Every finding on record at The Springs of Fairfield Bay

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to protect four (Resident #1, Resident #9, Resident #10, and Resident #12) of eight residents reviewed for abuse allegations from sexual abuse behavior by another resident. The findings include: A review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on 04/01/2021, revealed the facility must Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: Facility staff Other residents Consultants Volunteers Staff from other agencies Family members Legal representatives Friends Visitors and/or Any other individual. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The Abuse Policy did not address sexual abuse. There was no definition, training for recognition of sign and symptoms, or interventions to prevent sexual abuse. A review of facility Inservice Education Report dated 07/06/2026 revealed the DON and staff were educated on the Abuse, Neglect, Exploitation and Misappropriation Prevention Program. Resident #1 A review of an admission Record revealed that the facility admitted Resident #1 on 03/02/2021 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, and depression. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/08/2026, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #1 required setup-cleanup assistance for eating and maximal assistance for personal hygiene. Resident #1 required supervision or touching assistance on bed mobility and was always incontinent of both bowel and bladder. A review of Resident #1's Care Plan, revised on 08/25/2025, revealed the resident had impaired cognitive function related to dementia. Interventions initiated on 12/09/2024 included administering medications as ordered, to observe for side effects and effectiveness, cue, reorient and supervise as needed. A review of Physician's Orders revealed Resident #1 had an order to be admitted to hospice service for diagnosis of vascular dementia with other behavioral disturbance on 07/17/2025. Resident #9A review of an admission Record revealed that the facility admitted Resident #9 on 06/09/2022 with diagnoses that included sequelae (impairments) of cerebral infarction, flaccid hemiplegia affecting left nondominant side (paralysis to one side of the body with lack of tone), and follicular disorder. A review of the annual MDS, with an ARD of 04/15/2026, revealed Resident #9 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of Resident #9's Care Plan, dated 03/28/2025, revealed the Resident #9 had limited physical mobility related to contractures, and stroke. Interventions included using wheelchair for locomotion, requiring supervision with short distances and substantial assistance with longer distances. Resident #10 A review of an admission Record revealed that the facility admitted Resident #10 on 05/22/2025 with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorders, mixed receptive-expressive language disorder, and need for assistance with personal care. A review of the annual MDS, with an ARD of 05/12/2026, revealed Resident #10 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. A review of Resident #10's Care Plan, dated 05/29/2025, revealed the resident had impaired cognitive function related to cerebrovascular accident (stroke). Interventions included that the resident needed supervision and assistance with all decision making. The Care Plan also revealed Resident #10 had cataracts and could not see. Interventions included telling the resident where you were and arranging consultations with an eye care practitioner as needed. Resident #12 A review of an admission Record revealed that the facility admitted Resident #12 on 04/16/2024 with diagnoses that included essential tremors, generalized anxiety disorder, bipolar disorder, depression, and heart disease. A review of the quarterly MDS, with an ARD of 06/23/2026, revealed Resident #12 had a BIMS score of 14, which indicated the resident was cognitively intact. A review of Resident #12's Care Plan, dated 03/25/2025, revealed Resident #12 had limited physical mobility related to chronic pain and muscle wasting. Interventions included providing supportive care and assisting with mobility as needed. The Care Plan also revealed that the resident required supervision to partial assistance with locomotion using a wheelchair and walker. Resident #2 A review of an admission Record revealed the facility admitted Resident #2 on 03/04/2020 with diagnoses that included schizoaffective disorder, bipolar disorder, unspecified psychosis, major depressive disorder, and anxiety disorder. A review of the quarterly MDS, with an ARD of 07/01/2026, revealed Resident #2 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of Physician's Orders revealed Resident #2 had an order for an antidepressant medication to be given one time a day with an order date of 07/06/2026.A review of the antidepressant package insert revealed that the most commonly observed adverse reactions were insomnia, ejaculation disorder (primarily ejaculation delay), nausea, increased sweating, fatigue and somnolence, decreased libido, and anorgasmia. A review of Resident #2's Care Plan, dated 01/03/2025, revealed the resident does not always cope well, but I am working on it, when I can feel something is wrong, I speak to the Psych Advanced Practitioner Registered Nurse (APRN) about my feelings. Interventions included encourage resident to verbalize feelings regarding fear and anxiety. Evaluate for cause of fear or anxiety and reduce unnecessary stimuli. A review of Resident #2's Care Plan revision record on 07/13/2026 revealed there were no revisions to the care plan nor interventions in place for Resident #2 related to sexual behavior for protection of other residents or to prevent the incident from happening in the future During an interview on 07/14/2026 at 10:35 AM, Resident #9 stated Resident #2 grabbed Resident #9's genitalia under the blanket while the resident was asleep in bed. Resident #9 was unable to recall the exact date and time the incident occurred. Resident #9 stated the incident had been reported to the previous administrator by Resident #9. During an interview on 07/16/2026 at 9:20 AM, Resident #12 stated Resident #2 tried to touch them on the genital area in the past but were unable to recall the exact date and time. Resident #12 stated Resident #2 had their hand at Resident #12's thigh area in rubbing motion and moved towards the genital area. Resident #12 told Resident #2 to stop the action. Resident #12 stated it happened a long time ago and they did not report it at that time, until 07/06/2026 when the social worker came to collect witness statements for another incident Resident #2 then reported to the social worker they were touched inappropriately by Resident #2. A review of a Progress Note for Resident #2 dated 06/09/2026 at 8:35 PM by Registered Nurse (RN) #1, revealed that she notified a provider that she had received report from a hospice Certified Nursing Assistant (CNA) about an alleged abuse. The immediate interventions stated Floor staff made aware of situation and to keep residents separate, also monitor for further behaviors. Residents were separated, fellow resident assessed for injury or distress. The Assistant Director of Nursing (ADON) originally notified, followed by the Director of Nursing (DON) on 6/8/2026. A review of a Progress Note dated 06/08/2026 at 3:58 PM by the ADON, revealed Spoke to Resident #2 about being observed touching another resident inappropriately. The note also revealed the Resident denied completely and stated I may have put my hand on top of my friend's hand, but nowhere else. A review of a Progress Note dated 06/11/2026 at 11:13 AM by the DON, revealed the incident description as CNA reported to nursing staff that resident was too close to another resident, touching resident's hand. Long term interventions revealed that the resident [was] set up for psych referral, urinary analysis ordered. A review of a Progress Note dated 07/09/2026 at 1:42 PM titled as a late entry note referencing the incident on 07/05/2026 at 7:30 PM by the DON, revealed reported by staff that Resident #2 had hand under blanket of another resident in the day/activity room. The intervention was Psych to follow and medication review. A review of Resident #2's Psychology Progress Note dated 07/06/2026 at 10:47 AM revealed Resident #2 was seen for individual psychotherapy services to address social functioning, interpersonal boundaries, emotional adjustment, and progress toward the treatment objective of engaging in positive social interactions with peers, staff, and others. Staff reported a recent incident involving inappropriate physical contact/fondling of another resident. Following this incident, the resident was moved to a private room with a plan to continue individual psychotherapy services to address the concerns. During an interview on 07/14/2026 12:24 PM, CNA #8 stated that on 06/08/2026 at approximately 1:00 PM, while walking with another resident on the hall, she saw Resident #2 grabbing Resident #10's [genitalia] and making a rubbing motion. CNA #8 reported what she had seen to RN #1 immediately. CNA #8 stated she filled out a witness statement for the ADON and took a photo of the original statement. A review of a Witness Statement dated 06/08/2026 provided by CNA #8 revealed, Was walking down [NAME] Hall towards nurses' station when I saw [Resident #2] touching another resident inappropriately. Resident #2 had a hand on the other resident's [genitalia], outside of the pants and was making a rubbing and tapping motion. Notified [RN #1] immediately and she told [Resident #2] to get away from the other resident. During an interview on 07/14/2026 1:29 PM, CNA #6 stated on 07/05/2026 7:40 PM, she put Resident #1 in the recliner in the activity room, then left to round on other residents. When she came back to the activity room, she saw that Resident #2 had their hand inside Resident #1's pants in the genital area and was making jerking motions. She stated she separated Resident #2 and Resident #1. Resident #2 refused to leave the activity room and told CNA#6 to go away. CNA #6 stated she reported it to the floor nurse [RN#1], the ADON and the DON. CNA #6 stated she wrote a witness statement stating the sexual assault occurred and gave the copies of the witness statements to RN #1, the ADON and the DON. CNA #6 stated she was asked by the DON to write a new witness statement without the word sexual assault in the statement and wanted her to write that Resident #2 only put a hand on Resident #1's hand. CNA #6 stated she did not rewrite the witness statement. CNA #6 provided a picture of the original copy to this surveyor. CNA #6 stated she had also reported more than one time to the ADON previously that Resident #2 had touched Resident #9 inappropriately A review of a Witness Statement dated 07/05/2026 provided by CNA #6 revealed, As I passed by the day room, I caught Resident #2 placing their hand down the pants of Resident #1 who I had just placed in the recliner. After confronting the resident, they proceeded to say they did not have to go back to the room. Resident #2 sat and waited for me to leave the room so they could continue sexual assaulting the resident I placed in there. During an interview on 07/14/2026 9:45 AM, RN #1 stated she received report from CNA #8 on 06/08/2026 that Resident #2 was touching Resident #10 inappropriately. RN #1 stated that she went over and separated the residents. RN #1 stated she reported the incident to the ADON and the DON. She stated she also received report from CNA #6 on 07/05/2026 that Resident #2 was touching Resident #1 inappropriately and reported it to the ADON and DON. RN #1 stated the same allegations were made regarding Resident #2 touching Resident #9 and Resident #12 in the past, and the ADON was also made aware of those allegations. On 07/14/2026 at 1:00 PM, this surveyor requested the completed Incident and Accident (I&A) for the incident on 06/08/2026 from the Administrator. The Administrator provided witness statements and body audits dated in July. A review of witnesses' documents revealed they were collected from 07/06/2026-07/13/2026. There were no witness statements from CNA #6 or CNA #8 provided by the facility. The answers for all witness statements were no to the questions of have you ever seen [Resident #2] touch another resident's exposed private parts, and who did you report this to.A review of a Witness Statement located in the I&A documentation and dated 07/13/2026 identified as CNA #6 but filled out by RN #1 and signed by RN #1, stated No I have not witnessed anything personally, and I reported allegations to my chain of command beginning with my ADON. A review of a Witness Statement for Resident #9 stated they were touched inappropriately at the genital area by Resident #2. The statement had the month of July (7- at 1:00 PM) on it with no day or year filled in A review of Body Audits dated 07/06/2026 contained in the 06/08/2026 I&A documentation revealed there were no skin issues on Resident #1. There was slight redness to the buttock area with treatment on Resident #10. There was no body audit documented for Resident #9 or Resident #12. Review of a facility I&A List dated 03/2026 to 07/13/2026 revealed there was no incident on 07/05/2026 listed. During an interview on 07/14/2026 at 2:39 PM, the ADON stated he did not remember the details of the incident on 06/08/2026 or 07/05/2026 but recalled that he was told that Resident #2 was touching Resident #10 and Resident #1 inappropriately. The ADON stated he did a follow up by talking to Resident #2 about the incident on 06/08/2026, and Resident #2 denied anything other than putting their hand on their friend's hand. The ADON did not fill out or follow up with a witness statement. During an interview on 07/14/2026 at 3:17 PM, the DON stated RN #1 had reported the incident on 06/08/2026 where Resident #2 touched Resident #10 inappropriately and the incident on 07/05/2026 where Resident #2 touched Resident #1 inappropriately. She stated she immediately investigated the concerns and stated that Resident #2 only put a hand on Resident #10 to comfort, nothing inappropriate. The DON stated she asked the majority of staff, and nobody reported seeing the inappropriate touching. She did not have knowledge of the Witness Statement related to the incident on 06/08/2026. The DON stated she was aware of the correct process for reporting. She stated she should have reported the incidents to the State Agency. The DON stated she was not aware of Resident #9 being touched inappropriately in the past. During an interview on 07/16/2026 at 9:58 AM, the Social Worker stated she had collected a witness statement from Resident #12, who stated yes Resident #12 had been touched inappropriately by Resident #2 in the past. The social worker stated she gave the statement to the Administrator. During an interview on 07/14/2026 at 4:10 PM, the Administrator stated there was no documentation on the investigation about the incident on 06/08/2026. The Administrator stated she or one of the nurses went back and clarified with Resident #12 if they had been touched inappropriately by Resident #2 and the answer in the witness statement was No. The Administrator stated she was not aware of any missing witness statements. She stated Resident #2 used a hand to comfort other residents, nothing in appropriate. During an interview on 07/16/2026 at 8:46 AM, the APRN stated she was only aware of inappropriate touching by Resident #2 to Resident #9 last year. She was not aware of other incidents. The APRN stated Resident #9 was cognitively intact and that she believed the incident truly occurred. She asked Resident #2 if they had touched Resident #9, and Resident #2 denied touching Resident #9 inappropriately and went on hunger strike. The APRN stated she was worried due to Resident #2 being diabetic. She asked the DON about the incident and was told that it was under investigation. The APRN stated she was not aware of Resident #2's past history of sexual abuse. The APRN stated Resident #2 was currently in therapy with a counselor. The APRN stated she was just told about the incident involving Resident #1 last week and was told by the DON that it was just a comfort gesture, nothing inappropriate. During an interview on 07/16/2026 at 9:31 AM, a License Professional Counselor (LPC) stated she asked Resident #2 about the incident with Resident #1, but Resident #2 was guarded and did not want to talk about it. The LPC stated she was made aware of the incident by the DON in person, and this was the only occurrence she was aware of. The LPC did not know of any history or trigger for the behavior. During an interview on 07/15/2026 at 2:15 PM, the police department stated they were not notified of any related incidents.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure all alleged sexual allegations were fully investigated for four (Resident #1, Resident#9, Resident #10, and Resident #12) of eight residents reviewed for abuse allegations. The findings include: A review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on 04/01/2021, revealed the facility must Investigate and report any allegations within timeframes required by federal requirements. The Abuse Policy did not address sexual abuse. There was no definition, training for recognition of sign and symptoms, or interventions to prevent sexual abuse. A review of facility Inservice Education Report dated 07/06/2026 revealed the DON and staff were educated on the Abuse, Neglect, Exploitation and Misappropriation Prevention Program. Resident #1 A review of an admission Record revealed that the facility admitted Resident #1 on 03/02/2021 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, and depression. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/08/2026, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #1 required setup-cleanup assistance for eating and maximal assistance for personal hygiene. Resident #1 required supervision or touching assistance on bed mobility and was always incontinent of both bowel and bladder. A review of Resident #1's Care Plan, revised on 08/25/2025, revealed the resident had impaired cognitive function related to dementia. Interventions initiated on 12/09/2024 included administering medications as ordered, to observe for side effects and effectiveness, cue, reorient and supervise as needed. A review of Physician's Orders revealed Resident #1 had an order to be admitted to hospice service for diagnosis of vascular dementia with other behavioral disturbance on 07/17/2025. Review of a facility I&A List dated 3/2026 to 07/13/2026 revealed that there was no incident on 07/05/2026 listed. On 07/05/2026 at 7:40 PM Certified Nurse Assistant (CNA) #6 reported to Registered Nurse (RN) #1 she had witnessed Resident #2 with a hand under Resident #1's pants and made up and down motion at the genital area in the activity room. During an interview on 07/14/2026 1:29 PM, CNA #6 stated on 07/05/2026 at 7:40 PM, she put Resident #1 in the recliner in the activity room, then left to round on other residents. When she came back to the activity room, she saw that Resident #2 had their hand inside Resident #1's pants in the genital area and was making jerking motions. She stated she separated Resident #2 and Resident #1. Resident #2 refused to leave the activity room and told CNA#6 to go away. CNA #6 stated she reported it to the floor nurse [RN#1], the ADON and the DON. CNA #6 stated she wrote a witness statement stating the sexual assault occurred and gave the copies of the witness statements to RN #1, the ADON and the DON. CNA #6 stated she was asked by the DON to write a new witness statement without the word sexual assault in the statement and wanted her to write that Resident #2 only put a hand on Resident #1's hand. CNA #6 stated she did not rewrite the witness statement. CNA #6 provided a photo of the original copy to this surveyor. A review of a Witness Statement dated 07/05/2026 provided by CNA #6 revealed, As I passed by the day room, I caught Resident #2 placing their hand down the pants of Resident #1 who I had just placed in the recliner. After confronting the resident, they proceeded to say they did not have to go back to the room. They sat and waited for me to leave the room so they could continue sexual assaulting the resident I placed in there. A review of a Witness Statement located in the facility's Incident & Accident (I&A) documentation and dated 07/13/2026, identified as CNA #6 but filled out 1 and signed by RN #1, stated No I have no witnessed anything personally, and I reported allegations to my chain of command beginning with my Assistant Director of Nursing (ADON). During an interview on 07/14/2026 at 6:20 PM, Resident #1's family stated they were not notified about the incident on 07/05/2026. Resident #9 A review of an admission Record revealed that the facility admitted Resident #9 on 06/09/2022 with diagnoses that included sequelae (impairments) of cerebral infarction, flaccid hemiplegia affecting left nondominant side (paralysis to one side of the body with lack of tone), and follicular disorder. A review of the annual MDS, with an ARD of 04/15/2026, revealed Resident #9 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of Resident #9's Care Plan, dated 03/28/2025, revealed the Resident #9 had limited physical mobility related to contractures, and stroke. Interventions included using wheelchair for locomotion, requiring supervision with short distances and substantial assistance with longer distances. During an interview on 07/14/2026 at 10:35 AM, Resident #9 stated that Resident #2 grabbed Resident #9's[genitalia] under the blanket while the resident was asleep in bed. Resident #9 was unable to recall the exact date and time the incident occurred. Resident #9 stated they reported the incident to the previous administrator by Resident #9. During an interview on 07/14/2026 1:29 PM, CNA #6 stated she had reported to the ADON more than one time that Resident #2 touched Resident #9 inappropriately. Resident #10 A review of an admission Record revealed that the facility admitted Resident #10 on 05/22/2025 with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorders, mixed receptive-expressive language disorder, the need for assistance with personal care. A review of the annual MDS, with an ARD of 05/12/2026, revealed Resident #10 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. A review of Resident #10's Care Plan, dated 05/29/2025, revealed the resident had impaired cognitive function related to cerebrovascular accident. Interventions included the resident needs supervision and assistance with all decision making. The Care Plan also revealed that Resident #10 had cataracts and could not see. Interventions included telling the resident where you were and arranging consultations with eye care practitioner as needed. On 06/08/2026 at approximately 1:00 PM, on the hallway by nursing station, CNA#8 witnessed Resident #2 touching Resident #10 inappropriately by having a hand on Resident #10 genital area and making rubbing motion During an interview on 07/14/2026 12:24 PM, CNA #8 stated that on 06/08/2026 at approximately 1:00 PM, while walking with another resident on the hall, she saw Resident #2 grabbing Resident #10's [genitalia] and making a rubbing motion. CNA #8 reported what she had seen to RN #1 immediately. CNA #8 stated she filled out a witness statement for the ADON and took a photo of the original statement. A review of a Witness Statement dated 06/08/2026 provided by CNA #8 revealed, Was walking down [NAME] Hall towards nurses' station when I saw [Resident #2] touching another resident inappropriately. Resident #2 had a hand on the other resident's [genitalia], outside of the pants and was making a rubbing and tapping motion. Notified [RN #1] immediately and she told [Resident #2] to get away from the other resident. During an interview on 07/14/2026 at 7:47 PM, Resident #10's family stated they were not notified about the incident on 06/08/2026. Review of a facility I&A List dated 3/2026 to 07/13/2026 revealed an incident on 06/08/2026 documented as other. On 07/14/2026 at 1:00 PM, this surveyor requested the completed I&A for the incident on 06/08/2026 from the Administrator, The Administrator provided witness statements and body audits dated July instead. A review of witnesses' documents revealed they were collected from 07/06/2026-07/13/2026. There was no witness statement from CNA #6 or CNA #8 provided by the facility. There was a Witness Statement for Resident #9 stated they were touched inappropriately at the genital area by Resident #2. The statement had the month of July (7- at 1:00 PM) on it with no day or year filled in. On 07/14/2026 at 4:10 PM the Administrator stated there was no documentation on investigation about the incident on 06/08/2026. Resident #12 A review of an admission Record revealed that the facility admitted Resident #12 on 04/16/2024 with diagnoses that included essential tremor, generalized anxiety disorder, bipolar disorder, depression, and heart disease. A review of the quarterly MDS, with an ARD of 06/23/2026, revealed Resident #12 had a BIMS score of 14, which indicated the resident was cognitively intact. A review of Resident #12's Care Plan, dated 03/25/2025, revealed Resident #12 had limited physical mobility related to chronic pain and muscle wasting. Interventions included providing supportive care and assisting with mobility as needed. The Care Plan also revealed that the resident required supervision to partial assistance with locomotion using a wheelchair and walker. During an interview on 07/14/2026 9:45 AM, RN #1 stated she received report from CNA #8 on 06/08/2026 that Resident #2 was touching Resident #10 inappropriately. RN #1 stated that she went over and separated the residents. RN #1 stated she reported the incident to the ADON and the DON. She stated she also received report from CNA #6 on 07/05/2026 that Resident #2 was touching Resident #1 inappropriately and reported it to the ADON and DON. RN #1 stated the same allegations were made regarding Resident #2 touching Resident #9 and Resident #12 in the past, and the ADON was also made aware of those allegations. During an interview on 07/14/2026 at 2:39 PM, the ADON stated he did not remember the details of the incident on 6/08/2026 and 7/05/2026 but recalled that he was told that Resident #2 was touching Resident #10 and Resident#1. The ADON stated he did a follow up by talking to Resident #2 about the incident on 6/08/2026, and Resident #2 denied anything other than putting their hand on their friend's hand. The ADON did not fill out or follow up with a witness statement. During an interview on 07/14/2026 at 3:17 PM, the DON stated RN #1 reported the incidents on 06/08/2026 that Resident #2 touched Resident #10 inappropriately and on 07/05/2026 that Resident #2 touched Resident #1 inappropriately. She stated she immediately investigated the concerns and stated that Resident #2 only put a hand on Resident #10 to comfort, nothing inappropriate. The DON stated she asked the majority of staff, and nobody reported seeing the inappropriate touching. She did not have knowledge of the Witness Statement related to the incident on 06/08/2026. The DON stated she was aware of the correct process for reporting. She stated she should have reported both incidents to the State Agency. The DON stated she was not aware of Resident #9 being touched inappropriately in the past. During an interview on 07/14/2026 at 4:10 PM, the Administrator stated there was no documentation on the investigation about the incident on 06/08/2026. The Administrator stated she or one of the nurses went back and clarified with Resident #12 if they had been touched inappropriately by Resident #2 and the answer in the witness statement was No. The Administrator stated she was not aware of any missing witness statements. She stated Resident #2 used a hand to comfort other residents, nothing in appropriate. During an interview on 07/16/2026 at 8:46 AM, the APRN stated she was only aware of inappropriate touching by Resident #2 to [Resident #9] last year. She was not aware of other incidents. The APRN stated that Resident #9 was cognitively intact and that she believed the incident truly occurred. She asked Resident #2 if they had touched Resident #9, and Resident #2 denied touching Resident #9 inappropriately and went on hunger strike. The APRN stated she was worried due to Resident #2 being diabetic. She asked the DON about the incident and was told that it was under investigation. The APRN stated she was not aware of Resident #2's history of sexual abuse in the past. The APRN stated Resident #2 was currently in therapy with a counselor. The APRN stated she was just told about the incident involving Resident #1 last week and was told by the DON that it was just a comfort gesture, nothing inappropriate. During an interview on 07/16/2026 at 9:20 AM, Resident #12 stated Resident #2 tried to touch them on the genital area in the past but were unable to recall the exact date and time. Resident #12 stated Resident #2 had their hand at Resident #12's thigh area in rubbing motion and moved towards the genital area. Resident #12 told Resident #2 to stop the action. Resident #12 stated it happened a long time ago and they did not report it at that time, until 07/06/2026 when the social worker came to collect witness statements for another incident Resident #2 then reported to the social worker they were touched inappropriately by Resident #2. During an interview on 07/16/2026 at 9:31 AM, a License Professional Counselor (LPC) stated that she asked Resident #2 about the incident with Resident #1, but Resident #2 was guarded and did not want to talk about it. The LPC stated she was made aware of the incident by the DON in person, and this was the only occurrence she was aware of. The LPC did not know of any history or trigger for the behavior. During an interview on 07/16/2026 at 9:58 AM, the Social Worker stated she had collected a witness statement from Resident #12, who stated yes, they (Resident #12) had been touched inappropriately by Resident #2 in the past. The social worker stated she, gave the statement to the Administrator. During an interview on 07/15/2026 at 2:15 PM, the police department stated they were not notified of any related incidents.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to report alleged allegations of resident-to-resident sexual abuse for four (Resident #1, Resident #9, Resident #10, and Resident #12) of eight residents reviewed for abuse allegations. The findings include: A review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on 04/01/2021, revealed the facility must Investigate and report any allegations within timeframes required by federal requirements. The Abuse Policy did not address sexual abuse. There was no definition, training for recognition of sign and symptoms, or interventions to prevent sexual abuse. A review of facility Inservice Education Report dated 07/06/2026 revealed the DON and staff were educated on the Abuse, Neglect, Exploitation and Misappropriation Prevention Program. Resident #1 A review of an admission Record revealed that the facility admitted Resident #1 on 03/02/2021 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, and depression. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/08/2026, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #1 required setup-cleanup assistance for eating and maximal assistance for personal hygiene. Resident #1 required supervision or touching assistance on bed mobility and was always incontinent of both bowel and bladder. A review of Resident #1's Care Plan, revised on 08/25/2025, revealed the resident had impaired cognitive function related to dementia. Interventions initiated on 12/09/2024 included administering medications as ordered, to observe for side effects and effectiveness, cue, reorient and supervise as needed. A review of Physician's Orders revealed Resident #1 had an order to be admitted to hospice service for diagnosis of vascular dementia with other behavioral disturbance on 07/17/2025. During an interview on 07/14/2026 at 1:29 PM, CNA #6 stated on 07/05/2026 at 7:40 PM, she put Resident #1 in the recliner in the activity room, then left to round on other residents. When she came back to the activity room, she saw that Resident #2 had their hand inside Resident #1's pants in the genital area and was making jerking motions. She stated she separated Resident #2 and Resident #1. Resident #2 refused to leave the activity room and told CNA#6 to go away. CNA #6 stated she reported it to the floor nurse [RN#1], the ADON and the DON. CNA #6 stated she wrote a witness statement stating the sexual assault occurred and gave the copies of the witness statements to RN #1, the ADON and the DON. CNA #6 stated she was asked by the DON to write a new witness statement without the word sexual assault in the statement and wanted her to write that Resident #2 only put a hand on Resident #1's hand. CNA #6 stated she did not rewrite the witness statement. CNA #6 provided a photo of the original copy to this surveyor. A review of a Witness Statement dated 07/05/2026 provided by CNA #6 revealed, As I passed by the day room, I caught Resident #2 placing their hand down the pants of Resident #1 who I had just placed in the recliner. After confronting the resident, they proceeded to say they did not have to go back to the room. They sat and waited for me to leave the room so they could continue sexual assaulting the resident I placed in there. A review of a Witness Statement located in the facility's Incident & Accident (I&A) documentation and dated 07/13/2026, identified as CNA #6 but filled out by RN #1 and signed by RN #1, stated No I have no witnessed anything personally, and I reported allegations to my chain of command beginning with my Assistant Director of Nursing (ADON). During an interview on 07/14/2026 at 6:20 PM, Resident #1's family stated they were not notified about the incident on 07/05/2026. Review of a facility I&A List dated 3/2026 to 07/13/2026 revealed that there was no incident on 07/05/2026 listed. Resident #9 A review of an admission Record revealed that the facility admitted Resident #9 on 06/09/2022 with diagnoses that included sequelae (impairments) of cerebral infarction, flaccid hemiplegia affecting left nondominant side (paralysis to one side of the body with lack of tone), and follicular disorder. A review of the annual MDS, with an ARD of 04/15/2026, revealed Resident #9 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of Resident #9's Care Plan, dated 03/28/2025, revealed the Resident #9 had limited physical mobility related to contractures, and stroke. Interventions included using wheelchair for locomotion, requiring supervision with short distances and substantial assistance with longer distances. During an interview on 07/14/2026 at 10:35 AM, Resident #9 stated that Resident #2 grabbed Resident #9's[genitalia] under the blanket while the resident was asleep in bed. Resident #9 was unable to recall the exact date and time the incident occurred. Resident #9 stated they reported the incident to the previous administrator. During an interview on 07/14/2026 1:29 PM, CNA #6 stated she had reported to the ADON more than one time that Resident #2 touched Resident #9 inappropriately. Resident #10 A review of an admission Record revealed that the facility admitted Resident #10 on 05/22/2025 with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorders, mixed receptive-expressive language disorder, and need for assistance with personal care. A review of the annual MDS, with an ARD of 05/12/2026, revealed Resident #10 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. A review of Resident #10's Care Plan, dated 05/29/2025, revealed the resident had impaired cognitive function related to cerebrovascular accident (stroke). Interventions included that the resident needed supervision and assistance with all decision making. The Care Plan also revealed Resident #10 had cataracts and could not see. Interventions included telling the resident where you were and arranging consultations with an eye care practitioner as needed. During an interview on 07/14/2026 12:24 PM, CNA #8 stated that on 06/08/2026 at approximately 1:00 PM, while walking with another resident on the hall, she saw Resident #2 grabbing Resident #10's [genitalia] and making a rubbing motion. CNA #8 reported what she had seen to RN #1 immediately. CNA #8 stated she filled out a witness statement for the ADON and took a photo of the original statement. A review of a Witness Statement dated 06/08/2026 provided by CNA #8 revealed, Was walking down [NAME] Hall towards nurses' station when I saw [Resident #2] touching another resident inappropriately. Resident #2 had a hand on the other resident's [genitalia], outside of the pants and was making a rubbing and tapping motion. Notified [RN #1] immediately and she told [Resident #2] to get away from the other resident. During an interview on 07/14/2026 at 7:47 PM, Resident #10's family stated they were not notified about the incident on 06/08/2026. Review of a facility I&A List dated 3/2026 to 07/13/2026 revealed an incident on 06/08/2026 documented as other. On 07/14/2026 at 1:00 PM, this surveyor requested the completed I&A for the incident on 06/08/2026 from the Administrator, The Administrator provided witness statements and body audits dated July instead. A review of witnesses' documents revealed they were collected from 07/06/2026-07/13/2026. There was no witness statement from CNA #6 or CNA #8 provided by the facility. There was a Witness Statement for Resident #9 which stated they were touched inappropriately at the genital area by Resident #2. The statement had the month of July (7- at 1:00 PM) on it with no day or year filled in. On 07/14/2026 at 4:10 PM the Administrator stated there was no documentation on investigation about the incident on 06/08/2026. Resident #12 A review of an admission Record revealed that the facility admitted Resident #12 on 04/16/2024 with diagnoses that included essential tremor, generalized anxiety disorder, bipolar disorder, depression, and heart disease. A review of the quarterly MDS, with an ARD of 06/23/2026, revealed Resident #12 had a BIMS score of 14, which indicated the resident was cognitively intact. A review of Resident #12's Care Plan, dated 03/25/2025, revealed Resident #12 had limited physical mobility related to chronic pain and muscle wasting. Interventions included providing supportive care and assisting with mobility as needed. The Care Plan also revealed that the resident required supervision to partial assistance with locomotion using a wheelchair and walker. During an interview on 07/14/2026 9:45 AM, RN #1 stated she received report from CNA #8 on 06/08/2026 that Resident #2 was touching Resident #10 inappropriately. RN #1 stated that she went over and separated the residents. RN #1 stated she reported the incident to the ADON and the DON. She stated she also received report from CNA #6 on 07/05/2026 that Resident #2 was touching Resident #1 inappropriately and reported it to the ADON and DON. RN #1 stated the same allegations were made regarding Resident #2 touching Resident #9 and Resident #12 in the past, and the ADON was also made aware of those allegations. During an interview on 07/14/2026 at 2:39 PM, the ADON stated he did not remember the details of the incident on 06/08/2026 and on 07/05/2026 but recalled that he was told that Resident #2 had touched Resident #10 and Resident #1. The ADON stated he did a follow up by talking to Resident #2 about the incident on 06/08/2026, and Resident #2 denied anything other than putting their hand on their friend's hand. The ADON did not fill out or follow up with a witness statement. During an interview on 07/14/2026 at 3:17 PM, the DON stated RN #1 reported the incidents on 06/08/2026 that Resident #2 touched Resident #10 inappropriately and on 07/05/2026 that Resident #2 touched Resident #1 inappropriately. She stated she immediately investigated the concerns and stated that Resident #2 only put a hand on Resident #10 to comfort, nothing inappropriate. The DON stated she asked the majority of staff, and nobody reported seeing the inappropriate touching. She did not have knowledge of the Witness Statement related to the incident on 06/08/2026. The DON stated she was aware of the correct process for reporting. She stated she should have reported the incidents to the State Agency. The DON stated she was not aware of Resident #9 being touched inappropriately in the past. During an interview on 07/14/2026 at 4:10 PM, the Administrator stated there was no documentation on the investigation about the incident on 06/08/2026. The Administrator stated she or one of the nurses went back and clarified with Resident #12 if they had been touched inappropriately by Resident #2 and the answer in the witness statement was No. The Administrator stated she was not aware of any missing witness statements. She stated Resident #2 used a hand to comfort other residents, nothing in appropriate. During an interview on 07/16/2026 at 8:46 AM, the APRN stated she was only aware of inappropriate touching by Resident #2 to the roommate [Resident #9] last year. She was not aware of other incidents. The APRN stated that Resident #9 was cognitively intact and that she believed the incident truly occurred. She asked Resident #2 if they had touched Resident #9, and Resident #2 denied touching Resident #9 inappropriately and went on hunger strike. The APRN stated she was worried due to Resident #2 being diabetic. She asked the DON about the incident and was told that it was under investigation. The APRN stated she was not aware of Resident #2's history of sexual abuse in the past. The APRN stated Resident #2 was currently in therapy with a counselor. The APRN stated she was just told about the incident involving Resident #1 last week and was told by the DON that it was just a comfort gesture, nothing inappropriate. During an interview on 07/16/2026 at 9:20 AM, Resident #12 stated Resident #2 tried to touch them on the genital area in the past but were unable to recall the exact date and time. Resident #12 stated Resident #2 had their hand at Resident #12's thigh area in rubbing motion and moved towards the genital area. Resident #12 told Resident #2 to stop the action. Resident #12 stated it happened a long time ago and they did not report it at that time, until 07/06/2026 when the social worker came to collect witness statements for another incident Resident #2 then reported to the social worker, they were touched inappropriately by Resident #2. During an interview on 07/16/2026 at 9:31 AM, a License Professional Counselor (LPC) stated that she asked Resident #2 about the incident with Resident #1, but Resident #2 was guarded and did not want to talk about it. The LPC stated she was made aware of the incident by the DON in person, and this was the only occurrence she was aware of. The LPC did not know of any history or trigger for the behavior. During an interview on 07/16/2026 at 9:58 AM, the Social Worker stated she had collected a witness statement from Resident #12, who stated yes Resident #12 had been touched inappropriately by Resident #2 in the past. The social worker stated she gave the statement to the Administrator. During an interview on 07/15/2026 at 2:15 PM, the police department stated they were not notified of any related incidents.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to properly discard an expired medication for one of one medication cart reviewed. The findings include: During a concurrent observation and interview on 02/25/2026 at 3:06 PM, a histamine two medication bottle, with an expired date of 01/2026 was observed with the seal broken and available for administration in the East-Hall medication cart. Licensed Practical Nurse (LPN) #1 stated if a resident was administered an expired medication, it could have, a different effect and should not be given. During an interview on 02/26/2026 at 8:56 AM, the Assistant Director of Nursing (ADON) stated the medication carts were monitored by staff for recalls. The ADON also stated staff puts expired medications in a secured bin at least once a month and the expired medications were documented by prescription number and resident. The ADON indicated that Over the Counter (OTC) medications were disposed of the same way but put in the log under a general description. The ADON was unable to provide the disposal log for review. During an interview on 02/25/2026 at 11:03 AM the Administrator stated staff should check routinely for medication expiration dates, and the Pharmacist Consultant should check for expired medications as well. The Administrator stated he, was unaware of the last pharmacist check. The Administrator stated he expected that expired medications would not be available for use on the medication carts and he, did not know what the potential outcome could be for a resident receiving expired medications. Review of a [Brand Name] Order List Report printed on 02/25/2026 at 3:48 PM, showed no residents had active orders for the histamine two medication. Review of an undated facility policy titled, Storage of Medications indicated, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Number of residents sampled: Number of residents cited: Based on observations and interviews, it was determined that the facility failed to make facility survey results readily accessible to residents, family members, and legal representatives of residents. The findings include: On 02/24/2026 at 2:22 PM, this surveyor observed the survey book by the main entrance to the building where the assisted living and independent apartment facilities were located, not in the long-term care facility which was at the back of the building behind wooden doors only accessible by a coded keypad. During an interview on 02/24/2026 at 1:37 PM, the Director of Nursing (DON) stated the survey book was located at the front of the building, residents could go up there to meet with family. The DON identified two of thirty-four residents had the capacity to access the front of the building without having to ask for assistance During an interview on 02/24/2026 at 1:37 PM, the Assistant Director of Nursing (ADON) stated, the placement of the survey book was made a long time ago. The ADON also stated, the long-term care unit was behind locked doors on our healthcare side. During an interview on 02/24/2026 at 2:25 PM, the Registered Nurse Consultant (RN Consultant) #2 stated, the survey book was in front of the building in the main lobby; the long-term care residents would need staff assistance to look at the book because the long-term care residents were behind locked double doors at the back of the building. During an interview on 02/26/2026 11:03 AM, the Administrator stated, I am responsible for putting updated surveys in the book. The book is used for visitors and residents. The book should be readily available; it is kept in the lobby. That is not readily available, residents would have to be brought up with staff assistance to see the book

Based on observation, record review, and interview, the facility failed to ensure that (1) Food stored in the walk-in cooler, walk in freezer, dry storage area, and storage area shelves along a back wall were labeled with a receive date and sealed to prevent food borne illness for one out of one kitchen, (2) expired food items were promptly discarded on or before the expiration date to prevent the growth of bacteria, (3) cross contamination did not occur during lunch service by touching the surface area of the plate, touching food inside a scoop, and touching the inside of the bowl, and hands were washed properly after donning/doffing gloves. 1. The following are findings for the walk-in cooler: On [DATE] at 11:28 AM, six yellow onions in a cardboard box with no receive date labeled, the Dietary Manager confirmed there is not a received date. On [DATE] at 11:30 AM, thirty whole tomatoes in a cardboard box, no receive date labeled, Dietary Manager confirmed that it does not have a receive date. On [DATE] at 11:32 AM, two bags of flour tortillas, one bag is opened and half full, while the other is a full closed bag with no receive date, Dietary Manager confirmed findings. 2. These following are findings for the walk-in freezer: On [DATE] at 11:33 AM, a bag of ten frozen pizza sticks with no received date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:35 AM, a cardboard box of frozen fish fillets, full box with no received date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:36 AM, three boxes of not opened frozen vanilla shakes with no received date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:38 AM, an opened cardboard box of frozen tortillas, ,d+[DATE] of the way full, thick ice covered the left and right cardboard flaps, the bags of tortillas contained ice crystals on the outside and inside. Dietary Manager confirmed the findings, states the ice is thick, and covering the top and sides of the boxes underneath the fan in the walk-in freezer. On [DATE] at 11:40 AM, 2 boxes of vanilla ice cream, 2 boxes of orange sherbet not opened, with no receive date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:42 AM, unopened cardboard box of frozen turkey franks with no receive date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:44 AM, an opened cardboard box half full of frozen peas with no receive date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:45 AM A full cardboard box, of four, 6.5 pounds containers of frozen strawberries with no receive date, Dietary Manager confirmed there is no receive date. On [DATE] at 11:48 AM, a bag of frozen fries, and a half bag of fries with no receive date, Dietary Manager confirmed there is no receive date. 3. The following are findings in the Dry Storage Area: On [DATE] at 11:55 AM, two full bags of granola expired on [DATE], both bags have no receive date, Dietary Manager confirmed both findings. On [DATE] at 11:57 AM, five spaghetti sauce mix packets with no receive date, Dietary Manager confirmed there is no receive date. On [DATE] at 12:00 PM, a box of unopened apple juice and orange juice with no receive date, Dietary Manager confirmed there is no receive date on either box. On [DATE] at 12:02 PM, a box of unopened cornflakes with no receive date, Dietary Manager confirmed there was no receive date. 4. The following are findings in the upright deepfreeze: On [DATE] at 12:08 PM, 3 bags and a ,d+[DATE] bag of hot dog buns labeled ,d+[DATE], with ice crystals observed inside the bag, Dietary Manager stated that it looks like frostbite. On [DATE] at 12:10 PM, 3 loaves of bread labeled ,d+[DATE], with ice crystals observed inside the bag and all over the bread, Dietary Managers stated that it looks like frostbite and needs to be thrown out. On [DATE] at 12:10 PM, A ,d+[DATE] bag of corn hard tortillas, with ice crystals observed inside the bag and all over the tortillas. Dietary Manager confirmed no receive date and it looks like frost bite, I have no idea how old this is. 5. The following are findings for the storage shelves: On [DATE] at 12:12 PM, three bags of flour, 5 pounds each with no receive date, Dietary Manager confirmed that all three bags had no receive date. 6. On [DATE] at 12:15 PM, Dietary Manager pulled out the small grease trap for the griddle on the stove top, it was full of grease and crumbs throughout. Dietary Manager pulled out the grease trap under the stovetop, observed the foil is filled with various food particles, and dried grease. Dietary Manager stated during interview it should be done daily but it has been overlooked apparently. 7. On [DATE] at 11:38 AM, Dietary [NAME] put on gloves to cut regular Swiss steaks on a plate to ground in the blender. The Dietary [NAME] took off gloves, to pull apart the bottom part of the blender and then reassembled the blender. Placed on gloves and continued to cut up regular Swiss steaks and add into the blender. Took off gloves, then continued to take apart the bottom part of the blender and then reassembled the blender. Dietary [NAME] then washed hands. On [DATE] at 11:45 AM Dietary [NAME] put on gloves to cut up the last Swiss steak for the mechanical soft diets to be ground in the blender. After running the blender, Dietary [NAME] took apart the bottom part and the blade fell into the steam table pan containing the mechanical soft Swiss steak. Dietary [NAME] took out the blade and then knocked the top of the blender into the steam table pan to remove the rest of the ground Swiss steak, in the process the top of the blender touched the already grounded meat in the steam table pan. Took off, The Dietary [NAME] then began setting up the steam table serving line not washing hands after removing gloves, afterwards took the dishes from prepping the grounded Swiss steak to the dishwasher. The Dietary [NAME] then began the process of making gravy by putting water in the pan and putting it down on the stovetop. The Dietary [NAME] then proceeded to clean the stainless-steel preparation table from the Swiss steak preparation. Dietary [NAME] then washed hands. 8. On [DATE] at 12:30 PM, the Dietary [NAME] took a stack of plates out of the warmer, and put it at the end of serving line, the Dietary [NAME] then touched the food surface area with their thumbs on the top plate. Continued this process three more times, where the Dietary [NAME] touched the food surface area of the plate with their thumbs. On [DATE] at 12:35 PM, the Dietary [NAME] put on gloves and began serving trays on the steam table line, removed gloves and did not wash hands. Dietary [NAME] stopped serving trays to get a pizza cutter and a plate for a staff request, observed Dietary Cooks thumb touch the inside of the plate. Dietary [NAME] then continued serving trays after handing staff the requested items. Dietary [NAME] then left to get buns for hot dogs and hamburger, put on gloves to put a hamburger together. Removed gloves to get cheese for hamburger, Dietary [NAME] came back and asked, What do I do with the cheese slices that were left unsealed. Dietary Manager took the unsealed slices stated there was five of them and proceeded to throw them away. Dietary [NAME] then put on a glove removed the cheese slice and put it on the hamburger, then put it onto the plate. Dietary [NAME] removed glove did not wash hands continued serving. The Dietary [NAME] continued to serve lunch, stopping to put on gloves to pull cheese slices, add a handful of chips to a plate or bread for hamburgers. Dietary [NAME] then will remove gloves and not wash hands. Surveyor did not observe Dietary [NAME] wash hands On [DATE] at 12:40 PM, the Dietary [NAME] was preparing a tray; right thumb touched the rice in the scoop and added it to the plate for lunch service. On [DATE] at 12:42 PM, the Dietary [NAME] picked up the dessert, right thumb touched the inside of the bowl and added it to the plate for lunch service. On [DATE] at 2:41 PM, during an interview the Dietary Manager stated it is important to date food in the kitchen as you receive it on the trucks to not used expired food and to keep residents from getting sick. Dietary Manager stated hand hygiene is important to prevent food borne illness, you perform hand hygiene in between tasks and when changing gloves. Then, stated plates or bowls should not be touched with hands as anything on them could transfer to the residents. On [DATE] at 08:34 AM, during an interview the Dietary [NAME] stated hands should be washed between every task, and every time you change gloves. Then stated that it is cross contamination when hands are not washed. The Dietary [NAME] the inside of plates should not be touched or other items as it is cross contamination just in case you have something on your fingers. 9. A review of the facility policy Quick Resource Tool Handwashing states to As often as needed during food preparation and when changing tasks. 10. A review of the facility policy Clean and Sanitary states to The Dining Service Director will ensure that all employees are knowledgeable in the proper procedure for cleaning and sanitizing.

Based on observation, interview and record review, the facility failed to ensure 2 (Resident #21 and #27) of 2 sampled residents received nutritional supplements as ordered. The findings are: 1. Review of the Medical Diagnosis portion of Resident #21's electronic health record revealed a diagnosis of abnormal weight loss. a. Review of the Physician Orders portion of Resident #21's electronic health record indicated an order for nutritional supplements to be provided two times a day to promote weight gain. b. Review of a Care Plan revealed Resident #21 had potential for nutritional deficits related to ability to feed self, with the goal the resident will receive adequate nutrition. Interventions included providing supplements as ordered. 2. Review of the Medical Diagnosis portion of Resident #27's electronic health record revealed diagnoses of dementia, vitamin D deficiency, and vitamin B12 deficiency. a. Review of the Physician Orders portion of Resident #27's electronic health record indicated an order for nutritional supplements to be provided two times a day to promote weight gain. b. Review of Resident #27's Care Plan revealed the resident has the potential for nutritional deficits, with a goal of receiving adequate nutrition as evidenced by weight stable. Interventions included giving the resident supplements as ordered. 3. On 09/05/2024 at 8:30 AM, the surveyor was notified by Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #4 the facility had ran out of the ordered nutritional supplement approximately 1 week before survey began on 09/03/2024. 4. On 09/05/2024 at 11:58 AM, a list of residents with physician orders for nutritional supplements was provided by Director of Nursing (DON) that showed 2 of 46 residents were to receive nutritional supplements, Resident #21 and Resident #27. 5. On 09/05/2024 at 2:00 PM, the DON confirmed being responsible for ordering the required nutritional supplement. The DON verified the facility ran out of the ordered nutritional supplement on 08/25/2024 and received a shipment of the supplement on 09/03/2024. When shown the medication administration record for Resident #21 and Resident #27, the DON verified the residents could not have received the nutritional supplement as ordered as no supplement was available in the facility.

Based on observation, interview and record review, the facility failed to ensure an accident/hazard free environment was provided for 1 (Resident #3) of 1 sampled residents. The findings are: Review of a facility policy titled; Safety and Supervision of Residents indicated The environment as free from accident hazards as possible. A review of Medical Diagnosis indicated Resident #3 had a diagnosis of Alzheimer's disease that included dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2024 revealed the resident had a Staff Assessment for Mental Status (SAMS) of 1, which indicated the resident had severely cognitive impairment for their daily decision making. Review of Resident # 3's Care Plan on 07/17/2024, revealed the resident had dementia with an inability to care for self. On 09/04/24 at 10:24 AM, perineal skin cleanser and antiseptic mouth wash was observed in Resident #3's bathroom. The warning label on the bottles indicated to keep out of the reach of children. On 09/04/2024 at 10:30 AM, Certified Nursing Assistant (CNA) #1 was asked if perineal cleanser or antiseptic mouthwash should be stored in a resident's bathroom, and she stated the cleanser and mouthwash should not since there was a warning label on them. On 09/04/2024 at 10:35 AM, CNA #2 was asked if perineal cleanser or antiseptic mouthwash should be stored in a resident's bathroom, and she stated they should not. On 09/04/2024 at 10:45 AM, Licensed Practical Nurse (LPN) #3, she was asked if perineal cleanser or antiseptic mouthwash should be stored in a resident's bathroom, and she stated they should not since there was a warning label on them. On 09/05/2024 at 11:00 AM, the Director of Nursing stated the perineal cleanser and/or antiseptic mouthwash should not be stored in a resident's bathroom since there was a warning label on them.

Based on observation, record review and interview, the facility failed to ensure that food was in the proper form to meet resident needs for 1 of 1 meals observed. These are the findings: On 09/04/2024 at 11:38 AM, the Dietary [NAME] (DC) put on gloves and sliced meat to add to the blender to grind up for resident who were on mechanical soft diets (a diet requiring foods that are soft and easy to chew). The DC stated there are five mechanical soft diets. The surveyor observed them adding one sliced steak at a time to the blender. The DC ran the blender with one steak before adding it to the steam table pan, the surveyor observing larger chunks of meat in the puree. The surveyor observed the process repeated with the next four steaks, with each of them having large chunks of meat not properly pureed. On 09/04/2024 at 12:40 PM, the surveyor observed staff setting up a mechanical soft tray, when mixing up the meat with the gravy large chunks were visible. The staff member stated the ground meat is in larger chunks than normal, and you have to mix it up quite a bit to get it to have proper consistency. On 09/05/2024 at 2:41 PM, the Dietary Manager stated that ground mechanical soft should be grounded finely not too chunky or mushy, then stated the mechanical soft meat during lunch service yesterday had large chunks it in and that a resident on this diet could choke on it. On 09/06/24 at 08:34 AM, the Dietary [NAME] stated mechanical soft meats should look like ground beef once you chop it up, and the mechanical soft yesterday was not the greatest it came out a little bit chunky. A review of the facility policy Quick Resource Tool Food Palatability states that Food and liquids/beverages are prepared in a manner, form, and texture that meets each resident's needs.

Based on observations, record review, interviews and facility policy review, it was determined the facility failed to maintain proper infection prevention and control for 1 (Resident #36) of 2 residents reviewed for infection prevention. The Findings Are: Review of the Medical Diagnosis portion of Resident #36's electronic health record revealed diagnoses of malignant neoplasm of mandible, adult failure to thrive, and other chronic pain. Review of the Physician Orders portion of Resident #36's electronic health record revealed an order for enhanced barrier precautions due to an open wound on the resident's face. Review of a Care Plan, revised 06/06/2024, reveal the resident had been placed on enhanced barrier precautions related to a facial wound. Interventions included instructions for staff to wear gloves and gowns during high-contact resident care activities. On 09/05/2024 at 8:30 AM, Resident #36 was observed sitting in recliner in day room. The Director of Nursing (DON) and Certified Nursing Assistant (CNA) #4 were observed entering day room and arousing Resident #36. Without gloves, the DON and CNA #4 used repositioned Resident #36 up toward the top of the reclining chair. The DON and CNA #4 sat Resident #36 upright in chair, leaned the resident forward and applied a gait belt. The DON and CNA #4 transferred Resident #36 to a wheelchair and removed him/her from the day room. On 09/05/2024 at 8:51 AM, Resident #36 was observed being transported to the shower room by a hospice care aid. The hospice aid rolled the resident into shower room, and without wearing applying a protective gown, began showering the resident. The hospice aid was interviewed and asked if enhanced barrier precautions were followed, she confirmed that enhanced barrier precautions were not followed as ordered. On 09/05/2024 at 9:00 AM, the DON was interviewed and asked what enhanced barrier precautions consisted of when ordered. The DON verified a gown and gloves are to be worn when providing direct patient care. The DON acknowledged they had repositioned Resident #36, applied a gait belt to resident, and transferred the resident from reclining chair to wheelchair without applying gown or gloves. The DON also confirmed that showering/bathing a resident with orders for enhanced barrier precautions requires a gown and gloves to be worn. On 09/05/2024 at 9:20 AM, the Infection Prevention Nurse was interviewed and asked what precautions were recommended when a resident was on enhanced barrier precautions. The Infection Prevention Nurse indicated gown and gloves were to be worn when providing direct patient care. When asked if transferring and bathing/showering required use of gown and gloves, the Infection Prevention Nurse indicated gloves and a gown were not required when transferring resident. When shown enhanced barrier precaution guidelines posted on Resident #36's door, which illustrated that providers and staff must wear gloves and gown when transferring a resident, the Infection Prevention Nurse confirmed gown and gloves should be worn by staff when transferring a resident on enhanced barrier precautions. A review of a facility policy titled, Enhanced Barrier Precautions , dated 03/20/2024, indicated under the section, Initiation of Enhanced Barrier Precautions that enhanced barrier precautions were an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities.

Based on observation, record review, interviews, and facility policy review, the facility failed to initiate and update a comprehensive care plan for a resident with wandering and exit seeking behaviors for 1 (Resident #29) of 1 sampled resident reviewed for elopement. The Findings Are: Review of a Care Plan, initiated 08/20/24, revealed Resident #29 had diagnoses that included Alzheimer's disease and dementia. On 09/04/24 at 9:08 AM, Resident #29 was observed wandering down multiple halls in the facility and pushing on exit doors. On 09/05/24 at 10:40 AM, Certified Nursing Assistant (CNA) #4 stated, The resident (Resident #49) wanders around the facility throughout the day, and often goes to the exit doors and pushes on them. Review of the Care Plan, dated 06/14/2024, for Resident #29 revealed no documentation addressing wandering or exit seeking behaviors. Review of the Assessments portion of Resident #29's electronic health record revealed no elopement assessment. The surveyor requested to review an elopement assessment if completed in the resident's paper chart. The facility was unable to provide an assessment or confirm an assessment had been completed on Resident #29. Review of a document titled, DHS-703, revealed Resident #29 had been previously assessed as having a high potential for elopement. On 09/05/24 at 11:46 AM, the Director of Nursing (DON) confirmed Resident #29's care plan did not address wandering or exit seeking behaviors. When asked if Resident #29 displayed wandering and exit seeking behaviors, the DON stated, Yes, this resident will walk around the facility and at times will approach the doors. On 09/05/24 at 4:08 PM, the Administrator stated the facility has a goal to complete scanning all records into the facility's electronic medical record system by the end of September 2024. When asked what records or sections are completed at this time, the Administrator stated, The orders (physicians orders) section, MAR (medication administration record), care plans, assessments, and MDS (minimum data set). Mostly what we are completing now is scanning the old chart into [Facility Computer Software]. On 09/06/2024 at 8:40 AM, the MDS Coordinator stated all assessments should be completed prior to completing the care plan, and that Resident #29's care plan should address wandering and exit seeking behaviors.

Based on observation, interview and record review, the facility failed to follow Physician Orders for oxygen flow rate for 1 resident (Resident #137) of 2 (Residents #8 and #137) sampled residents. The findings are: Resident #137: a. A Physicians Order dated 09/18/23 noted Resident #137 was to receive oxygen at 2 liters per minute via nasal cannula as needed. b. A Baseline Care Plan dated 09/18/22 noted Resident #137 receives oxygen at 2 liters per minute as needed. c. On 10/02/23 at 11:16 AM, observed Resident #137's oxygen concentrator was set at 3 liters per minute. d. On 10/03/23 at 4:12 PM, observed Resident #137's oxygen concentrator was set at 1 liter per minute. e. On 10/03/23 at 4:17 PM, the Surveyor accompanied the Director of Nursing (DON) into Resident #137's room. The Surveyor asked the DON what the oxygen concentrator was set on. The DON answered, It's between 1 and 2. No, it's actually 1 liter per minute. f. On 10/04/23 at 12:21 PM, Resident #137 was lying in bed receiving oxygen at 2 liters per minute. g. On 10/04/23 at 1:03 PM, the Surveyor asked the DON who was responsible for monitoring oxygen settings daily. The DON answered, Every nurse on the floor when doing their rounds. The Surveyor asked the DON how correct settings were communicated from one nurse or staff member to another. The DON answered, If there has been a change it ' s in the report sheet from first shift to second shift. h. On 10/06/23 at 10:19 AM, the Nurse Consultant stated, There is no Oxygen Administration Policy.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered and sealed; dietary staff washed their hands before handling clean equipment, cold dairy products were maintained at a temperature at or below 41 degrees Fahrenheit (F); and hot foods were maintained at or above 135 degrees F on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria. These failed practices had the potential to affect 36 residents who received meals from the kitchen (total census:36 ), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 10:21 AM, the following observations were made in the milk and juice refrigerator: a. The temperature of the refrigerator where thickened milk and juice were stored was 50 degrees Fahrenheit. b. The temperature of the refrigerator where cartons of thickened milk and a carton of silk milk were stored was 59 degrees F. Dietary Employee #1 was asked to check the temperature of the thickened milk and silk milk. She did and the temperature of the thickened milk was 59 degrees F and the silk milk was 60.3 degrees F. Dietary Employee #1 stated, I will throw all of them away. 2. On [DATE] at 10:37 AM, there was an opened box of turkey bacon and box of regular bacon stored on a shelf in the walk-in refrigerator. The boxes were not covered or sealed. 3. On [DATE] at 10:39, there was an opened box of Brussels sprouts stored on shelf in the Walk-in freezer. The box was not covered or sealed. Dietary Employee #1 stated, That's how they sent it to us. 4. On [DATE] at 10:40 AM, Dietary Employee #2 scratched her face without washing her hands. She picked up clean dishes and stacked them on the plate warmer to be used in portioning food items to be served to the residents for lunch. 5. On [DATE] at 10:46 AM, Dietary Employee #3 was wearing gloves on his hands. He touched his mask with his gloved hands, contaminating the gloves. Without changing gloves and washing his hands, he picked up utensils by the tips that goes in the month and placed them on the napkins to [NAME]. Dietary Employee #3 was stopped and immediately was asked what should you have done after touching dirty objects and before handing clean equipment and he stated, I should have removed gloves and washed my hands. 6. On [DATE] At 10:50 AM., there was an opened box of baking soda stored on a spices rack in the kitchen. 7. On [DATE] at 11:09 AM, Dietary Employee #4 opened a food warmer and took out a pan of pork chops and placed it on the counter. Without washing her hands, she picked up a clean blade an attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed dietary for lunch. 8. On [DATE] at 11:10 AM, Dietary Employee #4 was wearing gloves and used her blouse to wipe off sweat on her face. Without changing gloves and washing her hands, she placed her hand on a pork chop to debone. She was stopped and was asked what should you have done after touching dirty objects and before handling clean equipment and or food items and she stated, Changed loves and washed my hands. 9. On [DATE] at 11:24 AM, Dietary Employee #5 turned the stove on and without washing his hands, he placed a glove on his hand contaminating the gloves in the process, he picked up a bun and placed it in a divided Styrofoam plate. He used his gloved hand to pick up lettuce leaf and slices of tomatoes and cheese and placed them on the buns and prepared cheeseburgers to serve to the residents who requested a cheeseburger for the lunch meal. 10. On [DATE] at 11:46 AM, Dietary Employee #4 washed the blender and blade in the 3-compartment sink. She turned off the faucet with her hand. Without washing her hands, she attached a clean blade at the base of the blender to be used in pureeing food items to serve to the residents on pureed diets. 11. On [DATE] at 11:57 AM. the temperatures of the food items when tested and read on the steam table by Dietary Employee #5 was regular pork chops 124 degrees F. The above meat items were not reheated before being served to the residents for lunch meal. 12. On 7//,d+[DATE] at 12:17 PM, the following observations made in the refrigerator in the nourishment room at the nurse's station were. a. A bottle of cranberry/apple juice on a shelf in the refrigerator had an expiration date of [DATE]. b. A bag of Nature Own Bread in a grocery bag had an expiration date of [DATE]. There was no date on the bag as when it was received, and there was no name on the bag as to whom it belonged to. c. There were two bags stored on a shelf in the refrigerator that contained slices of tomatoes. There was no name or date found on either zip lock bags to indicate when it was received or whom it belonged to. The tomatoes in both bags had white fussy and sage color. Dietary Employee #1 stated, They had mold and they are nasty An opened packet of bologna in the same bag with zip lock bags of tomatoes had an expiration date of [DATE]. 13. The facility's policy titled hand washing documented when to wash hands, After engaging in other activities that contaminate the hands.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. These failed practices had the potential to affect 25 residents who received regular diets, 7 residents who received mechanical soft diets and 4 residents who received pureed diets from the kitchen, according to a list provided by the Dietary Supervisor on 7/5/2022. The findings are: On 07/5/2022, the menu for the lunch meal documented the residents on regular diets and mechanical soft diets were to receive 4 ounces (oz) of pork chop. The residents on pureed diets were to receive #8 scoop (4 oz) of pureed pork chop, #8 scoop of pureed great northern beans which was equivalent to a ½ cup and #10 scoop of pureed cornbread which was equivalent to 3 to 4 (oz). a. On 7/05/2022 at 12:24 PM, Dietary Employee #5 used a 2 oz spoon to serve a single portion of ground pork chop to the residents on mechanical soft diets. The menu specified the residents on mechanical soft diets to receive 4 ounces of ground pork chop each. b. On 7/5/2022 at 12:29 p.m., Dietary Employee #5 used a #12 scoop (3 oz or 1/3 cup to serve a single portion of pureed great northern beans and used a #10 scoop to serve a single portion of pureed greens to the residents on pureed diets. The menu specified for the residents on pureed diets to receive a #8 scoop of pureed great northern beans and pureed greens which is equivalent to a ½ cup for each person. There was no cornbread or bread served to the residents on pureed diets for lunch. c. On 7/05/2022 at 12:41 PM, Dietary Employee #1 was asked to weigh the same amount of pork chop served to the residents at noon meal. She did so, and stated, It was 1.5 oz. d. On 7/05/2022 t 12:46 PM, Dietary Employee #5 was asked, What scoop size did you use to serve ground pork chop to all the residents who received mechanical softs? He stated, I used a #2 scoop. I gave a single serving to the residents on mechanical soft. e. On 7/05/22 t 01:16 PM, residents on regular diets were served pork chop with bones. f. On 7/05/22 at 02:24 PM Dietary Employee #4 was asked the reason residents on pureed did not receive any type of bread. She stated, For what I understood pureed diets can't get cornbread. They can only get 3 things on their plates. The plate has only 3 sections.

Based on observation, record review, and interview, the facility failed to ensure dietary staff used a alcohol wipe to cleanse the thermometer between food items when acquiring the temperatures on the steam table prior to lunch service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 30 residents who received their meals the kitchen. The findings are: 1. On 06/15/21 at 11:34 AM and 11:37 AM, during steam table temperature observation, Dietary Employee #1 wiped the thermometer with her gloved hand instead of an alcohol wipe which was on the counter next to her. 2. On 06/16/21 at 02:15 PM, Dietary Employee #1 was asked what the procedure was for cleaning the thermometer between foods when acquiring the temperature from the foods on the steam table? She stated, We use alcohol swab to clean it. Then she stated, I did it didn't I? She was asked, While acquiring temperatures yesterday on the steam table, did you use your gloved hand to wipe the thermometer off? She stated, I think I did, I should have used a wipe. She was asked, An alcohol wipe? She stated, Yes, an alcohol. 3. On 06/16/21 at 02:16 PM, the Certified Dietary Manager was asked what the facility policy regarding cleaning the thermometer between foods when acquiring the temperatures on the steam table. She stated, An alcohol wipe should be used. She was asked, Should the thermometer be wiped with a gloved hand? She stated, No, it shouldn't. It should be wiped with alcohol wipe between every food. She was asked, Is it your facility policy to clean the thermometer with an alcohol wipe? She stated, Yes, it's our policy. 4. On 06/17/21 at 01:55 PM, a Policy & [and] Procedure Manual was received from the Administrator documented, .remove the thermometer from the food item and immediately clean and sanitize. Repeat these guidelines until all hot food temperatures have been taken . Thermometers should be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (use a new swab for each sanitizing).

Based on interview and record review, the facility failed to ensure a surety bond provided adequate coverage for 7 (Residents #5, #6, #8, #14, #19, #21, and #26) of 12 (Resident #1, #5, #6, #7, #8, #11, #14, #15, #16, #19, #21, and #26) sampled residents who had trust funds deposited within the facility. This failed practice had the potential to affect 20 residents who had trust funds according to a list provided by the Administrator on 6/15/21. The findings are: 1. A copy of the surety bond was provided by the Administrator on 6/15/21 at 1:41 PM and documented, Surety Bond . the total sum of Ten Thousand dollars ($10,000.00) lawful money of the United States of America, for which the sum will and truly to be paid, said Principal and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally firmly by these presents .This bond shall be effective as of 12:01 A.M. June 01, 2017, and shall continue in full force and effect unless otherwise cancelled . 2. On 6/17/21, the bank statements were reviewed for the past 3 months. The May 2021 bank statement documented, .Ending Balance $27,816.15 . The April 2021 bank statement documented, .Ending Balance $28,864.07 . The March 2021 bank statement documented, .Ending Balance $21,081.64 . 3. On 6/17/21 at 1:45 PM, the Administrator was asked, Can you tell me why the amount of the surety bond was not enough to cover the resident funds? She stated, I spoke with the business manager after you spoke with me about it. She informed me that she had contacted the corporate office concerning surety bond not matching the amount in the bank . She was asked, Why is it important for the surety bond to be enough to cover the resident funds? She stated, Because there are a lot of fraudulent things going on. I know the residents has lost money because of embezzlement. I know the surety bond covers the residents' money. 4. A policy titled, Resident Right-Surety Bond-Security of Personal Funds that was provided by the Administrator on 6/17/21 at 2:02 PM documented, .It is the policy of the facility to protect the resident's personal funds in such a manner to acknowledge and respect resident rights .The facility will purchase a surety bond , or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility.

Based on observation and interview, the facility failed to ensure window ledges, hole in the wall, and windowsills were promptly repaired by maintenance services to provide an orderly, safe and comfortable environment to enhance the residents' quality of life in 1 of 1 facility. The findings are: a. On 6/16/2021 at 01:47 PM, during the survey observations, in resident rooms #18 and 24, the window ledges were broken, missing in part and/or in disrepair. In room #20, the windowsill is missing for 75% of the sill. In room #24, the windowsill is completely missing with damage to the underlayment the sill surface rests on. Resident #32 stated, .it's been like that a long time . The resident was asked if it had been like this for weeks or months. She stated, .weeks . At 1:57 PM, measurements were taken of the hole in room #20. This area was approximately 7.5 x 4.5, inches, and was missing the sheetrock completely, where the next wall was visible. This area was 38 inches from the corner of the wall to the beginning of the hole and 25 inches from the floor to the bottom edge of the hole. b. On 6/17/2021 at 2:49 PM, the Maintenance person was asked to measure the identified areas in room #20. The area measured 6 inches by 5 inches and the Maintenance person expressed his surprise at the size of the opening. This area was approximately at the elbow area of the bed next to the resident's bed. c. On 6/17/2021 at 2:53 PM, in room #18, Maintenance person #2 stated, The area missing is 75 inches because that is what it will take to fix it. He was asked, Why hasn't it been repaired before? He stated, We're under construction, if I fix it now, it'll just get messed up again. He was asked, When is this area scheduled for construction? He stated, I can't give you a date. He was asked, Will it be in the next month or year? He stated, Probably within the next year. He was asked, Why so long for repairs? He stated, We're working on other repairs right now. He was asked, Don't the residents deserve to have their homes in good repair? He stated, Yes, but we've been busy. He was asked, How do the staff let you know that something needs to be repaired? He stated, They write it in the book, and we check it. The maintenance log was reviewed, no documentation regarding the damaged areas was noted.

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage 8 hours a day, 7 days a week as required in 1 of 1 facility. This failed practice had the potential to affect 30 residents according to the Resident Census and Condition of Resident form dated 06/14/21. The findings are: 1. On 06/16/21 at 10:30 AM, the RN punch log was received from the Director of Nursing (DON). The RN coverage was reviewed for the past 4 weekends. There was no RN clock in, clock out documented for 5/22/21 and 5/23/21. 2. On 06/17/21 at 1:35 PM, the Administrator provided a copy of the schedule for May. There was not an RN scheduled for 5/22/21 and 5/23/21. 3. On 06/17/21 at 1:45 PM, the Administrator was asked, What are your requirements for RN coverage? She stated, I am required to have an RN 5 days a week through the business day. CMS requires coverage 7 days a week 8 hours a day. She was asked, Does the facility have an RN for at least 8 hours a day 7 days a week? She stated, Yes, and the DON counts as the one for the week. She was asked, Can you tell me why the facility didn't have an RN for at least 8 hours on May 22, 2021, and May 23, 2021? She stated, Due to a shortage of applicants. I have been advertising for a weekend RN since 2019. I hired one I think in November of last year. She gave her notice that her last day will be March. I have not been able to fill that position. My DON and my MDS Coordinator had been filling the weekend positions.

Based on record review and interview, the facility failed to ensure an as needed (PRN) anti-anxiety medication was limited to a 14-day period in the absence of a documented re-evaluation by the physician to determine the need for continued use to minimize the potential for adverse consequences for 1 (Resident #14) of 2 (Residents #14 and 16) who received [MEDICATION(S)] on a PRN basis. The findings are: Resident #14 had a diagnosis of Anxiety. A Quarterly Minimum Data Set] with an assessment reference date of 4/14/2021 documented a Brief Interview for Mental Status of 3 (0-7 indicates cognitively impaired) and had documented behaviors, not directed toward others occurred daily. a. A Care Plan with a review date of 5/20/2021 documented .Potential for noncompliance; Behavior problem . Dementia/poor cognition; long-term history of behavior . Potential for feelings of Anxiety, Restlessness, nervousness . situational crisis, . Potential for adverse medication side effects, of . anxiolytics medication . Potential of adverse medication side effect of psychoactive medication . b. The June 2021 Physician order documented .05/06/2021 [MEDICATION(S)] 1 mg [milligram] tab . PRN [as needed] Q [every] 6 HR [hour] (anxiety) first date: 05/06/2021 .last date: 08/06/2021 . c. The Medication Administration Record documented [MEDICATION(S)] 1 mg tab was initialed as given on date .5/6/2021 [at] 14:30 [2:30 PM], 5/7/2021 [at] 08:50 AM 5/22/2021 [at] 19:32 [7:32PM], 5/23/2021 [at] 16:56 [4:56 PM] and 6/7/2021 [at] 9:09 AM . d. On 6/15/2021 at 04:15 PM, the Director of Nursing (DON) was interviewed at the Administrator's office with the Administrator present. She was asked about residents PRN [MEDICATION(S)] order. She stated, .I wasn't aware you couldn't have a prn [MEDICATION(S)] order . The regulation was explained, and the Administrator stated, .that's right, you can only have it for 14 days, the order has to be rewritten . e. On 6/17/2021 at 09:53 AM, the DON was asked to provide documentation for a physician assessment for the prn anti-anxiety medication [MEDICATION(S)] between the dates of 5/12/2021 and 6/09/2021. In the presence of this surveyor, the DON reviewed resident #14's record and she stated, .I can't find anything, the physician did not see the resident between 5/12/2021 and 6/9/2021 . The DON was informed, when a prn anti-anxiety medication is ordered, an assessment is required every 14 days. She stated, No assessment had been completed within the 14-day reassessment period, [Physician] sees his own residents and doesn't utilize Telemed services at this time . The DON was informed, according to regulations, the physician is required to reassess any PRN anti-psychotic medication which included Anti-Anxiety medications every 14 days and document in the resident's record. She stated, I wasn't aware of that. There was no documentation provided for a physician's assessment during the time period above. f. On 6/17/2021 at 10:38 AM, a Procedure . Behavior and psychoactive Management Program . was received from the DON, and documented, .It is the policy of the facility to provide care and services to promote our resident's quality of life. It is the philosophy of the facility that all resident behavior has meaning. Our facility will work diligently to minimize the use of psychoactive medications in its resident population .Ensuring a thorough and comprehensive assessment of the resident's needs, behaviors, and prior medication and medical history . Thoroughly assessing the need for the inclusion of psychoactive medications into the residents' medications regime . Evaluating the effectiveness of Pharmacological and non-pharmacological interventions .

Based on observation, record review, and interview the facility failed to ensure signage was posted on 2 (Resident #1 and #2) of 2 case mix residents' doors who required droplet precautions; the facility failed ensure face masks were worn properly and dirty linen was handled in such a way as to prevent the possible spread of COVID-19. These failed practices had the potential to affect all 22 residents as documented on a list provided by the Administrator on 6/17/2020 at 8:52 a.m. The findings are: 1. On 6/17/2020 at 9:30 a.m., Housekeeping Staff #1 was wearing a facial covering. The facial covering was not covering Housekeeping Staff #1's nose. The Housekeeping staff then pushed a housekeeping cart down the hall past clients with her nose exposed. 2. On 6/17/2020 at 9:37 a.m., Housekeeping Staff #1 was sweeping in a resident's room. Housekeeping Staff #1's facial covering did not cover the staff member's nose. Resident #3 and Resident #4 were sitting in the room at this time. 3. On 6/17/2020 at 9:45 a.m., Housekeeping Staff #1 was asked if she had been trained on how to wear facial coverings. Housekeeping Staff #1 stated, Yes. I know this one is loose, and it does fall. It is supposed to be over the nose, but it falls. I have a whole bag full of them. 4. On 6/17/2020 at 11:14 a.m., Assistant Director of Nursing (ADON), the facility's infection preventionist, was asked if a facial covering should cover a staff member's nose. The Assistant Director of Nursing stated, Yes. 5. Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED]. b. On 6/17/2020 at 9:15 a.m., the resident was laying on her bed in her room. There were two red biohazard containers in the room and a there was a three-drawer plastic chest outside of her door. There was no sign on the resident's door to indicate what type of infection control precautions the resident was on. At 10:00 a.m., a droplet precautions sign was on the door. Licensed Practical Nurse (LPN) #1 was asked, Was that sign on the door earlier? She stated, No. She was in a room at the end of the hall and we moved her up here last night. We didn't move the sign with her. It should have been moved with her last night when she changed rooms. 6. Resident #2 was admitted on [DATE] and had [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED]. b. On 6/17/2020 at 9:02 a.m., the resident was in her room. There were two red biohazard bins in the room. There was no sign on the resident's door to indicate what type of infection control precautions the resident was on. At 9:29 a.m., LPN #1 stated, She just came here yesterday. She came from the Assisted Living Side after being in the hospital. The LPN was asked, Is she on isolation? She stated, Yes. They automatically go on for fourteen days. The LPN was asked, What type is she on? She stated, Contact Isolation. The LPN was asked, Is there a sign on the door to indicate what type of isolation / precautions she is on? She stated, No. The LPN was asked, Should there be a sign on this door? She stated, Yes. Absolutely. 7. On 6/17/2020 at 9:03 a.m., Restorative Aide #1 was walking down the hall carrying un-bagged linen. She was carrying the un-bagged linen in her right ungloved hand, to the soiled linen room. At 1:14 p.m., the ADON was asked, Should she have been transporting un-bagged dirty linen down the hall? She stated, No. They should have been bagged.