Every finding on record at White County Rehab and Nursing

Based on observation and interview, the facility failed to maintain resident rooms in a clean, odor free manner for 3 (R1, R2, and R3) of 3 residents reviewed for safe/clean environment in the sample of 12. Findings include:On 8/20/25 at 8:25 AM, R1s old room had a do not enter sign posted on it, and the door shut. No residents were observed to be residing in the room at this time. There was black, furry streaking, with a mold-like appearance noted around both light fixtures on the ceiling of the room. There were also green specks noted on the ceiling of the closet in the room which resembled mold. On 8/20/25 at 10:13 AM, V23 (Housekeeping) stated she knew there was something that appeared to resemble mold in R1s old room. V23 stated maintenance was working in that room but didn't know what maintenance was working on.On 8/20/25 at 11:17 AM, R1 stated, The last room I was in had mold in it. They noticed the mold two or three weeks ago. R1 confirmed he was referring to R1s old room and stated, they immediately moved me out of the room when they found it.On 8/20/25 at 12:18 PM, V10 (Certified Nurse Aide/CNA) stated she had seen mold in a couple of the rooms on 200 hall. V10 specified R1s old R2 and R3 room. V10 stated she had reported it to V21 (Housekeeping Supervisor) and V8 (Licensed Practical Nurse/LPN).On 8/20/25 at 12:23 PM, V11 (CNA) stated she had noticed some rooms with mold in them. V11 said there were one or two rooms with what appeared to be something resembling mold on 200 hall but V11 couldn't remember which rooms.On 8/20/25 at 12:29 PM, V12 (CNA) stated she had noticed something resembling mold in room R1s old room and said that was the only room V12 noticed it in.On 8/20/25 at 12:55 PM V13 (CNA) stated she had noticed something that looked like mold in some rooms on the 200 hall. V13 specified R2 and R3s room and stated there are residents currently residing in those rooms. V13 stated the first time she noticed it was about 2 weeks ago. V13 stated she reported it to the previous maintenance man (no longer employed at the facility) and V2 (Director of Nursing/DON). V13 stated that V2 and the previous the maintenance man told her they would look at it. V13 stated she didn't know what happened after that.On 8/20/25 at 1:04 PM, R2's room was noted to have furry, black spots and smears, resembling mold on the ceiling of the closet concentrated around the sprinkler head and one wall near the ceiling as well as a small area around the light fixture in the center of the room. There were also green streaks and spots, resembling mold, noted on the cork board above the other unoccupied bed in the room. V13 (CNA) was present in the room during this observation and verified the mold like appearing substance in the area she had previously stated in her interview. On 8/20/25 at 1:06 PM, R3's room was observed to have black, furry spots and smears resembling mold on the ceiling in the closet surrounding the sprinkler. There was a noted smell of mildew in the room and just outside of it. There were green patches and speckles resembling mold on one wall of the closet. The room was occupied at that present time by R3. V13 (CNA) was present during this observation. On 8/20/25 at 1:31pm, R3 was in his room and stated that something that looked like mold was first noticed in his room about a month ago. R3 stated as far as he knew, V1 (Administrator) or V2 (DON) had not come in and looked at it. R3 stated he had not reported it to anyone personally and didn't remember who reported it to him.On 8/20/25 at 1:54 PM, R1 stated he was concerned about becoming sick or getting an infection in the open wound of his foot when they discovered the mold like substance in his previous room on the 200 hall. On 8/20/25 at 2:05 PM, V9 (LPN) stated she had seen something that resembled mold in R1s old room. V9 stated she had heard from a night nurse there was also a substance in the closet of R2's room that resembled mold. V9 stated she had reported it to the maintenance man (that is no longer employed at the facility). V9 stated she would not feel comfortable staying in a room that had something that looked like mold in it.On 8/20/25 at 3:50 PM, V1 and V2 visualized the black, green, furry splotches, smears, and spots on the ceilings of the unoccupied room that R1 use to reside in as well as the rooms where R2 and R3 reside. V1 and V2 described the spots as mildew, but stated they are unsure as to what it is for positive. V1 and V2 both denied being aware of these areas of concern prior to this time. The Facility's Environmental/Homelike Environment Policy dated 12/27/23 states, Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observation and interview the facility failed to ensure the air conditioning unit was in working order in the kitchen to provide dietary staff a comfortable working environment. This failure has the potential to affect all 44 residents residing in the facility.Findings include: On 8/20/25 at 10:27 AM, V19 (Dietary Staff) stated the air conditioning unit has been down in the kitchen for approximately the last 3 months. V19 stated the reason for the long wait is the facility was waiting on a quote for new unit. V19 stated it does get hotter than usual in the kitchen with the air conditioning not working causing her to perspire more. On 8/20/25 at 10:32 AM, V15 (Dietary Staff) stated he has worked here one month, and the air conditioning hasn't worked in the kitchen since he's been here. V15 stated it does get hotter than usual in the kitchen with the air conditioner not working causing him to perspire more. On 8/20/25 at 10:35 AM, V16 (Dietary Staff) stated the air conditioning has been broken for a long time in the kitchen. V16 could not remember how long but stated it had been weeks at least. V16 stated it does get hotter than usual in the kitchen with the air conditioner not working causing her to perspire more. On 8/20/25 at 10:43 AM, V17 (Dietary Staff) stated the air conditioning in the kitchen has been broken and not running all summer. V17 stated the facility will have a technician come and work on it, get it fixed and then it's back down again within a few weeks. V17 stated she was told they need a whole new unit. V17 did confirm it gets hot in the kitchen without the air conditioning causing her to perspire more. On 8/20/25 at 10:50 AM, V18 (Dietary Staff) stated the air conditioning unit in the kitchen has been down all summer. V18 stated the kitchen is hotter without the air conditioning running, and it does cause her to perspire more. On 8/20/25 at 10:57 AM, V20 (Dietary Staff) stated the air conditioning in the kitchen has been down all summer. On 8/21/25 11:39 AM, R2 stated he did have some concern about eating food prepared in the kitchen because of the small but increased risk of contamination of food with employees' perspiration. On 8/21/25 at 11:41 AM, R1 stated he did have a small concern about eating food prepared in the kitchen because of the small but increased risk of contamination of food with employees' perspiration. On 8/21/25 at 12:05 PM, V6 (Dietary Manager) stated the air conditioning has been out most of the summer in the kitchen. V6 stated there was possible increased risk for contamination of food with employees' perspiration. V6 said it can become very hot and humid while working in the kitchen. On 8/21/25 at 9:16 AM, V4 (Regional Maintenance Director) stated the air conditioning has been out in the kitchen for approximately two to three weeks this last time. V4 stated the technician has had to come and repair it multiple times in the last few months. V4 stated it has taken so long to get a replacement air conditioning unit is because he is waiting on two more quotes. To replace the whole unit is very expensive and the facility wants to make sure they are not overspending. V4 stated he is reaching out at the end of this week for those last two quotes. V4 stated it also has been very difficult obtain parts for the old unit due to its age. On 8/21/25 at 12:05 PM, V5 (Dietician) stated there is an increased risk of possible contamination of food with dietary staff's perspiration due to the increased temperatures in the kitchen. V5 stated her main concern would be of the dry storage area and temperatures there being over eighty degrees could possibly decrease the freshness of the food stored there.On 8/20/25 at 3:46 PM, the temperature in the kitchen was reading eighty-five degrees Fahrenheit using the surveyor's infrared thermometer. The temperature on the thermostat in the kitchen near the entry of the dry storage area read eighty-seven degrees Fahrenheit. The room felt very warm and humid to this surveyor. On 8/21/25 at 9:03 AM, the temperature in the kitchen using this surveyor's infrared thermometer was ranging from eighty-two to eighty-nine degrees Fahrenheit, and the kitchen's thermostat was registering ninety-three degrees Fahrenheit. To this surveyor, the room felt very warm and humid at this time as well. On 8/21/25 at 10:59 AM, during the kitchen staff prepping for lunch meal, the temperature was eighty-seven degrees Fahrenheit by the thermostat in the kitchen near the dry storage area. This surveyor's infrared thermometer was registering eighty-six to eighty-seven degrees in the kitchen at the same time. The current census of the facility as of 8/20/25 according to the facility's Midnight Census Report documents 44 residents currently in the facility.

Based on interview and record review the facility failed to ensure they had sufficient staff to meet the needs of the residents timely for 4 of 5 (R6, R16, R18, and R19) residents reviewed for sufficient staff in the sample of 34. This failure has the potential to affect all 54 residents currently residing at the facility. Findings Include: The facility Midnight Census Report dated 2/22/25 documents 54 residents reside at the facility. 1. R19's Admission Record with a print date of 2/27/25 documents R19 was admitted to the facility on [DATE] with diagnoses that include diabetes. R19's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 08, which indicates a moderate cognitive deficit. R19's current Care Plan documents a Focus area of (R19) has a dx (diagnosis) of Diabetes Mellitus. Date Initiated: 07/14/2016. This Focus area includes the intervention of, Provide Diabetic snacks between meals and at bedtime per diet orders. On 2/24/25 at 1:42 PM, R19 stated they don't get snacks at night, and she is diabetic and is supposed to have a snack each night. 2. R16's Admission Record with a print date of 2/27/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, Chron's disease, and chronic pain. R16's MDS dated [DATE] documents a BIMS score of 15, which indicates R16 is cognitively intact. R16's current Care Plan documents a Focus area related to diagnosis of diabetes but does not include an intervention related to diabetic snacks. On 2/24/25 at 1:42 PM, R16 stated they didn't get snacks last night (2/23/25) because they only had two CNA's (Certified Nursing Assistants) working and they didn't have time to pass the snacks. On 2/25/25 at 2:49 PM, V7 (CNA) stated she worked from 2 PM to 10 PM on 2/23/25. V7 stated they only had three CNA's working and did not have the manpower to pass snacks. On 02/25/25 at 3:12 PM, V8 (CNA) stated she worked evening shift on 2/23/25. V8 stated she did not pass snacks to residents on 2/23/25. V8 stated they normally offer them after everyone lays down and they didn't get residents in bed until 9:00 PM because they were short staffed. 3. R6's Admission Record with a print date of 2/27/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include cerebral palsy, morbid obesity, diabetes, lack of coordination, and urinary incontinence. R6's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 is dependent on staff for bathing. R6's current Care Plan documents a Focus area of (R6) has an ADL self-care performance deficit r/t (related to) Limited ROM (range of motion), Limited Mobility, impaired balance. This Focus area has a start date of 2/7/2016 and the interventions for this Focus area include, Bathing/showering: The resident is (totally dependent) on (1) staff to provide (Shower) (2 times a week) and as necessary. R6's Follow Up Questions Report dated 1/1/25 to 2/26/25 documents R6 was assisted with bathing on 1/3, 1/7, 1/10, 1/14, 1/21, 1/24, 1/31, 2/7, 2/14, 2/18 and 2/21/25 with not applicable documented on 2/4/25. This indicates R6 went from 1/14/25 to 1/21/25 (six days) and from 2/7/25 to 2/14/25 (six days) with being assisted with bathing. 4. R16's Admission Record with a print date of 2/27/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, Chron's disease, and chronic pain. R16's MDS dated [DATE] documents a BIMS score of 15, which indicates R16 is cognitively intact. This same MDS documents R16 is dependent on staff for bathing. R16's current Care Plan documents a Focus area of (R16) has an ADL self-care performance deficit r/t (related to) Amputation (Left BKA-LE -below knee amputation left extremity, Prosthesis) & (and) (Left Side Arm Paralysis), Impaired balance, Limited Mobility, abnormal posture, difficulty in walking, muscle weakness, lack of coordination This Focus area has a start date of 2/6/2017 and includes the intervention of, Bathing/showering: The resident requires (Extensive assistance) by (1) staff with (Showering) (2 x's-times wk-week) and as necessary. On 2/23/25 at 10:17 AM, R16 stated she doesn't get a shower every three days like she is supposed to. R16 stated they are short staffed so they sometimes can't take showers as they should. R16's Follow Up Question Report dated 1/1/25 to 2/26/25 documents R16 received assistance with bathing on 1/7, 1/18, 1/21, 1/24, 1/28, 1/31, 2/7, 2/14, and 2/18. This same report documents R16 was not available and/or refused showers on 1/3, 1/10, 1/12, 1/14, 1/29, 2/21, and 2/25. This indicates R16 went from 1/14/25 to 1/21/25 (six days) without being offered assistance with bathing. 5. R18's Admission Record with a print date of 2/27/25 documents R18 was admitted to the facility on [DATE] with diagnoses that include osteoarthritis of the knee, pain, visual loss, muscle weakness, and urinary incontinence. R18's MDS dated [DATE] documents a BIMS score of 12, which indicates a moderate cognitive deficit. This MDS does not document the level of assistance R18 requires with ADL's. R18's current Care Plan documents a Focus area of, (R18) has an ADL self-care performance deficit r/t Dementia, difficulty in walking, lack of coordination, muscle weakness. This Focus area documents a start date of 2/7/2016 and includes an intervention of, GG- Shower/Bathe Self (Total Dependence x 1) with an initiation date of 9/23/23. R18's Follow Up Question Report dated 1/1/2025 to 2/26/2025 documents R18 received assistance with bathing on 1/7, 1/10, 1/14, 1/17, 1/18, 1/21, 1/31, 2/4, 2/7, 2/11, 2/14, 2/18, and 2/25/25. This indicates R18 went from 1/21/25 to 1/31/25 (9 days) without being offered assistance with bathing. On 02/25/25 at 2:49 PM, V7 (CNA) stated they were not able to provide shower assistance to residents on 2/23/25 partially due to no hot water and partially due to not having enough CNA's. On 02/25/25 at 3:19 PM, V9 (CNA) stated they work with three CNA's every other weekend and they are not able to meet the needs of the residents timely. V9 stated when they only have three CNA's showers are not always done as they should be. On 2/25/25 at 3:31 PM, V10 (CNA) when they only have three CNA's working not all showers are done as they should be. On 2/26/25 at 3:38 PM, V2 (Director of Nurses) stated she had not had any resident complain related to not getting bathed as they should. V2 stated residents should be offered assistance with bathing twice a week. On 2/27/25 at 3:00 PM, V2 stated she did not have reproducible evidence R40 was offered assistance with bathing from 2/19/25 to 2/26/25, R6 from 2/7/15 to 2/14/25, R18 from 1/21/25 to 1/30/25, and R16 from 1/14/25 to 1/21/25. On 2/25/25 at 3:31 PM, V10 (CNA) stated four CNAs were not enough to meet the needs of the residents timely. V10 stated they had three CNA's working at the time of the interview. V10 stated they were not able to get all of the showers done when they worked with only three CNA's. On 02/26/25 at 11:43 AM, V6 (CNA) stated she didn't think they had enough staff to meet the needs of the residents timely. V6 stated call lights aren't answered timely, incontinence care isn't provided the way it should be, and resident care is delayed. On 2/26/25 at 3:38 PM, V2 (DON/Director of Nurses) stated she had not had any complaints/concerns brought to her related to staffing. V2 stated staff had told her they wanted more help but had not said they weren't able to provide timely care. The facility Staffing Policy and Procedure dated 1/8/21 documents, Purpose: The purpose of this procedure is to provide guidelines for staffing the facility for resident care. Procedure: The facility will provide sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. Facility staffing includes but is not limited to Nurse Managers, Nurses, Certified Nurse Aides, Social Services, Activities, Therapy, Housekeeping and Dietary Staff.

Based on observation, interview, and record review the facility failed to ensure hot water was available for resident use for 5 of 5 (R3, R6, R15, R16, and R40) residents reviewed for hot water in the sample of 34. Findings Include: 1. R6's Admission Record with a print date of 2/27/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include cerebral palsy, morbid obesity, diabetes, lack of coordination, and urinary incontinence. R6's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 is frequently incontinent of bowel and bladder and is dependent on staff for toilet hygiene. On 2/23/25 at 2:17 PM, R6 was lying in bed and there was a strong odor of urine. V7 (CNA/Certified Nursing Assistant) entered R6's room with this surveyor and provided incontinence care. After providing care, V7 washed her hands in R6's bathroom sink and stated the water was not hot. 2. R16's Admission Record with a print date of 2/27/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, Chron's disease, and chronic pain. R16's MDS dated [DATE] documents a BIMS score of 15, which indicates R16 is cognitively intact. This same MDS documents R16 is dependent on staff for bathing. On 2/23/25 at 10:17 AM, R16 stated they don't have hot water. 3. R40's Resident Admission Record with a print date of 2/27/25 documents R40 was admitted to the facility on [DATE] with diagnoses that include heart failure, COPD, acquired absence of left leg above the knee, and foot drop. R40's MDS dated [DATE] documents a BIMS score of 15, indicating R40 is cognitively intact. This MDS does not document the level of assistance R40 requires for bathing. On 2/23/25 at 10:06 AM, when asked if she was receiving assistance with bathing, R40 stated, I won't take a cold shower, so I won't take one. R40 stated it had been about a week since they had hot water and she was supposed to get a shower twice a week. 4. R3's Admission Record with a print date of 2/27/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include Huntington's Disease and urinary incontinence. R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3 is cognitively intact. On 2/23/25 at 10:25 AM, R3 stated they haven't had hot water for around seven days. R3 stated it has been a week since she got to shower. 5. R15's Admission Record with a print date of 2/27/25 documents R15 was admitted to the facility on [DATE] with diagnoses that include morbid obesity, cellulitis, and heart disease. R15's MDS dated [DATE] document a BIMS score of 15, indicating R15 is cognitively intact. On 2/23/25 at 12:27 PM, the hot water in R15's bathroom sink was room temperature and did not warm up. On 2/23/25 at 2:11 PM, V7 (CNA) stated they don't have hot water and they are supposed to go to the kitchen and have them heat them up water if they need warm water for resident care. On 2/25/25 at 9 PM, V9 (CNA) stated they don't have hot water other than in the kitchen. On 2/26/25 at 11:43 AM, V6 (CNA) stated the facility doesn't have hot water and she gets hot water in a basin from the kitchen when she provides resident care. V6 stated she didn't know how long they had been without hot water but found out about it when she returned to work on 2/27/25. On 2/24/25 at 9:29 AM, V4 (Maintenance Director) stated the hot water had not been working since 2/19/25. V4 stated on 2/18/25 the breaker tripped, and he reset it. V4 stated then on 2/19/25 the breaker tripped again, and the hot water wasn't heating up. V4 stated they ordered a new element for the hot water heater, but it hadn't been delivered to the facility. V4 stated it they didn't have hot water in any of the resident bathrooms, the shower rooms, and laundry room. V4 was present with this surveyor when this surveyor's thermometer was calibrated using the ice water method and thermometer read 32.0 Fahrenheit. V4 and this surveyor checked the water temperature in the following rooms with the following readings, 9:31 AM, [NAME] Shower room- shower 83.3 degrees Fahrenheit, sink 86.0 Fahrenheit; 9:34 AM, East Shower room, shower 81.5 degrees Fahrenheit, sink 86.3 degrees Fahrenheit; Laundry room sink 82.0 degrees Fahrenheit; 9:42 AM, R3's bathroom sink 83.1 degrees Fahrenheit; 9:42 AM, R15's bathroom sink 84.9 degrees Fahrenheit. V4 stated the laundry room sink has the same hot water line that feeds the washers. On 2/24/25 at 10:08 AM, V4 (Maintenance Director) reviewed the facility water temperature logs with this surveyor and stated he had not checked the facility water temperatures since the hot water stopped working. On 2/26/25 at 3:38 PM, V2 (Director of Nurses) stated she didn't remember the exact day they realized the hot water wasn't working but it was one day last week. V2 stated they started to give a resident a shower and the water wasn't getting warm enough. V2 stated they still had hot water in the kitchen, and it was their expectation the facility staff would utilize the kitchen hot water to provide care to the residents as needed. V2 stated they did have residents on isolation precautions and the staff were educated to wash their hands with the cold water in the resident bathroom and then go rewash their hands in an area of the facility that had hot water. V2 stated the laundry room has bleach and all linens and clothes were being washed using bleach. On 2/23/25 at 1:12 PM, V1 (Administrator) stated the element went out on the hot water heater. V1 stated they have ordered the part, and it was supposed to arrive on 2/21/25 and then again on 2/22/25. V1 stated he was following up again and had the part rushed but it still hadn't arrived. V1 stated they still have hot water in the restrooms near the Administrator's office and in the kitchen. An Order form provided to this surveyor documents the element was ordered on 2/19/25. The facility Water and Climate Test for 20 days dated 2/2025 documents on 2/17/25 the water temperature was checked, and the following readings were obtained. room [ROOM NUMBER]- 106 degrees Fahrenheit, room [ROOM NUMBER]- 105 degrees Fahrenheit, room [ROOM NUMBER]- 105 degrees Fahrenheit, room [ROOM NUMBER]- 104 degrees Fahrenheit, room [ROOM NUMBER]- 104 degrees Fahrenheit, room [ROOM NUMBER]- 103 degrees Fahrenheit, room [ROOM NUMBER]- 103 degrees Fahrenheit, room [ROOM NUMBER]- 102 degrees Fahrenheit, room [ROOM NUMBER]- 102 degrees Fahrenheit, room [ROOM NUMBER]- 102 degrees Fahrenheit, room [ROOM NUMBER]- 103 degrees Fahrenheit, room [ROOM NUMBER]- 105 degrees Fahrenheit, Laundry room- 118 degrees Fahrenheit, and kitchen- 128 degrees Fahrenheit. The facility Water Temperatures Policy and Procedure dated 11/1/2019 documents, Policy Statement: It is the policy of this facility to maintain water temperatures comfortable for residents .

Based on interview and record review the facility failed to provide showers for residents needing assistance for 4 of 5 (R6, R16, R18, and R40) residents reviewed for activities of daily living (ADL's) in the sample of 34. Findings Include: 1. R6's Admission Record with a print date of 2/27/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include cerebral palsy, morbid obesity, diabetes, lack of coordination, and urinary incontinence. R6's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 is dependent on staff for bathing. R6's current Care Plan documents a Focus area of (R6) has an ADL self-care performance deficit r/t (related to) Limited ROM (range of motion), Limited Mobility, impaired balance. This Focus area has a start date of 2/7/2016 and the interventions for this Focus area include, Bathing/showering: The resident is (totally dependent) on (1) staff to provide (Shower) (2 times a week) and as necessary. R6's Follow Up Questions Report dated 1/1/25 to 2/26/25 documents R6 was assisted with bathing on 1/3, 1/7, 1/10, 1/14, 1/21, 1/24, 1/31, 2/7, 2/14, 2/18 and 2/21/25 with not applicable documented on 2/4/25. This indicates R6 went from 1/14/25 to 1/21/25 (six days) and from 2/7/25 to 2/14/25 (six days) without being assisted with bathing. 2. R16's Admission Record with a print date of 2/27/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, Chron's disease, and chronic pain. R16's MDS dated [DATE] documents a BIMS score of 15, which indicates R16 is cognitively intact. This same MDS documents R16 is dependent on staff for bathing. R16's current Care Plan documents a Focus area of (R16) has an ADL self-care performance deficit r/t (related to) Amputation (Left BKA-LE -below knee amputation left extremity, Prosthesis) & (and) (Left Side Arm Paralysis), Impaired balance, Limited Mobility, abnormal posture, difficulty in walking, muscle weakness, lack of coordination This Focus area has a start date of 2/6/2017 and includes the intervention of, Bathing/showering: The resident requires (Extensive assistance) by (1) staff with (Showering) (2 x's-times wk-week) and as necessary. On 2/23/25 at 10:17 AM, R16 stated she doesn't get a shower every three days like she is supposed to. R16 stated they are short staffed so they sometimes can't take showers as they should. R16's Follow Up Question Report dated 1/1/25 to 2/26/25 documents R16 received assistance with bathing on 1/7, 1/18, 1/21, 1/24, 1/28, 1/31, 2/7, 2/14, and 2/18. This same report documents R16 was not available and/or refused showers on 1/3, 1/10, 1/12, 1/14, 1/29, 2/21, and 2/25. This indicates R16 went from 1/14/25 to 1/21/25 (six days) without being offered assistance with bathing. 3. R18's Admission Record with a print date of 2/27/25 documents R18 was admitted to the facility on [DATE] with diagnoses that include osteoarthritis of the knee, pain, visual loss, muscle weakness, and urinary incontinence. R18's MDS dated [DATE] documents a BIMS score of 12, which indicates a moderate cognitive deficit. This MDS does not document the level of assistance R18 requires with ADL's. R18's current Care Plan documents a Focus area of, (R18) has an ADL self-care performance deficit r/t Dementia, difficulty in walking, lack of coordination, muscle weakness. This Focus area documents a start date of 2/7/2016 and includes an intervention of, GG- Shower/Bathe Self (Total Dependence x 1) with an initiation date of 9/23/23. R18's Follow Up Question Report dated 1/1/2025 to 2/26/2025 documents R18 received assistance with bathing on 1/7, 1/10, 1/14, 1/17, 1/18, 1/21, 1/31, 2/4, 2/7, 2/11, 2/14, 2/18, and 2/25/25. This indicates R18 went from 1/21/25 to 1/31/25 (9 days) without being offered assistance with bathing. 4. R40's Resident Admission Record with a print date of 2/27/25 documents R40 was admitted to the facility on [DATE] with diagnoses that include heart failure, COPD, acquired absence of left leg above the knee, and foot drop. R40's MDS dated [DATE] documents a BIMS score of 15, indicating R40 is cognitively intact. This MDS does not document the level of assistance R40 requires for bathing. R40's current Care plan documents a Focus area of I currently have an alteration to my ability to care for self and need assistance d/t (due to) musculoskeletal impairment. This Focus area has a start date of 11/3/2023 and includes the intervention of Bathing/Showering: (R40) requires Limited Assistance of (1-2) staff to provide (shower) (2x's/wk-2 times per week). Monitor nail length, clean under nails, notify nurse if nails need trimmed, avoid scrubbing & (and) pat dry sensitive skin. On 2/23/25 at 10:06 AM, when asked if she was receiving assistance with bathing, R40 stated, I won't take a cold shower, so I won't take one. R40 stated it had been about a week since they had hot water, and she was supposed to get a shower twice a week. R40's Follow Up Question Report dated 1/1/2025 to 2/26/2025 documents R40 was not offered assistance with bathing from 2/19/25 to 2/26/25 (six days). On 02/25/25 at 2:49 PM, V7 (CNA/Certified Nursing Assistant) stated they were not able to provide shower assistance to residents on 2/23/25 partially due to no hot water and partially due to not having enough CNA's. On 02/25/25 at 3:12 PM, V8 (CNA) stated they did not assist any residents with showering on 2/23/25. V8 stated she washed residents faces with a cold washcloth. On 02/25/25 at 3:19 PM, V9 (CNA) stated they work with three CNA's every other weekend and they are not able to meet the needs of the residents timely. V9 stated when they only have three CNA's showers are not always done as they should be. On 2/25/25 at 3:31 PM, V10 (CNA) when they only have three CNA's working, not all showers are done as they should be. On 2/26/25 at 3:38 PM, V2 (Director of Nurses) stated she had not had any resident complain related to not getting bathed as they should. V2 stated residents should be offered assistance with bathing twice a week. On 2/27/25 at 3:00 PM, V2 stated she did not have reproducible evidence R40 was offered assistance with bathing from 2/19/25 to 2/26/25, R6 from 2/7/15 to 2/14/25, R18 from 1/21/25 to 1/30/25, and R16 from 1/14/25 to 1/21/25. The facility Shower Care Policy and Procedure dated 11/1/2015 documents, Purpose: It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues 16. Showers/Baths/Bed baths are offered per regulation and taking into account personal preferences.

Based on interview and record review the facility failed to ensure restorative programs were administered for 3 of 4 (R4, R6, and R21) residents reviewed for restorative programs in the sample of 34. Findings Include: 1. R6's Admission Record with a print date of 2/27/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include cerebral palsy, morbid obesity, diabetes, lack of coordination, and urinary incontinence. R6's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R6 is cognitively intact. This same MDS documents no passive or active range of motion was performed in the last 7 calendar days. R6's current Care plan documents a Focus area of, (I (R6), have limited ROM (range of motion) r/t (related to) Impaired balance, Pain (Multiple locations), difficulty in walking, abnormal posture, muscle weakness. Date Initiated: 01/02/2020. This Focus area includes interventions of, Execute passive and active ROM exercises to all extremities daily. Date Initiated: 01/20/2020 .Let resident accomplish tasks at own pace. Date Initiated: 01/02/2020 On 2/26/25 at 10:56 AM, V16 (CNA/Certified Nursing Assistant) stated she was not aware of a restorative program for R6 or any other resident. V16 stated they do have the residents move their extremities when they are doing ADL's (Activities of Daily Living) with them but there is no documented restorative program that she is aware of. On 2/26/25 at 10:58 AM, V17 (CNA) stated she was not aware of any documented restorative program for R6 or any other resident. 2. R21's Resident Admission record with a print date of 2/27/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include chronic pain syndrome, repeated falls, muscle weakness, lack of coordination, and unspecified lack of coordination. R21's MDS dated [DATE] documents R21 has a moderate cognitive impairment. This same MDS documents R21 has not had any passive or active range of motion performed in the last seven days. On 02/26/25 at 11:40 AM, V6 (CNA) stated they don't have a restorative program. V11 stated there were no restorative programs specifically for R21 and she wasn't aware of any restorative programs for any residents currently residing at the facility. On 2/26/25 at 2:26 PM, V5 (Occupational Therapist/Director of Rehab) stated they combine restorative programs with their activities of daily living and therapy doesn't put any range of motion programs in place. On 02/26/25 at 11:20 AM, V2 (DON/Director of Nurses) stated resident restoratives are done with ADL's (Activities of Daily Living). V2 stated there is no specific restorative programs that are documented. 51735 3.) R4's Admission Record documents diagnoses including in part Multiple Sclerosis, dependence on wheelchair, muscle wasting and muscle weakness. The Admission Record documents R4 was admitted on [DATE]. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Section GG documents for functional limitations in range of motion that R4 had impairment on both sides for both upper and lower extremities. Section GG for mobility documents that R4 is dependent for shower/bathing, transferring, laying to sitting on side of bed, sit to laying and rolling in bed. Section GG for self-care documents that R4 is dependent for eating, toileting hygiene, shower/bathing, upper and lower body dressing, and putting on and taking off footwear. Section O of the same MDS documents R4 received 0 days of range of motion and 0 days of passive range of motion, with a look back period of 7 days. R3's current Care Plan documents a focus area dated 1/23/2019 of R4 has limited range of motion due to Multiple Sclerosis. Goal dated 1/23/2019 documents R4 will maintain and preserve mobility and functional independence. Intervention dated 1/23/2019 documents execute passive and active range of motion exercises to all extremities daily. Physician's Orders dated 2/11/2025 states R4 may wear hand orthotics at night, as needed, for contracture prevention. On 2/27/2025 at 1:13 PM, R4 stated the Certified Nurses Assistants only move his arms, legs, and hands when they are dressing R4. R4 stated sometimes the staff put hand braces on his hands. On 2/26/2025 at 2:25 PM, V5 (Occupational Therapist and Director of Rehab) stated R4 is currently in Occupational Therapy and Speech Therapy. V5 stated there isn't a restorative program at this facility and if she recommends any type of restorative therapy then it would be the Certified Nurses Assistants activities of daily living. On 2/27/2025 at 12:45 PM, V6, (Certified Nursing Assistant) stated they do not have a restorative program at this facility. V6 stated they lift R4's arms and legs when they perform care and dress R4. The facility did not have a reproducible restorative policy pertaining to restorative care.

Based on observation, interview, and record review the facility failed to ensure incontinence care was provided per current standards of practice for 2 of 3 (R6 and R18) residents reviewed for incontinence care in the sample of 34. Findings Include: 1. R6's Admission Record with a print date of 2/27/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include cerebral palsy, morbid obesity, diabetes, lack of coordination, and urinary incontinence. R6's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 is frequently incontinent of bowel and bladder and is dependent on staff for toilet hygiene. R6's current Care Plan documents a Focus area dated 2/7/2016 of, (R6) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Limited ROM (range of motion), Limited Mobility, Impaired balance. Date Initiated: 02/07/2016. This Focus area includes the following intervention, Toilet Use: The resident requires (Totally Dependent) by (2) staff for toileting. Date Initiated: 04/26/2017. On 2/23/25 at 2:17 PM, R6 was lying in bed and there was a strong odor of urine. V7 (CNA/Certified Nursing Assistant) entered R6's room with this surveyor. V7 uncovered R6 and R6's pajamas pants were around R6's ankles. V7 removed R6's pants and incontinence brief. R6's brief was wet but not saturated. V7 took dry toilet paper and wiped R6's groin wiping from front to back. V7 then assisted R6 to roll to the side and wiped R6's buttocks with dry toilet paper. R6 had feces on her buttocks, the toilet paper was covered in feces. V7 used more dry toilet paper to wipe R6's buttocks and it was again covered in feces. V7 got a wet paper towel from the bathroom and wiped R6's buttocks. The paper towel was covered in feces. V7 determined R6 was in the process of having a bowel movement. V7 placed a depend under R6's buttocks so she could finish the bowel movement and covered R6 with a blanket. 2. R18's Admission Record with a print date of 2/27/25 documents R18 was admitted to the facility on [DATE] with diagnoses that includes functional urinary incontinence. R18's MDS dated [DATE] documents R18 has a BIMS score of 12, which indicates R18 has a moderate cognitive deficit. This same MDS documents R18 is always incontinent of bowel and bladder and dependent on staff for toilet hygiene. R18's current Care Plan documents a Focus area of (R18) has an ADL self-care performance deficit r/t Dementia, difficulty in walking, lack of coordination, muscle weakness. Date Initiated: 02/07/2016. This Focus area documents interventions that include, Toilet Use: The resident requires (Extensive Assist) x (1) staff for toileting Date Initiated: 02/08/2016. On 2/26/25 at 2:00 PM, V18 (CNA) entered R18's room, donned a gown and gloves and assisted R18 to transfer from the wheelchair to the bed. V18 removed R18's incontinence brief that was saturated with urine. V18 put warm water in a basin and placed wash cloths in the basin. V18 used a bottle labeled shampoo/body soap and placed it directly on the wet washcloth after ringing the cloth out. V18 used several washcloths in the same manner and washed R18's groin area. V18 then used a dry towel to dry the area without rinsing it. V18 covered R18, doffed the gown and gloves. V18 exited the room without performing hand hygiene or washing, rinsing, and/or drying, R18's buttocks. On 02/26/25 at 3:54 PM, V2 (Director of Nurses/DON) stated they have peri care wash, and she would have to check to see if the shampoo/body wash was no rinse. V2 stated she would expect staff to wash buttocks when providing incontinence care and to use wash cloths and not dry toilet paper and wet paper towels. On 02/27/25 at 3:00 PM, V2 (DON) stated the shampoo/body wash doesn't have to be rinsed if it is mixed with warm water but if it is applied to a washcloth and directly to the body then it has to be rinsed. The facility Perineal/Incontinence Care Policy and Procedure dated 11/1/2015 documents, Purpose: To provide cleanliness and comfort to the resident, prevent infections and skin irritation, and observe the resident's skin condition. Procedure: .8. Cleanse the resident's perineal area using an approved no-rinse incontinence cleansing product, soap and water, or wipes. a. For female residents, separate labia and cleanse on side, then the other then the center of the labia toward the rectal area. i. Cleanse the perineal area from front to back. If sing soap that requires rinsing, rinse in the same manner and then pat dry. ii. The rectal area and buttocks should be cleansed as well wiping away from urethra 10. Assure all areas affected by the incontinence have been cleansed.

Based on observation, interview, and record review the facility failed to ensure residents received nutritional supplementation as recommended by the dietitian to prevent weight loss for 3 of 6 (R22, R31, R48) residents reviewed for nutrition in the sample of 34. Findings Include: 1. R31's Admission Record with a print date of 2/27/25 documents R31 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy. R31's MDS (Minimum Data Set) dated 1/7/25 documents R31 has a severe cognitive impairment. R31's current Care plan documents a Focus area of, (R31's) diet is (Regular diet, mechanical soft texture, Regular thin liquids). Resident is at a (Moderate) nutritional risk d/t (due to) dysphagia. Date Initiated: 7/02/2019. Interventions for this same Focus area include, Discuss food likes and dislikes. Date Initiated: 07/02/2019 .Respect resident preferences at all times Date Initiated: 07/02/2019 . R31's current Care Plan does not document a Focus area or intervention related to nutritional supplements and/or weight loss. R31's Annual Nutrition note dated 1/17/25 documents, Nutritional Review: Weight 120# (pounds) Diet Order: Regular Dysphagia Advanced; ice cream bid (twice daily); mighty shake with snack bid; snack between meals; med pass supp (supplement) 60cc (cubic centimeter) tid (three times a day). Resident weight is 120% of IBW (Ideal Body Weight) midpoint BMI (body mass index) = (equals) 23.4. Intake is reported as 50%-100%of most meals, does refuse breakfast at times. Resident feeds self. No current labs are available for review. No skin concerns reported to RD (Registered Dietitian). Estimated nutrient needs are 1540 kcal (kilocalories)/day, 55 grams protein/day and 1650 ml fluid/day. Diet appropriate to provide for estimated needs. R31's Order Summary Report dated 2/27/25 documents a physician order dated 2/8/24 for ice cream two times a day for supplement. On 2/23/25 at 12:15 PM, R31 was observed eating lunch. R31 was not served ice cream until it was brought to the attention of staff, by the survey team, that R31 was not served ice cream with her noon meal. On 2/24/25 at 12:17 PM, R31 was served chicken pot pie, green beans, bread, tea, and an ice cream sandwich. During this meal observation all residents were served an ice cream sandwich for dessert. R31 was not served a second helping of ice cream as a supplement. 2. R48's Admission Record with a print date of 2/27/25 documents R48 was admitted to the facility on [DATE] with diagnoses that include diabetes mellitus, heart disease, and altered mental status. R48's MDS dated [DATE] documents a BIMS score of 11, which indicates a moderate cognitive deficit. R48's current Care Plan documents a Focus area of, My current diet is NAS (no added sodium), Dysphagia Advanced, Regular/thin liquids. May have crispy bacon. Date Initiated: 11/11/2024. This same Focus area includes the following interventions, Provide diet as ordered by MD (physician) Date Initiated: 11/11/2024 Dietary consult if indicated. Encourage good nutrition and hydration. Date Initiated: 11/11/2024 . Monitor- weight Date Initiated: 11/11/2024 Nutrition-Snacks Date Initiated: 11/11/2024 . R48's current Care Plan does not document what supplements R48 is to receive. R48's Order Summary Report dated 2/27/25 documents a physician order dated 2/11/25 of, Ice cream two times a day for Supplement R48's Nutrition Progress note dated 1/17/25 documents Note Text: Weight 147.2# Diet Order: Dysphagia Mechanical NAS (may have crispy bacon) Resident has experienced a 6.3% weight gain over the past month. No presence of edema is reported. Intake varies at meals. Continue with present diet orders and weight monitoring. R48's Nutrition Progress note dated 2/10/24 documents, Note Text: Weight 137# Diet Order: Dysphagia Mechanical NAS (may have crispy bacon); house supplement with meals. Resident has experienced a 6.9% weight loss over the past month, weight fluctuations noted. Intake varies at meals. Recommend ice cream at lunch/supper and weekly weights. R48's weight was checked on 2/27/25 and was 141.2 pounds. This indicates a gain of 4.2 pounds or 3.06%. On 2/23/25 at 12:34 PM, R48 was sitting in the dining room, eating ground meat, cauliflower, mashed sweet potatoes, boost, tea, coffee, bread, and pudding. R48 was not served ice cream. On 02/24/25 at 12:12 PM, R48 was served chicken pot pie, green beans, bread, an ice cream sandwich, and tea. During this meal observation all residents were served an ice cream sandwich as dessert. R48 was not served a second helping of ice cream. On 02/25/25 at 1:14 PM, V14 (Dietary Manager) stated R31 and R48 should have been served ice cream on 2/23/25. When asked if they should have gotten a second helping of ice cream on Monday 2/24/25 at lunch when they were served an ice cream sandwich for dessert, V14 stated, I don't think so. I think that would be a lot. When asked how they got the extra calories if they didn't get the ice cream V14 stated she would check with the dietitian. On 02/25/25 at 1:18 PM, V14 (Dietary Manager) stated R31 and R48 should have been served ice cream with the ice cream sandwich at lunch on 2/24/25. On 02/26/25 at 11:03 AM, V3 (Dietitian) stated she saw R48 on 2/10/25 and recommended ice cream at lunch and supper and weekly weights. This surveyor reviewed with V3, the observation on 2/24/25 of R31 and R48 not getting a second ice cream when the ice cream sandwich was served as dessert. V3 stated they should have received the dessert on the menu and the ice cream as supplemental calories. When asked if there was a negative impact for them not getting the ice cream on 2/23/25 and the second helping of ice cream on 2/24/25, V3 stated, The ice cream was put in place to provide additional calories due to the weight loss. V3 stated R31's weights are currently stable and trending up and her intake has improved. On 02/26/25 at 3:35 PM, V2 (Director of Nurses) stated she would expect residents to be served supplements as ordered/recommended. On 2/28/25 at 8:20 AM, V11 (Physician) stated he did not think R31 not getting the ice cream on 2/23 and 2/24/25 would have had a negative impact on R31's weights. 3. R22's admission profile sheet documents an admitted [DATE]. This same document includes the following diagnoses: calculus of kidney and chronic kidney disease, stage 4 (severe) and unspecified hydronephrosis. R22's current month physician orders document a diet order for low concentrated sweets dysphasia advanced texture, regular consistency, no oranges/orange juice/bananas/fresh potatoes-limit milk to 1/2 cup per day, 1-ounce extra protein per meal and no added salt. R22's care plan has a focus area of R22's diet is a regular diet, mechanical soft texture and thin consistency. The goals for this focus area are as follows: the resident will not lose or gain more than 5 pounds through the review date of 5/12/2025, and the resident will comply with diet orders. The interventions for this focus are discuss food likes/dislikes and respect resident preferences at all times. On 2/23/25 at 12:30 PM, R22 was served his lunch of ground ham with gravy, yams, and mixed vegetables. R22 stated at this time I don't like that. R22 was then brought chicken noodle soup and a peanut butter sandwich. On 2/26/25 at 11:00 AM, V3 (Registered Dietitian) stated that the chicken noodle soup and peanut butter sandwich would not be equivalent to providing an extra ounce of protein at meals. The facility Nutritional Snacks and Supplements Policy and Procedure dated 12/30/2024 documents, Policy Statement, Nutritional supplements are available, and will be provided for all appropriate residents by the nursing staff 7. Supplements will be incorporated in care plans as needed

Based on interview, record review and observation the facility failed to maintain communication and collaboration with an offsite dialysis center for 1 (R22) of residents reviewed for dialysis in a sample of 34. The Findings Include: R22's admission profile sheet documents an admitted [DATE]. This same document includes the following diagnoses: calculus of kidney and chronic kidney disease, stage 4 (severe) and unspecified hydronephrosis. R22's current month physician orders document a diet order for low concentrated sweets dysphasia advanced texture, regular consistency, no oranges/orange juice/bananas/fresh potatoes-limit milk to 1/2 cup per day, 1-ounce extra protein per meal and no added salt. This same document lists dialysis on Tuesday, Thursday, and Saturday three times a week. R22's care plan has a focus area of: I currently require hemo dialysis related to chronic kidney disease. The focus area is: I will be complaint with labs and diagnostics if ordered by my doctor through the review date of 5/12/2025, I will be free of any discomfort or adverse side effects to therapies through the review date of 5/12/2025, and I will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date of 5/12/2025. The interventions for this focus are as follows: Administer medication and treatments orders by the physician and monitor for side effects, encourage resident to go to the scheduled dialysis appointments, and labs/diagnostics will be monitored per physician orders. On 2/25/25 at 1:30 PM, V20 (Registered Nurse) that the facility sends a three-ring binder that contains a communication log with R22 to all the dialysis treatments in his dialysis bag. V20 stated that when he refuses dialysis, they only chart that in the progress notes not in the binder. Review of this log for 2025 documents the following days that were filled out: 1/2/25, 1/11/25, 1/21/25, 1/30/25, 2/4/25, 2/22/25, 2/25/25. On 2/26/25 at 11:00 AM, V3 (Registered Dietitian) stated that they do not have a good communication with the dialysis unit, and they do not get the monthly labs unless the facility requests them every month. V3 stated that usually all communication is done through nursing, she does not talk with the dialysis clinic usually. On 2/26/25 at 2:00 PM, V2 (Director of Nursing) provided 6 months of R22's lab work from the dialysis clinic. V2 confirmed that she had to call the dialysis clinic today to get the copies, as they do not receive them on a monthly basis. V2 stated that the communication with the dialysis clinic could use some improvement.

Based on interview and record review the facility failed to ensure bedtime snacks were offered to 2 of 2 (R19 and R16) residents reviewed for snacks in the sample of 34. Findings Include: 1. R19's Admission Record with a print date of 2/27/25 documents R19 was admitted to the facility on [DATE] with diagnoses that include diabetes. R19's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 08, which indicates a moderate cognitive deficit. R19's current Care Plan documents a Focus area of (R19) has a dx (diagnosis) of Diabetes Mellitus. Date Initiated: 07/14/2016. This Focus area includes the intervention of, Provide Diabetic snacks between meals and at bedtime per diet orders. On 2/24/25 at 1:42 PM, R19 stated they don't get snacks at night, and she is diabetic and is supposed to have a snack each night. 2. R16's Admission Record with a print date of 2/27/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, Chron's disease, and chronic pain. R16's MDS dated [DATE] documents a BIMS score of 15, which indicates R16 is cognitively intact. R16's current Care Plan documents a Focus area related to diagnosis of diabetes but does not include an intervention related to diabetic snacks. On 2/24/25 at 1:42 PM, R16 stated they didn't get snacks last night (2/23/25) because they only had two CNA's (Certified Nursing Assistants) working and they didn't have time to pass the snacks. On 2/25/25 at 2:49 PM, V7 (CNA) stated she worked from 2 PM to 10 PM on 2/23/25. V7 stated they only had three CNA's working and did not have the manpower to pass snacks. On 02/25/25 at 3:12 PM, V8 (CNA) stated she worked evening shift on 2/23/25. V8 stated she did not pass snacks to residents on 2/23/25. V8 stated they normally offer them after everyone lays down and they didn't get residents in bed until 9:00 PM because they were short staffed. On 2/25/25 at 3:19 PM, V9 (CNA) stated he worked 2 PM to 10 PM on 2/23/25. V9 stated he didn't remember passing snacks to the residents that evening. On 2/25/25 at 3:31 PM, V10 (CNA) stated she worked from 12 PM to 6:30 PM on 2/23/25. V10 stated snacks are typically passed around 8:00 PM. On 02/26/25 at 3:38 PM, V2 (Director of Nurses) stated she hadn't had any complaints related to snacks not being offered. The facility Nutritional Snacks and Supplements Policy and Procedure dated 11/1/2015 documents, Nutritional supplements are available, and will be provided for all appropriate residents by the nursing staff 3. The dietary staff will deliver supplements to each nursing station at 10:00 am, 2:00 pm, and 7:00 pm (for H.S./hour of sleep snacks). 4. Bedtime snacks will be offered daily .

Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed per current standards of practice for 3 of 6 (R6, R18, and R31) residents reviewed for infection control in the sample of 34. Findings Include: 1. R6's Admission Record with a print date of 2/27/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include cerebral palsy, morbid obesity, diabetes, lack of coordination, and urinary incontinence. R6's MDS (Minimum Data Set) dated 1/2/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R6 is cognitively intact. This same MDS documents R6 is frequently incontinent of bowel and bladder and is dependent on staff for toilet hygiene. R6's current Care Plan documents a Focus area dated 2/7/2016 of, (R6) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Limited ROM (range of motion), Limited Mobility, Impaired balance. Date Initiated: 02/07/2016. This Focus area includes the following intervention, Toilet Use: The resident requires (Totally Dependent) by (2) staff for toileting. Date Initiated: 04/26/2017. On 2/23/25 at 2:17 PM, R6 was lying in bed and there was a strong odor of urine. V7 (CNA/Certified Nursing Assistant) entered R6's room with this surveyor. V7 uncovered R6 and R6's pajamas pants were around R6's ankles. V7 removed R6's pants and incontinence brief. R6's brief was wet but not saturated. V7 donned gloves, took dry toilet paper and wiped R6's groin wiping from front to back. V7 then assisted R6 to roll to the side and wiped R6's buttocks with dry toilet paper. R6 had feces on her buttocks and the toilet paper was covered in feces. V7 used more dry toilet paper to wipe R6's buttocks and it was again covered in feces. V7 got a wet paper towel from the bathroom and wiped R6's buttocks. The paper towel and V7's gloves were covered in feces. V7 doffed her gloves and donned a clean pair without performing hand hygiene between glove changes. V7 determined R6 was in the process of having a bowel movement. V7 placed a depend under R6's buttocks so she could finish the bowel movement and covered R6 with a blanket. 2. R18's Admission Record with a print date of 2/27/25 documents R18 was admitted to the facility on [DATE] with diagnoses that includes functional urinary incontinence. R18's MDS dated [DATE] documents R18 has a BIMS score of 12, which indicates R18 has a moderate cognitive deficit. This same MDS documents R18 is always incontinent of bowel and bladder and dependent on staff for toilet hygiene. R18's current Care Plan documents a Focus area of (R18) has an ADL self-care performance deficit r/t Dementia, difficulty in walking, lack of coordination, muscle weakness. Date Initiated: 02/07/2016. This Focus area documents interventions that include, Toilet Use: The resident requires (Extensive Assist) x (1) staff for toileting Date Initiated: 02/08/2016. On 2/26/25 at 2:00 PM, V18 (CNA) entered R18's room, donned a gown and gloves and assisted R18 to transfer from the wheelchair to the bed. V18 removed R18's incontinence brief that was saturated with urine. V18 doffed her gloves and donned clean gloves without performing hand hygiene. V18 put warm water in a basin and placed wash cloths in the basin. V18 used a bottle labeled shampoo/body soap and placed it directly on the wet washcloth after ringing the cloth out. V18 used several washcloths in the same manner and washed R18's groin area. V18 doffed gloves and donned clean gloves without performing hand hygiene. V18 then used a dry towel to dry the area without rinsing it. V18 covered R18, doffed the gown and gloves. V18 exited the room without performing hand hygiene or washing, rinsing, and/or drying, R18's buttocks. When asked why if she performed hand hygiene after providing incontinence care to R18, V18 stated she had forgotten. 3. R31's Admission Record with a print date of 2/27/25 documents R31 was admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy. R31's MDS (Minimum Data Set) dated 1/7/25 documents R31 has a severe cognitive impairment. On 2/26/25 at 3:20 PM, V12 (LPN/Licensed Practical Nurse) administered treatment to R31's left ankle and right heel. V12 changed gloves after administering treatment to R31's heel and before administering treatment to R31's ankle. V12 did not perform hand hygiene after doffing her gloves and before donning a clean pair of gloves. On 2/26/25 at 3:36 PM, V2 (Director of Nurses) stated hand hygiene should be performed after doffing gloves and before donning clean gloves. The facility Hand Washing Policy and Procedure dated 10/16/2023 documents, Policy Statement: Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination . Hands should be washed before resident care, after resident care, after breaks, after using the restroom, after smoking or eating, after blowing nose, after disposing of trash, after handling dirty dishes, after picking anything up from the floor, and at any other time deemed necessary.

Based on observation, interview, and record review, the facility failed to provide privacy during perineal, urinary catheter, and wound care for 1 (R1) of 3 residents reviewed for personal privacy in the sample of 3. Findings include: R1's Admission Record documented an admitted [DATE] with diagnoses including enterocolitis due to clostridium difficile, local infection of the skin and subcutaneous tissue, flaccid hemiplegia affecting right dominant side, cerebral infarction. R1's 11/20/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact. R1's care plan documented a 10/9/24 focus area of limited range of motion due to weakness and a 10/9/24 focus area of an alteration with the ability to care for self and need of assistance due to activity intolerance, decreased strength, endurance, and weakness. On 2/21/25 at 10:45 AM, V4 (Certified Nursing Assistant/ CNA) and V5 (CNA) completed hand hygiene and donned gowns and gloves then assisted R1 from his wheelchair to the bed with a mechanical lift. V5 removed R1's pants soiled with feces without pulling the privacy curtain. A knock sounded at R1's door and V4 and V5 shouted patient care before R1's door opened with R1 lying on the bed nude from the waist down, then V8 (Licensed Practical Nurse/ LPN) stated are you ready and closed the door. R1 asked V4 and V5 if they could put his pants on and V4 and V5 said no they were waiting on V8 to come to complete wound care. V5 opened R1's door looking for V8, with R1 lying on the bed nude from the waist down, then shut the door. On 2/21/25 at 11:15 AM, V8 (LPN) opened R1's door with R1 lying on the bed nude from the waist down. V8 and V4 assisted R1 to roll to his side and V8 told V4 that R1 needed a clean cloth pad. V4 opened R1's door, with R1 lying on the bed nude from the waist down and told V5 to bring another cloth pad and shut the door. While waiting for V5 to bring the cloth pad, V8 asked V4 if she had a sheet or something to cover R1 up with because he's very exposed here. V4 said the sheet was dirty and she did not have anything to cover R1 up with. V5 opened R1's door with R1 lying on the bed nude from the waist down and handed V4 a cloth pad and shut R1's door. On 2/21/25 at 11:35 AM, a knock sounded on R1's door, V4 opened the door with R1 lying on the bed nude from the waist down and V6 (CNA) and V7 (CNA) entered R1's room and shut the door. V4 and V8 doffed their gowns and gloves and opened R1's door with R1 nude from the waist down and exited the room. V6 and V7 assisted R1 to put on a clean incontinence brief and pants. R1 was lying on the bed nude from the waist down without the privacy curtain pulled and the door opening several times for approximately 1 hour. On 2/21/25 at 12:40 PM, R1 stated he felt exposed while staff were providing care. R1 said due to feeling exposed he had asked if they would put his pants on and they had refused. On 2/21/25 at 3:10 PM, V2 (Director of Nursing/ DON) stated it is the expectation that staff provide privacy when providing care. The facility's revised 9/11/20 Perineal/ Incontinence Care policy documented in part .Procedure . 1. Gather equipment for procedure . 3. Provide privacy . 6. Assist with position [sic] the resident into a safe and comfortable position; avoid overexposing the resident's body .

Based on observation, interview, and record review the facility failed to provide perineal, urinary catheter, and wound care per standards of practice to prevent infections for 1 (R1) of 3 residents reviewed for infection control in a sample of 3. Findings include: R1's Admission Record documented an admitted [DATE] with diagnoses including enterocolitis due to clostridium difficile, local infection of the skin and subcutaneous tissue, flaccid hemiplegia affecting right dominant side, cerebral infarction. R1's 11/20/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact. The same MDS documents that R1 is dependent for toileting hygiene, toilet transfers, and chair to bed transfers. R1 has an indwelling catheter, and R1 is always incontinent of bowel. R1's Care Plan documents a focus area of I currently have an infection d/t (due to) C-Difficile (clostridium difficile) with an initiation date of 01/28/2025. Documented interventions for this focus area include: Emphasize good hand washing techniques to all direct care staff and type of isolation: contact enteric precautions. R1's Care Plan also documents a focus area of I have an Indwelling Urinary Catheter and am at risk for opportunistic infection to enter my body with an initiation date of 12/26/24. Documented interventions for this focus area include: Enhanced Barrier Precautions during personal care. On 2/21/25 at 10:45 AM, V4 (Certified Nursing Assistant/ CNA) and V5 (CNA) completed hand hygiene and donned gowns and gloves then assisted R1 from his wheelchair to the bed with a mechanical lift. V5 removed R1's pants soiled with feces and pulled R1's urinary catheter collection bag trough the pant leg. V5 placed the urinary catheter collection bag on the fitted sheet. V4 took R1's soiled pants and placed them in a clear bag. V5 pulled down the front of R1's incontinence brief and fecal matter was noted to be on R1's lower stomach, groin folds, scrotum, and urinary catheter tubing. V5 used a blue plastic disposable under pad sprayed with peri wash to clean the feces off of R1 groin folds wiping from front to back and would wad up the dirty area of the disposable under pad and wipe again. V5 continued to clean feces from R1 with the disposable under pad with a wipe and wad method. V4 and V5 assisted R1 to roll to his side with some feces left on the urinary catheter tubing. V5 changed her gloves without preforming hand hygiene and removed the feces soiled incontinence brief. V5 proceeded to clean feces from R1's gluteal folds with a disposable under pad with peri wash sprayed on it with the same wipe and wad method. The bottom of the back of R1's shirt had feces present and the cloth pad under R1 was soiled with feces when V4 and V5 assisted R1 to roll onto his back. V5 changed her gloves but did not perform hand hygiene. V5 sprayed another disposable under pad with peri wash and wiped R1's groin folds and scrotum with the same wipe and wad method. V5 was observed to handle the bottle of peri wash with her soiled gloves several times replacing it on the bedside table or setting the bottle on the soiled pad. V5 sprayed another disposable under pad with peri wash and began cleaning R1's urinary catheter tubing then retracted R1's foreskin to clean R1's glans penis with the same wipe and wad method, continuing with the same disposable pad soiled with feces, V5 encircled R1's urinary catheter tubing at R1's urinary meatus and without holding the tubing to prevent traction pulled the disposable pad down the catheter tubing. V5 pulled the disposable under pad down R1's catheter tubing twice without holding the tubing to prevent traction. R1's urinary catheter was observed to move in and out of the urethra while V5 was cleaning the tubing and would back into the urethra when V5 released the tubing. V4 sat the bottle of peri wash on the bedside table where it was originally located. V4 and V5 said they were then waiting on V8 (Licensed Practical Nurse/ LPN) to complete wound care for R1 before they put a clean incontinent brief on R1. V5 then grabbed R1's door handle with her soiled gloves and opened R1's door looking for V8 then shut the door. V4 was asked if she usually used disposable under pads to provide perineal and urinary catheter care and V4 said not usually but the facility did not have any clean washcloths at this time to clean residents with. On 2/21/25 at 11:15 AM, V8 (LPN) entered R1's room with wound care supplies sitting them on the uncleaned bedside table. V8 and V4 assisted R1 to roll to his side and V8 sat R1's wound supplies on R1's feces soiled cloth pad. V8 told V4 R1 needed a clean cloth pad and V4 with the same soiled gloves opened R1's door and told V5 to bring another cloth pad and shut the door. While waiting for V5 to bring the cloth pad, V8 picked up wound care supplies from the soiled cloth pad and set them on the fitted sheet. V8 then sprayed wound cleaner on gauze 4x4 and started to pick pieces of feces from R1's thighs, buttocks, gluteal fold, and lower back. V5 opened R1's door and handed V4 a cloth pad. V8 performed hand hygiene and donned clean gloves, returned to R1's bedside and V4 with the same soiled gloves handed the cloth pad to V8. V8 rolled the soiled pad up and placed the clean cloth pad under it. V4 and V8 assisted R1 to roll to the other side and V4 removed the soiled pad. V4 and V8 assisted R1 to roll to the other side, still with feces on the bottom of the back of R1 shirt, to allow V8 to provide wound care. V8 performed hand hygiene and donned clean gloves before picking up the wound care supplies sitting on R1's fitted sheet and cleaned R1's right buttock wound. V8 performed hand hygiene and donned clean gloves before picking up the other wound care supplies from R1's bedside table and sitting them on R1's fitted sheet. V8 packed R1's wound and covered with a boarder dressing. V8 sprayed wound cleaner on gauze 4x4 and wiped more pieces of feces off of R1's upper thighs. On 2/21/25 at 11:35 AM, a knock sounded on R1's door, V4 with the same soiled gloves opened the door and V6 (CNA) and V7 (CNA) entered R1's room wearing gloves and gowns. V8 performed hand hygiene and V4 doffed her soiled gloves, without performing hand hygiene V4 opened R1's door and V8 and V4 exited. V4 closed R1's door by grabbing the outside handle. V7 picked up R1's urinary catheter collection bag and attempted to put it down a pant leg of a new pair of pants, not knowing R1's urinary catheter collection bag privacy cover was soiled with feces. V7 was asked if R1's urinary catheter collection bag privacy cover was clean and V7 said she thought that it had some dirt on it and removed the privacy bag and put the collection bag through the pant leg. Without performing hand hygiene or donning new gloves V7 picked up a clean incontinence brief and set it on the fitted sheet. V7 and V8 assisted R1 to roll to his side. V7 then picked up a towel and sprayed it with peri wash and cleaned more feces from R1's thighs, gluteal fold, and lower back. V7 rolled half the incontinence brief and placed it under R1's bottom. V7 an V8 assisted R1 to roll and V8 unrolled the other side of the brief under R1, then assisted him to roll onto his back. V8 sprayed another towel with peri wash and cleaned feces from R1's lower abdomen and groin folds. V7 and V8 closed the incontinent brief and assisted R1 to pull up his pants. V7 and V8 were asked if the back of R1's shirt had feces on it. V7 and V8 assisted R1 to roll to his side and said R1's shirt did have feces on it. V7 and V8 assisted R1 in removing his shirt and placed it in a clear bag. V8 went to R1's closet and retrieved a clean shirt, then V7 and V8 assisted in putting on the clean shirt. On 2/21/25 at 3:00 PM, V2 (Director of Nursing/ DON) said staff should follow the facility policy for infection control standards when performing perineal, urinary catheter, and wound care. The facility's revised 9/11/20 Perineal/ Incontinence Care policy documented in part .Procedure . 1. Gather equipment for procedure . 7. Remove soiled brief/ underpad from resident by rolling the brief/ underpad to contain as much fecal matter as possible. If gloves visibly soiled or you touch stool, remove gloves, complete hand hygiene and don new gloves . 8. Cleanse the resident's perineal area using an approved no-rinse incontinence cleansing product, soap and water, or wipes . b. For male residents, retract the foreskin if uncircumcised then clean the tip of the penis using a circular motion starting with the urethra and working down the shaft. i. The shaft, scrotum, rectal area and buttocks should be cleaned as well. 9. Use a clean area of cloth for each area cleansed. Use multiple cloths, if necessary, to maintain infection control practices . 11. Remove gloves and perform hand hygiene and apply clean gloves. 12. Change pad under resident if not changing pad during the perineal process paying attention to not contaminating new pad with soil from old pad . The facility's undated Catheter Care policy documented in part . 7. Perform perineal/ incontinence per facility policy prior to catheter care . 10. For a male resident, retract the foreskin of the uncircumcised penis to expose the urethral meatus and catheter insertion site. Clean from the tip of the penis down the shaft of the penis. Use a different area of the wash cloth for each wipe. Clean from the resident outward on the catheter 4-6 inches using clean area of cloth. Being careful not to place traction on the tubing. Maintain hand position throughout the procedure. Replace the foreskin. 11. Place securement device if appropriate for the resident as nursing measure . The facility's revised 11/9/19 Wound Care policy documented in part . General Guidelines . 3. Gather equipment. 4. Place items on a clean surface .

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 6. Findings Include: R2's Admission Record documents an initial admitted [DATE]. R2's Admission Record documented the following diagnoses of down syndrome, unspecified, type 2 diabetes mellitus without complications. R2's Minimum Data Set (MDS) annual assessment dated [DATE], documented a Brief Interview for Mental Status Score of 15, indicating R2 is cognitively intact. R1's Admission Record documents an initial admitted [DATE]. R1's Admission Record documented the following diagnoses of major depressive disorders, generalized anxiety disorder and delusional disorders. R1's Minimum Data Set (MDS) quarterly assessment dated [DATE], documented a Brief Interview for Mental Status Score of 15, indicating R1 is cognitively intact. R1's Facility Progress Notes dated 12/20/2024 at 10:11 AM by V9 (Licensed Practical Nurse/LPN), documented when other patient (R2) ask patient (R1) to stop yelling, he says he'll beat their f***ing ass to come outside. R1's Facility Progress Note dated 12/20/2024 at 5:17 PM by V9 (LPN) documented, R1 agreed to go to the local hospital to be assessed to see if acute infection causing change in his behavior or seek mental health help. Local ambulance called and transported R1 to local hospital. On 1/7/2025 at 10:15 AM, V9 (Licensed Practical Nurse/LPN) stated that R1 and R2 did have an argument in the dining room on 12/20/24. V9 stated that R1 was hollering at R2 and said, shut the f**k up. V9 stated when R2 asked R1 to be quiet, R1 said he will beat his f***ing ass to come outside. V9 stated, she did contact V2 (Director of Nursing/DON) to notify her of R1's behavior. V9 stated that V2 told her to separate R1 and R2, contact R1's physician and/or send R1 to the local emergency room for evaluation. V9 stated that she did leave a message for R1's physician (V10) and when V10's office returned her call related to R1 and said R1 could go to the hospital for mental health or do an emergency discharge due to R1 threatening people and destroying property. V9 stated, R1 did agree to go to the local hospital for evaluation. On 1/7/2024 at 10:11 AM V2 (DON) stated she had been notified via phone by V9 (Licensed Practical Nurse/LPN) on 12/20/2024 that R1 had been making accusations about R2. V2 stated, R1 had been having behavioral outbursts lately, and she encouraged V9 to contact R1's physician to notify him of R1's behavior or send R1 to the local emergency room for evaluation. On 1/7/2025 at 9:05 AM, R2 stated he had an argument recently with R1. R2 stated they argued over the music box playing during breakfast in the dining room. R2 stated he did report the argument to V5 (Administrator in Training). R2 stated R1 did make threatening comments to him, however, he did not want to say what R2 had said. On 1/7/2025 at 10:00 AM, R1 stated he had an argument with R2 in the dining room recently. R1 stated he was watching television in the dining room when R2 came in and turned on the music box. R1 stated he did go over and unplug the music box from the wall. R1 stated there were words exchanged between him and R2 but would not elaborate on what was said. R1 stated R2 did state he was going to call the police. R1 said, he thought V2 (Director of Nursing) had been called during the argument by V9 (LPN). R1 stated he assumed the argument had been reported to administration but, he never had been questioned about the altercation. On 1/7/2025 at 10:22 AM, V5 (Administrator in Training) stated there had been some conflict between R1 and R2. V5 stated, R2 did come to his office to discuss a recent verbal altercation that happened between R1 and R2 on 12/20/2024. V5 stated, R2 told him R1 had been calling him names and R2 did not want his family to know about it. V5 stated he did not start an abuse investigation per facility policy. The Facility's Initial Reportable Event dated 1/7/2025 documented an investigation had been started into the verbal altercation between R1 and R2 that occurred on 12/20/24. The facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure (dated 2024) documents under Policy: To Facility's residents have the right to be free from abuse, neglect misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and other currently or potentially working for the Facility (Associates). The same policy documents under Procedure, III. The Facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by resident or others, which include, but are not limited to: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; .

Based on interview and record review, the facility failed to timely initiate an investigate for an abuse allegation for 1 of 3 resident (R2) reviewed for abuse in a sample of 6. Findings Include: R2's Admission Record documents an initial admitted [DATE]. R2's Admission Record documented the following diagnoses of down syndrome, unspecified, type 2 diabetes mellitus without complications. R2's Minimum Data Set (MDS) annual assessment dated [DATE], documented a Brief Interview for Mental Status Score of 15, indicating R2 is cognitively intact. R1's Admission Record documents an initial admitted [DATE]. R1's Admission Record documented the following diagnoses of major depressive disorders, generalized anxiety disorder and delusional disorders. R1's Minimum Data Set (MDS) quarterly assessment dated [DATE], documented a Brief Interview for Mental Status Score of 15, indicating R1 is cognitively intact. R1's Facility Progress Notes dated 12/20/2024 at 4:00 AM by V11 (Registered Nurse/RN), documented LATE ENTRY, .R1 went in the nourishment room and dumped a cooler full of ice on the floor. R1 then opened doors to the smoke shack and left them wide open for the alarms to go off. R1 also unplugged the time clock, took mechanical lifts machine batteries out then dropped them and pushed every button of the fax machine. R1's Facility Progress Notes dated 12/20/2024 at 10:11 AM by V9 (Licensed Practical Nurse/LPN), documented when other patient (R2) ask patient (R1) to stop yelling, he says he'll beat their f***ing ass to come outside. On 1/7/2025 at 9:05 AM, R2 stated he did have an argument recently with R1. R2 stated they argued over the music box playing during breakfast in the dining room. R2 stated he did report the argument to V5 (Administrator in Training). R2 said that R1 made threatening comments to him and was concerned enough at the time to report it to V5. On 1/7/2025 at 10:00 AM, R1 stated he had an argument with R2 in the dining room recently. R1 stated he was watching television in the dining room when R2 came in and turned on the music box. R1 stated he did go over and unplug the music box from the wall. R2 stated that there were words exchanged between him and R2. R1 stated that he thought the argument was reported to V5 but was never questioned about the incident. On 1/7/2025 at 10:15 AM, V9 (Licensed Practical Nurse/LPN) stated that R1 and R2 did have an argument in the dining room on 12/20/24. V9 stated that R1 was hollering at R2 and said, shut the f**k up. V9 stated that when R2 asked R1 to be quiet, R1 said he will beat his f***ing ass to come outside. V9 stated she did contact V2 (Director of Nursing/DON) to notify her of R1's behavior. V9 stated V2 told her to separate R1 and R2, contact R1's physician and/or send R1 to the local emergency room for evaluation. V9 stated that she did leave a message for R1's physician (V10) and when V10's office returned her call related to R1 and said R1 could go to the hospital for mental health or do an emergency discharge due to R1 threatening people and destroying property. V9 stated R1 did agree to go to the local hospital for evaluation. R1's Facility Progress Note dated 12/20/2024 at 5:17 PM by V9 (LPN) documented, R1 agreed to go to the local hospital to be assessed to see if acute infection causing change in his behavior or seek mental health help. Local ambulance called and transported R1 to local hospital. On 1/7/2024 at 10:20 AM, V1 (Administrator) stated the abuse policy documents that the facility shall review altercations from resident to resident as potential situation of abuse. On 1/7/2025 at 10:22 AM, V5 (Administrator in Training) stated there had been some conflict between R1 and R2. V5 stated, R2 did come to his office to discuss a recent verbal altercation that happened between R1 and R2 on 12/20/2024. V5 stated R2 told him R1 had been calling him names and R2 did not want his family to know about it. V5 stated he did not start an abuse investigation per facility policy. On 1/7/2025 at 10:29 AM, V1 stated he was initiating an abuse investigation between R1 and R2 that happened on 12/20/2024. The Facility's Initial Reportable Event dated 1/7/2025 documented an investigation had been started into the verbal altercation that occurred on 12/20/24 between R1 and R2. The facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure (dated 2024) documents under Procedure, III. The Facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by resident or others, which include, but are not limited to: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; .

Based on observation, interview, and record review the facility failed to ensure staff donned Personal Protective Equipment (PPE) in accordance with current Center for Disease Control (CDC) recommendations for infection control practices to prevent the spread of communicable disease. This has the potential to affect all 54 residents residing in the facility. Findings Include: 1. R1's Admission Record documents an admitted [DATE] and included diagnoses of Metabolic Encephalopathy, Metabolic Acidosis, Chronic Kidney Disease, Congestive Heart Failure, and Epilepsy. R1's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. R1's Care Plan documents R1 currently has a communication deficit related to language barrier. The Goal is documented as R1 will be able to make basic needs known by using gestures and communication board on a daily basis through the review date. The Care Plan also documented R1 was diagnosed with Covid-19 per lab results on 11/21/2024. This Goal documents R1 will maintain in respiratory isolation through the current guidelines. Interventions document R1 will remain in Covid -19 isolation for designated time frame per CDC. R1's record titled Progress notes documents R1 tested positive on 11/20/2024. On 11/26/2024 at 10:30AM, R1 was observed walking around in the front of the facility. R1 was wearing a surgical mask around his chin. R1 was smiling but not answering questions. On 11/26/2024 at 10:40AM, R1 was at the nurse's station. V3 and V4 (both Certified Nurse Assistants/CNAs) were using hand gestures to direct R1 to R1's room. At this time, V3 and V4 were both wearing surgical masks only and entered R1's room with R1. V3 and V4 were guiding him into the room, touching his arms and bedding and attempting to get R1 to lie down. An isolation bin was noted outside R1's door which contained N95 respirators, gloves, and gowns. No eye protection was noted in the bin. There was Droplet Isolation signage on R1's door which listed the PPE required to enter the room. The signage documented N95 respirators, gloves, gowns, and eye protection was required. V3 and V4 did not don any of the required PPE prior to entering R1's room and only wore the surgical masks. On 11/26/2024 at 10:59AM, V1 (Administrator) was asked why staff are not wearing N95's. V1 stated most of the staff failed the Respiratory Fit Testing so they can't wear the N95's. V1 was asked if the facility has N95's available for the staff and if the supply is sufficient. V1 stated the facility has a proper amount of PPE supplies. On 11/26/2024 at 11:10AM, V3 (CNA) was noted at the nurse's station. V3 was asked why she didn't wear an N95 mask with the COVID positive residents (R1), and V3 stated I failed the fit testing, I could not smell the solution. V3 was asked to explain and V3 stated, when I had the mask on, I could not smell the solution. V3 was asked if she could smell the solution when she did not have the mask on and V3 replied yes, the best I can remember. V3 was asked how she protects herself and other residents when she cares for a COVID positive residents and V3 stated I use a regular (pointing at her surgical mask) and then I change into a new one when I leave the room. V3 was asked if when she was getting fitted for the N95 if different sizes of masks were offered and V3 stated yes there were 2 different sizes. V3 was asked what other PPE was required in a Droplet Isolation room and V3 stated a gown and gloves. On 11/26/2024 at 11:13 AM, V4 (CNA) was noted down the hall. V4 was asked if she wears an N95 mask when caring for COVID positive residents. V4 stated no I do not because I have never been fit tested . V4 was asked when she started working at the facility and V4 stated I have worked here for 2 years. V4 was asked what PPE she wears when caring for a COVID positive resident and V4 stated I wear my surgical mask and I change it when I leave. V4 was asked what other PPE she wears, and she stated gloves. V4 was asked if she wears eye protection and V4 stated No because I don't know where they are and have never seen them in the bins. V4 was asked if she has received education on COVID precautions, or Infection Control and proper prevention, V4 stated I have, but it has been a while. V4 was asked if she used a PAPR (Power Air Purifying Respirator) and V4 stated No, I don't wear those. 2. R2's Admission Record documents an admitted [DATE] and included diagnoses of Huntington's Disease, Neuromuscular Dysfunction, Muscle Wasting, and Anxiety. R2's MDS dated [DATE] documented a BIMS score of 15, indicating R2 is cognitively intact. A facility document titled Covid Test documented R2 was positive for Covid on 11/24/2024. On 11/26/2024 at 10:32AM, R2's room was noted to have isolation bins outside the door with N95 masks, gowns, and gloves in them. There was no eye protection noted in the bin. R2's door was halfway open, and R2 was resting in bed at this time. R2 was the only resident occupying this room. No Isolation signage was noted on R2's door. On 11/26/2024 at 10:33AM, V5 (CNA) was observed entering R2's room wearing only a surgical mask. V5 did not wear an N95 mask and did not don a gown, gloves, or eye protection prior to entering R2's room to provide care. On 11/26/2024 at 11:17AM, V5 (CNA) was standing at the nurse's station wearing a surgical mask. V5 was asked what type of mask she wears when caring for a COVID positive resident. V5 stated she wears a surgical mask because she has never been fit tested . V5 stated she started to put on an N95 to go into a COVID positive room and another CNA told her she was not allowed to wear that if she had not been fit tested . V5 stated she has worked at the facility about 2 months. On 11/26/2024 at 12:30PM, R2 was noted to be alert and oriented, and stated she was just tired and wanted to sleep. R2 did not want to be interviewed, stating I am just too tired. 3. R3's Admission Record documents admitted [DATE]. R3's MDS dated [DATE] documented a BIMS score of 10, indicating moderate cognitive impairment. A facility document titled COVID Test documented R3 was tested on [DATE] and results were positive. On 11/26/2024 at 10:15AM, R3's room had a bin outside the door with PPE observed to include N95 masks, gowns, and gloves. The door of R3's room had signage noting Respiratory/Droplet Isolation and listed the PPE required to enter the room. The signage documented N95 respirators, gloves, gowns, and eye protection was required. On 11/26/2024 at 10:30AM, R3 was noted to be non-interviewable. 4. R4's Admission Information documents an admitted [DATE] and included diagnoses of Muscle Atrophy and Wasting, Chronic Obstructive Pulmonary Disease, Anxiety, and Dyspnea. R4's MDS dated [DATE] documented a BIMS score of 15, indicating R4 is cognitively intact. A facility document titled COVID Test documented R4 tested positive for COVID on 11/25/2024. A Progress Note dated 11/26/2024 at 9:33AM documented R4 was sent to the emergency room per family request, for evaluation. On 11/26/2024 at 2:38 PM, V14 (Transportation Aide) was observed unloading R4 from the facility van. V14 stated she was returning from the emergency room . At this time, V14 was observed wearing only a surgical mask. R4 was not wearing a mask. V14 was asked if she was aware R4 tested positive for COVID and V14 replied Yes. R4 was confused and not interviewable at this time. R4 was transported through the facility via wheelchair with no mask on. 5. A facility document titled Covid Test documented R5 tested positive for COVID on 11/19/24. R5 had Droplet Isolation signage on the door listing the required PPE needed to enter including N95 respirators gloves, gowns, and eye protection. On 11/26/2024 at 2:30PM, V9 (Housekeeper) was walking around in R5's room and then exited the room. V9 was only wearing a surgical mask while in R5's room. V9 did not have an N95 mask on, nor a gown, gloves, or eye protection. V9 had the housekeeping cart outside the room but did not have any supplies in the room. V9 stated he had not been fit tested yet and he wears a surgical mask. 6. On 11/26/2024 at 2:20PM, R6 was noted sitting in the hallway without a mask on. R6 stated she has not had Covid, and she doesn't want it. R6 stated she doesn't like wearing a mask. R6 stated she does not have a roommate. 7. On 11/26/2024 at 2:24PM, R7 was sitting in the hallway with a mask pulled down on her chin. R7 stated I have a roommate and neither one of us has had COVID. 8. On 11/26/2024 at 2:26PM, R8 was sitting in the hallway without a mask. R8 stated her roommate tested positive so R8 was moved out immediately. R8 stated I am now in a room by myself, and I just hope I do not get COVID. R8 stated she was heading outside to smoke, and she doesn't wear a mask when going out to smoke. R8 stated so far, she is feeling good. At no time during the above observations on 11/26/24 between 2:20PM and 2:30PM while R6, R7 and R8 in the hallway, were the residents encouraged by staff to wear a mask. On 11/26/2024 at 12:10PM, V2 (Director of Nursing/DON) was asked what type of PPE is required/expected to be worn in a COVID positive resident's room, and V2 stated N95, gown, eye protection, and gloves. V2 was asked what staff wear if they have not been fitted for the N95's and V2 stated we have 2 PAPR's (Powered Air Purifying Respirators) in the facility. V2 was asked if those were enough for the staff to be able to care for all 12 of the COVID positive residents. V2 stated not really. V2 was asked if she was aware that the CNA staff currently working today say they have not been fit tested for N95 masks or that they failed the fit test. V2 stated I have a couple CNA's that passed the fit testing, but they are neither one working today. V2 stated she would reach out to corporate and see if they could get more PAPRs to have more available to use. V2 was asked if she does the N95 fit testing and V2 stated yes, fit testing is done annually and upon hire. V2 stated they had several (staff) fail the testing. V2 said I have had several to fail the test because they could not smell the solution before the mask was applied. V2 stated she has her Certification for Infection Preventionist. V2 stated she has provided the staff with education on COVID and Infection Control, but it has been a little while. On 11/26/2024 at 1:26PM, V6 (Regional Clinical Director & Registered Nurse/RN) stated she was aware that most of the staff were unable to pass the Respirator Fit Test. V6 stated the problem is that most of the staff had COVID in the past and lost their sense of taste and smell and so they cannot efficiently pass a Respiratory Fit Test. V6 stated the staff have to fill out a medical questionnaire prior to fit testing and if for any reason they don't pass the evaluation or can't take the test properly because of loss of taste or smell then it would be a liability on the company if we allowed them to wear the N95. V6 was asked if any of the staff at this facility had a medical condition that prohibited that staff member from wearing an N95, V6 stated not that she is aware of. V6 stated she was not aware of any staff being allowed to work if they were COVID positive. V6 was asked what the staff are to do when they must care for COVID positive residents and they cannot or are not allowed to wear a N95, V6 stated they are supposed to wear a PAPR. V6 asked if two PAPRs in this facility were enough for the staff to efficiently take care of the now 14 positive residents (at the time of this interview), and V6 stated no and I was not aware of the facility only having two. V6 stated she would get more PAPR machines in the facility today. V6 was asked what PPE was expected/required for the staff to wear when caring for a COVID positive resident, and V6 stated N95 or a PAPR, eye protection, gown, and gloves. V6 was asked how often Respiratory Fit testing was done in the facility, V6 stated annually and upon hire. V6 stated she was not aware of any new hires not having Respiratory Fit testing completed. V6 stated she would make sure those get done as soon as possible. On 11/26/2024 at 1:55PM V7 (MDS Coordinator - Registered Nurse/RN) stated she wears an N95 when caring for COVID positive residents. V7 stated she was fit tested at her other place of employment, but she failed the fit testing at this facility. V7 stated she does have her sense of taste and smell and doesn't understand why she didn't taste or smell the solution that was used during her fit testing here. V7 stated she will not enter a room of a COVID positive resident without an N95. V7 stated I am unsure if they have new solution or testing supplies here, but I have not had a repeat fit test so far. On 11/26/2024 at 2:34PM V10 (Registered Nurse/RN) was noted sitting at the nurse's station with a surgical mask in place. V10 stated she wears an N95 into the COIVD positive rooms when providing care. V10 stated she was fit tested at another place of employment but has not been fit tested at this facility, but she will not provide care to a COVID positive resident without an N95 to wear. V10 stated she was unaware of other staff entering COVID positive rooms without an N95 or PAPR on. V10 stated she has worked at this facility for a couple of months. The facility's Resident Listing Report dated 11/26/24 documented 54 residents residing in the facilty. The facility's Isolation Precautions Policy and Procedure dated October 28th, 2024 documents purpose: To establish transmission-based precautions for resident who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. Under Droplet Precautions the document stated 1. Implement droplet precautions for resident suspected confirmed to be infected with a communicable disease/infection transmitted via droplets generated by sneezing, talking, or during procedures such as suctioning. 2. Residents shall be placed in a private room when available. If a private room is not available, residents may be cohorted with roommate with the same illness. 3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves and mask prior to entering room; b. While providing direct resident care, remove gloves and perform hand hygiene after coming in contact with infectious material, c. Remove gloves and perform hand-hygiene before leaving room (do not use alcohol-based hand gels for isolation due to suspected or confirmed Clostridum difficile); 4. Adequately clean/disinfect item with an approved solution prior to removing the item from the room and before use on another resident. The Facility Assessment COVID-19 dated 9/12/2024, documents Health Care Personnel (HCP) and Essential Caregivers who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available or did not pass a fit test), gown, gloves, an eye protection. When available respirators (instead of facemasks) are preferred: they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions. Document lists other PPE (Personal Protective Equipment) include eye protection, gloves, and gowns. According to https://www.cdc.gov/covid/hcp/infection-control/index.html, Infection Control Guidance: SARS-CoV-2 documents the following CDC recommendations for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (Updated 3/18/24): 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection: Personal Protective Equipment - HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). - Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard (29 CFR 1910.134) - Additional information about using PPE is available in Protecting Healthcare Personnel

Based on observation, interview, and record review the facility failed to obtain scheduled medications from the pharmacy and secure emergency medications for 1 (R1) of 5 residents reviewed for medication administration in the sample of 8. This failure resulted in R1 abruptly stopping and missing his scheduled seizure medication resulting in R1 experiencing two seizures lasting approximately four minutes each. Additionally, this failure has the potential to result in prolonged, life-threatening seizures when abruptly stopping anti-seizure medication. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 9/23/24 at approximately 8:00 PM when the facility was unable to provide R1's scheduled seizure medications. The facility did not administer R1's seizure medications again on 9/24/24 at 8:00 AM and 8:00 PM. V6 (Regional Administrator), V2 (Director of Nursing), V3 (Care Plan Coordinator/ Registered Nurse), and V24 (Dietary Manager) were notified of the Immediate Jeopardy on 10/11/24 at 2:44 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 10/18/24, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings include: On 10/3/24 at 1:11 PM, V9 (Case Coordinator) stated when R1 was admitted to the facility R1 had two seizures in the first week due to the facility not administering R1's seizure medication. V9 stated she had been R1's case manager for the past year while R1 was residing in a group home. V9 stated in the year prior to this investigation R1 had three seizures. V9 stated R1 had never had two seizures in the same day. On 10/3/24 at 2:56 PM, V11 (R1's Power of Attorney) stated about two years prior to this investigation, R1 had started having more seizures. V11 stated prior to R1 being admitted to the facility R1 had been in the hospital to have a gastrostomy tube (g-tube) placed. V11 stated R1 had a seizure during the hospitalization . V11 stated R1 had been discharged from the hospital on 9/23/24 around 5:30 PM and the hospital had not sent any medications to the facility for R1. V11 stated you would think the hospital would have sent one or two doses of the medications with (R1) to the facility. R1's Admission Record documented an admitted [DATE] with diagnoses including dysphagia following cerebral infarction, extrapyramidal and movement disorder, and epilepsy. R1's 9/25/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 was severely cognitively impaired. R1's 9/23/24 After Visit Summary from the hospital documented in part . Start taking these medications . lacosamide 10 mg/ ml solution . Commonly known as: Vimpat . Administer 10 ml through peg tube 2 (two) times a day . Levetiracetam 500 mg/ 5 ml solution . Commonly known as: Keppra . Administer 10 ml (1,000 mg total) through tube 2 (two) times a day . oxcarbazepine 300 mg/ 5 ml (60 mg/ ml) suspension . Commonly known as: Trileptal . Administer 5 ml (300 mg total) through g-tube 2 (two) times a day . R1's September 2024 Order Summary Report from the facility's Electronic Medical Record documented the orders for Keppra solution 100 mg/ ml, oxcarbazepine oral suspension 300 mg/ 5 ml, and Vimpat oral solution 10 mg/ ml, as ordered on the hospital's Visit Summary, with an order date of 9/23/24. The facility's pharmacy Packing Slip documented R1's Keppra, Vimpat, and Trileptal were shipped to the facility on [DATE]. R1's E-Courier Delivery Status documented R1's medications were delivered to the facility on [DATE] at 12:18 AM. R1's September 2024 Medication Administration Record (MAR) documented R1 did not receive the 9/23/24 8:00 PM dose and the 9/24/24 8:00 AM dose of Keppra, Trileptal, or Vimpat. R1's September 2024 MAR documented R1 did not receive the 9/24/24 8:00 PM dose of Trileptal. R1's September 2024 MAR documented R1 did receive the 9/24/24 8:00 PM dose of Keppra and Vimpat and were initialed as being administered by V10 (Licensed Practical Nurse/ LPN). On 10/10/24 at 1:27 PM, V2 (Director of Nursing) stated she did not know why V10 had documented administering R1's 9/24/24 8:00 PM dose of Keppra and Vimpat when the medications were not delivered to the facility until 9/25/24 at 12:18 AM. V2 stated V10 must have documented in error. On 10/10/24 at 10:07 AM, V10 (Licensed Practical Nurse/ LPN) stated resident medications were delivered to the facility daily from approximately 12:00 AM to 2:00 AM. V10 stated if a resident is admitted after 5:00 PM the facility would not receive the resident's medication in that night's medication delivery but the next night's medication delivery, indicating the resident would be without medication for longer than 24 hours. V10 stated she was the nurse caring for R1 on the night shift of 9/24/24 to 9/25/24. V10 stated she did not know why she documented administering R1's Keppra and Vimpat on 9/24/24 at 8:00 PM. V10 stated she did not notify R1's medical provider on 9/24/24 when the facility did not have R1's seizure medications to administer. On 10/9/24 at 12:43 PM, V2 stated she was caring for R1 on the dayshift of 9/24/24. V2 stated on 9/24/24 she had notified R1's medical provider's office via fax of the facility not having R1's Vimpat, Trileptal, or Keppra and had contacted the pharmacy. V2 stated she was not sure if R1's medical provider had contacted the facility back with a substitution order or a medication hold order. The facility was not able to provide reproducible evidence or documentation that V2 had sent a fax to R1's medical provider's office or of V2 contacting the pharmacy on 9/24/24. On 10/8/24 at 9:47 AM, V20 (Pharmacist) stated the pharmacy received orders for R1 Vimpat, Trileptal, and Keppra on 9/23/24 at 9:56 PM. V20 stated the pharmacy sent R1's Vimpat, Trileptal, and Keppra on 9/24/24 due to not having an overnight pharmacist. V20 stated there was an overnight pharmacist on call and if a facility needed medications right away that pharmacist could try to get the medications to the facility from a closer pharmacy. V20 stated if the overnight pharmacist could not get the medications to the facility that night from a closer pharmacy they would get the medication from another pharmacy the next morning. V20 stated she was not sure if anyone from the facility had called the pharmacy to let them know. On 10/8/24 at 9:57 AM, V19 (Pharmacist in Charge) stated she did not see any documentation in her system of the facility contacting the pharmacy on 9/24/24 or ordering R1's Vimpat, Trileptal, or Keppra STAT (stat or immediately) or from a backup pharmacy on 9/24/24. V19 stated if a facility did not have a resident's medications, she would expect the facility to call the resident's medical provider to obtain an order for another medication until the resident's medication could arrive. On 10/3/24 at 3:27 PM, V3 (Care Plan Coordinator/ Registered Nurse) stated R1's Vimpat, Trileptal, or Keppra had not been ordered STAT or from a backup pharmacy. V3 stated when R1 was admitted on the evening of 9/23/24 there were a lot of things going on in the facility so V3 had stayed late to put R1's medication orders into R1's Electronic Medical Record (EMR). V3 stated since it was past 8:00 PM when R1's medication orders were entered R1's September MAR would document R1's 9/23/24 Vimpat, Trileptal, and Keppra were blank. On 10/10/24 at 10:25 AM, V4 (Physician) stated he was not made aware the facility was not administering R1's Keppra, Trileptal, or Vimpat due to the facility waiting on the medications to be delivered from the pharmacy. V4 stated R1 missing a dose of R1's seizure medication could cause R1 to have a seizure. The Center for Disease Control (CDC) website Treatment of Epilepsy (https://www.cdc.gov/epilepsy/treatment) documented in part . Medicine . Anti-seizure medicines limit the spread of seizures in the brain. It may take time to find the right medicine. Sometimes you'll need a combination of medicines. It's very important to take your medicine as prescribed . Do not skip or stop your seizure medicine . You should not skip or stop taking your seizure medicine without talking to your provider. Suddenly stopping your medicine might cause withdrawal symptoms, including life-threatening seizures. Taking your medicine is the most important thing you can do to prevent seizures . R1's Progress Note dated 9/24/24 at 4:09 AM documented R1 had a seizure lasting approximately four minutes with R1's oxygen saturation dropping to 80%, R1 becoming febrile, and tachycardic with R1 being lethargic, clammy, pale, and short of breath after the seizure. R1's Progress Note dated 9/24/24 at 11:31 AM documented R1 had another seizure lasting approximately four minutes. On 10/10/24 at 10:07 AM, V10 (LPN) stated she was the nurse caring for R1 on 9/24/24 at 4:09 AM when R1 had the first seizure. V10 stated she was completing medication pass when a Certified Nursing Assistant (CNA) alerted V10 that R1 was having a seizure. V10 stated when she entered R1's room, R1 was seizing with his eyes rolled back and his lips blue. V10 said she applied oxygen and recorded the time R1 was seizing. V10 stated R1's seizure stopped after 4 minutes. V10 stated after R1's seizure stopped R1 was slow to come back, lethargic, and tired. V10 stated she had contacted R1's medical provider and obtained an order to send R1 to the hospital. V10 stated V11 (R1's Power of Attorney) had refused to transfer R1 to the hospital. On 10/15/24 at 10:00 AM, V2 stated she was the nurse caring for R1 on 9/24/24 at 11:31 AM when R1 had the second seizure. V2 stated R1 had a seizure lasting four minutes. V2 stated V11 had refused to send R1 to the hospital and had instructed V2 if R1 had another seizure to send R1 to the hospital. On 10/9/24 at 1:32 PM, V5 (LPN) was asked what the facility would have done if R1's 9/24/24 seizures would have lasted longer than five minutes and V5 responded the facility would have called 911 for emergency services but there was nothing else the facility could have done for R1 due to the facility pharmacy not allowing the facility to keep injectable Ativan, injectable Valium, or rectal Valium gel in the emergency medication stock. V5 was asked what the facility would have done if R1's 9/24/24 seizures would have lasted longer than five minutes and county's emergency medical services were not able to arrive to the facility in a timely manner and V5 responded she did not know. The facility's medication room was toured and V5 used the pharmacy's emergency stock medication computer to show the facility did not have any injectable Ativan, injectable Valium, or rectal Valium gel available in stock or any other medications that could aide in stopping seizures timely. V5 stated when the facility changed pharmacy companies, about a year prior to this survey, the facility no longer kept any injectable Ativan or injectable Valium in the emergency stock medication. On 10/9/24 at 3:15 PM, V4 (Physician) stated he should be notified anytime a resident is having a seizure. V4 stated he would order the facility to call 911 for emergency services to transfer the resident to the hospital and if the seizure lasted longer than five minutes to administer intramuscular Ativan or Valium, whichever the facility had in stock in the emergency stock medication. V4 stated the facility should have injectable Ativan or Valium in the emergency stock medications and was not aware the facility did not. V4 stated there were several factors on how long a seizure had to last to cause brain damage, but it was possible brain damage could occur with a seizure lasting longer than five minutes. On 10/10/24 at 8:53 AM, V17 (Pharmacist) stated there had been a national shortage of Ativan and Valium periodically for the past 2 years. V17 stated due to the national shortage the pharmacy had not been able to stock the facility's emergency medication stock with injectable Ativan or Valium. V17 stated if the facility had an order for resident specific injectable Ativan or Valium the pharmacy could obtain the medication and have it sent to the facility or find an equivalent medication to be sent to the facility. V17 was asked why the pharmacy would be able to send injectable Ativan or Valium if it was resident specific but not able to send injectable Ativan or Valium for emergency stock medication and V17 stated she was not sure. V17 stated on 9/24/24 the facility had Ativan and Valium tablets in the emergency stock medication. V17 stated the physician could have ordered the facility to crush an Ativan or Valium tablet and administered it rectally. On 10/10/24 at 10:25 AM, V4 stated it is possible to administer an Ativan or Valium tablet rectally but V4 had never ordered it for someone having a seizure. V4 stated the onset of a rectally administered Ativan or Valium tablet would be about half an hour or approximately as long as administering the tablet orally. V4 stated the onset of the medication would take too long and emergency services would still have to be called. V4 stated the gold standard would be intravenous valium but V4 was unsure if the facility had that capability. The facility's undated pharmacy policy titled What to Do If a Medication is Not Available during a Med Pass documented in part . 1. Review the pharmacy packing slip to verify if the medication has been delivered. You may also check the (pharmacy website portal) to review the delivery status of the medication. 2. Check all medication carts for the missing medication. Did the resident recently transfer from room/ unit? 3. Check the medication room and confirm all pharmacy deliveries have been properly checked in. 4. Utilize the (emergency medication stock) for availability of the medication. Remove dose for administration and administer to the resident . 5. If the medication is not available in the (emergency medication stock), Is there an alternative medication (or dose equivalent) available to administer with a prescriber's order? 6. If the medication cannot be located and is not available in the (emergency medication stock), please notify the pharmacy or request delivery from a backup pharmacy, or request a stat delivery, and finally verify the medication will be sent on the next pharmacy delivery. 7. Notify the provider the medication will not be available for administration at the current scheduled time. Request an order to hold the medication and administer upon delivery from the pharmacy By following the steps above, we will avoid the need to document 'Medication not available.' This will ensure the resident receives the medication timely and avoids any further potential delay in treatment . The facility's March 19, 2020 Administering Medication policy documented in part . Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/ federal regulations . Procedure: . 6. Medications should be administered within one (1) hour of the prescribed times . 9. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and document a rational . The Immediate Jeopardy that began on 9/23/24 was removed on 10/18/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: 1. The provider was notified of the resident's seizure history and order for PRN (as needed) medication received. The pharmacy has delivered the PRN medication. R1's 10/11/24 progress note documented a 10/10/24 order for diazepam rectal gel 10 mg insert 1 application rectally as needed for seizure activity related to epilepsy give 1 dose then send to emergency room (ER). Order received by V3 (RN/ Care Plan Coordinator) on 10/9/24. Pharmacy notified of STAT delivery needed by V3 on 10/9/24. Medication verified by V17 (Pharmacist). Medication was received by facility on 10/9/24. 2. Review of residents with seizure disorder and last seizure date completed. Presented this information to all providers and requested whether seizure PRN medication needed based on history. An audit was completed by V3 on 10/9/24. 3. Care Plans have been reviewed and reflect current seizure/ epilepsy standards. An audit was completed by V3 on 10/9/24. 4. Licensed Nursing staff educated on: A. What to do if a medication is not available. B. Pharmacy process for ordering medication and checking on order status using the pharmacy portal, phone, and messaging system. C. How to use the (emergency stock medication). D. Updated Seizure policy. E. New admission clarification for need for PRN medication. F. Physician notification when medication not available. G. Delivery needs for any significant medication with any new admit. Education provided to nursing staff on 10/10/2024 by V25 (Pharmacy Nurse Consultant). Education provided by V1 to V2 and V3 on the pharmacy policy of What to do if a medication is not available on 10/18/24. 5. Review of (emergency stock medication) inventory by facility V4 (Physician/ Medical Director) on 10/10/24. 6. Facility to ensure review of admission to include review of potential residents with a history of seizure/ other dx that could have a significant impact without medication prior to admission and if applicable, ask provider if any medications are not available, what substitutions can be made based on availability of medication in the (emergency stock medication) or if medication can be placed on hold. Added to Referral review and admission checklist (update date 10/9/24). Audit 10/9/24 by V26 (RN); Admission check list updated 10/9/24 by V26. 7. Facility to ensure continued compliance, Preadmission screen/ admission question to provider if PRN antiseizure medication/ medication that could have a significant impact without its administration is needed for new admission weekly x 4 weeks and then present to the QAPI for review. Audits will continue based on the recommendations of the QAPI on review of the admission audit findings. V2 or Designee is responsible for implementing this plan of correction. The first audit was completed 10/9/24 for seizure med.

Based on observation, interview, and record review the facility failed to implement procedures for timely acquisition of medications to administer as ordered for 4 (R1, R4, R5, and R7) out of 5 residents reviewed for pharmacy services in a sample of 8. Findings include: 1. On 10/3/24 at 1:11 PM, V9 (Case Coordinator) stated when R1 was admitted to the facility R1 had two seizures in the first week due to the facility not administering R1's seizure medication. R1's Admission Record documented an admitted [DATE] with diagnoses including dysphagia following cerebral infarction, extrapyramidal and movement disorder, and epilepsy. R1's 9/25/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 was severely cognitively impaired. R1's 9/23/24 After Visit Summary from the hospital documented in part . Start taking these medications . lacosamide 10 mg/ ml solution . Commonly known as: Vimpat . Administer 10 ml through peg tube 2 (two) times a day . Levetiracetam 500 mg/ 5 ml solution . Commonly known as: Keppra . Administer 10 ml (1,000 mg total) through tube 2 (two) times a day . oxcarbazepine 300 mg/ 5 ml (60 mg/ ml) suspension . Commonly known as: Trileptal . Administer 5 ml (300 mg total) through g-tube 2 (two) times a day . R1's September 2024 Order Summary Report documented Keppra solution 100 mg/ ml, oxcarbazepine oral suspension 300 mg/ 5 ml, and Vimpat oral solution 10 mg/ ml as documented on the hospital's After Visit Summary with an order date of 9/23/24. The facility's pharmacy Packing Slip documented R1's Keppra, Vimpat, and Trileptal were shipped to the facility on [DATE]. R1's E-Courier Delivery Status documented R1's medications were delivered to the facility on [DATE] at 12:18 AM. R1's September 2024 Medication Administration Record (MAR) documented R1 did not receive the 9/23/24 8:00 PM dose and the 9/24/24 8:00 AM dose of Keppra, Trileptal, or Vimpat. R1's September 2024 MAR documented R1 did not receive the 9/24/24 8:00 PM dose of Trileptal. R1's September 2024 MAR documented that R1 did receive the 9/24/24 8:00 PM dose of Keppra and Vimpat and was documented as being administered by V10 (Licensed Practical Nurse/ LPN). On 10/10/24 at 1:27 PM, V2 (Director of Nursing) stated she did not know why V10 had documented administering R1's 9/24/24 8:00 PM dose of Keppra and Vimpat when the medications were not delivered to the facility until 9/25/24 at 12:18 AM. V2 stated V10 must have documented in error. On 10/10/24 at 10:07 AM, V10 (Licensed Practical Nurse/ LPN) stated resident medications were delivered to the facility daily from approximately 12:00 AM to 2:00 AM. V10 stated if a resident is admitted after 5:00 PM the facility would not receive the resident's medication in that night's medication delivery but the next night's medication delivery, indicating the resident would be without medication for longer than 24 hours. V10 stated she was the nurse caring for R1 on the night shift of 9/24/24 to 9/25/24. V10 stated she did not know why she documented administering R1's Keppra and Vimpat on 9/24/24 at 8:00 PM. V10 stated she did not notify R1's medical provider on 9/24/24 when the facility did not have R1's seizure medications to administer. On 10/9/24 at 12:43 PM, V2 stated she was caring for R1 on the dayshift of 9/24/24. V2 stated on 9/24/24 she had notified R1's medical provider's office via fax of the facility not having R1's Trileptal, Vimpat, or Keppra and had contacted the pharmacy. V2 stated she was not sure if R1's medical provider had contacted the facility back with a substitution order or a medication hold order. The facility was not able to provide reproducible evidence or documentation that V2 had sent a fax to R1's medical provider's office or of V2 contacting the pharmacy on 9/24/24. On 10/8/24 at 9:47 AM, V20 (Pharmacist) stated the pharmacy received orders for R1 Vimpat, Trileptal, and Keppra on 9/23/24 at 9:56 PM. V20 stated the pharmacy sent R1's Vimpat, Trileptal and Keppra on 9/24/24 due to not having an overnight pharmacist. V20 stated there was an overnight pharmacist on call and if a facility needed medications right away that pharmacist could try to get the medications to the facility from a closer pharmacy. V20 stated if the overnight pharmacist could not get the medications to the facility that night from a closer pharmacy they would get the medication from a closer pharmacy the next morning. V20 stated she was not sure if anyone from the facility had called the pharmacy. On 10/8/24 at 9:57 AM, V19 (Pharmacist in Charge) stated she did not see any documentation in her system of the facility contacting the pharmacy on 9/24/24 or ordering R1's Vimpat, Trileptal, or Keppra STAT (stat or immediately) or from a backup pharmacy on 9/24/24. V19 stated if a facility did not have a resident's medications, she would expect the facility to call the resident's medical provider to obtain an order for another medication until the resident's medication could arrive. On 10/3/24 at 3:27 PM, V3 (Care Plan Coordinator/ Registered Nurse) stated R1's Vimpat, Trileptal, or Keppra had not been ordered STAT or from a backup pharmacy. V3 stated when R1 was admitted on the evening of 9/23/24 there were a lot of things going on in the facility so V3 had stayed late to put R1's medication orders into R1's Electronic Medical Record (EMR). V3 stated since it was past 8:00 PM when R1's medication orders were entered R1's September MAR would document R1's 9/23/24 Vimpat, Trileptal, and Keppra were blank. On 10/10/24 at 10:25 AM, V4 (Physician) stated he was not made aware the facility was not administering R1's Keppra, Trileptal, or Vimpat due to the facility waiting on the medications to be delivered from the pharmacy. 2. R7's Admission Record documented an admitted [DATE] with diagnoses including: type 2 diabetes mellitus with foot ulcer, morbid obesity, and acute osteomyelitis. R7's 10/1/24 MDS documented a BIMS score of 15, indicating R7 was cognitively intact. R7's October 2024 MAR documented an order for Trulicity subcutaneous solution 0.75 mg/ 0.5 ml inject 0.75 mg subcutaneously one time a day every Wednesday with a start date of 9/25/24. On 10/16/24 at 10:10 AM, V13 (Registered Nurse) stated she did not have R7's Trulicity injection when she was completing the morning medication pass. V13 stated she was going to message the pharmacy and see if the medication had been delivered. On 10/16/24 at 10:40 AM, V2 (DON) stated she had logged into the pharmacy portal and R7's Trulicity had not been delivered to the facility. On 10/16/24 at 11:24 AM, V2 stated R7's Trulicity was going to be held today and would come from pharmacy in that night's delivery. V2 stated she had notified R7's medical provider to get an order to hold R7's 10/16/24 dose of Trulicity until 10/17/24. V2 stated she was not sure why R7's Trulicity had not been delivered to the facility. On 10/16/24 at 12:07 PM, V2 stated R7's Trulicity was scheduled to be given at 8:00 AM. V2 stated she notified R7's medical provider at 10:30 AM to get an order to hold the Trulicity. V2 stated she did not call the pharmacy first because it was not in the facility and wanted to speak with R7's medical provider first to be sure it would be ok to hold the Trulicity dose until the next day. On 10/16/24 at 12:39 PM, V1 was notified V2 had not followed the facility's pharmacy policy titled What to Do If a Medication is Not Available during a Med Pass due to V2 not requesting R7 Trulicity to be delivered to the facility by a backup pharmacy or requesting a stat delivery. 3. R5's Admission Record documented an admitted [DATE] with diagnoses including: vitamin D deficiency, mild protein-calorie malnutrition, alcohol dependance, and adult failure to thrive. R5's 8/12/24 MDS documented a BIMS score of 15, indicating R5 was cognitively intact. On 10/9/24 at 8:50 AM, V13 (Registered Nurse/ RN) was completing the medication administration for R5. V13 stated R5 did not have any Vitamin B12 tablets in the facility and would have to order them from the pharmacy. R5's October MAR documented an order for Vitamin B12 tablet give 1000 mg by mouth one time a day for supplement with a start date of 10/5/23. R5's October MAR documented R5 did not receive a vitamin B12 tablet on 10/9/24 or 10/10/24. On 10/17/24 at 1:48 PM, V2 verified R5's did not receive the order vitamin B12 tablet on 10/9/24. V2 stated the pharmacy portal documented R5's vitamin B12 tablets were delivered to the facility on [DATE] at 12:11 AM. V2 stated she was not sure R5's October MAR documented R5 did not receive a vitamin B12 tablet on 10/10/24 because the medication had been delivered prior to the 8:00 AM medication pass. V2 stated R5's vitamin B12 had not been ordered from a backup pharmacy or had a stat delivery request sent. 4. R4's Admission Record documented an admitted [DATE] with diagnoses including: hepatic encephalopathy, and cirrhosis of the liver. R4's September 2024 MAR documented an order for phenazopyridine 200 mg tablet give one tablet via peg tube 3 times a day for urinary health. R4's September 2024 MAR documented R4 did not receive a dose of phenazopyridine on 9/19/24 at 12:00 PM. On 10/17/24 at 1:48 PM, V2 verified R4 did not receive an ordered dose of phenazopyridine on 9/19/24 at 12:00 PM. V2 stated R4 was a new admission to the facility and the pharmacy portal documented R4's phenazopyridine was delivered to the facility on [DATE] at 12:14 AM. V2 stated R4's phenazopyridine had not been ordered from a backup pharmacy or had a stat delivery request sent. On 10/15/24 at 1:15 PM, V1 stated if a resident did not have an over-the-counter medication such as B12 or phenazopyridine V2 or another staff could purchase the medication at the pharmacy across the street from the facility and administer the medication instead of a resident missing a dose of the medication. On 10/15/24 at 1:27 PM, V25 (Pharmacy Nurse Consultant) stated all the resident medications were automatically refilled by the pharmacy. V25 stated all medications in the facility were resident specific medications and the pharmacy did not provide any over the counter stock medications. V25 stated the only medications that were not resident specific were medications that could not be placed into blister packs such as miralax. When V25 was asked how a nurse was to know if a resident's medication would run out before the medication was delivered to the facility V25 stated no resident should be out of medication because they are all automatically refilled. When V25 was asked why R5 did not have any vitamin B12 in the facility on 10/9/24 if all of the resident's medications were automatically reordered V25 stated he was not sure. When V25 was asked why R7 did not have any Trulicity in the facility on 10/16/24 if all of the resident's medications were automatically reordered V25 stated he was not sure. V25 then stated Trulicity is a medication that has to be manually reordered by nursing staff. When V25 was asked how nursing staff would know Trulicity had to be manually reordered V25 stated he was not sure. V25 stated he expected staff to follow the facility's pharmacy policy What to Do If a Medication is Not Available during a Med Pass if a medication is not available during medication pass. V25 stated this policy included what to do when the facility had a new resident admitted and needed their medications. V25 stated he did not expect staff would purchase over the counter medications from the pharmacy across the street from the facility to administer to residents. On 10/17/24 at 9:35 AM, V30 (LPN) stated she had received training on ordering resident medications but was not sure which resident medication were automatically refilled and which medications had to be manually ordered by the nurse. V30 stated due to not knowing which medications were automatically refilled the nurse would not know a resident did not have a medication until the nurse was completing medication pass. The facility's undated pharmacy policy titled What to Do If a Medication is Not Available during a Med Pass documented in part . 1. Review the pharmacy packing slip to verify if the medication has been delivered. You may also check the (pharmacy website portal) to review the delivery status of the medication. 2. Check all medication carts for the missing medication. Did the resident recently transfer from room/ unit? 3. Check the medication room and confirm all pharmacy deliveries have been properly checked in. 4. Utilize the (emergency medication stock) for availability of the medication. Remove dose for administration and administer to the resident . 5. If the medication is not available in the (emergency medication stock), Is there an alternative medication (or dose equivalent) available to administer with a prescriber's order? 6. If the medication cannot be located and is not available in the (emergency medication stock), please notify the pharmacy or request delivery from a backup pharmacy, or request a stat delivery, and finally verify the medication will be sent on the next pharmacy delivery. 7. Notify the provider the medication will not be available for administration at the current scheduled time. Request an order to hold the medication and administer upon delivery from the pharmacy . By following the steps above, we will avoid the need to document Medication not available. This will ensure the resident receives the medication timely and avoids any further potential delay in treatment . The facility's March 19, 2020, Administering Medication policy documented in part . Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/ federal regulations . Procedure: . 6. Medications should be administered within one (1) hour of the prescribed times . 9. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and document a rational . 13. Should a medication be withheld or refused, the physician will be notified when three (3) consecutive doses or a pattern of frequent withholding or refusal is noted. Documentation identifying the explanation of withholding or reason for refusal will be documented in the medical record .

Based on observation, interview and record review, the facility failed to implement current behavior interventions for a resident with inappropriate sexual behaviors and failed to re-assess and implement progressive individualized interventions for increased occurrences of unwanted sexual behaviors for 1 (R1) of 3 residents reviewed for behavioral health in the sample of 5. Findings include: R1's face sheet documented an admitted [DATE] with diagnoses including metabolic encephalopathy, epilepsy, cerebral infarction. R1's 7/14/24 Minimum Data Set, dated dated dated [DATE] documented no Brief Interview for Mental Status (BIMS) score due to R1 being rarely/ never understood. A handwritten document was provided by the V1 (Administrator) that documents interviews from R9 and R8 regarding an incident with R1. At the top of the document, it reads Interviews on 5/21/24. R9's interview: He (R1) followed (R8) to our room. (R8) went into the bathroom. He (R1) pulled the curtain and sat down on (R8's) rollator. He (R1) then got up and left the room. Later he (R1) came back in the room. He (R1) sat down on (R8's) bed. He (R1) pulled the curtain both times. We (R9 and R8) both told him to go. R8's interview: He (R1) followed me down here (room). I told him (R1) I had a roommate. He (R1) didn't stop. I went into the bathroom, and he (R1) sat down on my rollator. He (R1) came back to our room again after leaving the first time. He (R1) pulled the curtain and sat on the edge of my bed. He (R1) leaned over and kissed me on the lips two times. I motioned for him to leave. R9 yelled for staff. Staff led him away. R1's care plan documented a focus area initiated on 5/24/24 . I currently have an alteration in my behavior status (related to) agitation, wandering, inappropriate sexual behaviors . and listed the following interventions/ tasks: 5/24/24 my behaviors will be monitored every shift and documented, 5/24/24 Intervene as necessary to protect (R1's) rights and safety of others. Approach/ speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, 5/24/24 Minimize potential for the disruptive behaviors by offering tasks which divert attention such as encourage activity participation and monitored outdoor time, 5/24/24 Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes, 5/24/24 Praise any indication of (R1's) progress/ improvement in behavior, 5/30/24 Behavior - Inappropriate Sexual Behavior, 7/30/24 15-minute checks. A facility incident report regarding R1 and R7 dated 8/12/24 documented alleged abuse between R1 and R7 on 8/4/24. Both residents are marked as not interviewable. Under Detailed incident summary . the following is documented: This administrator was educated about an alleged incident between (R1) and (R7) on 8/4/24. Allegedly (R1) and (R7) were kissing and touching each other sexually . R1's care plan documented no new intervention for sexually inappropriate behaviors since 7/30/24. On 8/21/24 at 2:37 PM, V13 (Certified Nursing Assistant/ CNA) stated she had heard R1 had tried to be sexually inappropriate with R6's great-granddaughter. V13 stated she had not witnessed the incident but had heard other staff talking about it. V13 stated she was not sure when this incident happened. On 8/21/24 at 2:45 PM, V12 (Family Member) stated a couple weeks ago she and her [AGE] year-old granddaughter were in the facility visiting with R6. V12 stated her granddaughter had reported to her that a man in the facility's dining room had tried to touch her chest. V12 stated she did not witness the incident and was unsure if any staff witnessed the incident. V12 stated she had reported the incident to a staff member she thought was V14 (Licensed Practical Nurse/ LPN) but was not certain. V12 stated she was not sure what day the incident took place. On 8/22/24 at 10:32 AM, V14 (LPN) stated V12 had reported to V15 (CNA) that R1 had tried to inappropriately touch V12's granddaughter. V14 stated V15 had reported the incident to V14. V14 stated she was not sure what date or time the incident took place. V14 stated V15 had notified V1 (Administrator) via telephone after the incident occurred. On 8/22/24 at 10:45 AM, attempted to contact V15 via telephone. V15 did not answer and did not have a voicemail set up. On 8/22/24 at 10:45 AM, V1 stated V15 was employed at the facility on an as needed basis. V1 stated she would try to contact V15 to make V15 available for an interview. On 8/21/24 at 3:38 PM, V1 stated she was not aware of any incident involving R1 and V12's granddaughter. On 8/21/24 at 2:15 PM, V3 (Assistant Director of Nursing and Care Plan Coordinator) stated she was not aware of the incident between R1 and V12's granddaughter. On 8/20/24 at 1:06 PM, V6 (Housekeeper) stated she had two incidents with R1 being sexually inappropriate with her. V6 stated on one occasion she was walking through the dining room when R1 had come up to her and grabbed her breasts. V6 stated on another occasion R1 was outside and V6 was trying to assist another staff to get R1 back into the building when R1 grabbed her around the waist and refused to let go requiring another staff member to intervene. V6 stated she had reported both instances to V1 (Administrator). V6 stated she had not received any education on how to respond to R1 when R1 had sexually inappropriate behaviors. On 8/20/24 at 1:48 PM, V3 (Assistant Director of Nursing/ ADON and Care Plan Coordinator) stated she had never seen R1 have any inappropriate sexual behaviors. V3 stated R1 would rub staff's backs but V3 did not feel like this was a sexually inappropriate behavior. V3 stated a sexually inappropriate behavior was open to interpretation by staff. V3 stated if a staff member saw R1 having a sexually inappropriate behavior they should try to redirect R1 by assisting R1 to go for a walk outside or by offering a drink or snack. On 8/20/24 at 12:15 PM, V5 (Certified Nursing Assistant/ CNA) stated she had never been educated on what a sexually inappropriate behavior was. V5 stated what she would consider as a sexually inappropriate behavior might be different than what someone else would consider a sexually inappropriate behavior. V5 stated if R1 was to exhibit a sexually inappropriate behavior she would take him outside. V5 stated sometimes R1 was able to be redirected and sometimes R1 was not able to be redirected due to R1 not speaking English. V5 stated she had never received any education on what staff should do if R1 exhibits a sexually inappropriate behavior. On 8/20/24 at 12:09 PM, V7 (CNA) stated a sexually inappropriate behavior would be touching someone's breasts or rubbing someone's back if they don't want it. V7 stated she had not received any education on how to react to R1 if she saw R1 having a sexually inappropriate behavior. V7 stated she was not sure what activities she was supposed to redirect R1 with. On 8/20/24 at 1:00 PM, V4 (Registered Nurse/ RN) stated earlier in her shift R1 had tried to kiss a staff member. V4 stated she did not think trying to kiss a staff member was appropriate behavior, but V4 had never seen anything defining what a sexually inappropriate behavior was. V4 stated she was not sure if all the staff reacted to R1's sexually inappropriate behaviors the same way. On 8/21/24 at 9:25 AM, R1 was lying in bed in his room resting with the door closed. Continuous observation of R1's closed door from 9:25 AM until 10:25 AM was completed and no staff checked on R1. On 8/21/24 at 10:12 AM, no staff could be seen in the hallways, nurse's station, or dining room. 7 residents were sitting in the dining room with 4 of the residents being female. On 8/21/24 at 10:25 AM, V9 (Certified Nursing Assistant/ CNA) and V10 (CNA) were asked if they knew where R1 was located in the facility, and both responded they thought R1 was in his room but were not sure. On 8/21/24 at 1:40 PM, V11 (Licensed Practical Nurse/ LPN) stated there were 4 CNAs working in the facility from 6:00 AM until 2:00 PM. V11 stated the CNAs had designated residents for charting purposes but were not assigned as responsible for any specific resident's care. V11 stated the CNAs worked together in caring for all residents. V11 stated she was not sure if any CNA was assigned to complete R1's 15-minute checks. V11 stated there should be a form at the nurse's station documenting R1's 15-minute checks but V11 was unable to locate any form. V11 stated R1 was supposed to be checked on every 15 minutes due to R1's behaviors of wandering and history of being sexually inappropriate with female residents. On 8/20/24 at 2:29 PM, V2 (Director of Nursing/ DON) stated she expected staff to check on R1 every 15 minutes due to R1's behaviors. The facility's revised November 6, 2019, Care Plans Policy & Procedure documented in part .Our facility's Care Planning/ Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .

Based on interview and record review, the facility failed to ensure residents were free from resident-to-resident abuse for 3 (R1, R2, and R4) of 5 residents reviewed for abuse out of a sample of 13. Findings include: 1. The facility's final Long-Term Care Facility .Serious Injury Incident and Communicable Disease Report dated 8/12/24 documented alleged abuse between R4 and R1 on 8/4/24. Both residents are marked as not interviewable. Under Detailed incident summary . the following is documented: This administrator was educated about an alleged incident between (R4) and (R1) on 8/4/24. Allegedly (R4) and (R1) were kissing and touching each other sexually . Investigation did not confirm incident. (R5) is not a credible witness due to a BIMS (equal to) 5 and often story tells, which is part of his care plan. When (R1) was interviewed by (V6 - Registered Nurse/RN) she indicated that, No, that didn't happen. Staff that were working did not see any interactions between (R4) and (R1). Interview of (R5), conducted by Administrator and Social Services Director, did not substantiate the allegation. (R5) could not recall the name of the male nor the time, place, or day . Based on the investigation findings, I was unable to substantiate the abuse allegation, therefore, the allegation is unfounded . The facility's investigation of the 8/4/24 incident included a handwritten statement by V9 (Certified Nursing Assistant/CNA) that was dated 8/8/24 and documented in part . I (V9) come back from lunch break (R5) was standing up. I went over to him ask (sic) him what was wrong he said (R4) touch (sic) (R1) on her boobs on Sunday 11 AM 8/4/24 . The facility's investigation of the 8/4/24 incident included a handwritten statement by V6 (RN) with date written 8/8/24 . at the top of the document but indicated 8/4/24 was the incident date. This statement documented in part Was alerted by staff (V9) that (R5) was standing up from (wheelchair) in (dining room). This nurse went to (dining room) . (R5) told this nurse that (R4) was kissing (and) touching (R1). This nurse went and asked (R1) about what (R5) had said he saw. (R1) states No that did not happen. This nurse did not see anything that (R5) alleged happened . The facility's investigation of the 8/4/24 incident contained a handwritten interview of R5 that occurred on 8/8/24 documenting in part . (R1 and) 'the boy' were playing around together at the table. Asked when: 'thinks it was . day (R1) went to (hospital)' Both were enjoying it. (R1) was laughing. (R5) began to [NAME] off subject . This document was signed by V1 (Administrator) and V14 (Social Services). R1's Face Sheet documented an admitted [DATE] with diagnoses including major depressive disorder, anxiety disorder, dysphagia, schizophrenia, and delirium due to known physiological condition. R1's Minimum Data Set (MDS) dated [DATE] documented no Brief Interview for Mental Status (BIMS) score due to R1 being rarely/ never understood. R4's Face Sheet documented an admitted [DATE] with diagnoses including metabolic encephalopathy, epilepsy, and cerebral infarction. R4's MDS dated [DATE] documented no BIMS score due to R4 being rarely/ never understood. R4's Care Plan documented a focus area of .I currently have an alteration in my behavior status (related to) agitation, wandering, inappropriate sexual behaviors . noting a date initiated of 5/24/24. On 8/8/24 at 9:17 AM, V13 (Registered Nurse/RN) stated that R4 had inappropriate sexual behaviors. V13 said on one occasion R4 had tried to push V13 onto R4's bed and kiss her. V13 said on another occasion V13 was trying to administer R4's medications and R4 had grabbed V13 and tried to kiss V13. On 8/8/24 at 1:43 PM, V9 (CNA) said she was walking back in from lunch when she saw R5 standing up from his wheelchair yelling. V9 said R5 was saying that R4 touched R1's breast and was kissing her. V9 said that she did not observe this herself, this is what R5 told V9 as she entered. V9 said that when she walked in, R1 and R4 were by each other. V9 said that she took R1 and moved her to the nurse's station. V9 said that she reported what happened to V6 (RN). V9 said she thought V6 reported it to V1 (Administrator). On 8/8/24 at 1:59 PM, V6 (RN) stated she did know about R4 supposedly grabbing R1's breast and kissing her. V6 said the incident was hearsay from another resident and no staff witnessed it. V6 said she did not report it and knows that she is probably going to be in trouble, but I didn't witness it and no one else did either. V6 said she did not notify V1 (Administrator). R5's Face Sheet documented an admitted [DATE] with diagnoses including Parkinson's Disease, dysphagia, bipolar disorder, and cerebral infarction. R5's MDS dated [DATE] documented a BIMS score of 5, indicating R5 severe cognitive impairment. On 08/08/2024 at 2:20 PM, R5 presented as interviewable and stated that on Sunday (08/04/24), he was in the dining room and saw R4 start kissing R1. R5 stated that R1 was kissing R4 back. R5 said then R4 started to grab R1's breast and R1 started to grab R4's private area (penis). R5 said that he started yelling at them to stop. R5 stated I keep telling (R1) how disappointed in her I was and that she needed to stop it. R5 said that he saw V9 (CNA) coming in the doorway and R5 started yelling at V9. R5 said he told V9 what was going on and V9 took R1 away to the nurses station. R5 said he couldn't remember if R1 and R4 were still being inappropriate when V9 walked in the door. R5 said that he kept yelling at them to stop because it was inappropriate. During this interview, R5 appeared lucid, interviewable, alert and oriented to person, place, and time. 2. The facility's final Long-Term Care Facility .Serious Injury Incident and Communicable Disease Report dated 8/12/24 documented a resident-to-resident altercation that occurred on 8/6/24. The residents involved were noted to be R4 and R2. R4 was noted to be the perpetrator, R2 was noted to be the victim, and both are marked as not interviewable. Under Detailed incident summary . the following is documented This administrator was advised that an alleged physical altercation occurred between (R2) and (R4) on 8/6/2024 . Investigation revealed that (V10/CNA) was placing trays in the window to be cleaned when she turned around and seen (R2) grab onto another resident's Geri chair armrest. When (R2) grabbed onto the armrest (R4) sat his hand on her arm. Prior to setting his hand on (R2's) arm, (R4) was sweeping the floor around and under the table of where (R2) was sitting. No other staff witnessed the interaction and neither of the residents are interviewable. (V12 - Licensed Practical Nurse/LPN) was called to the area by (V10), who then left. (V12) separated the residents but did not witness the incident. (V12) observed (R4) with a broom in one hand and a dustpan in the other hand . Based on the investigation, it was determined that (R4) was trying to remove (R2's) hand from the Geri chair in order to be able to move her wheelchair to clean underneath it. (R4) did not purposely or intentionally wish to cause harm to (R2). Therefore, allegation of abuse was not substantiated. The facility's investigation of the 8/6/24 incident between R2 and R4 included a written statement from V10 (CNA) documenting in part .On Monday (sic) 8/6/24 I came from the window from putting a tray up. I looked up and saw (R4) try to move (R2) from the table and (R2) grabbed (another resident's) Geri chair and (R4) smacked (R2's) arm and I yelled for (V12) to come to the dining room, and (V12) separated (R2) and (R4) . The facility's investigation of the 8/6/24 incident also included a written statement from V12 (LPN) documenting in part .(V10/CNA) stated to this nurse that (R4) slapped (R2) on arm. This nurse immediately removed (R2) from area, assessed, (and) observed (no) redness, swelling on arm. (R2) was not in any distress. This nurse then told (V10) to call (V1/Administrator) as she is the abuse coordinator. When this nurse entered dining room (R4) had broom in one hand and dustpan in the other sweeping floor. Neither (R4) nor (R2) had any (signs or symptoms) of distress . R2's Face Sheet documented an admitted [DATE] with diagnoses including need for assistance with personal care, dysphagia, muscle wasting, lack of coordination, schizophrenia, cognitive communication deficit. R2's MDS dated [DATE] documented no BIMS score due to R2 being rarely/ never understood. R4's Face Sheet documented an admitted [DATE] with diagnoses including metabolic encephalopathy, epilepsy, cerebral infarction. R4's MDS dated [DATE] documented no BIMS score due to R4 being rarely/ never understood. On 8/8/24 at 1:50 PM, V10 (CNA) stated that on 8/6/24, V10 was walking through the dining room at the end of her shift to leave the facility and saw R2 sitting in a wheelchair at one of the dining tables. V10 said R4 came around the table and tried to move R2. V10 said R2 did not want to move and grabbed the arm rest of another resident's chair. V10 said when R2 grabbed the other resident's chair R4 slapped R2's arm. V10 said V10 yelled for V12 (LPN). V10 said V12 intervened and separated R2 and R4. V10 said she did not report the incident to V1 (Administrator) because she thought V12 would report the incident to V1. On 8/9/24 at 9:59 AM, V12 (LPN) said she was working on 8/6/24. V12 said V10 had reported to V12 that R4 had hit R2 in the dining room. V12 said she assessed R2 and did not find any injury. V12 said R2 was not interviewable and appeared to be unharmed. V12 said she did not report the incident to V1. V12 said it was V10's responsibility to report the incident because V10 was the staff that witnessed the incident. The facility's undated Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure documented in part . The facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy . III. The facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by residents or other, which include, but are not limited to . b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/ shoving, biting, spitting, threatening gestures, throwing objects . c. Sexually aggressive behavior such as saying sexual things, inappropriate touching/ grabbing . B. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the Facility will take steps to ensure that the resident is protected from abuse. These steps shall include evaluating whether the resident has the capacity to consent to sexual activity .

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (R10, R12) reviewed for abuse in a sample of 13. This resulted in R10 experiencing feelings of fear and uncertainty for his safety in his home. Findings included: 1. R10's face sheet documented R10 was admitted to this facility on 8/23/2023 with diagnoses of Traumatic Brain Injury, Cancer and Diabetes Mellitus among others. R10's MDS assessment dated [DATE] documented R10 has a BIMS score of 15 out of 15 total, which indicates R10 is cognitively intact. This same MDS documented R10 has no impairment to upper or lower extremities, does not ambulate and independently uses a wheelchair and/or walker for locomotion. R1's face sheet documented R1 was admitted to this facility on 11/29/2024 with diagnosis of Paranoid Schizophrenia, Major Depressive Disorder and Anxiety among others. R1's MDS (minimum data set) assessment dated [DATE] documented R1 has a BIMS (brief interview for mental status) score of 15 out of 15 total, which indicates R1 is cognitively intact. This same MDS documented R1 has no impairment to his upper or lower extremities, ambulates independently and does not use a wheelchair. On 6/4/2024 at 4:05pm, R10 stated on 5/8/2024 about 5:00pm, he was in his wheelchair, in the dining room, sitting at the dining room table waiting for supper to be served. R10 stated R1 suddenly became agitated started yelling he was God and then started kicking over tables. R10 stated next R1 came over by me and started pounding me on top of the head with his fist. R10 said he was trapped between the table and his wheelchair and could not get away from R1. R10 stated R1 just kept hitting me and it took several staff members to get R1 off of me. R10 stated he did not provoke R1 in anyway and has not really had any trouble from R1 in the past. R1 said the unprovoked attack scared him so he sought an emergency order of protection against R1 and does not want R1 around him ever again. R1 stated V4 (Dietary Manager/DM), V9 (Registered Nurse/RN) and R11 were in the dining room and witnessed the attack. R10 stated he declined to go to the emergency room for evaluation after the attack, but later agreed to get in facility mobile X-rays but they were negative. R10 stated other than a sore spot on his head caused by the top button on his hat being hit against his head when R1 kept hitting him, he did not receive any other injuries. On 6/3/2024 at 2:10pm, V9 (RN) stated she was in the dining room on 5/8/2024 at 5:00pm, passing supper medications. V9 stated R1 suddenly started yelling and saying he was God and kicking over empty tables and chairs. V9 stated R1 was yelling he was a [NAME] (Jewish) and was going to put the spirit into V4 (DM), V9 stated next R1 started hitting R10 on the head. V4 stated it took several staff members to get R1 away from R10. V9 stated the police came to the facility and interviewed R1 and R10. V9 stated R10 got an emergency odor of protection against R1. V9 stated R1 did abuse R10 when he hit him. On 6/3/2024 at 2:00pm, V20 (Certified Nursing Assistant/CNA) stated she was working on 5/8/2024 at 5:00pm. V20 stated everyone was in the dining room waiting for supper to be served when R1 started yelling he was God, kicked over empty tables and chairs and then stared hitting R10. V20 stated R1 was pounding R10, hitting him really hard with his fist. On 6/3/2024 at 2:05pm, V12 (CNA) stated she was working on 5/8/2024 at 5:00pm. V12 stated she was passing out supper trays when R1 started yelling and then attacked R10. V12 stated it took several staff to get R1 off of R10. On 6/3/2024 at 2:35pm, V1 (Administrator) agreed R1 had abused R10. V1 stated immediately after R1 attacked R10, R1 was taken to the emergency room for psychological evaluation, did not return to the facility and was discharged from the facility. V1 stated R1 would not be returning to this facility. A facility document titled State of Illinois, Illinois Department of Public Health-Long Term Care Facility-Serious Injury Incident and Communicable Disease Report with incident date of 5/8/2024 at 5:00pm documents the following in part: Final Report. (R1) allegedly struck (R10) several times while in the dining room awaiting dinner. Physician notified. POA's (power of attorneys) notified. Police notified . (R1) was exhibiting unusual behavior such as repeating things over and over again. He told (V4) that the sandwich was very good. He declined a second one when asked if he wanted another one. He told (V4) that he was a [NAME]. He told (V4) that he was going to out the spirit in (V4). After making the statements, he jumped up and began kicking the table and chairs chanting Kick the devil down. (R1) then hit (R10) on the head multiple times while staff intervened to separate them. 911 was called in order to transfer (R1) to the ER. While waiting for the ambulance to arrive, police arrived and took statements from (R1) and (R10). (R1) was delusional during the entire episode and during the police interview. (R1) told he police that he was God Almighty. (R10) declined ER evaluation. (R10) was assessed by nursing staff and no injuries were noted. (R1) went to the ER and did not return to the facility due to (R10) getting and emergency Order of Protection against (R1). (R1) was placed at a new facility. A handwritten, undated statement from R3 concerning what he witnessed when R1 assaulted R10 documented the following in part: I was eating my supper when out of the corner of my eye I seen R1 punching and attacking R10. (R1) Hit him (R10) several times in the head and cussed at him. (Event date 5/8/2024 at 5:00pm) A handwritten statement, dated 5/8/2024, from R2 concerning what she witnessed when R1 assaulted R10 documented the following in part: While sitting at the dinner table, R1 charged at R10 and started beating R10. The only thing R10 was doing was eating an ice cream sandwich. Progress note in R10's EHR (electronic health record), dated 5/8/2024 at 19:34 (7:34pm) documented the following: V8 (RN) heard a commotion going on in the dining room, (R1) was hitting R10 with his fist on the head. R10 was trying to get away, it took multiple staff to get R1 away from R10. R10 said he didn't do or say anything, that R1 just came up behind him and started hitting him in the head. Document titled State of Illinois, Circuit Court, Emergency Order of Protection documents R10 was granted an order of protection that began on 5/9/2024 at 10:33am and R1 is not allowed within 500 feet of R10. 2. R12's Face sheet documents R12 has an admitted [DATE] with diagnoses including: Paranoid Schizophrenia, Adjustment Disorder with Mixed Anxiety and Depression, Cerebral Infarction, Other Paralytic Syndrome following unspecified Cerebrovascular disease, Paralytic gait and Abnormalities of gait and mobility. R12's Minimum Data Sheet (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15 indicating R12 is cognitively intact. R6's Face sheet documents R6 has an admitted [DATE] with diagnoses including Encephalopathy, Cerebral Infarction, Polyneuropathy, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non dominant side, and Acquired absence of left leg below knee. R6's MDS dated [DATE] documents a BIMS score of 15 indicating resident is cognitively intact. R8's Face sheet documents an admitted [DATE] with diagnoses including Metabolic Encephalopathy, Essential Hypertension, Chronic Diastolic Heart Failure, Chronic Kidney Disease, Epilepsy and recurrent seizures and Cerebral Infarction. R8's MDS dated [DATE] section C is not completed therefore no BIMS score is documented. On 06/03/24 at 1:17 PM, R6 stated she does not think it is right that R8 came down to R6 and R12's room and put his arm around R12 and kissed her and nothing has been done about it. R8 came down to their room and sat next to R12, put his arm around her and kissed R12 twice. R6 stated, she told him to leave, but he doesn't understand English. They told V10 (Certified Nurse Aide/CNA) and V12 (CNA) and nothing has been done about it. R8 came back down to their room a couple times, she tried to shoo him away and he came back down, and she threw a shoe at him to keep him from coming in the room. R6 stated, her and R12 told V1 (Administrator) on 05/28/24 and then saw him rubbing a staff members arm and another staff's back, she doesn't feel that is helping when he doesn't understand. R12 is uncomfortable and more nervous about going to activities now. On 06/03/24 at 1:19 PM, R12 stated R8 came down to her room on Memorial Day weekend (05/25/24 - 05/27/24) closed the curtain between her and R6, sat on the bed next to her, put his arm around her and kissed her twice on the lips. R12 stated she told him to leave but he doesn't understand English. R12 stated R6 yelled for staff to help, and they took him out of the room. They told the CNAs (V10 and V12) they did not want him in their room. R12 stated, it scares her when he is down in their room, and she does not want him in there. R12 stated, she does not want R8 to touch or kiss her. On 6/3/24 a handwritten document was provided by the V1 (Administrator) that documents interviews from R6 and R12 regarding and incident with R8. At the top of the documents, it reads Interviews on 5/21/24. R6's interview: He (R8) followed (R12) to our room. (R12) went into the bathroom. He (R8) pulled the curtain and sat down on (R12's) rollator. He (R8) then got up and left the room. Later he (R8) came back in the room. He (R8) sat down on (R12's) bed. He (R8) pulled the curtain both times. We (R6 and R12) both told him to go. R12's interview: He (R8) followed me down here (room). I told him (R8) I had a roommate. He (R8) didn't stop. I went into the bathroom, and he (R8) sat down on my rollator. He (R8) came back to our room again after leaving the first time. He (R8) pulled the curtain and sat on the edge of my bed. He (R8) leaned over and kissed me on the lips two times. I motioned for him to leave. R6 yelled for staff. Staff led him away. On 06/03/24 at 1:38 PM, V1 (Administrator) stated she does not have an investigation for R8 and R12 for abuse. She stated, she did an investigation for wandering for R8. V1 stated, R12 and R6 stated, that R8 kissed R12 twice, during the wandering incident but it was determined the incident was a wandering event not a resident-to-resident sexual abuse or an inappropriate sexual behavior. On 06/04/24 at 2:10 PM, V12 (CNA) stated she was present for the incident between R12 and R8. V12 stated, we (V12 and V10 (CNA)) heard R6 yelling for help, we walked in and R8 was sitting on the bed next to R12 and had his arm around R12, they redirected R8 out of the room and back down the hall. V12 stated, she didn't see anything but R6 told her R8 kissed R12. V12 stated, he went back down there one more time that night about 30 minutes later and a couple times since then that she knows of. They just redirect him back to his room. V12 stated, she does not know if R8 understands them, but he will go with them. They will usually point to things or make motions to things if they are figuring out what he wants, he doesn't speak English. V12 stated, she reported this incident to V22 (Licensed Practical Nurse (LPN)) that evening right after the incident. On 06/06/24 at 2:20 PM, V10 (CNA) stated she was present the evening of the incident with R12 and R8. V10 stated, her and V12 (CNA) were in the room across from R12's room when they heard R6 yell. R8 had his arm around R12 but she did not see him kiss her, but R6 and R12 stated he did. V10 stated, this happened close to the end of the second shift so after 9:00 PM sometime. On 06/08/24 at 7:48 PM, V22 (Licensed Practical Nurse/LPN) stated, she was working on the evening the incident happened between R8 and R12. V22 stated, she was working on the other hall when V12 (CNA) came and got her and told her R6 and R12 told her R8 kissed R12 twice on the lips. V22 stated, she went and talked to R12, and she confirmed R8 kissed her twice. She assessed R12 then left the room and called her supervisor V15 (Care Plan Coordinator/CPC). V15 told her she should call V1 (Administrator) and report it. V22 stated, she hung up with V15 and called V1 and reported that R8 had went into R12's room and had his arm around her and kissed her twice. V22 stated (after checking her notes) she reported this to V1 on the evening of 05/26/24. V22 stated they removed R8 from the room and redirected him back to his room, but she does not know if he understood why, because R8 does not speak English. Facility abuse policy, dated 2022, documents the following: the facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation.

Based on interview and observation, the facility failed to maintain a door threshold in a manner to prevent accidents in 1 of 3 residents (R2) reviewed for accidents in a sample of 7. This failure resulted in R2 sustaining a nondisplaced fracture of shaft of fifth metacarpal bone of the left hand, nondisplaced fracture of proximal phalanx of left middle finger, closed nondisplaced fracture of proximal phalanx of left ring finger and age indeterminate left distal radius and ulna fracture. The findings include: R2's admission record documents an admitted to the facility on [DATE]. This same document notes R2 has diagnoses in part, which include fracture of unspecified part of neck of right femur, transient cerebral ischemic attack, unsteadiness on feet, and dementia in other diseases classified elsewhere. R2's MDS (Minimum Data Set) Section C dated 9/24/22 documents R2 has a BIMS (Brief Interview for Mental status) score of 3, which indicates R2 has severe cognitive impairment. This same MDS in section G documents that for transfers - (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) self-performance is extensive assistance and the support provided is two plus person physical assist. The facility Policy and Procedure titled Fall Reduction Policy with revision date 6/17/22 documents that each resident will be evaluated for risk of falls using a Fall Risk upon admission, readmission, upon a significant change of condition, quarterly and following each fall. This policy further states the following under Purpose: To provide an environment that remains as free of accident hazards as possible, to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries and to promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk. R2's Fall Risk Assess. dated 8/16/22 documents a score of 11. The same document notes that a score of 10 or greater indicates a high risk for falls. R2's Fall Risk Assess. dated 12/7/22 with description as significant change documents a score of 14, again indicating R2 is at a high risk for falls. The facility report titled Long Term Care Facility & IID-Serious Injury and Communicable Disease Report dated 12/12/22 with report type noted as the Final report documents that on 12/7/22 at 10:30am, R2 was being pushed in her wheelchair from outside to inside. R2 was reminded by staff members, V5 (CNA/Certified Nurse Assistant/ AD/Activity Director) and V8 (Activity Aide/Marketing Director) to lift her feet from the ground. R2 put her feet down. R2 fell from the wheelchair. R2 was assessed for injuries. R2 complained of pain in her hand/wrist. Physician was notified and daughter was notified. Physician ordered x-rays of left hand and wrist. X-ray was obtained. X-ray indicated a fracture through long and ring finger. Physician ordered R2 to be sent to ER (emergency room ) for treatment. R2 returned from ER with a sling and orders to follow up with ortho. Resident BIMS = 3 and she has diagnoses of difficulty walking, unsteadiness on feet .R2's care plan was reviewed and updated. R2's Care Plan has a focus area of I have had an actual fall .12/7/22: Major Injury (second et (and) third digit et metacarpal below 5th digit with a revision noted on 12/9/22. The corresponding goal documents: 12/7/22: I will comply with letting staff pull my wheelchair in backwards through outside door through review date with date initiated on 12/7/22. The Interventions/Tasks section documents Staff to pull R2's wheelchair through the door backwards over the threshold with date initiated of 12/7/22. R2's Care Plan has a focus area of I currently have an alteration to my ability to care for self and need assistance d/t (due to) fatigue, weakness with a date initiated of 4/8/21. The corresponding goal documents I will remain free of complications related to poor mobility, including contractures .fall related injury through the next review date with date initiated of 4/8/21. The Interventions/Tasks section documents an intervention of Locomotion: (R2) uses a wheelchair for locomotion. Foot pedals to be in place on wheelchair when staff is pushing (R2's) wheelchair for safety that was not added/initiated until 12/13/22. On 12/9/22 at 1:10pm, V5 (CNA/Certified Nurse Assistant) stated that she was pushing R2 forward in from outside through the west side door off of the dining room. V5 stated she told R2 to hold her feet up and scoot back in the wheelchair before she began pushing her. V5 stated they went to go through the doorway, the wheelchair hit the threshold, and it made the wheelchair stop. V5 stated that R2 had planted her feet down when they hit the threshold which caused a bump. V5 stated R2 went forward and fell out of the wheelchair. V5 stated she grabbed the back of R2's pants to keep her from falling, but she fell anyway. On 12/9/22 at 1:20pm, V7 (volunteer) stated he helps out at the facility since his wife works there. V7 stated he witnessed R2's fall on 12/7/22. V7 stated that V5 was pushing R2 inside from the west side door from smoking and V8 was holding the door. V7 stated that when the wheelchair hit the bottom of the door, R2 went forward and fell out of the wheelchair. V7 stated that V5 tried to stop the fall by grabbing R2's pants. On 12/9/22 at 1:40pm, R2 was alert and oriented times/x3 (person, place, and time) and answered questions appropriately. R2 stated that the wheel on her old chair had not been acting right, making it hard to go that way. On 12/9/22 at 12:30pm, V6 (Occupational Therapist/Regional Therapy Director) stated she had not been told that there was an issue with R2's wheelchair until after the fall on 12/7/22. V6 stated she was told the wheelchair was not working right. V6 stated there was an issue with the left front wheel turning in. V6 stated that on 12/7/22 at 10:20am, she got R2 a new wheelchair and she has been in the new one since her fall. On 12/13/22 at 9:30am, V1 (Administrator) stated she has not had any reports of R2's wheelchair not working prior to the fall. V1 stated that R2 propels herself around the facility. V1 also stated she was not aware that V6 got R2 a new wheelchair on 12/7/22. V1 stated staff should probably be bringing residents through that doorway backwards. On 12/9/22 at 1:20pm, the wheelchair R2 was using at the time she fell was observed by this surveyor along with V4 (Maintenance Director) and V5 (CNA). The left front wheel was noted to not touch the ground. When the wheelchair was pushed, the left front wheel turned inward and did not move. On 12/13/22 at 10:15am, V1 observed the wheelchair R2 was using at the time of her fall along with this surveyor and when noting this issue with the left front wheel, V1 stated Oh, I see what you mean. R2's After Visit Summary from local hospital emergency room documents the following diagnoses: left hand pain, nondisplaced fracture of shaft of fifth metacarpal bone, left hand, initial encounter for closed fracture, nondisplaced fracture of proximal phalanx of left middle finger, initial encounter for closed fracture, closed nondisplaced fracture of proximal phalanx of left ring finger, initial encounter for closed fracture, fall, initial encounter.

Based on observation, interview and record review, the facility failed to monitor for and prevent an elopement for 1 of 3 residents (R3) reviewed for elopement risk in the sample of 8. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 01/22/22 when the facility failed to monitor and prevent an elopement that resulted in R3 exiting and walking approximately 495 feet from the facility, falling, sustaining several abrasions, becoming septic, and experiencing a cardiac event. R3 was found to be hypothermic and initially unresponsive when located by staff next to a wooded area in a soccer field across from the facility. R3 was transported by ambulance to the local emergency roiagnom on [DATE] and subsequently transferred to an out of state hospital to achieve critical care treatment. V1 (Administrator) and V5 (Regional Director of Operations) were notified of the Immediate Jeopardy on 02/01/22 at 8:34 AM. The surveyor confirmed through observations, record review, and interview, that the Immediate Jeopardy was removed on 01/26/22, however the facility remains out of compliance at a severity level two as the facility evaluates the implementation and effectiveness of their interventions put in place with their removal plan. Findings include: R3's Resident Profile Sheet documents admission to this facility on 07/19/21. R3's Medical Diagnoses Sheet documents primary diagnoses of Dementia with behavioral disturbance and Hypertension. R3's most recent quarterly MDS (Minimum Data Set) dated 10/25/21 documents R3 is severely Cognitively Impaired, however, he is assessed as being independent with locomotion. R3's Wandering/Elopement Risk assessment dated [DATE] documents a score of 22 indicating he is high risk (normal range of 7 or higher = high risk). R3's Care Plan dated 07/19/21 documents the following in part - . Focus: My current risk for wandering/elopement is high risk . Goal: My safety will be monitored every shift by all staff. Interventions/Tasks: .I will be re-oriented to the unit and my room. I will wear a wander-guard for my safety, and it will be maintained and rotated as per facility policy. Staff will be aware of my location every 15 minutes and as needed . A facility initial Serious Injury Incident Report regarding R3's elopement documents the following in part - Incident Date: 01/22/22. Time of Incident: 6:15 AM. Resident Involved: (R3); Ambulatory; Interviewable: No; Alert and Oriented times: X (times) 2; Capable of Communication: Yes. Incident Description: Assessment performed by V7 (Licensed Practical Nurse/LPN) at 6:30 AM on 01/22/22. Detailed Incident Summary: Approximately 6:15 AM, heard door alarm to smoker's door. Staff immediately did head count . (R3) was not found. Staff went out and about facility with flashlights. Staff went walking toward field and found footprints. Found resident on ground. (V7 and V17-Certified Nurse Aide/CNA) removed jackets and put on resident and resident was responsive. 911 was called and more blankets were placed on him. EMTs (Emergency Medical Technicians) and police arrived and transferred him to (local hospital) ER (emergency room ). Called and asked about resident's condition. Resident in stable condition at this time with no fx (fracture) suspected, abrasions on knees only. A local Police Department Incident Report dated 01/22/22 documents the following in part - . On 01/22/22 at approximately 6:41 AM, R/O (responding officer) V9 (Police Sergeant), V10 (Police Officer) and (local) ambulance were dispatched to the soccer field next to (name of facility) for a male that had escaped from (name of facility). R/O V9 and Officer V10 arrived and found several employees on the field with the victim (R3). (R3) was covered up with blankets. R/O would note that the temperature outside was in the area of 15 degrees and that the ground had frosted over. One of the employees advised that they did not know how long he had been outside . Local County Ambulance Service arrived on scene and R3 was transported to the local hospital emergency room for treatment and evaluation. This report indicated further interviews would be conducted by the police officers inside the facility and included in the case file. This report documents three staff members who were initially observed at R3's side upon arrival as V7 (LPN), V21 (TNA - Nursing Assistant in training), and V25 (LPN). R3's local County Ambulance Service patient care report documents a service date of 01/22/22 - - . Primary Impression: Hypothermia; Secondary Impression: Altered Mental Status; Primary Symptoms: Weakness; Initial Patient Acuity: Emergent . This report further documents in part - . Initial 911 call received at 6:40 AM; Enroute: 6:43 AM; On scene: 6:48 AM; At patient: 6:49 AM; Patient Transferred to emergency room care: 7:43 AM .emergent to the soccer field next to (facility) for patient that was found outside. Arrived to find local police and nursing home staff on scene. Patient is a [AGE] year-old male lying prone on the ground in somewhat wet clothes with a pillow under his head. Patient has about 8-10 blankets on him. Patient is cold to touch, confused, and combative. Nursing staff state that the patient has been outside for at least 1 hour by the time staff noticed he was not in the facility. Nursing staff state that a door alarm went off, but they thought no one got out . This report further documents R3 was given IV (intravenous) therapy with heat pack placed around IV, 2 heated blankets with 5 heated packs placed under the blanket, and the rigs heat run on high until arrival at the emergency room where care was transferred at 7:13 AM on 01/22/22. Per https://www.localconditions.com/weather-carmi-illinois/ /past.php - the local temperature with wind speed on 01/22/22 was reported as follows: * 6:38 AM 12.2 degrees Fahrenheit (F) with winds south southeast at 4 miles per hour * 5:58 AM 12.2 degrees F * 5:38 AM 12.2 degrees F * 4:58 AM 10.4 degrees F * 3:58 AM 10.4 degrees F * 3:39 AM 10.4 degrees F Per https://www.weather.gov/safety/cold-wind-chill-chart the NOAA (National Oceanic and Atmospheric Administration) Wind Chill Chart Calculations, an outside temperature of 12.2 degrees F with a wind speed of 4 miles per hour as indicated by the local weather report on 01/22/22 above - wind chill is determined to be 5 degrees F (-15 degrees C (Celsius). R3's local hospital emergency department nursing triage report documents the following in part - Patient: (R3) .Arrival: 01/22/22 at 7:22 AM. Departure: 01/22/22 at 4:00 PM. Disposition: Transfer. Triage: Arrive by EMS (Emergency Medical Services) from a nursing home. Historian: Patient. Unaccompanied. Primary Physician: (V30) Chief Complaint: Patient to Emergency Department with Hypothermia. Per nursing home (NH) staff, patient was found outside laying face down in a soccer field across from the NH in approximately 12-degree weather. Patient was found in only a shirt and jeans without shoes on. NH staff is unsure how long patient had been outside, stating the alarm was faulty, but believes it was sometime before 6:00 AM. Patient moaning upon arrival and cold to touch 7:33 AM on 01/22/22. See EMS Report. IV fluids given (warmed fluids wide open). [CONDITION(S)] Screen: Positive .No infection suspected/documented - Temperature less than 96.8 degrees and heart rate greater than 90. 7:33 on 01/22/22 - Blood pressure: 175/135, Heart rate: 109 .Temperature: 86 degrees Fahrenheit (rectal) .The patient appears uncomfortable, lethargic, and has weakness, patient moaning. R3's local hospital ER Physician Clinical Report dated 01/22/22 at 7:33 AM documents the following in part - History of Present Illness and Chief Complaint: Fall (found outside across the street from the NH on the ground in 15-degree weather). Location of injuries: Hypothermic-EMS unable to get temperature. The injury occurred last time known in NH was prior to 5:30 AM. Alarm did not sound. Was found outside around 7:00 AM .the patient had loss of consciousness (was cold and unconscious when found outside) .Vital signs: Hypotensive. [CONDITION(S)] .Appearance: .appears uncomfortable, is pale and moderately dehydrated and is restless. He appears agitated, frail, elderly, and older than stated age (77). He shows no apparent trauma. Extremities: Abrasions present to the right lower extremity and right knee and left lower extremity and left knee. Toes on both feet are very cold to the touch, and pale .Neuro: Severely altered mental status, combative, lethargic, and disoriented to person, place, and time. Patient has incoherent responses. No responses to questions and commands. The emergency room report goes on to document - Course of Care: 01/22/22 at 10:56 AM .blood pressure dropped to 90s systolic. Will complete 30 ml (milliliter)/kg (kilogram) bolus of warmed fluids. The patient has [CONDITION(S)]/flutter with RVR (Reverse Ventricular Regurgitation). This appears to be new .could be demand Ischemia .transfer to higher level of care where Cardiology is available .the patient required critical care due to the acute impairment of vital organ systems (Cardiovascular and Central Nervous System) and a high probability of imminent and life-threatening deterioration. Numerous emergent and urgent interventions were required to prevent sudden life-threatening deterioration. Clinical Impression: 1) New onset [CONDITION(S)] flutter; 2) Frostbite with partial thickness skin loss involving right great toe, right 2nd toe, right 3rd toe, right 4th toe, right 5th toe, left great toe, left 2nd toe, left 3rd toe, left 4th toe, and left 5th toe with Hypothermia; 3) Severe Hypothermia secondary to exposure and Arrhythmia; 4) Probable bacterial Pneumonia; 5) Probable severe [CONDITION(S)] with altered mental status and acute Cardiovascular failure. No shock. Per https://medical-dictionary.thefreedictionary.com/demand-induced+ischemia - demand-induced ischemia is described as - Insufficient blood flow to meet the needs of the heart produced by [CONDITION(S)] and relative [CONDITION(S)] rather than by flow-limiting blockages within the coronary arteries. Demand ischemia may occur in [CONDITION(S)] with a rapid ventricular response; in [CONDITION(S)] or hypovolemia; or in [CONDITION(S)] or the systemic [CONDITION(S)] response syndrome. On 01/25/22 at 10:04 AM, V26 (ER Physician) stated he was the treating physician for R3 on 01/22/22. V26 stated he is not certain R3 has frost bite because it takes days to develop, but his toes were very, very cold and pale and he wanted the receiving hospital to monitor. V26 stated for an older person who is not clothed properly and wearing no shoes it does not take long at 12 degrees for the core temperature to drop, as his was at 86 after receiving emergency care since earlier that morning from paramedics on the scene. V26 confirmed it was very plausible for R3 to have been outside for an hour given his condition, and he did not question that. The facility schedule for the week of January 16, 2022 documents on Friday, 01/21/22 to Saturday 1/22/22 the following staff were working from 10:00 PM to 6:00 AM - V16 and V20 (CNAs), V6 (Registered Nurse - RN), and V21 (TNA - CNA in training) worked from 2:00 PM on 1/21/22 to 6:00 AM on 1/22/22. This same schedule documents the following staff beginning their shift on 01/22/22 at 6:00 AM - V17, V22, V23, V24 (CNAs), V7 (LPN), V19 (RN), and V25 (LPN). On 01/25/22 at 8:58 AM during a tour of the facility, a number code was written in marker at the top of the East and West metal door frames of the dining room. When asked about the numbers, V29 (Activities) verified the codes at the top of the door frames were to disarm the door alarms and they've been the same for a long time. The following interviews were conducted with V6 (RN), V7 (LPN), V17, and V21 (CNA), who were primarily involved during R3's elopement incident on 01/22/22 - On 01/25/22 at 9:37 AM, V17 (CNA) stated ever since R3 was known to take off his electronic elopement bracelet he has been on a 15-minute safety check system with staff. V17 is unsure of the date this was implemented, but thought it was sometime late last year. V17 confirmed she worked in the facility on 01/22/22 for the 6:00 AM to 2:00 PM shift. She stated V6 (RN) gave report and there was nothing remarkable regarding R3's night. V17 stated no one mentioned the 15-minute checks for R3, so she was not aware if they had been done or not. V17 stated the west side dining room door, zone 2, went off at 6:15 AM. Staff went to see if anyone had gotten out the door and did not see anyone at that point inside or out that would have tripped the alarm. V17 stated we then went to do a resident head count throughout the facility and realized R3 was not in the facility. V17 stated at approximately 6:20 AM, staff went out the two dining room doors and the front entrance door to look for R3. It was still dark enough outside at this time that we had used flashlights. We walked the building perimeter with flashlights. We also had 2 staff driving around looking on the frontage roads. No one saw R3, so we came back in the facility. V17 stated she and V7 (LPN) went back outside a second time and searched across the parking lot to the other side of the soccer field. At that time, it was twilight, and we could see better. We ultimately went further onto the soccer field to the other side and located R3 at approximately 6:38 AM at the northwest end of the tree line where the row of brush ends in the soccer field. R3 was laying on his stomach. He had a jacket with him, but it was not on. V17 stated she shook him and said his name. He made groaning noises, we covered him with our jackets until additional staff brought out blankets. R3 had one shoe off down by his feet. V17 stated V7 called into the facility and reported they had located R3. She understood V25 (LPN) was the one who called 911 from inside the facility. After the ambulance arrived, V17 stated emergency personnel rolled R3 over and that's when they discovered his other shoe underneath his body. V17 was not sure how long R3 had been outside. When asked about camera footage, V17 stated she doesn't think the cameras record and thinks it's a live stream monitor system located at the nursing station. When told the ambulance report documented a staff member had stated R3 was outside at least an hour and asked if this would be possible, V17 stated, Yes, it was possible he was outside that long. When asked if R3 was capable of punching in the alarm code for the outside doors and leaving undetected, she stated, It's possible, he takes his elopement alarm band off all the time. That's why we implemented the 15-minute checks. V17 confirmed R3 was not wearing his elopement bracelet on 01/22/22 when he left the facility and they located him in the field. On 01/25/22 at 10:20 AM, V6 (Registered Nurse - RN) stated she worked from 10:00 PM on 01/21/22 to 6:00 AM on 01/22/22. V6 stated R3 had been at the nursing station with her for most of the evening until about 3:00 AM, when at that time V6 told R3 it was time to go to his room and get some sleep because she needed to assist other residents. V6 confirmed she watched R3 go to his room and open his door but did not physically see him enter his room. V6 stated she did not see him again after that time. V6 confirmed she finished her morning medication pass and by that time the day shift had arrived just before 6:00 AM. V6 confirmed she gave report and clocked out at 6:08 AM. When she left the building at that time, there were no alarms going off and it was not apparent anyone had exited the building. When asked if R3 would be capable of punching in the code on the door alarm pad himself and exiting, she stated it was possible, he could read and the code was the same as always, or he could have gone out with our independent smokers. When asked about camera footage, V6 stated she did not think the cameras recorded, it was just a live stream monitor system located at the nursing station. On 01/25/22 at 11:25 AM, V21 (CNA) gave the following phone interview - V21 stated the last time she saw R3 was on 01/21/22 in the dining room for dinner at about 5:30 PM or 6:00 PM. V21 stated R3 always wandered around the facility. R3 would usually sit around the nursing station with staff. V21 stated R3 would need to be redirected, all day, every day away from every door in the facility. He would pack his bags and try to leave. One day he tried to get out the front door .We try to get him a snack and redirect. He has been out of the facility before right outside the door. I can't remember when this was. It is a normal thing for him to try and get out. The day of 01/21/22, I came in the back door from the ramp where the supplies are. He wanted to get out and I told him no. He would get mad. He would pack his things every day and one time he had dragged his recliner in the hallway. He will not keep the (elopement bracelet) on and I don't remember the last time he had it on .He would fiddle with it and break it. At least twice a day he would attempt to leave. I am not positive he would be able to punch in the code to get out, but I know he is with it enough some of the time so it's not out of the question he would be able to open the door with the code. I was part of the staff that went to his side when he was found outside. I had numerous blankets, the kitchen staff ran by me and got their first. (V7 and V17) saw tracks and found him first. The only thing I'm aware the facility had as an intervention for elopement were the 15 minute checks .I'm a CNA in training and I don't chart in the record yet. When asked about camera footage, V21 stated she does not think the cameras record. On 01/26/22 at 6:15 AM, V7 (LPN) stated at the end of her shift on 01/22/22 report to the oncoming shift was completed about 6:15 AM. V7 stated a resident head count was conducted after report and at that time, both dining room door alarms were going off. V7 stated this was strange because staff did not see anyone at that time who would have triggered the alarms. She explained there is a zone panel beside the call light panel at the nursing station and when an elopement band triggers the door alarms, it will give you the number assigned to that band. There was no indication that R3's elopement bracelet had breached the doors. V7 stated when they realized R3 was missing at head count, the facility was searched pretty quickly, and the outside search began. V7 stated they had a couple of cars drive the frontage road as well, but they did not locate R3. V7 stated she and V17 (CNA) went out again. It was getting lighter outside and at approximately 6:38 AM, we located R3 behind the shrub at the end of the tree line in the soccer field. V7 confirmed she called back to the facility at this time and V25 (LPN) called 911. When asked about camera footage, V7 also stated she did not think the cameras recorded and thinks it's just a live stream monitor system located at the nursing station. On 01/25/22 at 10:12 AM, V27 (Maintenance Director) stated after R3 eloped on 01/22/22 he came to the facility to check all the door alarms leading to the outside. V27 stated they were all in working order. He explained they are locked but if you press on the door in any spot, in 4 seconds the alarm will sound if not disarmed by inputting the code. V27 continued to state that after 15 seconds the door automatically releases and opens. This is for fire safety. The alarm is a loud beep on the door that is constant until the code is reset. When asked about the cameras in the facility, he stated they are just a live stream monitor and do not record footage. On 01/25/22 at 10:33 AM, V28 (Dietary Aide) stated he arrived for his shift at the facility on 01/22/22 about 5:15 AM. At around 6:15 AM, he stated V23 (CNA) came back and told me the head count was just done and they were missing R3 and asked me if I could help search. V28 stated, It was still really dark out, so I got my flashlight on my phone on. I walked the woods and in the soccer field close to the woods. I went around back to the dumpsters and all around the main road, and by the time I got to the helipad in front out of our facility, I heard yelling and saw staff at the soccer field, I ran over. Someone was coming out of the facility with blankets. We ran over and covered R3 up. We talked to him and he was responding but agitated. I heard him say No a couple of times. 911 had already been called by the time I joined them. The police arrived first, then the ambulance arrived around 6:50 AM. I left the facility out our side door directly leading outside, so I can't confirm if any alarms were going off in the facility at 6:15 AM. After everything was said and done, I know maintenance came in and checked all the door alarms. On 01/26/22 at 11:51 AM, V15 (Power of Attorney - POA) stated she does not believe the 15-minute checks work, the facility tried to minimize reporting the time R3 was outside .she is not happy with the incident of him getting outside or the fact he continuously removes his elopement monitor. She stated that one-on-one would be good, but that is not happening. They need to be accountable and provide the services and protection advertised for their residents. The facility provided hand-written staff statements as part of R3's incident investigation as follows - A statement dated 01/22/22 at 9:00 AM by V1 (Administrator) documents - Called V16 (CNA) .when asked the last time she physically laid eyes on (R3) she said about 4:30 AM. A statement by V16 (CNA) with no date or time documents in part - . last bed check I emptied (urinal from resident next door to R3) . I heard bathroom door open, and light come on. Peeked into (R3's) room. He was not in chair. That was about 4:30 AM. I went on and did my other bed checks . There is no confirmation in this note stating whether V16 did or did not see R3 at this time. On 01/26/22 at 11:14 AM, this surveyor attempted to contact V16 via cell phone for clarification of her statement taken by V1 versus her own written statement. The phone number provided for V16 went to voicemail with a mailbox that had not been set up to accept messages. V21's (TNA) statement dated 01/22/22 does not document the last time she saw R3 in the facility. V17's (CNA) statement dated 01/22/22 does not document the last time she saw R3 in the facility. V20's (CNA) statement dated 01/22/22 documents she worked the 10:00 PM to 6:00 AM shift on 01/21/22 and that R3 slept most of the night. No alarms went off while she was there. V6's (RN) statement documents at 2:30 AM, R3 and other residents were at the nursing station with her. At that time, she mentioned it was time for bed, asked R3 if he needed help and he said no. V6 observed R3 walking to his room .V6 continues to write that at 3:15 AM she approached R3's door for a dressing change, V16 opened R3's door and saw him asleep in his recliner. V6 did not want to disturb him, so she went to the next resident. The facility was unable to provide documentation and staff were unable to verbally confirm R3 was physically seen in the facility after 3:15 AM on 01/22/22. R3's January 2022 POS (Physician's Order Sheet) documents an order for elopement monitor dated 07/21/21 for right ankle with a change dated 11/03/21 to apply to right wrist. R3's progress notes dated 10/30/21 documents, Wander-guard is not on resident at this time. Unable to find . 15-minute safety checks remain in place. R3's record reflects a consistent pattern of R3 removing his electronic elopement bracelet from the note above to the morning of 01/22/22 when he eloped. R3's 15-minute Check Log dated 01/22/22 was noted to be blank after 3:15 AM, which is the last documented time anyone can confirm R3 was physically seen in the facility. In fact, the log is blank from midnight until 6:00 PM. However, a staff member whose shift did not begin until 6:00 PM the evening of 01/22/22 had pre-filled R3's 15-minute safety check log for her shift by signing her initials. It is confirmed by medical personnel documentation, interviews with law enforcement professionals, and staff interviews R3 was transported via ambulance to the emergency at 6:49 AM on 01/22/22. On 1/27/22 at 12:40 PM, V30 (Primary Care Physician - PCP) stated the facility did call him about R3's elopement on the morning of 01/22/22 and he informed staff to absolutely send R3 to the ER. V30 further stated he instructed the facility staff that if it was an emergent situation to first call 911, then call him, but confirmed he did not ask if they had already called 911. V30 stated that knowing R3 and the cold conditions on the morning of 01/22/22, V30 would not dispute the report of R3 being outside for at least an hour. V30 stated R3 had a heart monitor placed at the hospital prior to his return to the facility on [DATE]. V30 stated cold weather can certainly cause a Cardiac event, which is what R3 experienced on 01/22/22. V30 stated R3 is demented and cannot make good decisions. When told R3 will not leave his elopement monitor on, V30 stated R3 is on 15-minute safety checks. When told that the 15-minute visual checks had not been signed off as being done prior to R3's elopement on 01/22/22, the facility could not provide concrete documentation R3 was seen in the facility after 3:15 AM, and that a staff member who was scheduled to begin their shift later that evening on 01/22/22 had pre-filled her portion of documentation on R3's 15-minute visual check sheet, V30 stated, Oh, that is not good. I will have to speak with them about that. A facility policy titled, Wandering and Elopement Assessment and Prevention dated 11/15/15 and revised on 12/9/21 documents in part - Definition: Elopement is defined as a resident who departs the health care facility or enters a non-resident area within the facility, unsupervised and undetected. Procedure: Facility uses a multi-faceted approach to prevent elopement: 1. Environmental controls, such as but not limited to: a. Alarmed doors b. Alarmed bracelets (Wander Guard) c. Camera surveillance On 01/26/22 at 10:02 AM via cell phone, V5 (Regional Director of Operations) confirmed the facility cameras do not record. The Immediate Jeopardy that began on 01/22/22 was removed on 01/26/22 when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: Immediate Changes to Facility System: 1. Elopement policy and procedure was reviewed by administrator on 1/22/22. No changes to the policy were necessary. 2. Task reminder was added to Point Click Care for 15-minute checks on 1/26/22 by facility clinical director. 3. Double doors between nurses' station and dining room are being closed at 7 pm in order to provide extra measures of protection for those exit seeking residents. This safety measure was implemented on 1/25/22. 4. Education on elopement policy and procedure completed by all staff. The in-service began on 1/22/22 and was completed by all staff working at that time. In-service continued until 1/27/22 when final employee received in-service prior to working their assigned shift. Education was provided by administrator and DON. 5. 2-way radio communication in place to communicate when door alarms sound was implemented on 1/22/22. 6. Door codes were removed from being posted by doors on 1/26/22 by maintenance employee. 7. Door alarms were checked that morning, 1/22/22 and were working properly and continue to be checked weekly by maintenance staff. 8. Wander guards will be checked daily by nursing staff. If a wander guard is found to not be working, a new device will be placed on the resident. 9. Care plans were updated/audited on 1/24/22 by MDS Coordinator to reflect those at risk for elopement and will be updated quarterly and when deemed necessary based on need. 10. In-serviced nursing staff on proper documentation criteria. Was completed by DON on 1-25-22. Educational Plan: 1. Elopement drills will be completed monthly at random times for 3 months. 2. New admits will be assessed for elopement risk. 3. The administrator/designee will monitor compliance of the education plan weekly for 3 months.

Based on observation, interviews, and record reviews the facility failed to prevent and/or contain Covid-19 when the facility failed to 1. Ensure all staff who have a known exposure to Covid-19 are quarantined and tested per the facility policies and current CDC (Center for Disease Control) guidelines, 2. Ensure residents who exhibit respiratory symptoms are tested for Covid-19 per facility policies and current CDC guidelines, 3. Ensure disinfectant used to treat non-porous surfaces for Covid-19 are utilized per manufacturer guidelines for effective disinfection, 4. Ensure routine testing of staff is performed timely based on county positivity rates. 5. Ensure staff wear required PPE (Personal Protective Equipment) and discard contaminated PPE as required after use. 6. Ensure contaminated trash on the Covid-19 unit is disposed of per current standards of practice. 7. Ensure separate designated areas are available to don/doff and store PPE along with other supplies needed to prevent cross contamination. 8. Ensure asymptomatic residents' rooms are not located on the yellow unit designated for Covid-19 symptomatic residents. These systemic failures resulted in 2 (R19 and R21) residents testing positive for Covid-19. These failures have the potential to affect all 51 residents residing at the facility and result in an Immediate Jeopardy (IJ) to their health and safety. The IJ was identified to have begun on 7/23/2021 when the facility was notified V6 (CNA- Certified Nursing Assistant) had an exposure to Covid-19 and allowed V6 to continue working and providing care to all residents on 7/23/21, 7/26/2021, 7/28/2021, and 7/29/2021. The facility was notified of the Immediate Jeopardy on 8/6/2021 at 3:45 PM. The Immediate Jeopardy that began on 7/23/2021 was not removed at the time of the survey exit as a result of the facility failing to do the following: 1) Ensure staff utilize appropriate PPE per current standards of practice throughout the building, including the Covid-19 unit and the quarantine/symptomatic unit (i.e., yellow unit) for residents who display Covid-19 symptoms, during a facility outbreak of Covid-19. 2) Failed to ensure PPE was removed and/or sanitized upon exiting droplet/contact isolation rooms, 3) Failed to ensure a separate clean/dirty area was available for donning and doffing PPE when entering and exiting the Covid-19 unit 4) Failed to ensure contaminated trash from the Covid-19 and yellow unit is discarded according to current standards of practice. 5) Failed to redirect an unmasked quarantined resident with new onset of fever back to their room when they were observed by staff in the hallway. 6) Failed to ensure residents not displaying Covid-19 symptoms did not reside on the yellow unit for residents displaying Covid-19 symptoms. Findings Include: 1. The facility Coronavirus disease policy dated 6/7/2021 documents, The facility follows current guidelines and recommendations for managing Coronavirus in the facility. The policy documents under Visitor/Employee Screenings: Every individual wanting to enter the facility, regardless of reason, (including residents, staff, visitors, outside healthcare workers, vendors, etc.) and employees upon reporting to work, regardless of whether they have had a known [CONDITION(S)]-CoV-2 exposure, are to be screened at the entrance to the facility by a designated person by taking their temperature, assessing for Covid-19 like symptoms, confirming no diagnoses of Covid-19 before completing the appropriate period of isolation, confirming those who have had close contact with someone with Covid-19 infections in the prior 14 days (regardless of the visitor's vaccinations status), prior to entry. Under exposure to Covid-19 the policy documents, .Asymptomatic HCP (healthcare professionals) NOT FULLY VACCINATED who have had exposure to a confirmed or suspected case of Covid-19, may return to work after completing a 14-day quarantine without testing if no symptoms have been reported during the quarantine period . The facility Covid-19 staff and visitor screen log documents V6 (CNA/Certified Nursing Assistant) was screened on 7/22, 7/23, 7/26, 7/28, and 7/29/2021 for the 2-10 pm shift with an (N) documented under each of the following questions: Do you have any of the following symptoms; fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache? Do you have new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? Have you had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? Have you had close contact with someone with Covid-19 infection in the prior 14 days (applies only to visitors) regardless of vaccination status? This indicates V6 answered no to all of the screening questions including the question regarding exposure to someone with Covid-19. On 8/6/2021 at 10:02 AM, when asked why the question on the facility Covid-19 staff and visitor screening log regarding close contact within someone with Covid-19 in the prior 14 days documents it applies only to visitors V1 stated, That is the one (log) they (their corporate office) sent. It should apply to everyone, not just visitors. On 8/8/2021 at 11:27 AM, after reviewing the current guidelines and facility policy, V1 (Administrator) stated she agreed all staff and visitors should be screened for exposure to Covid-19 and should follow the current guidelines of quarantine if they have been exposed to someone with a suspected or confirmed case of Covid-19. On 7/28/2021 at 2:20 PM, V6 stated she has had one dose of the Covid-19 vaccine and she is due to get the second dose next week. V6 stated she was told she had been exposed to Covid-19, but she did not have any symptoms. V6 stated she reported the exposure to V1 (Administrator) on 7/23/2021 and was told she could continue working since she did not have any symptoms. When asked if she had been screened prior to working, V6 stated she was. When asked why she had marked (N) indicating no exposure to anyone with Covid-19, V6 stated she was not paying attention when she filled out the screening log. The facility Certified Nursing Assistant/CNA Schedule for the week of July 18, 2021 documents V6 (CNA) was scheduled to work evening shift (2-10 PM) on 7/19, 7/20, 7/22, and 7/23/2021. The CNA schedule for the week of July 25,2021 documents V6 was scheduled to work on 7/26, 7/28, 7/29, and 7/30/2021. On 7/28/2021 at 11:00 AM, V3 (Assistant Director of Nurses/ADON) stated V6 had worked on 7/23, 7/26, 7/28, and 7/29/2021. On 7/28/2021 at 11:00 AM, V1 (Administrator) stated if staff answered yes to the screening question asking if they have been exposed to someone who tested positive for Covid-19, and they had symptoms, they would be sent home and recommended to get tested . V1 stated she was not sure of the facility protocol if the individual did not have symptoms. V1 stated she did have one staff member (V6/CNA) who reported she had been told she was in contact with a person (V15-unidentified family member) who tested positive for Covid-19. V1 stated that V6 reported the contact with V15 (unidentified family member who tested positive for Covid-19) on 7/23/2021. V1 stated V6 was asymptomatic and worked on 7/23/2021. V1 stated V6 then had 7/24 and 7/25/2021 off but worked again on Monday, 7/26/2021. V1 stated she (V1) did not follow facility policy because she had forgotten what it said. The Shift Duty List and Daily Shower sheets document V6 had the following assignments 7/23/2021 pass ice (200/300) 7/26/2021 V/S's (vital signs) and dentures (200/300), 7/28/21 ice (100/300) and hall supper trays, 7/29/2021 V/S's and dentures (200/300) and hall supper trays. This indicates V6 was in contact with all 51 residents residing at the facility after her exposure to Covid-19. On 7/29/2021 at 2:45 PM, V13 (CNA) stated all the CNA's typically work together. V13 stated there is an assignment sheet that documents what area and duties you are assigned for that shift. V13 stated, as noted on the sheet titled, shift duty list and daily shower sheet dated 7/23/2021, V6 had ice duty with V14 (CNA) which means they both take ice to all of the residents in the facility. On 7/29/2021 at 3:10 PM, V6 (CNA) stated she was with V15 (unidentified family member who tested positive for Covid-19) on 7/21/2021. V6 stated the last time she was tested for Covid-19 was at work on 7/19/2021 and that test result was negative. V6 stated she had not been tested since her exposure to V15. (There is no facility documentation of V6 receiving a Covid-19 test on 7/19/2021). On 7/29/2021 at 3:15 PM, V2 (DON/Director of Nurses) stated she was not aware V6 had been exposed to V15 (unidentified family member) until it was brought to her attention by the surveyor on 7/28/2021. V2 stated V6 either had to be tested or she should leave the facility. V2 stated she was going to test V6 who was currently working at the facility providing care to residents. On 7/29/2021 at 3:20 PM, V2 (DON) stated they were going to do a rapid test on V6 (CNA). On 7/29/2021 at 3:38 PM, V1 (Administrator) stated they had the results of V6's rapid Covid-19 test. V1 stated the second line (the line that indicates if the test result is positive) was faintly present so she wasn't 100% certain it was a positive result. On 7/29/2021 at 4:01 PM, V1 (Administrator) stated they did a second rapid Covid-19 test on V6 and the line that indicates a positive test was still there, however it was still light (or faint). V1 stated since that line was present, they were going to send V6 to get a rapid PCR (Polymerase Chain Reaction) test done and would tell her to leave the facility now to have that done. V6's local hospital lab results dated 7/30/2021 documents a positive Novel Coronavirus [CONDITION(S)]-CoV-2 test. On 7/30/2021 at 10:25 AM, V1 (Administrator) confirmed V6 had reported to the facility on [DATE] (prior to starting her 2-10 PM shift) she had an exposure to V15 (unidentified family member) who told V6 they had tested positive for Covid-19. V1 stated V6 reported she had been with V15 two days prior to V15 testing positive. V1 confirmed V6 had worked at the facility after the exposure to V15. When asked what the facility policy stated regarding working after known exposures, V1 stated the policy said if they needed them and they were asymptomatic they could work. V1 stated she told V6 that if she became symptomatic, she needed to leave work. V1 stated staff were currently wearing a surgical mask and eye protection when providing care to all residents. V1 stated V6 had one dose of a two dose Covid-19 vaccine and she believed they had nine residents currently not vaccinated. When asked if they had implemented anything new based on the positive rapid test result of V6, V1 stated, they had not because they consider that a screening tool. V1 stated if V6's lab test result shows a positive result then they would implement full PPE (personal protective equipment), and nasal swab testing of all staff. When asked about residents V1 stated, I think they would be tested . On 8/6/2021 at 3:45 PM, V1 (Administrator) and V39 (Regional Administrator) stated they had allowed V6 (CNA) to work after exposure to Covid-19 because she (V6) was asymptomatic, and they were in a staffing crisis. V1 and V39 stated they had followed the current guidelines and made attempts to find alternate options. V1 stated she would send this surveyor all of the steps they had taken in an email. On 8/6/2021 at 5:40 PM, this surveyor received an email from V39 (Regional Administrator) that documented on 7/23/2021, V2 called all facility staff and no staff were available to work. V2 called a sister facility and they had no staff available to work and they were unable to contact the staffing agency for assistance. On 8/10/2021 at 11:05 AM, V1 (Administrator) stated they had not attempted to call the staffing agency to see if they had anyone to cover shifts because they (staffing agency) have never provided staff for the facility when they have called them in the past. V1 stated when the facility calls the staffing agency, they are told they don't have anyone for the area the facility is located in. When asked if they had made any attempts to cover V6's shift on 7/26, 7/28, and 7/29/2021, V1 stated, No. The facility daily census dated 7/28/2021 documents the current facility census as 51 residents. The facility Weekly Covid-19 Vaccination summary with a reporting date of 5/31/2021 documents R7-R11 did not receive the Covid-19 vaccine. R12 is documented as receiving one dose of a two-dose vaccine (Pfizer), and as refusing the second dose. On 7/30/2021 at 11:56 AM, V2 confirmed R7-R11 had not received a Covid-19 vaccine, and R12 was not fully vaccinated. This indicates 7 of 51 residents residing at the facility have not been fully vaccinated for Covid-19. R19's facility face sheet dated 8/10/2021 documents R19 was admitted to the facility on [DATE] with diagnoses that include dysphagia, [CONDITION(S)] disease, acute kidney failure, and chronic obstructive pulmonary disease. R19's facility progress notes dated 8/5/2021 document R19 was transferred to a regional hospital for evaluation after a fall. R19's regional hospital lab results dated 8/7/2021 document a positive Covid-19 test result. R21's facility face sheet dated 8/10/2021 documents R21 was admitted to the facility on [DATE] with diagnoses that include diabetes, hypertension, heart disease, and history of heart attack. R21's facility progress notes dated 8/4/2021 document R21 was transferred to the local hospital for evaluation of a low hemoglobin and was admitted to the local hospital for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility Covid-19 assessment dated [DATE] documents under testing of staff and residents with Covid-19 symptoms or signs, Residents who have signs or symptoms of Covid-19 must be tested . While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions (TBP) in accordance with facility policy. Once test results are obtained, the facility must take the appropriate actions based on the results. Signs and symptoms of Covid-19 listed in the facility policy under Appendix C include fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. A. R5's facility face sheet dated 8/5/2021 documents R5 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, [CONDITION(S)], [CONDITION(S)], cerebral infarct, hypertension, and diabetes. R5's progress notes document on 6/14/2021 R5 had a cough, oxygen saturation of 75%, diminished lung sounds, and coughing up light yellow/green mucous. After oxygen was administered R5's oxygen saturation rebounded to 94%. R5's progress notes document a chest x-ray was ordered and an oral antibiotic was started. R5's chest x-ray results dated 6/14/2021 document no acute disease under impression. R5's medical record does not document Covid-19 testing was done. On 8/4/2021 at 11:10 AM V1 (Administrator) stated they did not test R5 for Covid-19 when she developed symptoms on 6/14/2021 because she had a chest x-ray that showed no acute disease process. B. R6's facility face sheet dated 8/5/2021 documents R6 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)], muscle weakness, [CONDITION(S)], Alzheimer's disease, chronic obstructive pulmonary disease, non-Hodgkin's [CONDITION(S)], and [CONDITION(S)]. R6's facility progress notes document on 7/11/2021 R6 was shaking, not acting like herself, complaining of a headache, with an oxygen saturation of 86%, as needed breathing treatment was administered and oxygen started. R6's oxygen saturation rebounded to 96%. R6 was placed on contact/droplet isolation related to the symptoms. On 7/12/2021, R6's progress notes document R6's physician was notified of an elevated temperature, shortness of breath, and increased confusion. R6's physician ordered a chest x-ray and lab work. R6 had an oxygen saturation of 64% on room air and was reminded to wear oxygen, with oxygen saturation rebounding to 80% after 30 minutes with oxygen. On 7/13/2021, R6's progress notes document R6's physician called and ordered an oral antibiotic related to an elevated white blood count. R6's lab results dated 7/12/2021 document an elevated white blood count and a urinary tract infection. R6's chest x-ray results received on 7/12/2021 document no acute respiratory disease. R6's medical record does not document a Covid-19 test was done until 7/28/2021 when R6's physician ordered a rapid test in house related to increased shortness of breath. The rapid Covid-19 test was documented as being negative for Covid-19. On 8/4/2021 at 11:10 AM, V1 (Administrator) stated R6 was not tested for Covid-19 when she developed symptoms on 7/11/2021 because she had a chest x-ray done that showed no acute disease process. On 8/4/2021 at 1:25 PM, V1 (Administrator) confirmed R5 and R6 did not have Covid-19 testing done when they developed symptoms. V1 stated they ruled out Covid-19 because they had normal chest x-rays and the physician put on his progress note R6 had [CONDITION(S)] (chronic obstructive pulmonary disease) and their temperatures went down. V1 stated their policy says if they can determine the symptoms are related to another disease process, they do not have to test for Covid-19. When asked what disease process a normal chest x-ray determines, V1 did not have a response. When asked if there was new guidance related to a negative chest x-ray being a test for Covid-19, V1 stated she would send me the guidance when she found it. The facility did not provide guidance related to a chest x-ray being a test for Covid-19 throughout the survey process. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html dated 1/7/2021 documents .At least daily, take the temperature of all residents and ask them if they have any COVID-19 symptoms. Perform [CONDITION(S)] testing of any resident who has signs or symptoms of COVID-19. Clinicians should use their judgment to determine if a resident has signs or symptoms consistent with COVID-19 and whether the resident should be tested . Individuals with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Some may present with only mild symptoms or other less common symptoms . 3. On 7/30/2021 at 11:34 AM, V16 (Housekeeper) was observed cleaning/disinfecting R14's room. V16 sprayed the bathroom with peroxide multipurpose cleaner and then sprayed the bedside table. V16 immediately wiped the bedside table with a dry rag. V16 confirmed the rag was dry and that the table was dry. When asked about the contact time for the peroxide multipurpose cleaner V16 stated, I am not sure. V9 (Housekeeping Supervisor) would know. On 8/3/2021 at 12:24 PM, V9 (Housekeeping Supervisor) stated the contact time for the peroxide multipurpose cleaner was thirty seconds. V9 stated V16 should have sprayed the table down and waited thirty seconds before wiping it with a dry rag. On 8/10/21 at 11:37 AM, V7 (Housekeeping) was asked to provide a disinfecting demonstration. V7 stated she was recently trained by V9 regarding use of the sanitizing chemicals. V7 states the facility uses a peroxide based disinfectant and it has to sit 4 minutes on the surface for disinfection. V7 states the facility uses a blue solution that you put in the toilets and let sit for 4 minutes, and also a peroxide solution on the floors, which sits for 4 minutes. V7 displays to this surveyor the solution used on the floors which is a yellow label noting peroxide disinfectant. V7 is observed starting to clean in what is labeled as R20's room, but R20 is not present in the room during this time. V7 starts by spraying the peroxide disinfectant onto the bedside table, letting it set for 7 seconds as evidence by observing a watch, and wiping the solution with a dry rag, creating a dry surface. V7 was asked at this time how long she needed to let the solution set to ensure disinfection in which she responded, 4 minutes. V7 was asked how long she let the solution set, in which she responded, Not 4 minutes, sorry. V7 was then observed spraying the top of the tv cabinet with the same solution, allowing the solution to sit for 12 seconds, then wiping it with the same rag. V7 continued this process by spraying the front of the tv cabinet, allowing a 4 second contact time before wiping. V7 confirmed she cleans all over the building. V7 is observed wearing a surgical mask and face shield at this time. V7 stated when on the Covid-19 unit, staff must wear a gown, booties, gloves, face shield, and the mask that is fitted around your mouth and hard to breath in. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-homes-facility-wide-testing.html dated 3/29/2021 documents, .Use an EPA-registered disinfectant from List N:disinfectants for coronavirus (COVID-19)external icon on the EPA website to disinfect surfaces that might be contaminated with [CONDITION(S)]-CoV-2. Ensure HCP are appropriately trained on its use and follow the manufacturer's instructions for all cleaning and disinfection products (e.g., concentration, application method, and contact time) . https://www.ecolab.com/offerings/all-purpose-cleaning/peroxide-multi-surface-cleaner-and-disinfectant documents .This EPA-registered product disinfects . kills [CONDITION(S)]-CoV-2 in 30 seconds . 4. The Facility Assessment Covid-19 dated 7/29/2021 documents under Non- Outbreak Scenario-Routine testing of Staff, In the event the facility has had no Covid-19 in the facility (employee or resident) .The facility must establish a testing schedule based on metrics in the region and extent of the virus in the community. Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . Table 1 labeled Routine testing intervals vary by community covid-19 activity level documents if the community activity level is low (less than 5%) then minimum testing frequency for all staff is once monthly. If the community activity level is medium (5-10%) then the frequency for testing all staff is once weekly. If the community activity level is high (greater than 10%) then the frequency for testing all staff is twice weekly. The Facility Assessment Covid-19 dated 7/29/2021 documents, The facility should begin testing all staff at the frequency prescribed in Table 1 based on the county positivity rate reported in the past week. Facility should monitor their county positivity rate every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table above. If the county positivity rate increases to a higher level of activity, the facility should begin testing staff at the frequency shown in the table above as soon as the criteria for the higher activity are met. If the county positivity rate decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the county positivity rate has remained at the lower activity level for at least two weeks before reducing testing frequency. The facility provided county positivity rate log dated 7/16/2021 documents the county test positivity 7-day rolling average increased from 1.9% on 7/1/2021 to 7.1 on 7/2/2021, which indicates the facility should have been completing routine weekly testing for Covid-19 for all staff. The rate increased from 7.5% on 7/6/2021 to 11.1% on 7/7/2021, which indicates the facility should have been completing twice weekly routine testing. On 7/13/2021, the rate dropped to 9.5% and remained between 6.4% and 9.5% until 7/19/202, when it then increased to 11.9% and has stayed above 10%. This indicates the facility should have been completing routine staff testing for Covid-19 twice weekly from on or around 7/7/2021. The undated facility test log documents staff testing for Covid-19 was completed on 6/1, 6/9, and 7/8/2021. On 6/1/2021, the log documents a blank line next to test performed and test results for 6 (V17, V18, and V20-V23) of the 48 staff listed. On 6/9/2021, the log documents a blank line next to test performed and test results for 6 (V1, V7, and V23-V26) of the 48 staff listed. On 7/8/2021, the log documents a blank line next to test performed and test results for 15 (V6, V13, V20, V23-V26, and V28-V35) of the 48 staff listed on the log. V6's local hospital lab results dated 7/30/2021 document V6 tested positive for Covid-19. On 7/30/2021 at 10:25 AM, V1 (Administrator) stated the county positivity rate was 10.3 and had been above 10% for the past two weeks. When asked how often they were performing routine testing for Covid-19 for all staff, V1 stated they were going to start testing weekly on Monday of next week (8/2/2021). V1 stated the current guidance is to test weekly if the county positivity rate is above 10% and she guessed she just missed last week's testing. On 8/3/2021, this surveyor reviewed the county positivity rates with V1 and CDC guidelines on routine staff testing in LTC (long term care) facilities. V1 stated she was thinking they tested all staff weekly if the rate was greater than 10%. On 8/4/2021 at 11:10 AM, V1 confirmed the last date routine staff testing was performed was 7/8/2021. V1 stated if the line next to the staff members name was blank on the log then that means they did not get tested that week. This indicates 27 staff members did not complete routine staff testing on the dates listed on the log (6/1, 6/9 and 7/8/2021), and routine staff testing was not performed by the facility at the frequency established by the current guidelines and the facility policy. 5. Review of a table titled Table 2: Recommended Personal Protective Equipment (PPE) for Covid-19 in Long-Term Care Facilities, Moderate to Substantial Community Transmission of Covid-19 (5% or greater test positivity) dated 5/5/21 and found at https://www.dph.illinois.gov/sites/default/files/LTC%20PPE%20Use%20COVID-19%20Mod%20to%20Substantial%20Transmission%205.5.pdf documents that for a moderate to substantial transmission outbreak, PPE to be worn for the care of the resident, including for residents not in transmission based precautions for any reason, an N95 respirator or facemask only if N95 is unavailable, eye protection, and gown/glove use per standard precautions is required. The facility Coronavirus Disease (Covid-19) policy dated 6/7/2021 documents under Core Principles of Covid-19 Infection Prevention .Require face covering or mask (covering mouth and nose), in accordance with CDC guidance and FDA guidance. Under Outbreak procedures the policy documents, In the event of an outbreak, (defined as a single-facility-onset Covid-19 infection in a resident or a single new case of facility-associated Covid-19 infection in a staff member. Healthcare personnel should wear full PPE (gloves, gown, surgical mask, eye protection) for the care of all residents irrespective of Covid-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facilities with re-usable N95 or equivalent masks should make these masks available to all HCP's (healthcare personnel) who are fit tested when caring for residents. If additional masks are needed, when the facility maintains a par level of at least 250 N95 or equivalent masks, then an N95/equivalent should be used at all times by fit-tested staff only. If stock is below 250, N95 should be used for aerosol generating procedures only. On 7/30/2021 at 12:12 PM, V1 (Administrator) stated on 7/19/21 the facility county positivity rate was 9.8% and on 7/30/21 the facility county positivity rate was 10.3%. On 8/12/21 at 10:33 AM, V1 (Administrator) stated the current Covid-19 positivity rate for White County is 17.3%. On 7/29/2021 V6's rapid Covid-19 test done at the facility showed a faint pink line indicating a positive test result. V6's local hospital lab results dated 7/30/2021 documents a positive Novel Coronavirus [CONDITION(S)]-CPV-2 test. On 8/10/2021 at 12:06 PM, V2 (DON/Director of Nurses) stated two staff members (V20 and V35) had tested positive for Covid-19 on 8/8/2021. On 8/10/21 at 11:09 AM, V39 (Regional Administrator) states that the facility currently has one positive resident case of Covid-19, R19, who tested positive at the hospital after being sent out for evaluation following a fall. V39 states the facility has a designated Covid-19 area within the facility that R19 is currently residing on. A. On 7/30/2021 at 11:20 AM, V20 (CNA/Certified Nursing Assistant) stated all staff wear a surgical mask and face shield while providing care to the residents. V20 was observed wearing a surgical mask and face shield, as were all other staff observed working during this survey time on 7/30/2021. On 7/30/2021 at 11:39 AM, V25 (LPN/Licensed Practical Nurse) stated they have enough PPE. On 8/3/2021 at 11:01 AM, V2 (DON) stated they have enough PPE and she counts it three times weekly. V2 stated all staff are currently wearing N95's and eye protection at all times. On 8/6/2021 at 4:00 PM, this surveyor walked through the facility with V1 (Administrator) present. V1 was wearing a surgical mask and a face shield. V1 stated she was not able to wear an N95 mask due to medical reasons. V42 (CNA) was observed wearing a face shield and a surgical mask while providing care to the residents on the 100 hall. When asked why she was wearing a surgical mask instead of an N95, V42 stated she had been told she did not have to wear an N95. V1 (Administrator) then stated they can either wear a surgical mask or an N95. V1 confirmed the facility remained in outbreak status at this time and that R21 had tested positive on 8/4/2021. All other staff observed during the walk through were wearing an N95 mask. On 8/10/21 at 11:10 AM, V39 (Regional Administrator), V2 (Director of Nursing/DON), and V3 (Assistant Director of Nursing/ADON) were observed wearing a surgical mask along with eye protection while in the facility. On 8/10/21 at 11:19 AM, V2 (DON) stated staff are expected to wear eye protection, and surgical mask within the facility if not on the Covid-19 positive unit. V2 states they designate staff to work the Covid-19 unit, and those staff are expected to wear eye protection, an N95 grade face mask, and gown while on the positive unit. On 8/10/2021 at 11:52 AM, V11 (CNA) was observed transporting residents to the dining room wearing a surgical mask and face shield. On 8/10/21 at 12:13 PM, V10 (LPN) states that since last week she has been educated on Covid-19 regarding wearing eye protection and a mask at all times. V10 is observed wearing a surgical mask and face shield during this interview. V10 states she does not work on the Covid-19 unit. V10 states you can wear a surgical mask anywhere and in any room in the facility, except on the Covid-19 unit, in which she states then an N95 grade mask is required. On 8/12/21 at 9:43 AM, V7 (Housekeeping) was observed wearing a surgical mask and face shield within the facility. On 8/12/2021 at 10:42 AM, V43 (Regional Nurse) was observed following this surveyor onto the Covid-19 unit. V43 was wearing a gown, gloves, face shield, and surgical mask. When asked if she had an N95 on (under the surgical mask) V43 stated, No, I can't wear an N95. Is that a problem? This surveyor referred V43 to the current CDC guidance to determine what PPE should be worn. On 8/10/2021 at 11:05 AM, when asked if staff had been fit tested for N95's, V1 (Administrator) stated they had, but there may be one or two new staff that had not been tested [TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent resident to resident abuse and provide protection from a resident with a history of sexually aggressive behavior for 7 of 7 residents (R3, R4, R5, R6, R7, R10, and R11) reviewed for abuse in the sample of 14. This failure resulted in R3, R4, R5, R6, R7, and R10 having feelings of anxiousness, loss of sleep, and fearful they will be hurt in their home. This failure resulted in an Immediate Jeopardy which was identified to have begun on 6/9/19, when the facility failed to investigate potential allegations of resident to resident sexual abuse and failed to implement preventative measures/care plan interventions to ensure continued resident safety. Facility Administrator notified of immediate jeopardy on (MONTH) 4, 2019. While the Immediate Jeopardy was removed on 9/4/19 the facility remains out of compliance at Severity Level 2 as additional time is needed to monitor the effectiveness of the policy/procedure changes and the staff training. Findings include: R1's EMR (Electronic Medical Record) documents that he is [AGE] years old with an admission date of [DATE]. [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE], documents that R1's cognition is severely impaired. R1's MDS documents that R1 has Hallucinations and Delusions, is able to walk in the room and corridor, and self-transfer without assist. A Psychiatric History document from a local Mental Health Center, provided by the facility dated 7/26/18, documents the following: In the past he (R1) has a history of becoming violent and assaulting people. He (R1) has a history of being sexually inappropriate, touching and grabbing females. He also has made inappropriate sexual comments. Psychiatric treatment plan: [REDACTED]. R1's Pre-Admission Screening documents obtained by surveyor on 8/22/19 from V28 (Case Coordinator, local mental health agency) and dated 8/2/18, documents that this Client (R1) has a long history of mental illness with current [DIAGNOSES REDACTED]. One admission occurred continuously from 1982 - 2003. R1 has spent most of his adult life in inpatient Mental Health Centers. Records indicate extensive history of aggression from verbal altercations to physical and sexual violence. On 8/19/19 at 9:00AM, R1 was observed in his room coloring and watching TV unattended. On 8/19/19 at 9:30AM, R1 was observed in his room writing on paper. This surveyor approached R1 and he requested surveyor to shut the door to his room, sit on his bed next to him, and hold his hand. When surveyor declined and began to talk to R1, he ran out of the room and went to the dining room. R1 continued to watch surveyor for the next 30 minutes as R1 sat unattended in the dining room. On 8/19/19 at 11:00AM, R1 was seen in the social service office going through a purse, unattended for approximately 15 minutes. On 8/22/19 at 2:00PM, surveyor presented R1's Pre-Admission Screening documents, including the Level 1 Summary, Assessment Summary Information, and Level 2 Determination and Disposition, to V1 (Administrator), V7 (Social Services Director) and V16 (Administrator for Sister Facility). V7 stated that she did not obtain this information when the resident was admitted . A Progress Note dated 8/22/19 documents R1 was picked up via ambulance and taken to a local hospital. R1's Progress Note dated 8/23/19 at 8:07AM, and documented by V7 (Social Service Director) notes the following: R1 was sent to an area hospital, threatening to kill staff, unable to redirect and behaviors kept escalating. 1. R1's Progress Notes dated 7/21/19, document the following: (R1) went into a female resident's room to use her bathroom leaving the door open. The female resident stated that he came out of the bathroom and headed toward her sitting on her bed informing her that she was his wife. (R1) then placed his Left hand on her neck and right hand on her chest and pushed her down on the bed attempting to kiss her. Female resident told him to get out that his wife is down the street as she pushed him away he attempted to swing but did not hit her. Social services, DON and MD notified of this situation. On 8/19/19 at 11:00 AM, V1 (Administrator) stated the other resident in R1's progress notes dated 7/21/19 was identified as R5. On 8/20/19 at 1:15PM, with regard to the 7/21/19 progress note above, R5 stated that she was sitting on her bed, and R1 came out of her bathroom, pushed her back onto the bed and tried to kiss her. R5 said she yelled for the nurse. R5 stated that R1 thinks she is his wife. R5 stated sometimes R1 just comes into her room and stares at her. R5 added that R1 makes her feel uncomfortable, and that she is scared he will hurt her. On 8/20/19 at 3:00PM, V2 (Director of Nurses) stated that the 7/21/19 incident involving R1 and R5 was not investigated, and the police were not notified. On 8/27/19 at 9:45AM, R5 stated that she was so glad R1 was gone and hopes he does not come back. R5 then started to cry, making it difficult for her to talk. She stated she was so afraid he would hit her, try to have sex, or sleep with her. 2. R1's Progress Note dated 6/9/19 at 5:44AM, documents the following: Nurse opened the door to (R1's) room to find res standing in the dark by the dresser with no pants on. The female res. that occupies that room was in bed. When asked to leave the room (R1) started yelling 'she's my wife, close the door.' (R1) was redirected to his room. It was explained to res that it was not his wife and he could not be in her room. On 8/22/19 at 10:00AM, V10 (RN) stated that V15 (RN) assessed R11 after the 6/9/19 incident. V10 stated that R11 did not acknowledge the incident or show signs of distress. V10 went on to say that R11 is not interviewable but was alert and awake at the time of the incident. V10 added that R1 acknowledged that he could not could not be is R11's room with his pants down. On 8/22/19 at 10:30AM, R11 was in the TV room. R11 was very pleasant and alert but was unable to carry on a conversation. When this surveyor attempted to ask R11 questions about the incident, R11 was unable to answer, instead stating thank you for the food and for coming down from Chicago to see her. On 8/28/19 at 1:00PM, V26 (Registered Nurse/RN) identified the resident in R1's 6/9/19 progress note as R11. V26 stated that the incident on 6/9/19 occurred about 5:35AM or 5:40AM. V26 stated when she walked in, R1 was standing across the room from R11 just staring at her with no pants on. He was not masturbating, and he was not erect. V26 stated R11 was awake and alert at that time. R11 had her gown on as appropriate, and her blankets were still on like she was left. V26 said when I asked R11 if she was ok, she stated yes. V26 said after R1 was removed, an assessment was performed on R11 to check for injury, and R11 had no signs or symptoms of injury. R11's MDS (Minimum Data Set) dated 7/17/19 documents that the resident is Rarely or Never Understood. This same MDS documents that R11 is a 2 person assist for transfers, does not walk, and uses a wheelchair for mobility. The facility was unable to provide documentation that an investigation was completed regarding the 6/9/19 incident between R1 and R11. There was also no documentation that the Director of Nursing, Administrator, Police, or IDPH was notified of this incident. 3. A Progress Note for R1 dated 6/26/19 at 9:01PM, documents the following: Resident went into a room with two women (R10 & R5). He claimed (R5) was his wife. The other woman (R10) called 911 and the police called the facility to inform us that R10 had an intruder in her room. He was sitting in (R5's) wheeled walker next to her bed. Another progress note in R1's record dated a few days later on 6/30/19, documents the following: This nurse heard horrifying screams coming from a female on 200 hall. I ran down to a resident's room where there are 2 female residents there. One was in bed, the other in her recliner. The one in the recliner had been the one screaming. The divider curtain was pulled between the 2 women. The one screaming was behind the curtain. When I pulled the curtain back I found a male resident (R1) with the screaming female. She stated that he had his hands on her and was verbally threatening to kill her. I ask if she was alright. She said she was alright. I told the male resident to leave the room. He was not to be in female resident's room. He left. Then met the ADON (Assistant Director of Nursing) and a CNA (Certified Nurse Aide) coming down the hall, the male resident was behind me. He started yelling at us that he wanted a cigarette, NOW. I told him his cigarettes were on the other nurse's cart and I did not have the keys. The other nurse was on his break. He became so agitated that the ADON went to look for the other nurse to get the keys to his cart. He eventually walked off. Then he came back to the nurse's station and took another CNA's drink off the nurse's desk. On 8/20/19 at 3:00PM, V2 (Director of Nurses/DON) stated that neither she nor the Administrator were notified of the incidents on 6/26/19 or 6/30/19, therefore it was not investigated. On 8/21/19 at 11:15AM, R10 stated that R1 has been in her room [ROOM NUMBER] times, and each time she was very afraid of him. R10 stated she has called 911 and requested police assistance because she is afraid that the facility will not come in time to prevent R1 from hurting her. R10 stated that R1 has grabbed her belly and tried to pull her clothes off. R10 went on to say that he (R1) has stolen 2 packs of cigarettes from her. She repeated that the reason she called the police is because the facility will not protect the residents and keep him out of resident rooms and out of our belongings. On 8/21/19 at 2:45PM, V14 (Licensed Practical Nurse/LPN) stated that the incidents on 6/26/19 and 6/30/19 involved R5 and R10, with R1 being the male that entered the female's rooms. Regarding the incident on 6/30/19, V14 stated R5 was in the bed and R10 was the one screaming in the recliner. She stated as soon as she told R1 to leave the room, he left and returned to his room. V14 stated she did not see R1 touch R10. On 8/26/19 at 1:45PM, V17 (Police Officer) stated that an officer responded to the 6/26/19 incident, talked to R10, and no charges were made. 4. R1's Progress Notes dated 8/18/19, documents the following: A female peer reported to this nurse that while out on the patio (R1) asked her for a cigarette and when she said no he grabbed her breast. Peer claims she is scared of Res. and wanted to file a report. DON, ADON and police were notified. On 8/19/19 at 9:50AM, R3 stated that R1 has touched and rubbed her butt, and these incidents occurred around 3 weeks ago, 10 days ago, and last night. R3 stated she reported this to the nurse, and the nurse told her she couldn't do anything since she did not see it. R3 stated I tried to get away from him (R1), I am afraid of him and do not want anyone to touch me. R3 stated that this happened out at the smoking shelter, and no one goes outside with him (R1). R3 stated he (R1) is not monitored, and other residents are afraid of him as well. R3 added that last night at the smoking shelter he told other residents that he could kill them and get away with it. On 8/19/19 at 1:00PM, V1 (Administrator) identified the other resident in R1's progress note dated 8/18/19 as R3 and stated that this incident had not been investigated at the time it occurred. On 8/19/19 at 2:00PM, V14 (Licensed Practical Nurse) stated that she remembers the incident that occurred yesterday (on 8/18/19), and that R3 was upset and crying because R1 grabbed her breast and stated he wanted to kill her. V14 stated she called the police at this time. V14 went on to say that R1 has lots of behaviors, most of them are sexual, and R1 thinks everyone is his wife. V14 stated that most of the residents are afraid of R1. On 8/28/19 at 3:00PM, V14 stated that at the time of the 8/18/19 incident R3 made a report and wanted charges filed. V14 stated that the Police Officer said he could not arrest R1 because R1 really does think he is R3's husband. V14 stated that the police officer also refused to arrest R1 because the Police Department does not want a psychotic person in their jail. On 8/28/19 at 3:15PM, R3 stated she plans to make a report and press charges against R1. An Incident Report Form-IDPH Notification with Date of Incident entered as 8/18/19 and time entered as 19:21 (7:21PM), documents the following: Resident (R3) upon exiting smoking area reported to nurse resident (R1) asked for a cigarette et she replied 'no.' The latter resident then grabbed her arm, touching her L (left) breast. Incident was reported to local police (officer name) et investigated. This report has a fax date and time stamp of 8/19/19 at 15:09 (3:09PM). The Incident Report Form documents the type of incident as Alleged Sexual Act. On 8/19/19 at 1:00PM, V1 (Administrator) stated that this incident had not been investigated at the time it occurred. On 8/26/19 at 1:45PM, V17 (Police Officer) stated he responded to the call regarding the altercation between R3 and R1. No charges were made at the time. 5. a) R1's Progress Notes dated 8/11/19 at 11:35AM, documents the following: This nurse saw resident (R1) walking 200 hall and starting to walk into a female resident's room. Went to female resident's room. Other resident was asleep in her chair. Resident was standing in front of her with his hands in his pants. Was told to leave her room immediately. He hesitated at first and then left and went to his room. DON aware. On 8/19/19 at 11:00AM, R4 and R6 were observed sharing the same room. On 8/20/19 at 9:45AM, V9 (Licensed Practical Nurse) stated that R4 and R6 were the other residents involved in R1's 8/11/19 progress note. V9 stated she was the nurse that removed R1 from R4 and R6's resident room. She stated that at the time of the 8/11/19 incident, R1 was standing in front of R4 who was asleep. R1 had his hands in his pants and was massaging himself. On 8/20/19 at 1:40PM, R4 stated that R1 sneaks into her room and has done this at least 4 times. R4 stated that she is afraid he (R1) will do something to her or to her roommate. R4 then stated that in the evening, R1 often just stands in the hall outside her room and stares at her, adding this makes it impossible for me to sleep at night. R4's MDS dated [DATE] documents that R4 requires one-person physical assist for Transfers, Walking in the room, Walking in the hall, Dressing and Toileting. R4's MDS also documents that R4 is cognitively intact. 5. b) On 8/20/19 at 1:50PM, R6 stated that R1 thinks she is his wife, has been in her room [ROOM NUMBER]-6 times, and has grabbed her arm twice. R6 stated she screamed both times and R1 ran away. R6 stated that she is afraid of R1, and that fear keeps her from being able to sleep well at night. R6 also stated that R1 often stands in the hall and just stares into her room. R6 stated that she is afraid that R1 will grab her and hurt her physically, adding that she cannot get out of bed by herself and requires a mechanical lift to get into her wheelchair. R6's MDS dated [DATE] documents that R6 requires 2 or more assist for bed mobility, transfer, and dressing, and R6 uses a wheelchair. R6's MDS also notes that R6 is cognitively intact. No documentation could be found in R4 or R6's record regarding the 8/11/19 incident with R1. In addition, the facility was unable to provide any documentation that an investigation was completed regarding the incident on 8/11/19 between R1, R4, and R6. There was no documentation to note that the police were notified of these incidents. 6. R1's Progress Notes dated 6/17/19, document the following: A female resident came to nurses and reported to this nurse that a male resident (R1) came into her room uninvited. She told him he needed to leave. He did not leave, he scared her. He ask her if they could talk, she said 'No, you need to leave.' He then ask her for the keys to the lock box. She told him she didn't know what he was talking about and that she did not have any keys and told him to leave again. He started cussing her, but did leave the room. She watched him from her wheelchair go down the hall. She stated that he went straight up to the 200 med cart and was jiggling the drawers, trying to get them to open. When he couldn't get the locked cart open he walk off. This incident was reported to social services. On 8/21/19 at 2:45PM, V14 (Licensed Practical Nurse/LPN) stated the resident in R1's 6/17/19 progress note was R6. V14 stated that R6 felt very threatened from the 6/17/19 incident when R1 entered R6's room. V14 stated that R6 is not mobile and requires at least 2 staff members to help her with transfers and mobility. V14 stated she just tried to calm R6, as at the time of this incident R1 was not responding to any intervention that V14 tried to keep R1 out of resident's rooms. On 8/22/19 at 9:30AM, R6 stated she is very afraid of R1. R6 stated I know that the staff tried to comfort me, but when you are not able to run away you are a sitting duck, ready for (R1) to hurt you. (R1) thinks I am his wife and has grabbed me before. I am tired of not being able to sleep well at night because of (R1). R6 added that she cannot get out of bed by herself and is a mechanical lift for transfers. No documentation could be found regarding an investigation for the 6/17/19 incident between R6 an R1, and no interventions put in place to ensure R6's safety. R6's MDS dated [DATE] documents that R6 requires 2 or more assist for bed mobility, transfer, and dressing, and resident uses a wheelchair. R6's MDS also documents R6 is cognitively intact. 7. A Report to IDPH dated 8/15/19 documents a Date of Occurrence: 3 weeks per resident account regarding R7. The report states R7 was outside on the patio in the smoking area when R1 approached her and she thought he was going to ask for a cigarette and instead he grabbed her left boob and shook it. The document goes on to state that R7 said nobody was around. She came inside and told the nurse. The narrative summary of Incident states: Nursing staff was questioned about incident. All staff denied having any reports from resident about contact with resident. The follow-up Report to IDPH documents the same information, however states R7 stated that she did not report it. She stated she was outside with R1 by herself, there were no residents or staff outside R1 is placed on 15 minute checks per nursing and CNA's. He is only to go out with staff assist. On 8/19/19 at 10:30AM, R7 stated that she and everybody is afraid of R1. R7 also stated that when R1 is on the prowl, everyone stays away from him. R7 said no one should have to live in fear of another resident hurting or molesting them. R7 said the nurses are telling her that they cannot do anything because there is not a witness. R7 stated that R1 yells and screams at other people until he gets what he wants, and this is mostly to get cigarettes. On 8/19/19 at 10:45AM, R8 stated that R1 likes to go outside and smoke. R8 said R1 thinks everyone is his wife, and that we want to have sex with him. R8 stated We are afraid of him as he likes to touch, grab, and rub on us. R8 stated that R1 also likes to yell at the nurses and other residents to get him more cigarettes. On 8/20/19 at 10:00AM, R1 was noted outside in the smoking area. R12, R13 and R15 were also outside smoking at the same time. There was no staff member outside monitoring R1 in the smoking area at this time. On 8/20/19 at 8:00AM, V3 (RN/Assistant Director of Nursing-ADON) stated that R1's behaviors only started around two months ago when he became obsessed with cigarettes and using intimidating body postures to get them. At first R1 was showing physical aggression, and now he is becoming more sexual. V3 stated that R1 is presently not redirectable during his sexual episodes. On 8/21/19 at 9:30AM, R13 stated that R1 is a problem for the facility. R13 said that the problem is R1 thinks every woman in the building is his wife. R13 stated that some of the men have also had problems because R1 steals cigarettes from them, and then R1 threatens to kill them. R13 said that R1 has not tried to kill anyone, but has grabbed the women residents' arms and breasts, and has touched the nurses and CNA's as well. On 8/21/19 at 12:30PM, V2 (DON) stated that the only intervention put in place to prevent the incidents with R1 and the other residents was to add STOP signs to the female's doorways and to try to monitor more frequently. When V2 was questioned regarding the specifics of 'monitor more frequently,' V2 was unable to give more information or be more definitive. On 8/22/19 at 8:30 AM, V4 (RN) stated that R1 has lots of behaviors, and an issue with grabbing women and masturbating in women's rooms at night. V4 stated that very few interventions are being put in place to help with the behaviors. On 8/22/19 at 8:35AM, V7 (Social Service Director) stated that R1 needs to be in a locked down unit. V7 stated that R1 does not respond to behavior modification, does not listen, does not follow rules, and that R1 continues to escalate in behaviors. V7 stated at the present time, staff is not to bring their kids to work and staff is to be more aware of visitors in the building as well as where R1 is at all times. V7 stated she has been trying to find alternative placement for R1, as well as work with the State's Attorney and the area mental health professionals. On 8/22/19 at 10:10AM, R12 stated that he has had some trouble with R1. R12 went on to say that R1 has stolen his cigarettes and threatened to punch him (R12) when R12 tried to get the cigarettes back. R12 stated that he stays away from R1 because of R1's temper. R12 stated that R1 goes after women because of his sexual behaviors. R12 went on to say that at one time he shared a room with R1 and had to move because R1 would not let him stay in that room and sleep. R12 added that he really liked that room but moved because R1 was often rubbing his genitals and he (R12) did not like to see that. On 8/26/19 at 11:45AM, V3 (RN/DON) stated that everyone is cautious and on high alert while R1 was in the building. The residents would not go out to smoke when R1 was smoking in the smoking area, or the residents would come back in to avoid him. V3 stated that the residents tried to stay away from R1 as much as possible or would try to stay in a safe area, especially after R1 hit staff member V4 (RN). On 8/27/19 at 11:00AM, V10 (RN) stated that the whole building was constantly on edge while R1 was in the building. The residents were afraid of him and often stayed in their room with their doors shut. On 8/27/19 at 3:30pm, V20 (CNA) stated that R1 was having worse behaviors and it took 2 CNA's to care for him because of the behaviors. V20 said about one month ago, R1 called me into his room and shut the door. V20 stated she screamed because she could not see him or the door to get out. V20 said R1 did not touch her, and she left the room and told the nurse. V20 said later in the evening, when I walked past his room he was standing in the middle of the room, pants were at his ankles, and R1 was masturbating with an erection. V20 said this incident was reported to the nurse but she was unaware of her response. V20 stated that at first, it was just staff related and then R1 began going after the female residents. V20 said she gave him a lot of cigarettes because she was afraid of his behaviors. On 8/27/19 at 4:00PM, V21 (CNA) stated that R1 had lots of behaviors and staff had to keep him out of other residents' rooms, especially the female resident rooms. One day before he was discharged R1 told me 'I bet you are good in the sex thing' and he tried to rub my butt. V21 stated that she reported it to the nurse. On 8/29/19 at 2:20PM, V26 (former Administrator/Regional Administrator) stated that R1 was transported to the facility on [DATE] by the state operated mental health facility. V26 stated no PAS (Pre-Admission Screening) was ever provided, only the initial OBRA (Omnibus Budget Reconciliation Act) screen was given approximately 1-2 days before R1's admission. V26 stated the PAS was requested, but only the OBRA was received. V26 said he spoke to the social worker at the mental health facility prior to admission and she stated that R1 was well behaved and had dementia. The facility's Policy and Procedure Abuse and Neglect Prevention, revised 8/2019, documents the following: 1. The resident has the right to be free from verbal, sexual, physical and mental abuse It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. 2. All staff are mandated reporters. All staff must be on constant vigilance to insure no resident is subjected to the above from anyone including staff, family and visitors. 3. The staff is to report to their supervisor, the Administration, and Director of Nursing. 4. Once the facility administration becomes aware of any of these alleged violations, the home will report within 2 hours of knowledge of the incident to the designated state agency. CMS indicates that the term immediately means as soon as possible. It is irrelevant whether the facility investigated the incident and determined the allegations were unfounded: all alleged violations must be reported immediately within 2 hours of knowledge on the incident. 5. After the facility submits an immediate report of an alleged violation, the facility must conduct a thorough investigation: . and report the results in the investigation to the state agency within 5 working days or as designated by state law. The facility may report the results of an investigation by completing the remainder of the reporting form and resubmitting it to the state agency. On 9/9/19 the surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediacy: 1. R1 was discharged from the facility on 8/22/19. 2. Revisions to the facility Abuse Policy and Procedure were completed on 8/23/19 by the Regional Director of Clinical Services and were noted to include notification of law enforcement for reasonable suspicion of crimes. 3. All staff on all shifts were in-serviced between the dates of 8/23/19 and 9/4/19 on the abuse and reporting policy by the Administrator, Director of Nursing, and Assistant Director of Nursing. 4. Management team was provided in-service education by the Regional Director of Clinical Services regarding thoroughly screening residents prior to admission to identify risks and ensure necessary services/protective measures can be provided. Staff that received the in-service education included Social Services, Business Office, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Maintenance, and Marketing. This in-service was completed on 9/4/19. T