MEDICATION(S)] in place of the [MEDICATION(S)] until the [MEDICATION(S)] came in so he wouldn't have any pain issues. I saw her put them in the drawer, sign the narc [narcotic] book, and put them in the drawer. Didn't anyone else go in the drawer. I watched the cameras. I pulled all the meds [medication] to look. We went through every card of medicine, and shred box. I personally don't feel like they delivered the medicine, but [LPN #2] won't admit it. h. On 11/02/22 at 10:08 AM, the Surveyor asked LPN #1, Do you know of any nurses that don't log the [MEDICATION(S)]'s in the narcotic book when they are received from the pharmacy? LPN #1 stated, [LPN #2] handed me some medicine and the [MEDICATION(S)] was in there. She said, 'Here's your medicine.' I put the medicine in the bottom of the drawer at the nurse's station. Then I went to check on my patient. I came back and got the medicine and put them in the bottom of the nurse's cart. The ones that were narcotics, I put them in the bottom, and the narcotics, I put them in the narcotic box, but I hadn't log them in yet. Then when I got some free time, I logged in the narcotic according to what was on the card and how many was on there. i. On 11/02/22 at 10:15 AM, the Surveyor asked the DON, Did you watch [LPN #2] on the camera from the time she received the medication from the pharmacy until the time she handed the medication to [LPN #1]? The DON stated, Yes, I did. We watched the entire movement. Nobody took any medication. j. On 11/02/22 at 11:05 AM, during a phone interview with LPN #2, the Surveyor asked, What happened to [Resident #2's] [MEDICATION(S)]? She stated, I counted the [MEDICATION(S)] when I received it from the pharmacy. It was, I think 84 for [Resident #2]. To be exact I think someone else was standing there to. I walked the narcotics over to the other nurse on the other side. I put them in her hand and walked off. I think I might have had 6 cards that we counted in my hands. She was sitting at the desk at the computer. The Surveyor asked, What did [LPN #1] do with the medications when you handed them to her? LPN #2 stated, I walked off, and I'm not real sure what she did with them. The Surveyor asked, Did she count them when you handed them to her? She stated, No ma'am. k. On 11/02/22 at 11:30 AM, the Surveyor asked the DON, When did you realize that [Resident #2] had 42 [MEDICATION(S)]'s that were missing? She stated, When the Pharmacy Consultant told me. l. On 11/02/22 at 12:25 PM, the Surveyor asked LPN #1, When did you realize [Resident #2] was missing 42 [MEDICATION(S)]? She stated, When he had ran out. I called the pharmacy to order more, and they said it's not time. The pharmacist was here, and she overheard our conversation, and she called hospice. They said they sent 84 pills out. The Surveyor asked, Should you have put the narcotics in an unlock drawer? She stated, No, I shouldn't have. I should have immediately locked them up. m. On 11/02/22 at 12:40 PM, the Surveyor asked the Pharmacy Consultant, What is the policy on counting and logging in narcotics? She stated, When they come in from the pharmacy, they are supposed to sign them and do their count. They are supposed to immediately log it into their narcotic book. The Surveyor asked, Should the facility contact the State Board of Nursing when narcotics are missing? She stated, Yes, but we couldn't determine which nurse was at fault. n. On 11/02/22 at 12:59 PM, the DON stated, I've contacted the State Board of Nursing . o. The facility policy titled, Policy Controlled Substances, provided by the DON on 11/02/22 at 11:49 AM documented, .Schedule II, III, IV, and V controlled medications are stored separately from other medications under a double lock in a locked cabinet or safe designed for that purpose . Upon delivery of controlled medication to the facility, the number of controlled medications must be verified with two licensed nurses with signatures on the delivery manifest log indication the medications listed, and the amounts are correct .

Based on record review and interview, the facility failed to ensure all controlled medications were maintained in a secured location and failed to ensure all controlled medications had a detailed record of receipt for medications belonging to 1 (Resident #2) of 2 (Residents #2 and #3) sampled residents who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an Opioid 7 days of the 7 day look back period. a. The Care Plan with a revision date of 04/12/22 documented, . The resident has a terminal prognosis r/t [related to] [CONDITION(S)] .The resident's comfort will be maintained through the review date .Work with the nursing staff to provide maximum comfort for the resident . b. The August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 04/02/2022 . c. The Incident Report dated 8/23/22 documented, .On 08/22/2022, 1530 [3:30 PM] [Director of Nursing (DON)] was notified by Pharmacy Consultant that [Resident #2] was out of [MEDICATION(S)] but when the Charge Nurse tried to reorder the medication, she was told by the Pharmacy that the medication was not due for a refill because 84 pills had been delivered on 08/12/2022 . By 08/22/2022, 1600 [4:00 PM] the Pharmacy Consultant immediately audited the Pharmacy Delivery manifest for 08/12/2022 and found [MEDICATION(S)] 84 pills listed for [Resident #2] and signed as received by LPN [Licensed Practical Nurse #2] at 1555 [3:55 PM]. On 08/22/2022, DON [Name] conducted a phone interview with [LPN #2] and she affirmed that she checked the [MEDICATION(S)] received was 84 tablet which was 42 tablets on 2 different cards and then handed the medication to [LPN #1] who was the Charge Nurse for [Resident #2]. [LPN #1] placed the medications in an unlocked file drawer at the nurses station . d. The form titled, Report of Loss of Controlled Substance Form documented, .Type of Loss: Pharmacy Consultant auditing and noted medications were not present in facility. Charge nurse signed verifying 84 tablets. Medication handed to nurse of resident. When 2nd [second] nurse logged medication onto controlled log 42 were added. Nurse #2 states she was only handed 42 tablets on blister pack . e. The form titled, List of Controlled Substances Lost or Stolen documented, .[MEDICATION(S)]/APAP .10/325mg tablets, Total Quantity Lost or Stolen 42 . f. The August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A H indicating the medication was held was documented on 08/23/22 at 8:00 PM, 08/24/22 and 08/25/22 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM and 08/26/22 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM and 4:00 PM. g. On 11/02/22 at 9:38 AM, the Surveyor asked the DON, Do you know of any nurses that don't log the [MEDICATION(S)]'s in the narcotic book when they are received from the pharmacy? The DON stated, The way it went about, we watched the camera. She put the medicine in a drawer. I can't verify that [LPN #2] gave her [MEDICATION(S)]. We did verify she gave [Resident #2] [MEDICATION(S)]. We gave the [MEDICATION(S)] in place of the [MEDICATION(S)] until the [MEDICATION(S)] came in so he wouldn't have any pain issues. I saw her put them in the drawer, sign the narc [narcotic] book, and put them in the drawer. Didn't anyone else go in the drawer. I watched the cameras. I pulled all the meds [medication] to look. We went through every card of medicine, and shred box. I personally don't feel like they delivered the medicine, but [LPN #2] won't admit it. h. On 11/02/22 at 10:08 AM, the Surveyor asked LPN #1, Do you know of any nurses that don't log the [MEDICATION(S)]'s in the narcotic book when they are received from the pharmacy? LPN #1 stated, [LPN #2] handed me some medicine and the [MEDICATION(S)] was in there. She said, 'Here's your medicine.' I put the medicine in the bottom of the drawer at the nurse's station. Then I went to check on my patient. I came back and got the medicine and put them in the bottom of the nurse's cart. The ones that were narcotics, I put them in the bottom, and the narcotics, I put them in the narcotic box, but I hadn't log them in yet. Then when I got some free time, I logged in the narcotic according to what was on the card and how many was on there. i. On 11/02/22 at 10:15 AM, the Surveyor asked the DON, Did you watch [LPN #2] on the camera from the time she received the medication from the pharmacy until the time she handed the medication to [LPN #1]? The DON stated, Yes, I did. We watched the entire movement. Nobody took any medication. j. On 11/02/22 at 11:05 AM, during a phone interview with LPN #2, the Surveyor asked, What happened to [Resident #2's] [MEDICATION(S)]? She stated, I counted the [MEDICATION(S)] when I received it from the pharmacy. It was I think 84 for [Resident #2]. To be exact I think someone else was standing there to. I walked the narcotics over to the other nurse on the other side. I put them in her hand and walked off. I think I might have had 6 cards that we counted in my hands. She was sitting at the desk at the computer. The Surveyor asked, What did [LPN #1] do with the medications when you handed them to her? LPN #2 stated, I walked off, and I'm not real sure what she did with them. The Surveyor asked, Did she count them when you handed them to her? She stated, No ma'am. k. On 11/02/22 at 11:30 AM, the Surveyor asked the DON, When did you realize that [Resident #2] had 42 [MEDICATION(S)]'s that were missing? She stated, When the Pharmacy Consultant told me. l. On 11/02/22 at 11:49 AM the DON provided a form titled, Policy of Controlled Substances. It documented, .Schedule II [2], III [3], IV [4], and V [5] controlled medications are stored separately from other medications under a double lock in a locked cabinet or safe designed for that purpose .Upon delivery of controlled medication to the facility, the number of controlled medications must be verified with two licensed nurses with signatures on the delivery manifest log indication the medications listed, and the amounts are correct . m. On 11/02/22 at 12:25 PM, the Surveyor asked LPN #1, When did you realize [Resident #2] was missing 42 [MEDICATION(S)]? She stated, When he had ran out. I called the pharmacy to order more, and they said it's not time. The pharmacist was here, and she overheard our conversation, and she called hospice. They said they sent 84 pills out. The Surveyor asked, Should you have put the narcotics in an unlock drawer? She stated, No, I shouldn't have. I should have immediately locked them up. n. On 11/02/22 at 12:40 PM, the Surveyor asked the Pharmacy Consultant, What is the policy on counting and logging in narcotics? She stated, When they come in from the pharmacy, they are supposed to sign them and do their count. They are supposed to immediately log it into their narcotic book. The Surveyor asked, Should the facility contact the State Board of Nursing when narcotics are missing? She stated, Yes, but we couldn't determine which nurse was at fault. o. On 11/02/22 at 12:59 PM, the DON stated, I've contacted the State Board of Nursing .

Based on record review and interview, the facility failed to ensure all controlled medications were maintained in a secured location and failed to ensure all controlled medications had a detailed record of receipt for medications belonging to 1 (Resident #2) of 2 (Residents #2 and #3) sampled residents who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an Opioid 7 days of the 7 day look back period. a. The Care Plan with a revision date of 04/12/22 documented, .The resident has a terminal prognosis r/t [related to] [CONDITION(S)] .The resident's comfort will be maintained through the review date .Work with the nursing staff to provide maximum comfort for the resident . b. The August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 04/02/2022 . c. The Incident Report dated 8/23/22 documented, .On 08/22/2022, 1530 [3:30 PM] [Director of Nursing (DON)] was notified by Pharmacy Consultant that [Resident #2] was out of [MEDICATION(S)] but when the Charge Nurse tried to reorder the medication, she was told by the Pharmacy that the medication was not due for a refill because 84 pills had been delivered on 08/12/2022 . By 08/22/2022, 1600 [4:00 PM] the Pharmacy Consultant immediately audited the Pharmacy Delivery manifest for 08/12/2022 and found [MEDICATION(S)] 84 pills listed for [Resident #2] and signed as received by LPN [Licensed Practical Nurse #2] at 1555 [3:55 PM]. On 08/22/2022, DON [Name] conducted a phone interview with [LPN #2] and she affirmed that she checked the [MEDICATION(S)] received was 84 tablets which was 42 tablets on 2 different cards and then handed the medication to [LPN #1] who was the Charge Nurse for [Resident #2]. [LPN #1] placed the medications in an unlocked file drawer at the nurses station . d. The form titled, Report of Loss of Controlled Substance Form documented, .Type of Loss: Pharmacy Consultant auditing and noted medications were not present in facility. Charge nurse signed verifying 84 tablets. Medication handed to nurse of resident. When 2nd [second] nurse logged medication onto controlled log 42 were added. Nurse #2 states she was only handed 42 tablets on blister pack . e. The form titled, List of Controlled Substances Lost or Stolen documented, .[MEDICATION(S)]/APAP . 10/325mg tablets, Total Quantity Lost or Stolen 42 . f. The August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A H indicating the medication was held was documented on 08/23/22 at 8:00 PM, 08/24/22 and 08/25/22 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM and 08/26/22 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM and 4:00 PM. g. On 11/02/22 at 9:38 AM, the Surveyor asked the DON, Do you know of any nurses that don't log the [MEDICATION(S)]'s in the narcotic book when they are received from the pharmacy? The DON stated, The way it went about, we watched the camera. She put the medicine in a drawer. I can't verify that [LPN #2] gave her [MEDICATION(S)]. We did verify she gave [LPN #1] [MEDICATION(S)]. We gave the [MEDICATION(S)] in place of the [MEDICATION(S)] until the [MEDICATION(S)] came in so he wouldn't have any pain issues. I saw her put them in the drawer, sign the narc [narcotic] book, and put them in the drawer. Didn't anyone else go in the drawer. I watched the cameras. I pulled all the meds [medication] to look. We went through every card of medicine, and shred box. I personally don't feel like they delivered the medicine, but [LPN #2] won't admit it. h. On 11/02/22 at 10:08 AM, the Surveyor asked LPN #1, Do you know of any nurses that don't log the [MEDICATION(S)]'s in the narcotic book when they are received from the pharmacy? LPN #1 stated, [LPN #2] handed me some medicine and the [MEDICATION(S)] was in there. She said, 'Here's your medicine.' I put the medicine in the bottom of the drawer at the nurse's station. Then I went to check on my patient. I came back and got the medicine and put them in the bottom of the nurse's cart. The ones that were narcotics, I put them in the bottom, and the narcotics, I put them in the narcotic box, but I hadn't log them in yet. Then when I got some free time, I logged in the narcotic according to what was on the card and how many was on there. i. On 11/02/22 at 10:15 AM, the Surveyor asked the DON, Did you watch [LPN #2] on the camera from the time she received the medication from the pharmacy until the time she handed the medication to [LPN #1]? The DON stated, Yes, I did. We watched the entire movement. Nobody took any medication. j. On 11/02/22 at 11:05 AM, during a phone interview with LPN #2, the Surveyor asked, What happened to [Resident #2's] [MEDICATION(S)]? She stated, I counted the [MEDICATION(S)] when I received it from the pharmacy. It was, I think 84 for [Resident #2]. To be exact I think someone else was standing there to. I walked the narcotics over to the other nurse on the other side. I put them in her hand and walked off. I think I might have had 6 cards that we counted in my hands. She was sitting at the desk at the computer. The Surveyor asked, What did [LPN #1] do with the medications when you handed them to her? LPN #2 stated, I walked off, and I'm not real sure what she did with them. The Surveyor asked, Did she count them when you handed them to her? She stated, No ma'am. k. On 11/02/22 at 11:30 AM, the Surveyor asked the DON, When did you realize that [Resident #2] had 42 [MEDICATION(S)]'s that were missing? She stated, When the Pharmacy Consultant told me. l. On 11/02/22 at 12:25 PM, the Surveyor asked LPN #1, When did you realize [Resident #2] was missing 42 [MEDICATION(S)]? She stated, When he had ran out. I called the pharmacy to order more, and they said it's not time. The pharmacist was here, and she overheard our conversation, and she called hospice. They said they sent 84 pills out. The Surveyor asked, Should you have put the narcotics in an unlock drawer? She stated, No, I shouldn't have. I should have immediately locked them up. m. On 11/02/22 at 12:40 PM, the Surveyor asked the Pharmacy Consultant, What is the policy on counting and logging in narcotics? She stated, When they come in from the pharmacy, they are supposed to sign them and do their count. They are supposed to immediately log it into their narcotic book. The Surveyor asked, Should the facility contact the State Board of Nursing when narcotics are missing? She stated, Yes, but we couldn't determine which nurse was at fault. n. On 11/02/22 at 12:59 PM, the DON stated, I've contacted the State Board of Nursing . o. The facility policy titled, Policy Controlled Substances, provided by the DON on 11/02/22 at 11:49 AM documented, .Schedule II [2], III [3], IV [4], and V [5] controlled medications are stored separately from other medications under a double lock in a locked cabinet or safe designed for that purpose . Upon delivery of controlled medication to the facility, the number of controlled medications must be verified with two licensed nurses with signatures on the delivery manifest log indication the medications listed, and the amounts are correct .

Based on observation, record review and interview, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition; dietary staff washed their hands before handling clean equipment to prevent the potential for cross contamination; failed to ensure food items stored in the freezer and the kitchen area were covered or sealed and failed to ensure expired food items were promptly removed/discarded by the expiration or use by dates to prevent the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen . These failed practices had the potential to affect 65 residents who received meals from the kitchen (total census: 65) as documented on a list provided by the Director of Nursing on [DATE] at 9:04 AM. The findings are: 1. On [DATE] at 1:19 PM, the interior surfaces of the metal sections of the ice machine where the ice is formed before dropping into the ice collector had a wet sage colored residue on it. The Dietary Supervisor was asked to wipe the residue on the interior surfaces of the ice machine metal sections. She did, and the sage colored residue easily transferred to the tissue. She was asked to describe the contents within the ice machine. She stated, There was a sage residue. She was asked, How often do you clean the ice machine and who uses ice from the ice machine? She stated, We clean it daily. I just missed that area. We use it to fill beverages served to the residents at mealtimes and the CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. 2. On [DATE] at 1:20 PM, Dietary Employee #1 was sweeping the kitchen floor when she went into the dish washing machine room. She pushed a trash can out of the way. She then, removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she picked up clean dishes and placed them in a clean rack with her fingers touching the interior surfaces of the dishes. 3. On [DATE] at 1:25 PM, Dietary Employee #1 picked up her backpack from the dish washing room and took it to the Dietary Supervisor's office. She walked back to the dish washing machine, pulled gloves from the glove box, and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she picked up clean dishes and stacked them on a rack to use in portioning food items to be served to the residents for the supper meal. She immediately was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 4. On [DATE] at 1:31 PM, the following observations were made in the kitchen: a. An open box of plain salt was stored on a rack under the food preparation counter. The box was not covered. b. A bag of [Brand] bread was stored on a rack under the food preparation counter with an expiration date of [DATE]. c. An opened box of cream of wheat was stored on a rack under the food preparation counter. The box was not covered. 5. On [DATE] at 1:37 PM, an opened box of dinner rolls was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 6. On [DATE] at 3:57 PM, Dietary Employee #2 was wearing gloves on his hands when he took out an empty bucket with a rag in it out of the food preparation sink, contaminating the gloves. Without changing gloves and washing his hands, he used his gloved hand to pick up glasses by the rims and placed them on the tray on the counter to be used in serving beverages to the residents for supper meal. 7. On [DATE] at 8:15 AM, Dietary Employee #1 picked up dirty dishes and placed them on a rack and pushed it into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side in dishwasher area and without washing her hands picked up clean gloves from the glove box and placed them on her hands, contaminating the gloves. She used her gloved hands to removed dishes from the dish rack and stacked them on the clean side of the counter to be used in portioning food items to be served to the residents for the lunch meal, touching the insides of the plates with her gloved fingers. She immediately was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands before putting gloves on. 8. On [DATE] at 8:31 AM, Dietary Employee #3 touched her mask and without washing her hands, she picked up clean dishes to stack on a shelf. She immediately was stopped and was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 9. On [DATE] 10:54 AM, Dietary Employee #4 was wearing gloves on her hands when she picked up mittens and used them to remove a pan of pork chops from the steam table and placed it on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in grounding meat items for the residents who received mechanical soft or pureed diets. At 10:56 AM, she placed 6 servings of deboned pork chops into a blender, ground and poured into a pan. At 11:00 AM, she placed 6 more servings of pork chops into the blender, ground and poured into the same pan. At 11:01 AM, she placed 8 more servings of pork chops into the blender, ground and poured into the same pan. She placed the pan of ground pork chops on the steam table. She did not change gloves or wash her hands before she picked up pork chops and placed them into the blender and ground. She poured the meat into the same pan and placed it on the steamtable to be served to the residents who received mechanical soft diets for lunch. At 11:03 AM, she was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.

Based on record review and interview, the facility failed to ensure each section of the Minimum Data Set (MDS) was coded accurately to reflect the residents' status for 3 (Residents #32, #23 and #39) of 21 (Residents #8, 48, 1, 21, 23, 45, 5, 62, 54, 52, 7, 66, 27, 25, 32, 58, 39, 67, 63, 24 and 44) sampled residents whose MDS was reviewed. The findings are: 1. Resident #32 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 4/8/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). Toilet use was coded 8/8 - Activity did not occur during the lookback period. He did not have a catheter. He was always incontinent of bladder. He was always continent of bowel. a. The Care Plan dated 5/25/21 documented, .Toileting- extensive assist . Bowel and Bladder: incont [incontinent] in bowel and bladder . b. On 06/08/22 at 10:30 AM, the MDS Coordinator was asked to review Resident #32's Quarterly MDS with an ARD of 4/8/22. She was asked, What did you document under toilet use? She answered, He didn't use the bathroom, so I coded it 8/8. She was asked to read the instructions for that section and stated, I misunderstood the directions. 2. Resident #23 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 3/17/22 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS. Toilet use was coded 8/8 - Activity did not occur during the lookback period. She did not have a catheter. She was always incontinent of bladder and bowel. a. The Care Plan dated 5/12/21 documented, . Toileting-dependent . Bowel and Bladder: incont in bowel and bladder. Staff provides incont care . b. On 06/08/22 at 10:30 AM, the MDS Coordinator was asked to review Resident #23's Quarterly MDS with an ARD of 3/17/22. She was asked, What did you document under toilet use? She answered, The same thing happened and that was before I took the training. I will fix those. c. On 06/09/22 at 1:05 PM, the Director of Nursing (DON) was asked, What does 8/8 mean on an MDS? She answered, It means the activity did not occur. She was asked, If a resident is always incontinent of bladder and bowel, should their toilet use be coded as 8/8? She answered, No. She was asked, If a resident is always incontinent of bladder but always continent of bowel, should their toilet use be coded as 8/8? She answered, No. d. The RAI (Resident Assessment Instrument) Manual documented, .ASSISTANCE - Code 8, activity did not occur: if the activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day lookback period. ADL SUPPORT - Code 8, ADL activity itself did not occur during the entire period: if the activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period . 3. Resident #39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 4/15/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and received hospice care. a. The Admission MDS with an ASD of 04/21/21 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and did not receive hospice care. b. The Census Profile documented the resident as a Hospice Private Pay resident. c. The Quarterly MDS with an ARD of 7/15/21 documented the resident as receiving Hospice care in the Nursing Facility. d. On 06/08/19 at 1:12 PM, MDS Coordinator was asked, Regarding Hospice care admissions and MDS information, is a Significant Change MDS was needed? She replied, No. She was admitted to the facility with hospice care and admitted as Private Pay and then spend down for Medicaid. There should not have been a Significant Change done because she was admitted with hospice care. She was asked, So the Admission MDS dated [DATE] should have documented the resident as having hospice care? She replied, I can't tell you why the admission MDS does not document her as having hospice care in the nursing facility I was not doing the MDS's then. e. On 6/9/22 at 12:15 PM, the Infection Control Nurse was asked, What should be included on the MDS when a resident is admitted to the facility? She replied, Everything about the resident, the special treatments, the diagnosis, the care they will need. She was asked, Should the MDS reflect if the resident is admitted into the facility on hospice care? She replied, Yes, if not it could cause inaccurate care plans, care, reimbursement, and the following MDS's. 4. The facility policy titled, Resident Assessment Instrument Process, received from the DON on 06/09/22 at 1:50 PM documented, .one of the functions in the RAI/MDS process is to gather data in order to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident .

Based on observation, record review and interview, the facility failed to develop and implement a comprehensive care plan to include measurable objectives, goals, outcomes, and timeframes to meet the residents' needs for 6 (Resident #48, #5, #54, #52, #39 and #8) of 20 (Residents #8, 48, 21, 23, 45, 5, 62, 54, 52 7, 66, 27, 25, 32, 58, 39, 67, 63, 24 and 44) sampled residents whose care plans were reviewed. The findings are: 1. Resident #5 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/4/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. The Care Plan dated 5/24/21 documented, . Toileting-limited assist as needed . Bowel and Bladder: usually cont (continent) of bowel and bladder but incont (incontinent) episodes have occurred - assist with incont care as needed . The Care Plan did not address an indwelling catheter. b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Ensure drainage bag is placed below level of bladder. Secured proper to leg every day and night shift every 28 day(s) 16 French AND as needed may change PRN [s needed] for obstruction or accidental removal . c. On 06/08/22 at 10:04 AM, the MDS Coordinator was asked, Is Resident #5's suprapubic catheter documented on the Care Plan? She answered, No. She was asked, Should the presence of a catheter be documented on the Care Plan? She answered, Yes. I will do that right now. d. On 06/09/22 at 1:05 PM, the Director of Nursing (DON) was asked, Should the presence of a catheter be documented on the Care Plan? She answered, Yes. 2. Resident #48 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 5/11/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required limited physical assistance of one person for bed mobility and transfers and used bed rails daily. a. The Care Plan with a revision date of 04/05/22 documented, . Encourage use of prescribed assistive devices . The Care Plan did not address Resident #48's [CONDITION(S)] or the use of side rails. b. On 06/06/22 at 3:28 PM, Resident #48 was lying in bed with half side rails up on both sides of the bed. She was asked, Can you raise and lower those rails? She answered, I haven't tried to. c. On 06/07/22 at 11:36 AM, Resident #48's Electronic Medical Record did not contain a Side Rail Use Assessment or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] d. On 06/08/22 at 9:15 AM, the MDS Coordinator was asked, What is a Care Plan? She answered, What we use to say how to care for the residents and what they want and what they need. She was asked, Please define the term 'Prescribed Medical Devices'? She answered, Splints, and such. Anything like that where we would have to have an order from the doctor. Walkers and wheelchairs and canes do not have to be prescribed. She was asked, Would a side rail that is used for bed mobility be considered a Prescribed Medical Device? She answered, No. I care plan them, but we don't have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes. She was asked, Are her side rails documented on the Care Plan? She answered, Yes. She was asked, Please show me where they are documented on the care plan? She answered, It's not on there. She pulled up the Tasks section in the electronic medical record and reviewed. She was asked, Are the side rails documented in the tasks? She answered, It's not there. e. On 06/08/22 at 10:03 AM, the MDS Coordinator was asked, Is [Resident #48's] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, No. She was asked, Should that be documented on the Care Plan? She answered, Yes. f. On 06/09/22 at 1:05 PM, the DON was asked, Should a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes. She was asked, Should the use of side rails be documented on the Care Plan? She answered, Yes. 3. Resident #54 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 6/7/22 at 2:29 PM, Resident #54's The Care Plan with a revision date of 05/10/22 did not address the use of an anticoagulant medication. c. On 06/08/22 at 10:05 AM, the MDS Coordinator was asked, Should the use of anticoagulant medications be documented on the Care Plan? She answered, Yes. She was asked, Is the use of anticoagulant medications documented on [Resident #54's] Care Plan? She answered, I see a Care Plan for medication management but not one that talks about anticoagulant. d. On 06/09/22 at 1:05 PM, the DON was asked, Should the use of anticoagulants be documented on the Care Plan? She answered, Yes. 4. Resident #39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 4/15/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and required limited physical assistance of one person with transferring and extensive physical assistance of one person with toilet use and bed mobility. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 06/10/22 did not address Goals or Interventions for hospice care. 5. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 11/02/21 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS and received hospice care. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 06/06/22 did not address Goals or Interventions for hospice care. 6. Resident #52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 05/04/21 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] < [less than] 92% . b. The Care Plan with a revision date of 05/18/22 did not address oxygen therapy. 7. On 06/09/22 at 9:21 AM, Certified Nursing Assistant (CNA) #1 was asked, Do you have access to the resident orders in [Facility Computer Software]? She stated, No, I don't think we do. We have access to the Care Plans and the care information should be on it. CNA #1 was asked, So when you come in and a new resident has been admitted , how would you know if the resident is on oxygen or hospice care? She stated, Oh, that will be on the Care Plan. 8. On 06/09/22 at 11:30 AM, the Infection Control Nurse was asked, Who uses Care Plans in the facility to provide care? She replied, CNAs, Nurses, anybody who is providing care to the resident. She was asked, If a resident is receiving hospice care, or receiving oxygen, should that be included on the Care Plan? She replied, Of course 9. On 06/09/22 at 11:40 AM, the MDS Coordinator was asked, Who is responsible for preparing the residents Care Plans? She replied, We have the Interdisciplinary Team that does the Care Plan. She was asked, What information should be included on the Care Plan? She replied, Any information like the diagnosis, the activities of daily living, behaviors, medications. She was asked, If a resident is receiving hospice care or receiving oxygen in the facility, should that be included on the Care Plan? She replied, For sure. 10. On 6/9/22 at 12:24 PM, the DON was asked, If a resident is receiving hospice care in the facility should that be reflected on the residents Care Plan? She replied, Yes, and I am aware of the Care Plans having issues, and we are QAing [Quality Assurance] that. She was asked, How could an inaccurate Care Plan impact a resident? She replied, Impact the care they receive and like I said we are aware that the last nurse that was doing the Care Plans was just checking all the options and when we started discussing them with her, she quit. 11. The facility policy titled Comprehensive Care Plan, provided by the DON on 6/8/22 at 11:10 AM documented, . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental and psychosocial needs .

Based on observation, record review and interview, the facility failed to ensure the Care Plan was reviewed and revised to include the necessary information to meet the residents' care needs for 2 (Residents #27 and #63) of 6 (Residents #7, 26, 27, 39, 41 and 44) sampled residents who had falls in the last 120 days and 7 (Residents #8, 21, 26, 39, 44, 53, and 63) sampled residents who were receiving hospice care. The findings are: 1. Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with toilet use and limited physical assistance of one person with bed mobility, transfers and ambulation on the unit and had 1 fall since admission. a. The Progress Note dated 04/06/22 at 1:20 PM documented, .fall 4/6/22 at 1:20pm. Fall occurred in the hallway. Resident was in a hurry/rush at the time of the fall. Reason for the fall was evident, attempting to leave hall . b. The Significant Change MDS with an ARD of 4/11/22 documented .decline in ADLS [activities of daily living] with fracture of right arm . c. The Progress Note dated 04/16/22 at 7:00 PM documented, .fall 4/16/22 at 7:00 pm fall occurred dining hall, resident walking around dining hall tripped over a w/c [wheelchair] . d. The Care Plan with an initiated date of 05/11/21 and a revision date of 06/10/22 documented, .Potential for falls witnessed fall 1/15/22 witnessed fall 4/16/22 . Evaluate for causative factors. Glasses on when awake. Keep glasses clean and in good repair. Keep bed in low/lowest position. Keep call bell and frequently used items within each reach. Keep mobility aids close to resident Keep room well lit and free of obstacles and clutter. Monitor for and report any potential side effects of resident meds OT [Occupational Therapy] screen for positioning as needed. Provide resident/family teaching to include safety measures to reduce fall risk and what to do if a fall occurs. PT [Physical Therapy] screen and TX [treat] as ordered. Remind resident and reinforce safety awareness lock brakes on bed chair etc [etcetera] before transferring. When rising from a lying position sit on side of bed for a few minutes before transferring/standing. Educate/remind resident to request assistance prior to ambulation and wear appropriate footwear. Report all falls to responsible party and physician. Use 1/2 side rails to prompt independence with turning and reposition. W/C for mobility . e. On 06/08/12 at 12:12 PM, the MDS Coordinator was asked, Should a resident's Care Plan be revised if the resident has had a fall in the facility? She replied, It should be updated with any changes and new interventions. She was asked, What happens if the Care Plan is not updated/revised? She replied, It does not give the staff the updates on the resident and could set them up for further risk or injury. f. On 0/09/22 at 12:27 PM, the Director of Nursing (DON) was asked, When should a resident's Care Plan be revised? She stated, Anytime there are changes in the resident's condition, treatments, care. She was asked, Should the Care Plan be revised with a resident having a fall? She replied, Sure, and like I said we are aware of the issues with the Care Plans and the old nurse that was doing them just clicked all the interventions when she did them and left us really with nothing to add to the Care Plan as far as new interventions. 2. Resident #63 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Advance Directive dated 11/2/2021 documented, [Resident #63] wishes not to receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Nurse Practitioner's Note dated 11/23/2021 documented, .he [Resident #63] has made the decision to continue hospice care; he has stopped [CONDITION(S)] treatment . d. The Care Plan with a revision date of 04/12/22 did not address receiving hospice services or that [CONDITION(S)] services had been discontinued. e. On 6/09/22 at 2:45 PM, the Assistant Director of Nursing (ADON) was asked, Should a Care Plan be revised if a resident starts receiving hospice services? The ADON stated, Yes, a Care Plan should be updated any time a residents care changes. The ADON was asked, If a resident's Care Plan shows that [CONDITION(S)] services are being used but the resident is no longer receiving [CONDITION(S)] should the Care Plan be revised? The ADON stated, Yes, the [CONDITION(S)] should be removed from the Care Plan. f. On 6/09/2022 at 2:50 PM, Licensed Practical Nurse (LPN) #2 was asked, Should a residents Care Plan reflect that the resident is receiving hospice services? LPN #2 stated, Yes, but hospice shows up on the resident dashboard. LPN #2 was asked, If a resident receiving hospice services was not on the Care Plan would you know how to coordinate the care needed with the hospice agency? LPN #2 stated, I guess not. g. The RAI (Resident Assessment Instrument) Manual Section 4.7 documented, .The Care Plan must be reviewed and revised periodically . on an ongoing basis to reflect changes in the resident and the care that the resident is receiving . individualized interventions .

Based on observation, record review and interview, the facility failed to ensure all medications were stored according to professional standards of practice, and expired medications in 1 medication room were disposed of according to professional standards of practice. This failed practice had the potential to affect 10 mobile residents who reside on the D hall, as documented on a list provided by the Director of Nursing on 6/10/22 at 10:19 AM and had the potential to affect 5 residents who receive [MEDICATION(S)] on an as needed basis, as documented on a list provided by the Director of Nursing on 6/8/22 at 1:54 PM. The findings are: 1. Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 06/06/22 at 12:56 PM, a container of Pain Relief Cream 4% (percent) [MEDICATION(S)]/topical analgesic was sitting on the Resident #8's bedside table. b. On 06/07/22 at 8:40 AM, a container of Pain Relief Cream 4% [MEDICATION(S)]/topical analgesic was sitting on Resident #8's bedside table. The resident stated, I am not sure who uses it, but I do not. The label on the container stated, .For external use only, avoid contact with eyes, Keep out of reach of children. If swallowed get medical help or contact a poison control center immediately . c. The facility policy titled, Storage of Medications provided by the Director of Nursing (DON) on 6/10/22 at 10:19 AM documented, Ensure medications are stored in a safe, secure, and orderly manner . medications are stored in the containers in which they are received . d. As of 06/10/22 at 10:43 AM, Resident #8's electronic record did not document an assessment for self-administration of medications and there was not a Care Plan for self-administration of medications. e. On 06/10/22 at 10:49 AM, the MDS Coordinator was asked, Is [Resident #8] assessed for self-administration of medications? She answered, No. Her family keeps bringing that muscle rub up here and we contacted them yesterday to please stop leaving it in her room. 2. On 06/09/22 at 8:10 AM, the locked refrigerator on the Memory Care unit was inspected under the supervision of Licensed Practical Nurse (LPN) #3. A plastic pharmacy bag contained 6 prefilled syringes with instructions on label, [MEDICATION(S)] 0.5mg SQ [subcutaneous] x [times] 14 days for Resident #22. Each syringe had an expiration of 10/2021. The pharmacy bag containing the syringes had an expiration date of 4/24/22. LPN #3 was asked, Should these still be in here? He stated, No they should have been disposed of already since they are expired. He was asked, Do you have to count these each shift for narcotics reconciliation? He answered, Yes we have to count them each change of shift. He was asked, Why are they still in here? He answered, We just have missed them. a. On 06/09/22 at 9:45 AM, accompanied by the Director of Nursing (DON) a follow up observation of the medication (6 [MEDICATION(S)] 0.5mg prefilled syringes-oral) labeled for Resident #22 with an expiration date on each syringe of 10/2021 completed. She reviewed the Narcotics Administration Record that documented the 6 syringes left on this prescription filled by [Pharmacy]. The plastic pharmacy bag they were in showed a different lot number than the actual prefilled syringes and the instructions on the bag, [MEDICATION(S)] inj. [injectable] 2mg/ml [milligrams per milliliter]-inject IM [intramuscularly] 1 x a day PRN [as needed] x 14 days. The prefilled syringes were for 2mg/ml and were prefilled with 0.5ml with compound [MEDICATION(S)] gel for PO [by mouth] administration. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order received on 03/15/22 documented, [MEDICATION(S)] 0.5mg syringe PO Q12 hours. The DON stated, Well the issue is that this bag with this prescription number is not for this prefilled [MEDICATION(S)] PO, one says IM and one says PO. We should have already gotten rid of this. She has not taken any of it per the Narcotics Sign Out book in a long time, but I see where that is confusing. b. On 06/09/22 at 12:50 PM, the DON stated, The medications should have been removed in October [2021]. I am sure the nurses were looking at the date on the bag 04/22/22 but still that is out of date, and it should have been pulled. It has been taken care of now. I did look back on the MAR for this year and she has not had to have it and as for the 14 day PRN order, the pharmacy is not clicking a button, so it flags us about the 14 days, and we are fixing that as well.

Based on observation, record review and interview, the facility failed to ensure residents who required [CONDITION(S)] services had Physician Orders for [CONDITION(S)] services for 1 (Resident #25) of 1 sampled resident who received [CONDITION(S)]. The findings are: Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/02/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and received [CONDITION(S)]. a. The Care Plan with a revision date of 04/08/22 documented, .The resident needs [CONDITION(S)] . r/t [related to] renal insufficiency . Encourage resident to go for the scheduled [CONDITION(S)] appointments . b. The June 2022 Physician's Orders did not address [CONDITION(S)]. c. On 06/08/22 at 12:18 PM, the Director of Nursing (DON) was asked, Should there be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated Yes, I will look for one and see if it is in there. I know we have one because she was transferred from another facility with [CONDITION(S)]. d. On 06/08/22 at 12:28 PM, the DON stated, I found this, and it has some information about the [CONDITION(S)], but it has already been changed again so it really doesn't help. She provided a copy of the patient Information form with discharge information .her [CONDITION(S)] time is [Name] is MWF [Monday, Wednesday, Friday] at 10 am . e. On 06/09/22 at 12:17 PM, the MDS Coordinator was asked, Should there be a Physician's Order for [CONDITION(S)]? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, What could not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Inaccurate care being provided in relation to the [CONDITION(S)] and all the care she needs. f. On 06/09/22 at 12:25 PM, Infection Control Nurse (IC) was asked, Should there be a Physician's Order for [CONDITION(S)]? She stated, Yes. She was asked, What could not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, It could cause the nurses not to have the right information needed to provide care to the resident with the [CONDITION(S)] and accurate care being provided in relation to the [CONDITION(S)] and the [CONDITION(S)] catheter care, and the forms needed and the coordination of care for the transport, or if the resident refuses to go and other forms care needed. g. On 06/09/22 at 12:45 PM, DON was asked, If there is no order for [CONDITION(S)] on a resident that goes to [CONDITION(S)] what issues could this cause? She stated, I have fixed it and put the order in. I want to be able to enter the orders myself.

Based on record review and interview, the facility failed to ensure an updated determination evaluation and review was received after the 60 day expiration date for a resident with a mental disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #26, #24 and #19) sampled residents who required a PASARR (Preadmission Screening and Resident Review) as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 6/8/22 at 11:09 AM. The findings are: 1. Resident #48 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an Assessment Reference Date of 5/11/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 06/06/22 at 3:30 PM, the Director of Nursing (DON) was asked to provide the PASARR for Resident #48. She stated, A PASARR wasn't done but she's leaving tomorrow anyway. b. On 06/07/22 at 11:22 AM, the Administrator was asked to provide the PASARR for Resident #48. She stated, (State Designated Professional Associates) told the DON in an email that since she was here for Medicare they did not have to screening. c. The letter from (State Designated Professional Associates) dated 02/22/22 provided by the DON on 06/07/22 at 12:25 PM documented, . Has been approved for 60 days of convalescent care/medical review by OLTC [Office of Long Term Care] and may enter the nursing home of his/her choice. The DON was asked to provide a letter from (State Designated Professional Associates) that would have been provided to the facility after the 60 day convalescent care period. She stated, I was told I don't have to send all that information to (State Designated Professional Associates) if they are a short-stay Medicare resident. She was asked to provide the documentation where she was given these instructions. She stated, I don't have it. d. On 06/08/22 at 9:46 AM, the DON was asked to contact (State Designated Professional Associates) and see if they would email her about not needing to do a Level 2 screening for Resident #48. She stated, I called them yesterday and they told me something entirely different than what they told me before. But we still aren't going to do one because she is leaving. 2. The facility policy titled Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability (PASARR), provided by the DON on 6/8/22 at 11:10 AM documented, .Ensure each resident in a nursing facility is screened for a mental disorder (MD - also referred to as mental illness) . prior to admission . Individuals who have or are suspected to have MD . may not be admitted to this facility unless approved based on Level I PASARR evaluation and determination . PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care . PASARR requires that all applicants to a Medicaid Certified nursing facility be evaluated for serious mental disorder .

Based on observation, record review and interview, the facility failed to ensure an oxygen humidifier was changed per orders to prevent potential complications and infection for 1 (Resident #52) of 6 (Residents #39, 45, 52, 53, 62 and 63) sampled residents who received oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 06/08/22 at 1:34 PM. The findings are: Resident #52 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 5/4/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on the Brief Interview for Mental Status and received oxygen therapy. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen 2 L [liters] per nasal cannula as needed for shortness of breath or sats [saturations] below 92% [percent] as needed for shortness of breath or O2 [oxygen] Sats < [less than] 92% . Change humidifier H2O [water] q [every] week and prn [as needed] as needed every night shift every Saturday . b. The June 2022 Treatment Administration Record (TAR) documented the humidifier H2O was changed on 06/04/22. c. On 06/06/22 at 10:00 AM, Resident #52 was lying in bed with oxygen on via nasal cannula. The humidifier H2O was connected to the oxygen concentrator and was dated 5/28/22. d. On 06/07/22 at 8:30 AM, Resident #52 was out with staff smoking in the smoking area. The oxygen was on and running and the nasal cannula was lying on bed. The humidifier H2O was dated 5/28/22. e. On 06/08/22 at 8:10 AM, Licensed Practical Nurse (LPN) #1 was asked, Who is responsible for oxygen humidifier equipment being changed? She stated, The night shift does that every Saturday. f. On 06/08/22 at 9:00 AM, Resident #52 was lying on her bed with oxygen on via nasal cannula. The humidifier H2O was dated 6/7/22. g. On 06/09/22 at 11:00 AM, LPN #2 was asked, The humidifier on the resident's oxygen, what does the date written on it indicate? She replied, That is the date that it was changed by the staff. She was asked, How often is the oxygen tubing and humidifier changed? She stated, It is generally changed weekly and as needed. The night shift changes it usually on Saturdays. She was asked, If you were to walk in a room today and the resident was using oxygen and you noticed the date on the humidifier was 5/28/22, Should it have been changed already? She replied, Yes, it should have been changed this last weekend. I think. h. On 06/09/22 at 11:24 AM, the Assistant Director of Nursing was asked, Do you have a policy regarding oxygen humidifiers and the care of it? She stated, Not for the humidifier, we count the humidifier as part of the oxygen and the tubing, and we use that policy/procedure. We change it per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked, If I observed a humidifier dated 5/28/22 when I was in a resident's room on 6/6/22, should it have been changed already? She stated, Yes, they should have changed it 6/4/22. i. On 06/09/22 at 12:30 PM, the Director of Nursing (DON) was asked, What issues could a humidifier that is not changed per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, It is old and bacteria. j. The facility policy titled, Oxygen and Nebulizer Tubing Changes, provided by the DON on 06/08/22 at 1:39 PM documented, .all Oxygen and Nebulizer tubing is changed weekly and PRN by night Shift Employees .

Based on observation, record review and interview, the facility failed to ensure interventions to prevent elopement were developed and care planned promptly after an elopement risk assessment identified a resident as at risk for elopement and failed to ensure a resident who was at risk for elopement and was actively exhibiting exit-seeking behaviors was adequately supervised in order to prevent the resident from eloping by exiting the building through his bedroom window for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who resided on the Secure Memory Unit. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who exited the facility undetected by staff, and had the potential to cause more than minimal harm to 5 residents who were at risk for elopement and resided on the Secure Memory Unit, as documented on a list provided by the Administrator on 11/1/21 at 10:30 AM. The Administrator was notified of the past immediate jeopardy situation on 10/29/21 at 4:30 PM. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of Non-Alzheimer's Dementia, [CONDITION(S)], and Anxiety. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/21 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance with toileting, limited assistance with dressing and personal hygiene and was independent with bed mobility, transfers, locomotion, and eating, and exhibited wandering behaviors on 4 to 6 of the past 7 days that placed him at significant risk of getting to a potentially dangerous place. a. The Elopement Evaluation dated 10/17/21 at 11:00 AM documented, .Score 5 . Category: At Risk .EVAL [evaluation] .2. Does the resident have a history of or attempted leaving the facility without informing staff? A. Yes . 5. Is the wandering behavior a pattern, goal-directed (i.e. [such as] specific destination in mind, going home etc. [et cetera])? a. Yes . b. A Nurse's Note dated 10/26/21 at 13:52 (1:52 PM) documented, .Resident's sister-in-law came for visit and took resident out to patio. Resident upon return to unit became combative and looking for exit to front door. Resident redirected and came back to unit assisted by staff. Resident talking to wife on phone at this time. No exit seeking noted at this time . c. A Nurse's Note dated 10/26/21 at 17:19 (5:19 PM) documented, .Resident awake ambulatory thru hallway pacing back and forth on hallways. Resident refused evening meal. Resident went to room . Call received from resident spouse stating that resident is at [local discount store] and that the police called her and would bring him back to facility. Noted resident's window open and screen broken and on ground. Resident arrive to facility via police car escorted by police X [times] 4. Resident combative and resistant to police and staff. Resident fighting staff and non-compliant. Resident redirected and escorted back into facility . d. A Nurse's Note dated 10/26/21 at 18:42 (6:42 PM) documented, .Upon arrival to facility for scheduled work around 6 pm received a phone call by resident's family that resident was seen at [local discount store] Upon assessment of resident's room, noted resident's window open with screen broken. Police brought resident back to facility around 6:15 [PM] . e. The Care Plan dated as initiated 10/27/21 documented, The resident is an elopement risk / wanderer r/t [related to] history of attempts to leave facility unattended . Interventions . Distract resident from wandering by offering pleasant diversions, structured activities, food . Resident window altered to only be raised to a certain height . There was no documentation the resident's risk for elopement was addressed on the Care Plan prior to 10/27/21. f. On 10/29/21 at 9:20 AM, Certified Nursing Assistant (CNA) #1 was asked, Did you work the day [Resident #1] got out of the facility? CNA #1 stated, Yes, I was working that morning. The next day they let me know he had gotten out. I was told he went to the [local discount store] and that the police picked him up at [fast food restaurant]. CNA #1 was asked, Is the [local discount store] far from the facility? CNA #1 stated, It is on the highway. g. On 10/29/21 at 11:45 AM, the Maintenance Supervisor was asked to go with the surveyor to Resident #1's room on the Memory Unit. Once in the room, the Maintenance Supervisor was asked, How did [Resident #1] manage to get the window open and get outside? The Maintenance Supervisor pointed to the clasps on the top of the lower window and stated, He was able to [NAME] the clasp, and the window fell forward. He was a very anxious person and a lot sharper than most residents. The Maintenance Supervisor pointed to the brackets on the window frame above the lower window and stated, Those brackets made sure that the window could only come up 6 inches. When I examined the windows, trying to work out what he had done, I realized that there were clasps on the window that allowed it to lay down so that it could be cleaned. Once the window was down, he knocked the screen out and was able to get out. The Maintenance Supervisor was asked, When did you secure all the unit windows to ensure no one else could open them? The Maintenance Supervisor stated, The next day at 7:30 AM; as soon as the hardware store opened, I bought the brackets. I then put brackets in front of all the windows, so that they could not lay forward. The Maintenance Supervisor was asked, Has any other resident ever gotten out of the unit through the windows? The Maintenance Supervisor stated, No, not that I remember. The Maintenance Supervisor was asked, How long have the brackets that stop the window from going any higher than 6 inches been in place? The Maintenance Supervisor stated, They have been there at least 6 months. There were other brackets prior to that, but they were not as secure, so I changed them out. The Maintenance Supervisor was asked, Once the resident went out of the window, was he able to leave the property? The Maintenance Supervisor stated, Yes there is no fence. The Maintenance Supervisor was asked, Is it the same for the rooms on the other side of the hall? The Maintenance Supervisor stated, Yes. The surveyor and the Maintenance Supervisor walked to the back exit door and the Maintenance Supervisor pointed to a slab outside and stated, The facility plans are to build a gazebo and a fence, but we are still in the construction stage. h. On 10/29/21 at 12:15 PM, Licensed Practical Nurse (LPN) #1 was interviewed via telephone and was asked, On the day [Resident #1] eloped, was 17:19 [5:19 PM] the last time you saw the resident prior to getting the phone call from his wife saying he was at the [local discount store]? LPN #1 stated, Yes. He had been pacing back and forth on the hallways. He came in the dining room, but he refused his tray and went to his room. At 6 PM, when his wife called saying he was at the [local discount store] and the police would bring him back, I went to the room and saw that he had opened the window some kind of way, and the screen was broken on the ground. LPN #1 was asked, Was the resident exit seeking earlier in the day? LPN #1 stated, He was very agitated after his sister-in-law visited. His wife was called, and he calmed down a little. LPN #1 was asked, When was the Administrator aware that the resident had left the building? LPN #1 stated, She was in the facility when the resident was brought back by the police. LPN #1 was asked, Who fixed the window in the resident room that evening? LPN #1 stated, Maintenance came in and put the window back in. When the resident got back, we did a body audit, and he was not hurt. The resident was kept one-on-one after he got back. An extra staff member was called, and they came in immediately. i. On 10/29/21 at 1:40 PM, the Assistant Director of Nursing (ADON) was asked, Was [Resident #1] an elopement risk when he was admitted to the facility? The ADON stated, Yes that is why he was on the Memory Care. The ADON was asked, Did [Resident #1] exit-seek when he was admitted ? The ADON stated, He did a lot of wandering initially, not really exit-seeking, but after family visits, he would try to leave. The ADON was asked, Did that happen with all family that visited? The ADON stated, Yes, but he really just had his wife and his sister-in-law that visited. His wife could calm him down more. The ADON was asked, Did [Resident #1] get sent to the behavior unit on 9/30/21 because his exit-seeking behaviors had increased? The ADON stated, At that time he kicked the back door on the Unit trying to get out. The DON was asked, How was [Resident #1] when he came back from the Behavior Unit on 10/12/21? The DON stated, He was good. He was calm, happy and very communicative. The ADON was asked, What happened on October 26th to cause [Resident #1] to want to leave the facility? The ADON stated, His sister-in-law came and she took him to the enclosed smoking area outside the dining room. It was difficult for staff to get him back on the unit. He was agitated. It was discussed with the staff working that day not to bring him off the unit again since it agitated him. The ADON was asked, How was it decided that the sister-in-law should not visit anymore? The ADON stated, That day the wife informed us that the sister-in-law would tell the resident that she would try to get him out of the nursing home and that was what was upsetting him. His wife did talk to him after he got agitated and that seemed to calm him down. He was not trying to open doors or windows. The staff on the unit said that he had not eaten supper and they planned on taking him a snack, but they got the call from his wife stating he was out of the building before meal service was completely finished. The ADON was asked, Who fixed the window after they discovered it was opened? The ADON stated, Maintenance did. The ADON was asked, Prior to this incident, had staff been in-serviced on interventions related to [Resident #1]'s behaviors, such as agitation and exit seeking? The ADON stated, The staff had a general in-service about how to address resident behaviors, but not one that was specific to his behaviors. The ADON was asked, Who develops the residents' care plans? The ADON stated, The MDS Coordinator does. j. On 10/29/21 at 1:50 PM, the MDS Coordinator was asked, Did [Resident #1] have a care plan that addressed his risk for elopement prior to the care plan dated 10/27/21? The MDS Coordinator stated, No. I found out he was an elopement risk in the morning meeting the day after it all happened. I was told to do a care plan by the Director of Nursing and the Administrator. I did it after the meeting on the 27th. k. On 10/29/21 at 4:15 PM, Certified Nursing Assistant (CNA) #2 was asked, Were you working on the Memory Unit the afternoon [Resident #1] eloped? CNA #2 stated, Yes I was. CNA #2 was asked, How was the resident's behavior that afternoon? CNA #2 stated, He was acting like his usual self. He would follow you to the main door and then he paces a lot, so I didn't think anything of his behavior. He was in the dining room during dinner, and he refused his tray. He said he was not hungry. CNA #2 was asked, What time did he go to his room? CNA #2 stated, I remember seeing him in the hall when I was feeding residents, so I am not sure exactly. CNA #2 was asked, Had [Resident #1] ever tried to go out the window before? CNA #2 stated, Not that I am aware of. CNA #2 was asked, Have you been in-serviced about what to do if a resident like [Resident #1] is exit-seeking? CNA #2 stated, I have had in-service about what to do when residents are acting aggressively. CNA #2 was asked, Has any other resident gotten out of the Memory Unit? CNA #2 stated, Not that I am aware of. CNA #2 was asked, Did you see what the resident did to the window? CNA #2 stated, I did not see the window. It happened during dinner. I believe he broke the lock and pushed the screen out. I know he did not cut himself or anything. CNA #2 was asked, When you work on the Memory Unit, how often do you check on the residents that are in their rooms? CNA #2 stated, I walk the hall every 30 minutes if we are not in the dining room. I thought he went and took a shower. He can do that for himself and has a shower in his room. l. The policy titled, Elopement, provided by the Director of Nursing on 10/29/21 at 5:00 PM, documented, .Procedure . A resident is at risk for elopement if one or more of the following .1. The resident has expressed a desire to leave .4. The resident has a history of wandering, attempted elopement, behavior suggesting an intent to leave or seeking to find something or someone, standing by exits, trying to open locked doors .The following additional interventions: initiate alarms, place resident in room near the nursing station away from exits . or Memory Care Unit . 2. The facility removed the immediate jeopardy and corrected the failed practices on 10/27/21, prior to the survey, as evidenced by the following: a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/26/21 and provided by the Administrator on 10/29/21 at 11:00 AM documented the following: Findings and Actions Taken: On 10/26/21, 6:10 PM [Resident #1] returned to the facility. Resident was assessed for injuries and psychosocial well-being after returning to the facility On 10/26/21 at 6:07 PM, DON [Director of Nursing] contacted the Behavior Unit at [Medical Center] and was approved to get [Resident #1] into the facility the next morning. On 10/26/21 from 6:10 PM to 12:30 PM [10/27/21] when [Resident #1] was transferred to the Behavior Unit, he was one on one direct observation by a CNA. On 10/26/21, LPN checked the locking mechanisms on the windows in the other rooms on the secure unit. All were intact and had not been tampered with. On 10/27/21 at approximately 10:00 AM, the Maintenance Supervisor replaced all the safety locks on the secure unit windows with more aggressive locking devices. On 10/26/2021, the Administrator/designee began in-service training with the facility staff regarding identification of resident triggers or behaviors that indicate increased anxiety and potential attempts at elopement from the facility. In-servicing continued until all staff in-serviced by 10/28/2021. b. A In-Service Training record dated 10/26/21 documented, Agenda: On 10/26/21, the Administrator/designee began in-service training with the facility staff regarding identification of resident triggers or behaviors that indicate increased anxiety and potential attempts at elopement from the facility. In servicing continued until all staff in-serviced by 10/28/21 . c. An in-service sheet dated 10/27/21 documented, .Subjects Covered: When a resident is agitated, allow space and cool down time. Only approach from the front and use soft tone to gain trust. Do not overcrowd with multiple staff members . d. An in-service dated 10/27/21 documented, .Subjects Covered: Memory Care residents should not leave the secure unit unless accompanied by a staff member. Permission from a POA [Power of Attorney]/Guardian of the resident must be obtained before changes in environment are made .

Based on record review and interview, the facility failed to ensure an allegation of resident-to-resident sexual abuse was immediately reported to the Administrator, the Office of Long Term Care (OLTC), and other authorities in accordance with State Law, which resulted in a delay implementing protective measures to prevent further potential abuse and a delay in initiating an investigation for 1 (Resident #2) of 4 (Residents #2, #6, #7 and #8) sampled residents who were female. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who was the alleged victim of sexual abuse, and had the potential to affect 41 residents who were female, as documented on the Matrix for Providers list provided by the Minimum Data Set (MDS) Coordinator on 8/23/21 at 4:14 p.m. The Administrator was informed of the immediate jeopardy on 8/25/21 at approximately 3:30 P.M. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/08/21 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS) and required extensive assistance of 1 person for bed mobility, transfers, and dressing. The Care Plan dated as initiated 5/21/21 documented, .The resident has a communication problem r/t [related to] Language barrier . Bed mobility-extensive assist .Transfers - extensive assist .walking- non-ambulatory . Observe and report any changes in mental status . 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS with an assessment reference date of 6/15/21 documented the resident scored 2 (0-7 indicates severe impairment) on a BIMS; did not exhibit verbal or physical behavior symptoms directed toward others, but did exhibit other behavioral symptoms (such as pacing, rummaging, public sexual acts, disrobing in public) on 1 to 3 of the last 7 days; exhibited wandering behavior on 1 to 3 of the last 7 days; and was independent with walking in room and in corridor. a. A Nurse's Note dated 7/2/21 at 2:09 a.m. documented, .resident [#3] was reported to be in another resident's room by another resident, upon entering the room the resident was standing next to and holding the resident of the room's hand and rubbing it, resident redirected to his room without incident and explained to him that he cannot be going into other residents' rooms at night while they are sleeping. Will continue to monitor. b. A Late Entry Behavior Note dated 7/4/21 at 3:30 p.m. documented, .starting in AM [morning], resident's behavior getting more aggressive toward staff and visitors. Per CNA [Certified Nursing Assistant] was in 2 different female rezs [resident's] rooms exposing himself, he was removed, rubbing on staff inappropriately . followed employee out door unbeknownst to them, rez [resident] returned to bldg. [building] and kept blocking doorway . broke window and pushed screen partially out . Dr. [Doctor] called, new order noted, med [medication] given in lt [left] deltoid . [MEDICATION(S)] 0.5 mg [milligram] . c. On 08/24/21 at 3:46 p.m., the Administrator was asked if a reportable or an incident report was completed when Resident #3 exposed himself to female residents. She stated, That's my first-time hearing that today. Let me look into it, and I'll get back with you. d. On 08/24/21 at 4:00 p.m., the Administrator entered the conference room where the Surveyor was working and stated, There was no reportable or incident report completed. This is what I found out so far. [CNA #1] was here and she said he [Resident #3] did not show his privates. I can't get in contact with the RN [Registered Nurse] Weekend Supervisor. She was asked, Can you ask [CNA #1] to come to the conference room? She stated, [CNA #1] isn't here; she was here the day after. One of the residents heard something about it. [Licensed Practical Nurse (LPN #2] did tell me about him standing in [Resident #2's] room holding her hand and he told him to get out of her room. e. Nurses' Notes dated 8/24/2021 at 4:30 p.m. documented, .Resident seen in another resident's room pulling his pants down to have a bowel movement on the bed . f. On 08/25/21 at 8:30 a.m., Resident #4 was asked, Did you see someone in [Resident #2]'s room? He stated, I did, [Res #3] . Turned it in to the nurse's station. I feel sorry for her [Resident #2]. The day she came in, she was falling out of the bed. I went to get a cup of coffee, and he [Resident #3] had her [Resident #2's] hand down his britches. He was asked, Do you know what date this happened? He stated, My birthday was the 5th of July, and it happened around my birthday. I told [LPN #2]. The poor woman [Resident #2] can't speak English, and it was late at night. Most of the time, [LPN #2] works the evening shift or the night shift. g. On 08/25/21 at 9:10 a.m., LPN #2 was asked, Can you tell me about what happened with [Residents #2 and #3?] He stated, I went walking down the hall; I knew he was rubbing his belly and then he went to rubbing his hands, and I told him to stop and walked him back to his room. I told him he can't go in her room that late at night because she's not able to give consent. I was the night shift nurse that night. He was asked, Can you tell me about what was reported to you by [Resident #4?] He stated, He told me he [Resident #3] was in there and to go and check on her because [she] can't talk. He was asked, Did you ask [Resident #4] what he saw? He stated, He said, 'he seems to be holding her hand'. He was asked, Did you report it to the supervisor? He stated, Yes, I texted [Director of Nursing (DON)], [Assistant Director of Nursing (ADON)] and [Administrator]. He was asked, Was an investigation completed on this incident? He stated, That, I don't know. He was asked, Did anyone talk to you about the incident after it happened? He stated, No, they just went by what I said. He was asked, Did you perform a body audit on her that night? He stated, I gave her a quick look-over to make sure she didn't have any bruising at the time. h. On 08/25/21 at 10:00 a.m., Social Services Staff #1 provided a handwritten note which was not dated; he stated he received it from the RN Weekend Supervisor. It documented, [Resident #8] said last nite [Resident #7] on BSC [bedside commode] & [and] [Resident #3] kept peeking in door then busted into room & [Resident #8] had to run him out . [Resident #4] says late one night [Resident #3] had [Resident #2] by the wrist, putting her hand down his pants rubbing him . Also standing in [other female resident's] door for a long time. Per [Resident #8] . i. On 08/25/21 at 10:25 a.m., the RN Weekend Supervisor was asked, Can you tell me about what happened with [Resident #2] and another resident? She stated, I took the smokers on a smoke break, and [Resident #4] said he saw [Resident #3] standing beside [Resident #2's] bed, holding her wrist and was exposed, and had her hand holding his privates. She was asked, Were you the RN Supervisor when you were informed? She stated, Yes, I only work weekends. She was asked, What did you do to protect the residents after you found out? She stated, Just to keep him out of there. I've never seen him in there, but he does roam the halls. Social Services walked over, and I told him I was going to call the Administrator. He jerked the paper from me and said he was going to call the Administrator himself, so I gave it to him. She was asked, Who are you supposed to report abuse to? She stated, The Administrator . but Social Services took it and said, 'I'm going to call the Administrator myself on this'. I said, 'OK'. She was asked, Can you tell me what you did again to protect the resident? She stated, I went to check on her. She was asked, How did you ensure he didn't go back in her room, or another resident's room? She stated, People watching all the time. She was asked, Was he put on one-on-one? She stated, No, not at that time. His family came in and said we can send him off for anything we wanted to do. He was put on C Hall, I believe, that day. I can't say that was the exact date. She was asked, Were any interventions put in place that day? She stated, No, just everybody to be aware not to let him in there and to keep an eye on him. She was asked, Can you tell me why an investigation wasn't started immediately? She stated, When Social Services took the note, I figured he was on top of it, because he was very anxious to get it. She was asked, Did any of the department heads talk to you about the incident after it was reported to you? She stated, No. j. On 08/25/21 at 10:44 a.m., the RN Weekend Supervisor stated, We tried to get him put into a facility, but they said they couldn't take him, because he didn't meet the criteria and he was violent. She was asked, Did the facility try to get him in a behavioral facility because of the sexual conduct or because he tried to break out? She stated, Oh yes, because that day, it was because of the breakout. He busted the window out and everything, and he shoved a visitor [referring to the incident documented in the Behavior Note on 7/4/21]. k. On 08/25/21 at 10:45 a.m., Social Services Employee #1 was asked, When you received the note from the RN Weekend Supervisor, who did you inform? He stated, The Administrator. He was asked, What did she say? He stated, Notify family and the doctor and that would be nursing who would try to get him sent out. He was asked, After she [Administrator] informed you of the steps, who did you tell? He stated, [RN Weekend Supervisor], and I know that they did start calling people, because I kept checking back. He was asked, Who is responsible for starting an investigation? He stated, It would be the Administrator or the DON. He was asked, Do you know if an investigation was started? He stated, No ma'am, I do not know that. He was asked, What was done to protect the resident after the facility was informed of possible sexual abuse? He stated, We removed [Resident #3] to a secure area. He was asked, Was he moved the same day? He stated, Yes ma'am. He was asked, How did the facility ensure that [Resident #3] wouldn't sexually assault a female resident on the secure unit? He stated, We moved him to the end of the hall, where it's all males. He was asked, Does he walk independently? He stated, He does, but the doctor ordered him something to help sedate him. If I remember right, he crawled out the window the next morning. His daughter-in-law tried to get him a bed [in a behavioral treatment facility] on Sunday but wouldn't no one take him. l. On 08/25/21 at 10:57 a.m., the Administrator was asked, What information were you given concerning [Residents #2 and #3]? She stated, What I remember is [LPN #2] telling me in a text that [Resident #3] went into [Resident #2's] room and holding her hand and rubbing it. He told him he couldn't do that and redirected him. [RN Weekend Supervisor] had called me on a Sunday, I assume on the 11th, that [Resident #3] was having behavior issues. They were trying to get him to a behavior unit. They got him moved to the secure unit and gave him an injection to calm him down. He went to the behavior unit on the 12th [7/12/21]. She was asked, What type of behaviors did she tell you he was having? She stated, Aggression towards the staff, he pushed the window out, and I believe he kicked at a family member. She was asked, Did Social Services call you to inform you that a resident reported that [Resident #3] was observed putting [Resident #2's] hand down his pants? She stated, I don't recall that. She was asked, Do you have any knowledge of the incident? She stated, I heard about it on that Monday, when he was going to behavior [unit]. The DON said she had talked to other staff members and her [Resident #2's] hand was not down his pants and that he [Resident #3] was holding his hands. She was asked, If a resident or staff member reports sexual abuse, should an investigation be started? She stated, Yes. She was asked, The note that was given to Social Services documented that [Resident #4] saw [Resident #3] put [Resident #2's] hand down his pants. Can you tell me why an investigation wasn't started? She stated, The DON started an investigation; obviously, it wasn't written down. She was asked, What did you do to protect [Resident #2] and other female residents after you received the note concerning the incident? She stated, He was moved to the memory care hall and given medications until we could get him out of the building. She was asked, What did you do to protect the female residents on the memory care unit? She stated, We moved him down to where the men are at, but there's a higher staff ratio back in memory. m. On 08/25/21 at 12:16 p.m., LPN #3, who worked on the secure unit, was asked, What information were you given on how to monitor and care for [Resident #3?] She stated, Just to not approach him because at times he's combative. They told me to speak to him before you just jump in there. That way you'll know how his behavior is. She was asked, Were you informed that he had inappropriate sexual behaviors? She stated, No ma'am, I didn't know that. n. On 08/25/21 at 12:24 p.m., Certified Nursing Assistant (CNA) #2, who worked on the secure unit, was asked, Were you given any information on how to monitor and care for [Resident #3?] She stated, No ma'am. She was asked, Were you informed that he had inappropriate sexual behaviors? She stated, No. o. On 08/25/21 at 12:36 p.m., CNA #3 was asked, Were you given any information on how to care for and monitor [Resident #3]? She stated, No. She was asked, Were you informed that he had inappropriate sexual behaviors? She stated, No. 3. The facility's Abuse Prohibition Policy and Procedure, provided by the Administrator on 8/25/21 at 8:57 a.m., documented, .This facility shall comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect, and report, if applicable, any event that is not consistent with the usual operation of nursing facility or the standard care for certain residents . Identification: Any staff member who has reasonable cause to suspect that a resident has be [been] subjected to conditions or circumstances, which have or could have resulted in abuse or neglect is required to immediately notify the facility Administrator or DON . The Administrator or DON will notify the local law enforcement agency for any alleged, suspected, or witnessed occurrences of abuse or neglect to resident, or direct the charge nurse to do so if they are not present in the facility . the Administrator or DON will notify the Office of Long-Term Care of any alleged, suspected, or witnessed . neglect to a resident .Report Abuse Immediately!!! The administrator and DON are to be call [called] immediately for any abuse allegation . Any staff member can make this call. 4. The immediate jeopardy was removed, and the scope / severity reduced to E on 08/25/21 at 6:20 p.m. when the facility implemented the following plan of removal: Plan of Removal: F609 - Failure to Report Allegation . The Administrator on / by 8/25/2021 (1500 [3:00 p.m.]) completed the state required DMS [Division of Medical Services] 7734 form for Resident #2 regarding the allegation of sexual abuse by Resident #3 toward Resident #2 and submitted the completed form to the Office of Long Term Care by 8/25/2021 (1530 [3:30 p.m.]) along with notification of local law enforcement. The Administrator on / by 8/25/2021 (1530) began a full documented investigation on the state required DMS-762 Form of the allegation by Resident #4 that he saw Resident #3 inappropriately touching Resident #2. The Nurse Consultant on 8/25/21 (1430 [2:30 p.m.]) provided in-service training with the Administrator regarding reporting all allegations of abuse to the appropriate state agencies and documenting the investigation on the require [required] DMS-7734 [Division of Medical Services] and DMS-762 forms. The Administrator / designee on 8/25/21 (1530) began in-service training with all facility staff regarding: (1) the requirement to report all allegations of abuse to the Administrator immediately either directly or through the Charge Nurse who will report it directly to the Administrator. (2) allegations should be reported so that appropriate investigations can be completed (3) investigations should be documented on the appropriate state required forms. All employees will be in-service each shift until all employees are in-serviced. The Administrator, DON / designee on 8/25/2021 (1600 [4:00 p.m.]) began conducting private interviews with all residents and employees to identify if any other persons witnessed [Resident #3] being inappropriate with another resident .

Based on record review and interview, the facility failed to ensure an allegation of resident-to-resident sexual abuse was investigated and protective measures were immediately put in place to prevent further potential abuse for 1 (Resident #2) of 4 (Residents #2, #6, #7 and #8) sampled residents who were female. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who was the alleged victim of sexual abuse, and had the potential to affect 41 residents who were female, as documented on the Matrix for Providers list provided by the Minimum Data Set (MDS) Coordinator on 8/23/21 at 4:14 p.m. The Administrator was informed of the immediate jeopardy on 8/25/21 at approximately 3:30 P.M. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/08/21 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS) and required extensive assistance of 1 person for bed mobility, transfers, and dressing. The Care Plan dated as initiated 5/21/21 documented, .The resident has a communication problem r/t [related to] Language barrier . Bed mobility-extensive assist .Transfers - extensive assist .walking- non-ambulatory . Observe and report any changes in mental status . 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS with an assessment reference date of 6/15/21 documented the resident scored 2 (0-7 indicates severe impairment) on a BIMS; did not exhibit verbal or physical behavior symptoms directed toward others, but did exhibit other behavioral symptoms (such as pacing, rummaging, public sexual acts, disrobing in public) on 1 to 3 of the last 7 days; exhibited wandering behavior on 1 to 3 of the last 7 days; and was independent with walking in room and in corridor. a. A Nurse's Note dated 7/2/21 at 2:09 a.m. documented, .resident [#3] was reported to be in another resident's room by another resident, upon entering the room the resident was standing next to and holding the resident of the room's hand and rubbing it, resident redirected to his room without incident and explained to him that he cannot be going into other residents' rooms at night while they are sleeping. Will continue to monitor. b. A Late Entry Behavior Note dated 7/4/21 at 3:30 p.m. documented, .starting in AM [morning], resident's behavior getting more aggressive toward staff and visitors. Per CNA [Certified Nursing Assistant] was in 2 different female rezs [resident's] rooms exposing himself, he was removed, rubbing on staff inappropriately . followed employee out door unbeknownst to them, rez [resident] returned to bldg. [building] and kept blocking doorway . broke window and pushed screen partially out . Dr. [Doctor] called, new order noted, med [medication] given in lt [left] deltoid . [MEDICATION(S)] 0.5 mg [milligram] . c. A Behavior Care Plan dated 7/11/21 documented, 7/11/21 Resident has become combative with staff, urinating in the floor, walking up and down hallways into other residents' rooms . Interventions: Administer meds as ordered. Monitor and document for side effects. Anticipate and meet the resident's needs. Monitor behavior episodes . Notes: Move resident to C Hall . 7/12 [7/12/21] Sent resident out to behavior [behavioral unit] . d. On 08/24/21 at 3:46 p.m., the Administrator was asked if a reportable or an incident report was completed when Resident #3 exposed himself to female residents. She stated, That's my first-time hearing that today. Let me look into it, and I'll get back with you. e. Nurses' Notes dated 8/24/2021 at 4:30 p.m. documented, .Resident seen in another resident's room pulling his pants down to have a bowel movement on the bed . f. On 08/24/21 at 4:00 p.m., the Administrator entered the conference room where the Surveyor was working and stated, There was no reportable or incident report completed. This is what I found out so far. [CNA #1] was here and she said he [Resident #3] did not show his privates. I can't get in contact with the RN [Registered Nurse] Weekend Supervisor. She was asked, Can you ask [CNA #1] to come to the conference room? She stated, [CNA #1] isn't here; she was here the day after. One of the residents heard something about it. [Licensed Practical Nurse (LPN #2] did tell me about him standing in [Resident #2's] room holding her hand and he told him to get out of her room. g. On 08/25/21 at 8:30 a.m., Resident #4 was asked, Did you see someone in [Resident #2]'s room? He stated, I did, [Res #3] . Turned it in to the nurse's station. I feel sorry for her [Resident #2]. The day she came in, she was falling out of the bed. I went to get a cup of coffee, and he [Resident #3] had her [Resident #2's] hand down his britches. He was asked, Do you know what date this happened? He stated, My birthday was the 5th of July, and it happened around my birthday. I told [LPN #2]. The poor woman [Resident #2] can't speak English, and it was late at night. Most of the time, [LPN #2] works the evening shift or the night shift. h. On 08/25/21 at 9:10 a.m., LPN #2 was asked, Can you tell me about what happened with [Residents #2 and #3?] He stated, I went walking down the hall; I knew he was rubbing his belly and then he went to rubbing his hands, and I told him to stop and walked him back to his room. I told him he can't go in her room that late at night because she's not able to give consent. I was the night shift nurse that night. He was asked, Can you tell me about what was reported to you by [Resident #4?] He stated, He told me he [Resident #3] was in there and to go and check on her because [she] can't talk. He was asked, Did you ask [Resident #4] what he saw? He stated, He said, 'he seems to be holding her hand'. He was asked, Did you report it to the supervisor? He stated, Yes, I texted [Director of Nursing (DON)], [Assistant Director of Nursing (ADON)] and [Administrator]. He was asked, Was an investigation completed on this incident? He stated, That, I don't know. He was asked, Did anyone talk to you about the incident after it happened? He stated, No, they just went by what I said. He was asked, Did you perform a body audit on her that night? He stated, I gave her a quick look-over to make sure she didn't have any bruising at the time. i. On 08/25/21 at 10:00 a.m., Social Services Staff #1 provided a handwritten note which was not dated; he stated he received it from the RN Weekend Supervisor. It documented, [Resident #8] said last nite [Resident #7] on BSC [bedside commode] & [and] [Resident #3] kept peeking in door then busted into room & [Resident #8] had to run him out . [Resident #4] says late one night [Resident #3] had [Resident #2] by the wrist, putting her hand down his pants rubbing him . Also standing in [other female resident's] door for a long time. Per [Resident #8] . j. On 08/25/21 at 10:25 a.m., the RN Weekend Supervisor was asked, Can you tell me about what happened with [Resident #2] and another resident? She stated, I took the smokers on a smoke break, and [Resident #4] said he saw [Resident #3] standing beside [Resident #2's] bed, holding her wrist and was exposed, and had her hand holding his privates. She was asked, Were you the RN Supervisor when you were informed? She stated, Yes, I only work weekends. She was asked, What did you do to protect the residents after you found out? She stated, Just to keep him out of there. I've never seen him in there, but he does roam the halls. Social Services walked over, and I told him I was going to call the Administrator. He jerked the paper from me and said he was going to call the Administrator himself, so I gave it to him. She was asked, Who are you supposed to report abuse to? She stated, The Administrator . but Social Services took it and said, 'I'm going to call the Administrator myself on this'. I said, 'OK'. She was asked, Can you tell me what you did again to protect the resident? She stated, I went to check on her. She was asked, How did you ensure he didn't go back in her room, or another resident's room? She stated, People watching all the time. She was asked, Was he put on one-on-one? She stated, No, not at that time. His family came in and said we can send him off for anything we wanted to do. He was put on C Hall, I believe, that day. I can't say that was the exact date. She was asked, Were any interventions put in place that day? She stated, No, just everybody to be aware not to let him in there and to keep an eye on him. She was asked, Can you tell me why an investigation wasn't started immediately? She stated, When Social Services took the note, I figured he was on top of it, because he was very anxious to get it. She was asked, Did any of the department heads talk to you about the incident after it was reported to you? She stated, No. k. On 08/25/21 at 10:44 a.m., the RN Weekend Supervisor stated, We tried to get him put into a facility, but they said they couldn't take him, because he didn't meet the criteria and he was violent. She was asked, Did the facility try to get him in a behavioral facility because of the sexual conduct or because he tried to break out? She stated, Oh yes, because that day, it was because of the breakout. He busted the window out and everything, and he shoved a visitor [referring to the incident documented in the Behavior Note on 7/4/21]. l. On 08/25/21 at 10:45 a.m., Social Services Employee #1 was asked, When you received the note from the RN Weekend Supervisor, who did you inform? He stated, The Administrator. He was asked, What did she say? He stated, Notify family and the doctor and that would be nursing who would try to get him sent out. He was asked, After she [Administrator] informed you of the steps, who did you tell? He stated, [RN Weekend Supervisor], and I know that they did start calling people, because I kept checking back. He was asked, Who is responsible for starting an investigation? He stated, It would be the Administrator or the DON. He was asked, Do you know if an investigation was started? He stated, No ma'am, I do not know that. He was asked, What was done to protect the resident after the facility was informed of possible sexual abuse? He stated, We removed [Resident #3] to a secure area. He was asked, Was he moved the same day? He stated, Yes ma'am. He was asked, How did the facility ensure that [Resident #3] wouldn't sexually assault a female resident on the secure unit? He stated, We moved him to the end of the hall, where it's all males. He was asked, Does he walk independently? He stated, He does, but the doctor ordered him something to help sedate him. If I remember right, he crawled out the window the next morning. His daughter-in-law tried to get him a bed [in a behavioral treatment facility] on Sunday but wouldn't no one take him. m. On 08/25/21 at 10:57 a.m., the Administrator was asked, What information were you given concerning [Residents #2 and #3]? She stated, What I remember is [LPN #2] telling me in a text that [Resident #3] went into [Resident #2's] room and holding her hand and rubbing it. He told him he couldn't do that and redirected him. [RN Weekend Supervisor] had called me on a Sunday, I assume on the 11th, that [Resident #3] was having behavior issues. They were trying to get him to a behavior unit. They got him moved to the secure unit and gave him an injection to calm him down. He went to the behavior unit on the 12th [7/12/21]. She was asked, What type of behaviors did she tell you he was having? She stated, Aggression towards the staff, he pushed the window out, and I believe he kicked at a family member. She was asked, Did Social Services call you to inform you that a resident reported that [Resident #3] was observed putting [Resident #2's] hand down his pants? She stated, I don't recall that. She was asked, Do you have any knowledge of the incident? She stated, I heard about it on that Monday, when he was going to behavior [unit]. The DON said she had talked to other staff members and her [Resident #2's] hand was not down his pants and that he [Resident #3] was holding his hands. She was asked, If a resident or staff member reports sexual abuse, should an investigation be started? She stated, Yes. She was asked, The note that was given to Social Services documented that [Resident #4] saw [Resident #3] put [Resident #2's] hand down his pants. Can you tell me why an investigation wasn't started? She stated, The DON started an investigation; obviously, it wasn't written down. She was asked, What did you do to protect [Resident #2] and other female residents after you received the note concerning the incident? She stated, He was moved to the memory care hall and given medications until we could get him out of the building. She was asked, What did you do to protect the female residents on the memory care unit? She stated, We moved him down to where the men are at, but there's a higher staff ratio back in memory. n. On 08/25/21 at 12:16 p.m., LPN #3, who worked on the secure unit, was asked, What information were you given on how to monitor and care for [Resident #3?] She stated, Just to not approach him because at times he's combative. They told me to speak to him before you just jump in there. That way you'll know how his behavior is. She was asked, Were you informed that he had inappropriate sexual behaviors? She stated, No ma'am, I didn't know that. o. On 08/25/21 at 12:24 p.m., Certified Nursing Assistant (CNA) #2, who worked on the secure unit, was asked, Were you given any information on how to monitor and care for [Resident #3?] She stated, No ma'am. She was asked, Were you informed that he had inappropriate sexual behaviors? She stated, No. p. On 08/25/21 at 12:36 p.m., CNA #3 was asked, Were you given any information on how to care for and monitor [Resident #3]? She stated, No. She was asked, Were you informed that he had inappropriate sexual behaviors? She stated, No. 3. The facility's policy titled, Abuse Prohibition Policy and Procedure, provided by the Administrator on 8/25/21 at 8:57 a.m., documented, .This facility shall comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect, and report, if applicable, any event that is not consistent with the usual operation of nursing facility or the standard care for certain residents . Investigation: The facility will ensure that all alleged or suspected incidents involving resident abuse, exploitation, neglect, or misappropriations of resident property are thoroughly investigated .The investigation will begin at the time the alleged abuse is reported. When the alleged abuse is reported, the administrator will be investigating by obtaining witness statements. If the administrator or DON is not present in the facility during the alleged abuse, the charge nurse will be instructed by the administrator or DON to obtain witness statements . 4. The immediate jeopardy was removed the scope / severity reduced to E on 08/25/21 at 6:20 p.m. when the facility implemented the following plan of removal: Plan of Removal: F610 - Failure to Protect . The Administrator on / by 8/25/2021 (1500 [3:00 p.m.]) completed the state required DMS [Division of Medical Services] 7734 form for Resident #2 regarding the allegation of sexual abuse by Resident #3 toward Resident #2 and identified that Resident #3 was removed from the room of Resident #2 immediately . The Administrator on 8/25/2021 identified on / by 07/11/2021, the Administrator instructed the Nursing Staff to move Resident #3 to the locked Behavior Unit to separate Resident #3 from Resident #2. The Administrator on 8/25/2021 identified that on 7/11/2012 [sic], that the Charge Nurse notified the physician for Resident #3 and obtained an order to send Resident #3 to the Behavioral Unit at the hospital for evaluation as soon as possible. The Administrator on 8/25/2021 identified that on 07/11/2021, the Administrator also instructed the nursing staff monitor Resident #3 every 30 minutes for visual observation and location to protect other residents until resident could be transferred to the behavioral unit. The Nurse Consultant on 8/25/2021 (1430 [2:30 p.m.]) provided in-service training with the Administrator regarding protecting other residents from allegations of abuse by providing documented observations of Resident #3 every 30 minutes until the Resident #3 was transported to the behavioral unit on 7/12/2021. The Administrator on 8/25/2021 identified that Resident #3 returned from the behavioral unit on 7/26/2021 with a new medication, [MEDICATION(S)] for the resident's behaviors and that the resident has been taking the medication daily since that time. The Administrator on 8/25/2021 implemented direct observation of Resident #3 while continued assessment by nursing staff and physician is completed to determine if any further abusive behaviors have occurred. The Administrator / designee on 8/25/21 (1530) began in-service training with all facility staff regarding the requirement to protect other residents from allegation of abuse by removing the accused resident away from other residents and providing direct observation of that resident until the resident behaviors are resolved.

Complaint # (AR 730) was substantiated (all or in part) with these findings: Based on observation, record review, and interview, the facility failed to ensure transport staff transferred a resident from her motorized mobility scooter onto a seat on the facility van rather than allowing her to sit on the scooter during transport, which resulted in an inability to properly apply the van's safety restraints and anchoring system to prevent potential injury for 1 (Resident #1) of 1 case mix resident who utilized a motorized mobility scooter. This failed practice resulted in Immediate Jeopardy, (removed) which caused or could have caused serious harm, injury, or death to Resident #1, who was allowed to sit on her motorized mobility scooter during transport, which resulted in the scooter tipping sideways with the resident when the van made a sharp turn. The failed practice had the potential to cause more than minimal harm to only this resident, the only resident in the facility who utilized a motorized mobility scooter, according to a list provided by the Human Resource Director on 10/30/19 at 9:30 a.m. The Director of Nursing (DON) and Human Resource Director were informed of the Immediate Jeopardy condition on 10/29/19 at 5:35 p.m. The findings are: 1. The facility's Van / Bus Transportation Policy and Procedure, provided by the Certified Nursing Assistant (CNA) Supervisor on 10/29/19 at 1:57 p.m., documented, Secure Wheelchair . 3. Attach the four tie-down hooks to solid frame members . Ensure tie-downs are fixed at approximately 45 degrees, and within angles shown . 4 Ensure all tie-downs are locked and properly tensioned . Systems should only be used with forward facing wheelchairs - (brand name restraint) 4-point securement systems and components comply with all applicable requirements of related safety regulations and standards . Installation Instructions Vehicle Anchorage & Accessories for 4 point Wheelchair Securement Systems to provide transportation as needed in a safe manner . This policy did not address transport of residents on scooters and specified that only forward-facing wheelchairs should be utilized with the van's restraint system. 2. The Owner's Manual for Resident #1's motorized mobility scooter, provided by the Maintenance Director on 10/29/19, did not address utilizing or securing the scooter for automobile transport. 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/14/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, was independent with locomotion on and off unit, and used a wheelchair. a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 documented, Date and Time of Incident (if known): 10/21/2019 Time: 4:19 AM Date and Time of Discovery: 10/21/2019 Time: 4:19 a.m.TRANSPORT AIDE / (CNA #1) was transporting (Resident #1) . from the physician's office back to the facility . (Resident #1) . was in her scooter per her request in the transport van. The scooter was strapped in and (Resident #1) . had her seatbelt fastened. (CNA #1) stopped at the red light and made a left turn and the scooter fell and (Resident #1) . slid off onto her right knee. (CNA #1) stopped immediately and up-righted the scooter and ask . if she was hurt. (CNA #1) . stated, 'She was just shook up.' (CNA #1) contacted the facility of the incident . Upon arriving back at the facility, a head to toe assessment was completed and no bruises or abrasions were noted at this time . b. On 10/29/19 at 11:40 a.m., Resident #1 was asked to explain how she fell off the scooter on the van. She stated, It was (CNA #1's) first time driving me, and I just got on the scooter. It was my first time sitting on the scooter and her first, too. I was strapped and the scooter strapped in. (CNA #1) turned a corner, and the scooter tilted over on me. She pulled over and got me up. She was asked, were you injured? She stated, Not right then; my body wasn't sore until the next day. After that, no more problems . She was asked if this was her first accident on the van. She stated, Yes, ma'am. I usually sit in the front seat, but that day had a different driver. The driver usually drives the scooter onto to the van and parks it. That was first time I sat on the scooter. The driver that day had never driven me. Another girl was usually driving the van. c. On 10/29/19 at 1:50 p.m., the Director of Nursing (DON) was asked if CNA / Transport Aide #1 was the only driver of the facility van. She stated, Yes, we don't usually schedule appointments on the weekend. We do have a secondary driver, (CNA #3) . The DON was asked what material was used to train the van drivers. She stated, (CNA #1) was re-trained by the Maintenance Director. (CNA #3) was not re-trained, because she only drives if (CNA #1) is not here. At 3:34 p.m., the DON was asked how long CNA #1 had driven the facility van. She stated, Not long. She was asked how long. The DON didn't answer the question. She was asked who was driving the van before CNA #1 started driving it. She stated, (CNA #3). The DON was asked, How are you monitoring to ensure (CNA #1) is transporting residents safely? She stated, The incident just happened last week, and if we were monitoring it, we hadn't done it this week. At 3:40 p.m., the DON approached the surveyor and stated, I will have the Maintenance Director in-service (CNA #3). She will be coming in shortly. She was asked if residents were transported on the van today and stated, No. d. On 10/29/19 at 12:10 p.m., CNA #1 was asked to explain how Resident #1 fell off her scooter during transport on 10/21/19. She stated, We were leaving the doctor's appointment, and she (Resident #1) wanted to sit on the scooter while on the van. She was asked how she secured the resident on the scooter. She stated, There are 4 straps on the van. Her scooter is shaped like a triangle; it has 3 wheels. One on each corner of the scooter. I strapped down the 2 tires on the back and 1 on the front and put her seat belt on. She was asked how the resident got to the physician appointment. She stated, I took her. She was asked if the resident was sitting on the scooter. She stated, Yes, ma'am. The same way we went is the same way we came back. She was asked how the scooter turned over on the resident. She stated, I turned in a deep curve, and I heard her tip over. I pulled over and asked her if she was okay. Her (sic) and the scooter was (sic) tilted over against the wall in the van. She was not on the floor. She was leaned against the wall and the scooter leaned against her. Her right knee was pressed against the wall. She was asked, Was she on the floor? CNA #1 stated, No, ma'am. She was asked if the scooter landed on top of the resident. She stated, No ma'am, I pulled her up back onto the scooter. I asked (Resident #1) if she was okay and then called the facility. I asked (Resident #1) if she was hurt, and she said her knee was hurting from it leaning up against the wall. I asked (Resident #1) if she could walk to the back seat. She said she was shaken up. CNA #1 was asked, How often do you transport (Resident #1)? She stated, That was my first time. CNA #1 was asked who trained her on how to ensure the safety of a scooter for transport. She stated, The Maintenance Director and when I started driving the van. CNA #1 was asked, who trained you on safety for van transports? She stated, I drove the van; he (Maintenance Director) showed me the inside of the van and how to strap the wheelchair in. She was asked if she was trained on how to load and secure a scooter and stated, No. She was asked, should a resident sit on the scooter during a van transport? CNA #1 stated, No. e. On 10/29/19 at 1:25 p.m., the Maintenance Director was asked for the manufacturer's guidelines for the passenger van and scooter transport. He was then asked, should a resident sit on a scooter while being transported on the facility van? He stated, No, (transport staff) should load the scooter, and the resident should sit in a seat. No one has been trained to operate a scooter (on the van) prior to the accident. You should never put a scooter with a resident sitting on it on the van. Not enough wheels on the scooter to tie down. I looked at (Resident #1's) scooter. The scooter only has 3 wheels. There is no safe way to transport a scooter on the van with a resident on it. We decided if a resident gets on and off a scooter, they can sit on the seat in the van. Even if you strap the wheels on both sides of the scooter, there is not 4 places to tie down. Just by hooking 3 straps, it's not safe. We only trained our people on transporting wheelchairs. We have hauled the scooter on the van before, but not with a person sitting on it. I looked in the manufacturer's guidelines on transporting a person on a scooter. I didn't find anything on scooter transport. If it's not in the manufacturer's guidelines on how to do it safely, we don't need to be transporting resident on the scooter. f. On 10/29/19 at 3:27 p.m., Resident #1 was asked if van transportation had been provided to her since 10/21/19 and, if so, how she was transported. She stated, .Yes . I drove the scooter up to the van, she (transport staff) drove the scooter on the van and parked it, and I sat in the van seat. g. On 10/29/19 at 3:35 p.m., the DON provided this surveyor a document titled, Transports After 10/21/19, which documented there were 3 residents transported on 10/22/19, 1 resident transported on 10/23/19, 3 residents transported on 10/24/19, and 1 resident transported on 10/25/19, 10/27/19, and 10/28/19. h. On 10/29/19 at 5:00 p.m., CNAs #1 and #2 loaded a wheelchair onto the facility van. There were 4 anchors with tie-downs installed on the floor of the van and one large lap and shoulder belt installed from the wall. There was approximately a 3 to 4-foot distance between each anchorage from left to right, with a tie-down separately attached to each anchor. Per the transport instructions referenced at paragraph 1 above, each of the 4 tie-downs should be attached to solid frame members of a wheelchair, which would result in the restraints being in a square or rectangular formation. The resident's scooter had only 3 wheels and was narrower in the front than in the rear, making it impossible to properly utilize the van's 4-point restraint system. i. On 10/30/19 at 1:50 p.m., the Administrator and DON were asked, Was it safe for the resident to sit on her scooter while being transported on the facility van? They both stated, No. When asked about the monitoring of transport staff, the Administrator stated, We monitor every month or more often for staff putting people on the van in the wheelchair. We monitored them in July. She was asked to provide documentation of the monitoring. j. The facility removed the immediate jeopardy and reduced the scope / severity to D on 10/22/19, as evidenced by the following: 1.) The facility identified the failed practice and reported the incident to the Office of Long-Term Care (OLTC) on 10/22/19 at 11:00 a.m., as documented on the OLTC Incident and Accident Report, DMS form 7734 dated 10/21/19. The facility remained within their 5-working day investigation period when the complaint investigation was initiated. 2.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 10/22/19 documented, .Section III - Findings and Actions Taken . (CNA #1) was retrained per Maintenance and Safety Coordinator on proper loading, tie down and transporting residents per manufacturer's guidelines. Driver observed and understood instruction and was able to demonstrate ability to comprehend transporting residents in a safe manner. (CNA #1) was also instructed to take a regular wheelchair for all residents for transport and to no longer take electric scooters . Van Driver will be spot checked by Safety Coordinator periodically . 3.) A Complete In-Service Training Report dated 10/22/19 documented the DON trained CNA #1 on the following: No electric scooters are allowed on the van. Use only wheelchairs. 4.) A Skills Check-off sheet dated 10/22/19 documented CNA #1 was retrained and successfully performed a return demonstration on van transports. 5.) On 10/29/19 at 5:00 p.m., during the observation of CNAs #1 and #2 loading and securing a wheelchair on the van, no concerns were identified with their ability to correctly utilize the van's anchoring system to secure the wheelchair. As of 10/29/19, the facility was unable to provide evidence that any staff other than CNA #1 had been trained on the facility's new rule regarding not allowing scooters on the van; however, there was no evidence any other staff member had ever attempted to transport a resident on a scooter in the facility van, before or since the incident on 10/21/19.

Complaint # (AR 681) was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure mechanical lifts were maintained in working order; to ensure a faulty mechanical lift that tipped over during a resident transfer was immediately pulled from service; and to ensure Certified Nursing Assistants (CNAs) were trained and knowledgeable in the safe use of mechanical lifts as per manufacturer instructions to decrease the potential for transfer related injuries for 1 (Resident #10) of 7 (Residents #4, #5, #10. #12, #16, #17 and #18) case mix residents who required transfers using a Hoyer lift. The facility also failed to ensure Certified Nursing Assistants (CNAs) immediately reported the incident to a licensed nurse to allow an assessment to be conducted before moving the resident, which could result in exacerbation of any potential injury for 1 (Resident #10) of 7 (Residents #4, #5, #10. #12, #16, #17 and #18) case mix residents who required transfers using a Hoyer lift. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #10 who was being transferred in a Hoyer lift on two occasions when it tipped to the side and had the potential to cause more than minimal harm to 9 residents who were identified as requiring a Hoyer lift for transfers, according to a list from the Director of Nursing (DON) on 9/17/15 at 11:50 a.m. The Administrator was notified of the Immediate Jeopardy on 9/17/15 at 5:36 p.m. The findings are: 1. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 7/30/15 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status; was totally dependent on the physical assistance of one person for bed mobility, was totally dependent on the physical assistance of two-plus people for transfers and locomotion, did not walk, was unsteady and only able to stabilize with staff assistance during surface-to-surface transfers; had limitation in range of motion of a lower and upper extremity on one side; used a wheelchair for locomotion; and was 70 inches tall and weighed 220 pounds. a. The Resident Plan of Care dated 8/30/15 documented, At risk for fall related injury D/T (due to) Right sided Paralysis . Safety measures to reduce fall risk . Report falls to physician and responsible party . Fall Risk assessment Quarterly and PRN (as needed) after falls . Provide / monitor use of adaptive devices . Assist with Transfers . Resident has ADL (activities of daily living) Self-Care Deficit . (nursing) staff to provide all ADL care to ensure daily needs are met . requires total assist with . transfers . The undated Nursing Assistant Closet Care Plan documented, .Transfer Skills . With 2 assist . Mechanical Lift. b. On 9/17/15 at 9:07 a.m., Certified Nursing Assistant (CNA) #1 was asked if she gets Resident #10 up. She stated, Yes, two of us with a lift. The CNA was asked if the resident had ever fallen or had been dropped from the lift. CNA #1 stated, Yeah, there were two of us in there. He didn't hit the floor, but we had to catch the lift. The CNA was asked, Who was with you? CNA #1 stated, (CNA #3.) CNA #1 was asked if they told anyone about the problem with the lift. The CNA stated, I think she (CNA #3) reported it. I was just over there helping her and we did the lift like we were supposed to. CNA #1 was asked, Did they check the lift? The CNA stated, I don't know, I was gone. I was off a couple of days. CNA #1 was asked, Was the resident checked for any injuries? CNA #1 stated, Since I didn't report it, I'm not sure. But he didn't hit anything. He didn't hit the ground. CNA #1 stated this occurrence might have been around the end of August 2015. On 9/17/15 at 9:50 a.m., CNA #1 was asked if the resident was eased to the floor. The CNA stated, It's hard for me to remember. I know we were keeping the lift from turning over. I think we did ease him to the floor . c. On 9/17/15 at 9:18 a.m., CNA #3 was asked to explain what happened when the lift tipped with Resident #10. She stated, The lift tilted. We hooked the lift up by color and as we got ready to lift him, we locked the lift. As I was pumping him up, the lift was still locked and the lift started to tilt over. (CNA #1) grabbed the middle of the lift and I grabbed the top part of the lift. We couldn't get the lift straightened up so we eased (Resident #10) to the floor. The weight of the lift was on my back. Due to the fact that we could keep the lift from falling on him, he wasn't hurt. We unhooked the lift and asked him if he was hurt anywhere. He was shaking his head no. We unhooked the lift and then redid it with the sling hook-ups, and started to pump it up again. The lift started to tilt again. We eased him back down on the floor and did a two person transfer with a gait belt. He is able to bear weight on one side and pivot. We put him in the wheelchair; then we moved him to his bed. We had been going to move him from his wheelchair to his bed . We left the room and reported to the nurse who was here. That was (Licensed Practical Nurse (LPN) #1). I don't know what was done after that. I have a friend (CNA #4) who worked last night (9/16/15) and she said it was tilting with them too when they were transferring (Resident #10). I guess they were able to do like me and (CNA #1) did, I don't know . On 9/17/15 at 9:54 a.m., LPN #1 was asked if a report was given to her about the lift tilting with Resident #10. She stated, No; no one reported anything about the lift to me. d. On 9/17/15 at 9:42 a.m., CNA #4 stated, I assisted another aide . last night. We had him (Resident #10) in the lift, hovering above the bed and letting it down. As soon as we got him down to about an inch or two over the bed, the lift started to tilt. I grabbed him and secured him to make sure he didn't hit anything and just finished putting him in bed. CNA #4 was asked if this had ever happened before. The CNA stated, I usually work on C-Hall and we don't have anyone who needs the lift. CNA #4 was asked if she told anyone. The CNA stated, The lead CNA (CNA #5). On 9/17/15 at 2:10 p.m., Lead CNA #5 was asked if the lift had been reported to her the night before (9/16/15). She stated, (CNA #4) came to me last night and reported that the black Hoyer lift tipped with (Resident #10) last night when they were putting him to bed, but they were over the mattress and he wasn't hurt. I should have told the DON (Director of Nursing) but was busy passing trays and he wasn't hurt. I take full responsibility for it. e. On 9/17/15 at 11:50 a.m., Restorative CNA #6 stated, There are 3 Hoyer lifts that are all stored on B hall in the storage room. The Restorative CNA was asked if any lift could be used on any hall. The Restorative CNA stated, Yes. The Restorative CNA was asked if she had any complaints or problems with Hoyer lifts tilting. The Restorative CNA stated, No, the legs have to be spread apart so it won't tip. On 9/17/15 at 12:00 p.m., CNA #11 was asked if she had ever had a Hoyer lift tip. She stated, If the legs are spread out it won't tip. f. On 9/17/15 at 12:30 p.m., the DON was asked what was done after Resident #10 was lowered to the floor the end of August 2015 and after last night, 9/16/15. She stated she was unaware of the incidents. On 9/17/15 at 2:08 p.m., the DON stated, I am doing in-services and have pulled that black Hoyer off. They are not to use it on a resident. g. On 9/17/15, CNAs were interviewed regarding attendance of inservices in use of mechanical lift. 1) At 10:03 a.m., CNA #3 was asked if she had been in-serviced on the lift. She stated, Not since I got my license, but when I was a Nursing Assistant. 2) At 4:10 p.m., CNA #8 was in Resident #10's room. She was asked if she had been in-serviced on the lift. She stated, No. 3) At 4:11 p.m., CNA #9 was in Resident #10's room. She was asked if she had been in-serviced on the lift. She stated, On another job. 4) At 4:15 p.m., CNA #10 was in Resident #10's room. She was asked if she had been in-serviced on the lift. She stated, I have worked here 5 years, so I'm sure I must have been. h. On 9/17/15 at 2:25 p.m., the surveyor had CNA #1 and CNA #3 (the two CNAs who experienced the lift tilting the end of August 2015) transfer the surveyor from a chair to a bed while another surveyor observed their technique. The CNAs used the black lift that had been used on the two occasions it had tipped. The lift sling was positioned under the surveyor and the corresponding straps at head and knee attached to the lift. The surveyor was raised with CNA #1 controlling the lift and CNA #3 supporting the surveyor. While the lift was being raised, CNA #3 placed her foot on the right leg of the lift. After the transfer was completed, CNA #3 was asked why she put her foot on the leg of the lift. She stated, Well, I didn't want her to fall. i. On 9/17/15 at 3:45 p.m., CNA #3 was wheeling the black lift down the hall and left it by Resident #10's door. She was asked if that lift was supposed to be used. She stated, The maintenance man said he fixed the lift and it was okay. j. On 9/17/15 at 3:53 p.m., CNA #8 and CNA #9 were in Resident #10's room to complete a transfer with the black Hoyer lift. CNA #8 laid disposable under pads on the resident's bed. CNA #9 removed the resident's leg rests from his wheelchair. CNA #8 opened the legs of the lift and placed the lift legs around the resident's wheelchair. The lift sling was positioned with the top notch on the second loop and the bottom notch on the last loop; the lift was locked. The lift was raised up while CNA #9 turned the resident's body and supported him. CNA #8 closed the legs of the lift and CNA #9 raised the resident's bed. Resident #10 was transferred with the lift legs closed, and the lift was pushed under the resident's bed. CNA #9 told CNA #8 to open the lift legs because, All the weight is over there. k. On 9/17/15 at 4:16 p.m., the Maintenance Supervisor was asked what had been the problem with the lift. He stated, I tightened it. The wheel was loose. The Maintenance Supervisor was asked if the loose wheel could cause the lift to tip. He stated, Yeah, it could. He was asked if he completed routine checks on the lifts. He stated, Yes, I check the batteries and for loose parts one time a month. The CNAs tell me if the lifts are not working okay or they write in my book. The Maintenance Supervisor was asked if the CNAs had written the problem with the lift in his book. He stated, No, I haven't had it written in my book. He was asked if he kept a checklist when the lifts were tested . He stated, I don't keep a checklist. He was asked how he remembered when the lifts were checked. The Maintenance Supervisor stated, Well a month is every 31 days. 2. The Patient Lift Owners Manuel and Instructions were provided on 9/17/15 at 4:25 p.m. by the Administrator and documented, .When using an adjustable base lift, the legs MUST BE in the maximum OPENED / LOCKED position BEFORE lifting the patient . Casters and axle bolts require inspection every six (6) months to check for tightness and wear. Regular maintenance of the patient lift and accessories is necessary to assure proper operation . 3. On 9/18/15 at 9:50 a.m., Immediate Jeopardy was removed and the scope and severity was reduced to an E when the facility implemented the following Plan of Removal: a. The Administrator on/by 9/17/15, 6:00 p.m. reassessed the functioning of the mechanical lift in use and removed it from use. b. The Administrator on 9/17/15 by 8:00 p.m. arranged to purchase a new mechanical lift and have it available for use by 9/18/15, 3:00 a.m. c. The DON (Director of Nursing) identified and listed all residents for whom the mechanical lift was used by staff interview and resident care plans. d. The Treatment Nurse checked all residents for whom the mechanical lift was used for any signs of injury, but none were identified. e. The Administrator informed all of the nursing staff that they could not utilize the mechanical lift until they had received inservice training and demonstration on proper use of the lift. f. The QA (Quality Assurance) Nurse provided inservice training to the CNA supervisor and Restorative Aide and all began immediate inservice training with demonstration on all nursing staff present regarding: (1) the proper use of the mechanical lift for proper technique to maintain resident safety; (2) immediate reporting of any problems with the mechanical lifts during use to the Charge Nurse and removal of the lift from use until assessed by the Administrator or Maintenance Supervisor; (3) staff cannot use the mechanical lift until they have received inservice training and demonstration. g. The CNA Supervisor and/or Restorative Aide will continue to conduct inservice training and demonstration to all nursing staff present regarding: (1) the proper use of the mechanical lift for proper technique to maintain resident safety; (2) immediate reporting of any problems with the mechanical lifts during use to the Charge Nurse and removal of the lift from use until assessed by the Administrator or Maintenance Supervisor with all nursing staff members have been trained and observed prior to them utilizing the lift and: (3) staff cannot use the mechanical lift until they receive inservice training and demonstration. Each shift will be inserviced until all nursing staff is inserviced. h. The Administrator/designee will conduct daily observations of all residents being transferred using the mechanical lift to ensure proper technique and functioning of the lift. Any discrepancies will be corrected immediately by the CNA. i. The Maintenance Supervisor will check all mechanical lifts for proper functioning every month. Any discrepancies will be corrected immediately by removal of the lift from use until fully functional and immediate Administrator notification. The Maintenance Supervisor will maintain a log of all repairs of the mechanical lifts. He will also maintain a monthly check of all lifts.