**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to protect a cognitively impaired resident with known sexual behaviors from sexual activity with a staff member for one (Resident #14) of three residents reviewed for abuse and neglect. The findings include: A review of the [City Name] Police Department Incident Report dated 08/17/2025, revealed on 08/17/2025 at 12:31 PM, an officer was dispatched to the facility for a general information report and was met by the Administrator. The Administrator reported Certified Nursing Assistant (CNA) #2 walked in on Resident #14 performing oral sex on Housekeeper (HSKP) #3. The Administrator reported to the officer Resident #14 was not seriously cognitively impaired, was highly sexual, and was known for groping other employees and having frequent sexual contact with other residents of the facility. CNA #2’s statement to the officer stated she was alerted by another employee to look in Resident #14’s room. She observed Resident #14 on their knees with their underwear down performing oral sex on HSKP #3 in the bathroom. CNA #2 left and reported the incident. The officer’s statement was that he informed HSKP #3 he was terminated and needed to leave the property. HSKP #3 stated nothing inappropriate happened, turned in his keys, and was escorted off the property. The officer informed the Administrator that a report would be filed, and the Criminal Investigation Division (CID) would look into possible charges. The Administrator reported she informed the family, and a full body medical exam would be done on Resident #14 to investigate if any other sexual contact was made. The officer informed the Administrator the CID might reach out for further information. On 08/19/2025, a [NAME] at the CID contacted the Administrator and stated she would be speaking with the prosecuting attorney about the incident and obtaining a subpoena for medical records. A review of Resident #14’s admission Record revealed the facility admitted the resident on 06/27/2024, with diagnoses that included stroke, loss of sensation and movement after a stroke affecting the right dominant side, moderate dementia, moderate major depressive disorder, mood disorder, and anxiety disorder. A family member was listed as the Resident #14’s responsible party. A review of Resident #14’s admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/29/2024, revealed a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. Resident #14’s admission MDS also revealed no sexual behaviors were identified. A review of Resident #14’s significant change MDS, with an ARD of 09/27/2024, revealed a BIMS score of 07, which indicated the resident had severe cognitive impairment. Resident #14’s quarterly MDS also revealed no sexual behaviors were identified. A review of Resident #14’s quarterly MDS, with an ARD of 12/18/2024, revealed a BIMS score of 09, which indicated the resident had moderate cognitive impairment. Resident #14’s quarterly MDS also revealed no sexual behaviors were identified. A review of Resident #14’s quarterly MDS, with an ARD of 03/20/2025, revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Resident #14’s quarterly MDS also revealed no sexual behaviors were identified. A review of Resident #14’s quarterly MDS, with an ARD of 05/05/2025, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. Resident #14’s quarterly MDS also revealed no sexual behaviors were identified. A review of Resident #14’s annual MDS, with an ARD of 07/28/2025, revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #14’s annual MDS also revealed no sexual behaviors were identified. All MDS assessments conducted by the facility’s trained staff revealed Resident #14 was never cognitively intact but rather was assessed from severe cognitive impairment to moderate cognitive impairment requiring assistance and not identified as having any sexual behaviors. A review of Resident #14’s Care Plan Report revealed the resident had impaired cognitive function related to dementia. The residents Care Plan included interventions to ask yes/no questions in order to determine the resident’s needs, and cue, reorient and supervision as needed. Resident #14’s speech was unclear with a goal for the resident to make needs known, interventions included minimizing or eliminating environmental distractions such as television, radio, or background noise, and notifying the nurse of changes in Resident #14’s ability to communicate. Resident #14’s Care Plan also included that the resident had difficulty understanding others at times. The resident may miss part or the intent of a message and may require a person to repeat the message or provide some cues at times for understanding. Resident #14’s “ability to express ideas, wants and needs is sometimes understood. Resident #14 had a diagnosis of depression, mood disorder, and anxiety. Care Plan interventions included administering medication as ordered and observing for side effects and effectiveness and discussing with the resident/family/caregivers any concerns, fears, issues regarding health and other subjects. Resident #14’s Activities of Daily Living (ADLs) were identified as weight bearing assist due to hemiplegia affecting the right side following a Cerebral Vascular Accident (CVA), dementia, and was sexually active. The goal was for the resident to maintain their usual performance through the review period. The residents Care Plan also included intervention to provide touch assistance for dressing and lying to sitting, and staff would respect the resident’s privacy during sexual activity with consenting partners. A review of Resident #14’s Care Plan Meeting Note dated 09/26/2024, revealed the resident’s representative attended the Care Plan meeting. The facility failed to identify on the forms appropriate location whether Resident #14 was invited or attended the meeting. Under the nursing section it was written, Explained to family that [Resident #14] is sexually active and has a consenting partner. Will try to provide privacy and will educate [pronoun] on sexual safety. The document was signed by the Director of Nursing (DON), MDS Nurse, the Administrator, and three other unidentified staff members. A review of Resident #14’s Physician Orders revealed the resident had no orders for safe sex education, screening for sexual transmitted diseases (STD)s, or competency evaluation for sexual consent. A review of HSKP #3’s employee file revealed a copy of the Abuse & Neglect Policy including reporting abuse signed and dated by HSKP #3 on 01/22/2025. An Employee Attestation” which acknowledged the facility was legal and in compliance with all state and federal laws signed by HSKP #3 on 01/22/2025. A Team Member Acknowledgement and Certification of Understanding Compliance and Ethics Program signed and dated by HSKP #3 on 03/27/2025. An Employee Discipline Form indicating termination of HSKP #3 for Inappropriate relations with [Resident #14]. Receiving oral sex from a resident. Employee comments revealed, Employee denies allegations but was caught in the act by [Certified Nursing Assistant #2]. This was signed and dated by both the Administrator and the Director of Nursing (DON) on 08/17/2025. A review of Advanced Practice Registered Nurse (APRN) #10’s Progress Note dated 08/05/2025, revealed Resident #14 had a history of impaired cognition, major depressive disorder, mood disorder, generalized anxiety disorder, hemiplegic and/or hemiparesis following a stroke, cerebral infarct, dysphonia (change in the quality or pitch of a person’s voice), emotional adjustment, and vascular dementia with behavioral disturbances. The reason for the referral was resident has periods of inappropriate behavior and staff reported multiple indecent behaviors with other residents. APRN #10’s Progress Note revealed Resident #14’s Psychiatric: Mental Status: normal mood and confused. Orientation: not oriented to time and place and to person. Mood disorder- onset 10/11/2022- Has periods of inappropriate behavior towards other residents. Send referral to mental health provider. A review of Resident #14’s Hospital Visit documentation dated 08/17/2025, described the resident as “General: Appears Alert, Oriented to person, to place, to time, Behavior is cooperative.” “Discharge Assessment: Patient awake, alert, and oriented x 3. No cognitive and/or functional deficits noted. Patient verbalized understanding of disposition instructions.” “Neuro: Awake, alert, GCS [Glascow Coma Scale] 15, oriented to person, place, time, and situation. Cranial nerves II-XII grossly intact. Motor strength 5/5 in all extremities. Sensory, grossly intact. Cerebellar exam normal. Normal gait.” The findings contradict multiple assessments performed by the facility staff since the resident’s admission. Narrative indicated, the resident was found by an aide engaged in sexual activity with another employee. The resident was sent to the hospital to obtain a rape kit. The resident stated repeatedly to the hospital staff the engagement was completely consensual. “The act was witnessed and included oral sex only, not vaginal or anal penetration.” The resident reaffirmed multiple times when asked in several different ways that the act was consensual, welcomed, and she willingly participated. [Resident #14] seemed to be fully competent to make that determination. No rape kit was performed to rule out any other sexual contact based on this determination. The doctor determined the patient had the mental capacity to make her own medical decisions. A review of Resident #14’s Hospital Visit Documentation revealed an Event Log that indicated Resident #14 arrived at the Emergency Department on 08/17/2025 at 3:42 PM, was seen by the Physician at 4:53 PM, and a medical exam was performed at 6:53 PM. A discharge order was placed at 6:53 PM, ER Care was Complete at 6:53 PM, and Resident #14 departed at 7:16 PM. A review of Resident #14’s Discharge Instructions dated 08/17/2025, indicated “The examination and treatment you have received in the Emergency Department today have been rendered on an emergency basis only and are not intended to be a substitute for an effort to provided complete medical care. You should contact your follow-up physician as it is important that you let him or her check you and report any new or remaining problems since it is impossible to recognize and treat all elements of an injury or illness in a single emergency care center visit.” A review of a Behavioral Health Note from 08/18/2025 revealed, Resident #14 had a cerebral infarction onset 07/20/2021, Hemiplegia and/or Hemiparesis following a stroke onset 07/20/2021, impaired cognition 07/20/2021, major depressive disorder 10/11/2022, generalized anxiety disorder 10/11/2022, mood disorder onset 10/11/2022, emotional disorder 10/11/2022, and a new diagnosis of neurocognitive disorder 08/18/2025 and Inappropriate sexual behavior 08/18/2025. Resident #14 was seen vis telemedicine, using interactive audio/video telecommunication, at the request of facility staff. The appointment was medically necessary due to staff report of inappropriate sexual behavior. Past medical history/psychiatric history includes the history of CVA with aphasia (age 30), neurocognitive disorder, Atrial Fibrillation, and anemia. Physical Exam noted behavior as; child-like, smiled spontaneously, no unusual movement or psychomotor behavior. Cognition: Alert and oriented to person and place. Speech; without pressured speech, appropriate rate, tone, volume. Constitutional: General appearance: chronically ill. Mood; euthymic. Fine. Affect; flat. Thought Process; Unable to assess. Thought content; Denies [suicidal ideation, homicidal ideation], No delusions, hallucinations, phobias, obsessions. Judgement; Poor. Memory; Poor. Insight; Poor. Assessment: Resident was a difficult historian due to aphasia and neurocognition disorder, therefore history was obtained from staff and records. A review of Laundry Aide #12’s Witness Statement dated 08/17/2025, revealed Laundry #12 was entering the 200-Hall when HSKP #3 asked her if Resident #14 was in their room. Laundry #12 informed HSKP #3 the resident may be eating breakfast, and he should go ahead and clean Resident #14’s room first since the resident liked to rub people. Laundry #12 took some clothes to another resident and reported HSDK #3 was acting as if he were cleaning up, 10 seconds later he went in [Resident #14’s] room. Laundry #12 then informed CNA #2. A review of HSKP #4’s Witness Statement dated 08/18/2025, revealed Resident #14 was 'constantly grabbing and touching staff and other residents for many months without anything being done about it. During an interview on 08/19/2025 at 4:40 PM, CNA #2 stated the event on Sunday [08/17/2025] was traumatizing for her. I never want to see that. It was breakfast time, and I was across the hall passing a tray. The laundry lady came up and signaled to the resident’s door. The housekeeping cart was on the floor and Resident #14 is very sexually active. I went to [the resident’s] bedroom and just opened the bathroom door. The resident was on [pronoun] knees with [pronoun] pants off in front of the housekeeping guy giving him oral sex. They both grabbed their pants, and the housekeeper stated, 'Oh [expletive]'. I shut the door, and the housekeeper came out about 20 secs after me. He said, 'Oh my God, what's going to happen. I don't know if it’s abuse.' [Resident #14] had sexual contact with residents. I could tell when it was on their mind. [Resident #14] would start walking down 300 hall, it’s a male resident hall. I knew something was off with both of their demeanors, the vibe was off. It’s not HSKP #3’s hall to clean on the weekends. I've never seen the door shut before. When I walked in there was no forcing on either part and the room smelled like sex. [HSKP #4] is better, he doesn't go in the room, or he asks me to stand in there. During an interview on 08/20/2025 at 5:18 PM, HSKP #3 stated, [Resident #14] was always groping and touched other residents, and grabbed me, I was a lowly housekeeper. It was my job cleaning the restroom. I had another incident where [Resident #14] got me, I laughed it off, I slapped the resident’s arm a little bit too hard, and [Resident #14] slapped me back. I had no sexual contact with the resident before. I did not have my pants down, [Resident #14] had their pants down. It is not true I received oral sex from [Resident #14]; I was cleaning the restroom. There was no sexual contact. I slapped the resident’s arm away and it may have been too hard. During an interview on 08/20/2025 at 5:45 PM, this surveyor observed Resident #14 sitting alone on the front patio. This surveyor approached and asked the resident some simple questions. Resident #14 was asked about the care and treatment at the facility and if it was good. Resident #14 responded, yeah. This surveyor asked the resident if they had friends and the resident responded, “friends, friends, friends,” while shaking their head yes. Resident #14 was asked about any relationships and the resident said, “nah.” The resident was asked if they had ever kissed or touched any residents or staff, resident responded with a sound, “hmmm.” Resident #14 was asked if they knew HSKP #3, resident responded, “Kinda.” Resident #14 was asked if they had ever kissed or touched HSKP #3 in the private areas. Resident #14 responded with a sound like clicking made with the tongue. Resident #14 turned away and no longer interacted with the surveyor. During an interview on 08/20/2025 at 11:49 AM, Resident #14’s Responsible Party stated the facility had reported the incident on Sunday, 08/17/2025. I did not consent to sex with a staff member. I don't think it caused [Resident #14] any pain, trauma, or negative psychosocial outcomes. [The resident] had always been sexually active. The facility called me Sunday about the incident with the staff member. I did not make it up there. I haven't talked to [Resident #14] since the incident. It doesn’t do any good calling. I don't think [the resident] denied it this time but just smiled is what they said. They were supposed to be giving the resident a psych evaluation this week. [Resident #14] had a stroke at 38 and has not been right. I have no idea if [the resident] is coming up with the situations on their own. I can't get a straight answer out of [the resident] since the stoke. During an interview on 08/21/2025 at 9:11 AM, HSKP #4 stated, Whenever I try to clean [Resident #14] tries to grab you or touch me, [Resident #14] tries to shake [their] butt on you. I will walk out if I see [Resident #14] coming. I assumed the nurse was aware. They told me to avoid the resident if I saw them coming in. I told CNA #2. During an interview on 08/21/2025 at 9:14 AM, CNA #2 stated she has charted some stop and watches' regarding Resident #14’s sexual behaviors and documented it in the activity task under behaviors. A review of Resident #14’s Behavioral Monitoring & Interventions for the last 30 days revealed, Resident #14 had Public Sexual Acts on 08/03/2025, documented at 5:59 PM. On the evening of the inappropriate sexual contact with HSKP #3 08/17/2025, Resident #14 had the following behaviors documented at 5:59 PM: Cursing at others, Expresses frustration/Anger at others, Public sexual acts, and Agitation. During an interview on 08/21/2025 at 10:55 AM, the Medical Director (MD) stated he directly oversaw the APRNs, and they called with any questions. The DON or Administrator call me if they have a reportable, I come out and do rounds once a month on the 2nd Wednesday. [Resident #14’s] sexual activity had come up during conversations and it's an ongoing issue. I know [pronoun] was doing things out in public, and they try to redirect to the residents’ own room out of public. The staff encouraged the resident not to interact with that behavior; they have discussed it with the family. I am not familiar with the regulations. If they are engaging in that they should be of sound mind to give consent. I don't know her specifically. During an interview on 08/21/2025 at 11:34 AM, APRN #11 stated, the facility did notify him about Resident #14’s inappropriate sexual behavior, and he did a referral to mental health. These were sexual behavior before Sunday 08/17/2025, about a week ago. I think it was with another resident. It was at night in the front entrance way, or maybe outside on the front porch. Someone was coming in and notified the nurse. The resident was giving oral sex. I did talk to the resident, and they told me to mind my business. The resident didn't know where they were at but was orientated to person only. It is hard to comprehend what Resident #14 says. Some things are a little clearer and you can piece them together. I would talk to Resident #14’s Representative for consent purposes. Resident #14 does know if they need to go to the bathroom and it’s time to eat. I have seen the resident in some activities. [Resident #14] was doing speech therapy for the cognition, and restorative therapy too. In my opinion I would not say [Resident #14] was capable of giving consent for sex. The [Representative] said the resident had a history of sexual activity. I think it was discussed in the care plan about the resident’s activity with other residents. They did not notify me about the Sunday 08/17/2025 incident with staff. No, there was no consent or expectation of [Resident #14] interacting with staff sexually given in the Care Plan meeting by the [Representative]. The staff should not do anything inappropriate like that. They need to come here and do your job. Resident behaviors are not consent for staff to interact with them sexually. If they notice something like that, they need to notify someone. The staff have been trying to do more therapy to give the [Resident #14] something to do, like dance too for distraction. Any staff should back away and say no. The staff should notify a nurse, and it should be charted under the resident’s behaviors. Then notify me or the MD. [Resident #14] should only be with female staff, if it's a male staff they should have a female there to limit the exposure. During an interview on 08/21/2025 at 11:57 AM, the DON stated because of Resident #14’s stroke the resident could not carry on a conversation. We know [Resident #14] enough and has been around enough we can communicate with [Resident #14’s] wants and needs. I have never seen it, but [Resident #14] likes to give oral sex [to residents]. I don't know how many partners there have been. It has been reported to me about four different times, not oral sex, just sitting on the front porch with residents. This last incident someone caught [Resident #14] in the act. The interventions are for the Resident #14 to see mental health, get prior approval for a medication to and increase other medications. This is to see if they will suppress hyper sexuality. I talked to [Resident #14] this last week and said if anyone is ever wanting something from the resident they don’t want to do, [Resident #14] doesn't have to and should come tell me. We were discussing with [Resident #14] and the officer the resident said I'm an adult. The facility staff talked to resident’s Representative in a care plan meeting, and it was determined not to be a new behavior, and the Representative was mortified about it. It is not my expectation the residents should have sex with employees. I would not let [Resident #14] give consent for anything medical with a BIMS of 10, dementia, and the post CVA. I think [Resident #14] knows what they are doing. I don't know if [Resident #14] knows the consequences of being sexually active, how to have safe sex. [Resident #14] has not been tested for STDs, but we ordered it. I have never had to assess someone to be safe while sexually active. I don’t know how to assess for competency; I would depend on our provides. I absolutely believe staff interacting with residents sexually crosses the line. I have educated staff that any erratic behavior for [Resident #14] they are to report to me and the Administrator. [Resident #14] was the first one I have ever had this situation, so this is new to me. During an interview on 08/21/2025 at 12:26 PM, the Administrator stated, due to [Resident #14’s] stroke deficits we know what [Resident #14] is saying, and the resident will say ok and yep. You must ask a close-end question. [Resident #14] can give consent for a medical procedure. The DON had conversation about safe sexual activity, and I had a long conversation about it. [Resident #14] doesn't want to discuss it and will roll [their] eyes. I feel like Resident #14 is competent enough to make decisions. We had mental health see the resident this week and they did some medication changes. We have to monitor and go forward. We have explained all the sexual activity consequences and STD issues to the resident the expectation is definitely not for ‘that’ to happen at all.’ HSKP #3 was terminated immediately. We have all the in-services on abuse and neglect you don't do that. I can't say for sure there were any interventions in place, there was nothing in place for a male not going in to [Resident #14’s] room alone. We have done an in-service that is going in this reportable if there is any new or erratic behavior it needs to be reported to me and the DON immediately. During an interview on 08/20/2025 at 4:34 PM, [NAME] [CID] City Police Department stated, she was waiting on subpoenas for both HSKP #3 and Resident #14’s information and the CID was going to thoroughly investigate the incident. The [NAME] stated, This is an active open case, and we will be turning everything over to the prosecutor's office. A review of a facility undated policy titled, Abuse and Neglect Policy and Procedures, Investigation & Reporting, revealed, “it is a policy of this facility to ensure that a system is in place to prevent and detect mistreatment, neglect and abuse of residents and the misappropriation of resident property.” “The following criteria will be utilized in the abuse prevention system: Employee training referred to the “Residents Rights, Abuse and Neglect Policy, Corporate Compliance, and Rules of employee conduct; Understanding residents abusive conduct, understand differences that lead to conflict. Protective and Prevention Measures included, staff and residents will be supervised in an effort to identify inappropriate behaviors that could signal possible abuse. Identifying situations in which abuse/neglect is more likely to occur included: Upon admission to the facility, each resident will be assessed to determine if they are at risk for abusing others or if the resident may be at a higher risk for abuse than other residents. The assessment may include the use of family interviews and documentation from previous institutional providers.” The Abuse Policy did not address sexual abuse. No definition, training for recognition of sign and symptoms, or interventions to prevent sexual abuse. A review of a facility undated policy titled, Compliance and Ethics Program, indicated the “facility recognizes the importance of and is committed to adhering to legal, professional, and ethical standards of conduct.” “The Program applies to various individuals who are associated with Facility, hereafter collectively referred to as ‘Team Members’.” “All Team Members are required to report any suspected instance of abuse or neglect immediately to the Compliance Officer, Compliance Team, or their supervisor.” “d. Any alleged, suspected or witnessed occurrence of sexual abuse to residents by an individual.” A review of the Arkansas Code, Subchapter 17- Adult and Long-Term Care Facility Resident Maltreatment Act, Section 12-12-1708- Persons required to report adult or long-term care facility maltreatment, stated, (Q) An employee in a facility was a mandated reported of any suspected abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility document review, it was determined that the facility failed to identify sexual behaviors on a resident’s comprehensive care plan as a behavior resulting in no goals, interventions, or plan for safe sexual activity, assessed competency for consent, redirection from other residents, and protection from unethical staff for 1 (Resident #14) of 8 residents reviewed for comprehensive person-centered care plans. The findings include: A review of “Centers for Medicare & Medicaid Services [CMS], Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User’s Manual, Version 1.19.1, October 2024” indicated on its overview, “The RAI helps nursing home staff gather definitive information on a resident’s strengths and needs, which must be addressed in an individualized care plan. It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident’s status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident’s unique path toward achieving or maintaining their highest practical level of well-being.” For the section on behaviors and intent the RAI indicated, “the items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact.” A review of the admission Record indicated the facility admitted Resident #14 on 06/27/2024, with diagnoses that included stroke, loss of sensation and movement to the right side of the body after a stroke, moderate dementia, moderate major depressive disorder, mood disorder, and anxiety disorder. A family member was listed as the Resident #14’s responsible party. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/29/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment. The MDS identified no sexual behaviors. The quarterly MDS, with an ARD of 09/27/2024, revealed Resident #14 had a BIMS score of 7 which indicated the resident had severe cognitive impairment. The MDS identified no sexual behaviors. The quarterly MDS, with an ARD of 12/18/2024, revealed Resident # 14 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. The MDS identified no sexual behaviors. The quarterly MDS, with an ARD of 03/20/2025, revealed Resident #14 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. The MDS identified no sexual behaviors. The quarterly MDS, with an ARD of 05/05/2025, revealed Resident #14 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. The MDS identified no sexual behaviors. The annual MDS, with an ARD of 07/28/2025, revealed Resident #14 had a BIMS score of 10 which indicated the resident had moderate cognitive impairment. The MDS identified no sexual behaviors. All MDS assessments conducted by the facility’s trained staff revealed Resident #14 was never cognitively intact but rather was assessed from either severe cognitive impairment to moderate cognitive impairment requiring assistance and was identified as not having any sexual behaviors. A review of Resident #14’s Care Plan Report, with a review date of 08/08/2025, revealed Resident #14’s Activities of Daily Living (ADL)s were identified as weight bearing assist due to hemiplegia affecting the right side following a CVA [Cerebral Vascular Accident], dementia, as being sexually active. The goal was for the resident to maintain their usual performance through the review period. Interventions included providing touch assistance for dressing and lying to sitting and that staff would respect the resident’s privacy during sexual activity with consenting partners. On 08/17/2025 after an inappropriate sexual encounter with an employee, Licensed Practical Nurse (LPN) #9 added to Resident #14’s Care Plan with revisions on 08/18/2025. LPN #9 indicated a problem that Resident #14 was sexually active with others that consent. The Care Plan had a goal that the resident’s sexual behaviors would decrease. Approaches/Tasks to achieve the goal were that Resident # 14 would receive a mental health referral, was sent to the ER [Emergency Room], and that staff would respect the resident’s privacy during sexual activity with a consenting partner. A review of a Care Plan Meeting Note dated 09/26/2024, revealed Resident #14’s representative attended the care plan meeting. The facility did not identify on the yes or no question whether Resident #14 was invited to or attended the meeting. Under the section “nursing” it was written, “Explained to family that [Resident #14] is sexually active and has a consenting partner. Will try to provide privacy and will educate her on sexual safety.” The document was signed by the DON, Minimum Data Set (MDS) Nurse, the Administrator, and 3 other unidentified staff members. A review of Physician Orders, revealed Resident #14 had no orders for safe sex education, screening for sexually transmitted diseases (STD)s, or competency evaluation for sexual consent. A review of Advanced Practice Registered Nurse (APRN) #10’s Progress Note dated 08/05/2025 revealed, Resident #14 had a history of impaired cognition, major depressive disorder, mood disorder, generalized anxiety disorder, hemiplegic and/or hemiparesis following a stroke, cerebral infarct, dysphonia (change in the quality or pitch of a person’s voice), emotional adjustment, and vascular dementia with behavioral disturbances. The reason for the referral was “resident has periods of inappropriate behavior” and “staff reported multiple indecent behaviors with other residents.” “Psychiatric: Mood Status: normal mood and confused. Orientation: not oriented to time and place and to person.” “Mood disorder- onset 10/11/2022- Has periods of inappropriate behavior towards other residents.” “Send referral to mental health provider.” A review of the [City Name] Police Department Incident Report dated 08/17/2025 revealed, on 08/17/2025 at 12:31 PM, an officer was dispatched to the facility for a general information report and was met by the Administrator. The Administrator reported to the officer that CNA #2 walked in on Resident #14 performing oral sex on HSKP #3. The Administrator then reported to the officer Resident #14 was not seriously cognitively impaired, was highly sexual and was known for groping other employees and having frequent sexual contact with other residents of the facility. CNA #2’s statement to the officer indicated she was alerted by another employee to look in Resident #14’s room. There, CNA#2 had observed Resident #14 on their knees with their underwear down performing oral sex on HSKP #3 in the bathroom. CNA #2 left and reported the incident. The officer’s statement indicated he informed HSKP #3 he was terminated and needed to leave the property. HSKP #3 stated nothing inappropriate happened, turned in his keys, and was escorted off the property. The officer informed the administrator that a report would be filed, and the Criminal Investigation Division (CID) would look into possible charges. The Administrator reported she informed the family, and a full body medical exam would be completed for Resident #14 to investigate if any other sexual contact was made. The officer informed the Administrator that the CID might reach out for further information. On 08/19/2025 a [NAME] at the CID contacted the Administrator and stated she would be speaking with the prosecuting attorney about the incident and obtaining a subpoena for medical records. A review of HSKP #4’s witness statement dated 08/18/2025 revealed, Resident #14 was “constantly grabbing and touching staff and other residents for many months without anything being done about it.” During an interview on 08/21/2025 at 9:11 AM, HSKP #4 stated, “Whenever I try to clean [Resident #14] tries to grab or touch me. [Resident #14] tries to shake [their] butt on you. I will walk out if I see [Resident #14] coming. I assumed the nurse was aware. They told me to avoid the resident if I saw them coming in. I told CNA #2” about the behaviors. During an interview on 08/21/2025 at 9:14 AM, CNA #2 stated, she had charted some “stop and watches,” a tool used by staff to bring attention to a resident showing signs of a change or escalation in their status, regarding Resident #14’s sexual behaviors and documented it in the activity task under behaviors. A review of Resident #14’s Behavioral Monitoring and Interventions for the last 30 days revealed, Resident #14 had “Public Sexual Acts” on 08/03/2025 documented at 5:59 PM. On the evening of the inappropriate sexual contact with HSKP #3, Resident #14 had behaviors documented at 5:59 PM, that included, “Cursing at others, Expresses frustration/Anger at others, Public sexual acts, and Agitation.” During an interview on 08/21/2025 at 10:55 AM, the Medical Director (MD) stated he directly oversaw the APRNs, and they call with any questions. “The DON or Administrator call me if they have a reportable. Resident #14’s sexual activity had come up during conversations and it's an ongoing issue. “I know [pronoun] was doing things out in public, and they try to redirect to the resident’s own room out of public. The staff encouraged the resident not to interact with that behavior; they have discussed it with the family. “I am not familiar with the regulations.” If they are engaging in that they should be of sound mind to give consent. I don't know [Resident #14] specifically.” During an interview on 08/21/2025 at 11:34 AM, APRN #11 stated, the facility did notify him about the inappropriate sexual behavior, and he completed a referral to mental health. These were sexual behaviors before Sunday 08/17/2025, about a week ago. “I think it was with another resident. It was at night in the front entrance way, or maybe outside on the front porch. Someone was coming in and notified the nurse. The resident was giving oral sex. The resident didn't know where they were at and was orientated to person only. It is hard to comprehend what Resident #14 says. Some things are a little clearer and you can piece them together. I would talk to Resident #14’s Representative for consent purposes. In my opinion I would not say [Resident #14] was capable of giving consent for sex. The [Representative] said the resident had a history of sexual activity. Resident behaviors are not consent for staff to interact with them sexually. [Resident #14] should only be with female staff, if it's a male staff they should have a female there to limit the exposure.” During an interview on 08/21/2025 at 11:57 AM, the DON stated that because of Resident #14’s stroke the resident cannot carry on a conversation. “We know [Resident #14] enough and have been around enough we can communicate with [Resident #14’s] wants and needs.” I have never seen it, but [Resident #14] likes to give oral sex. I don't know how many partners there have been. It has been reported to me about 4 different times, not oral sex just sitting on the front porch with residents. This last incident someone caught [Resident #14] in the act.” The interventions are for Resident #14 to see mental health, get prior approval for a medication to and increase other medications. This is to see if they will suppress hyper sexuality. The facility staff talked to resident’s Representative in a care plan meeting, and it was determined not to be a new behavior. During the care plan meeting the behavior was discussed. Resident #14’s representative gave consent, “well not really giving consent the [Representative] wishes the resident wouldn't do it. It is not my expectation the residents should have sex with employees. During an interview on 08/21/2025 at 12:26 PM, the Administrator stated, Resident #14 had grabbed on female and male staff members and male residents. “[Resident #14] had several boyfriends we have had care plan meeting with family. The DON had conversation about safe sexual activity, and I had a long conversation about it. We had mental health see the resident this week and they did some medication changes. We have to monitor and go forward. We have explained all the sexual activity consequences and STD issues to the resident. I don't have answers for why [Resident #14] wase not care planned for any of the sexual behaviors. I don't feel comfortable answering; it probably should have been. We don't have a policy and procedure on it. “We redirect [Resident #14] and tell the resident they shouldn't do that. I can't say for sure there were any interventions in place, there was nothing in place for a male not going in to [Resident #14’s] room alone. During an interview on 08/21/2025 at 3:04 PM, the MDS Nurse explained the sexual activity was entered on the Care Plan. “It was located under the ADLs because it was [Resident #14] and another resident consenting. It was not considered a behavior and there were no interventions for sexual activity. When something happens or gets reported we update the care plan at that time.”

Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the dry food storage were covered or sealed to prevent potential cross contamination; expired dairy product and food items were promptly removed and discarded on or before the expiration date, and dietary staff washed their hands, before handling clean equipment or food items for one of one meal observed. The findings include: During an observation and interview on 08/18/2025 at 10:15 AM, the refrigerator contained one half gallon of butter milk inside the milk cart which had an expiration date of 8/17/2025. The Dietary Manager stated she checked the milk to make sure none was expired and had missed that one. During an observation and interview on 08/18/2025 at 10:21 AM, this surveyor observed the following on the bread rack: Three bags of bread on the bread rack had an expiration date of 08/14/2025. The Dietary Manager stated she checked the bread rack to make sure none were expired and had missed those three. There were three opened bags of hamburger buns on the bread rack in the storage room. The bags were not sealed, exposing them to heat, moisture and potential for pests. The Dietary Manager stated unsealed bags would cause spoilage, and there was potential for pests to crawl into the bags. During an observation and interview on 08/18/2025 at 10:35 AM, Dietary Aide (DA) #5 turned on the food preparation sink faucet to fill a pitcher with water. DA #5 turned off the faucet with her bare hands, contaminating her hands. Without washing hands, DA #5 used her contaminated hands to pick up glasses by their rims and pour beverages to be served to the residents for lunch. DA #5 stated she should have washed her hands after touching the faucet with her bare hands to prevent the glasses from getting dirty. During an observation and interview on 08/18/2025 at 11:23 AM, this surveyor observed the ice scoop holder was attached to the handle of the ice chest near the entrance door to 300-hall leading to the ice machine room. The scoop holder had dirt at the bottom, and the scoop was resting directly on it. When the surveyor and the Dietary Manager entered the room where the ice machine was located, this surveyor observed another ice chest was in the room. The ice scoop holder was also nailed to the ice chest’s handle, and it had dirt on the inside and the corners. The scoop was again resting directly on the dirty residue. Certified Nursing Assistant # 6 stated the night staff were responsible for keeping the ice scoop holders clean. The Dietary Manager also stated that evening staff were supposed to bring the ice-scope holders to the kitchen for washing whenever they became dirty. During an observation and interview on 08/18/2025 at 12:10 PM, this surveyor observed DA # 7 who was assisting with the lunch meal picking up cartons of milk, milk shakes, and condiments and placing them on trays. Without washing her hands, DA #7 picked up cups and glasses with beverages in them by the rims and placed them on the trays to be served to the residents during the lunch meal. DA # 7 stated she should have washed her hands after handling dirty objects, such as cartons of supplements, and before handling clean equipment. During an observation and interview on 08/18/2025 at 3:21 PM, this surveyor observed DC #8 push the blender motor to the edge of the counter, contaminating her hands. Without washing her hands, she used her bare hand to pick up a clean blade and attached it to the base of the blender to puree fooditems for the residents who received pureed diets. DC#8 stated she should have washed her hands after touching dirty objects such as the blender motor, before handling clean equipment. A review of a facility policy titled, “Hand washing and Glove Usage in Food service” indicated employees should wash their hands before starting work, after leaving and returning to the kitchen preparation area and after touching anything else such as dirty equipment, and work surfaces.

Based on observation, record review, and interview, the facility failed to ensure care plan interventions were consistently implemented for 1 (Resident #1) of 4 (Residents #1, #2, #3, and #4) sampled residents whose care plans were reviewed for continuity of care. The findings are: Resident #1 had diagnoses of Alzheimer's disease and moderate dementia with agitation as specified in the Medical Diagnosis section of the electronic health record (EHR). Review of the annual Minimum Data Set with an Assessment Reference Date of 05/21/2024, indicated Resident #1 had a Brief Interview for Mental Status score of 02, which indicated the resident was severely cognitively impaired and required partial to moderate assistance with personal hygiene. Review of the Care Plan, dated 05/29/2024, indicated Resident #1's usual performance with activities of daily living (ADLs) was non-weight bearing due to dementia and some tasks included bilateral AFOs (Ankle-Foot Orthosis) when out of bed for bilateral foot drop. Another focused problem included Resident #3 was at risk for impaired skin integrity and tasks included keep nails trimmed/filed to minimize jagged edges initiated on 01/22/2024 and protective sleeves to be worn at all times that was initiated on 06/03/2024. On 07/01/2024 at 10:18 AM, Resident #1 was observed lying in bed with eyes closed and yelling, Can I get up?. There were no bilateral protective sleeves on the resident at this time. On 07/01/2024 at 12:08 PM, Resident #1 was observed sitting up in a wheelchair in the front entrance common area and there were no bilateral protective sleeves on either arm or an AFO brace on either leg. On 07/02/2024 at 10:47 AM, Resident #1 was observed lying in bed, eyes closed. There were two small broken areas of skin on the resident's right outer arm with bright red dried blood in both areas. There were no bilateral sleeves on either of Resident #1's arms at this time. On 07/02/2024 at 10:26 PM, during an interview, Certified Nursing Assistant (CNA) #1 confirmed the residents' care plans in the computer was how she knew how to care for them. On 07/03/2024 at 11:06 AM, during an interview, CNA #2 confirmed Resident #1 was to have sleeves on the arms every day. On 07/03/2024 at 11:34 AM, during an interview, CNA #2 confirmed Resident #1's care plan was how the staff knew what care to provide but denied any knowledge that Resident #1 was to have AFO braces on when out of bed. On 07/03/2024 at 12:04 PM, during an interview, the Administrator confirmed the facility did not have a policy or procedure on care plans. On 07/03/2024 at 1:33 PM, during an interview, the Assistant Director of Nursing (ADON) confirmed there were AFO braces in Resident #1's room and that the resident was care planned to have them on when out of bed due to foot drop.

Based on observation and interview, the facility failed to ensure privacy and dignity was maintained for 1 Resident (Resident #14) of 1 Resident observed during activity of daily living care. This failed practice had the potential to affect 78 residents currently residing in the facility. Findings included: a. On 05/13/2024 at 01:27 PM, Certified Nursing Assistant (CNA) # 3 and CNA #4 entered Resident # 14's room, to perform brief change and peri-care. b. An observation on 05/13/2024 at 01:33 PM, CNA #3 removed resident's brief. A window, to the left side of the Resident's bed, had a window shade for privacy, and the shade was open. CNA # 4 was standing on the left side of the Resident's bed, in front of the window. CNA #4 turned around and looked out of the window twice and did not close the window shade. CNA #3 removed Resident #14's pants, unfastened and lowered resident's brief, exposing abdomen, private area, and legs. c. During the observation on 05/13/2024 at 01:35 PM, CNA # 4 turned around and closed the window shade. d. On 05/13/2024 at 01:44 PM, Resident # 14's room door was opened during the Resident's transfer from the bed to the wheelchair. CNA #8 did not knock on door and stated Resident #52 was in the hallway. e. During an interview, on 05/13/2024 at 01:47 PM, CNA #4 stated the window shade should have been closed before brief was removed to provide privacy. f. During an interview on 05/13/2024 at 02:07 PM, CNA #3 stated privacy should have been provided prior to the care of Resident #14. g. During an interview on 05/15/2024 at 09:35, the Director of Nursing (DON) indicated staff should provide privacy when providing any care for the resident's dignity, so no one sees them if they are naked, and it is a Resident right. h. During an interview on 05/15/2024 at 02:00 PM, CNA #8 stated, I didn't, but we are supposed to knock for privacy before entering a Resident's room. i. In an interview on 05/16/2024 at 02:55 PM, the Administrator indicated staff should provide privacy during care and should knock and announce, when entering a resident's room it is a dignity issue and for privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview it was determined that the facility failed to ensure Resident #178's personal and medical information was protected from potential unauthorized persons. The finding include: Resident #178 had a diagnosis of Depression and Cerebral Infraction. According to Quarterly Minimum Data Set (MDS) with the Assessment Reference Date 04/24/23 documented that Resident 178 scored 15 (13-15 indicating cognitive intact) on the Brief Interview of Mental Status prior to discharge from the facility on 05/29/23. admission MDS dated [DATE] was still in progress. A Care Plan for Resident #178, with the initiate date of 05/06/24, Resident #178 had no discharge plans anticipated at that time and the current plan was to remain in facility for Long Term Care. On 05/15/24 at 09:05 AM, the Surveyor and Licensed Practical Nurse (LPN) #3 entered Resident # 178's room LPN #3 was positioned with back to the medication cart that was in the hallway. The Surveyor noted medication cart was unlocked with keys in the lock, the resident's medication was on top of the cart, the laptop computer was open to the Electronic Medication Administration Record (E-MAR) profile that displayed Resident #178's person information, medical choices, and medication order. On 05/15/24 at 09:10 AM, LPN #3 confirmed the medication on top of the cart was left unattended, the keys were in the lock of the unlocked cart, and the computer screen was unlocked and displaced the Resident's personal and medical information. On 05/16/24 at 09:00 AM, the Director of Nursing confirmed that unauthorized people can see the Resident information including but not limited to date of birth , picture, and orders if the nurse's computer was unlocked to display the resident's profile. On 05/16/24 at 9:05 AM, the Assistant Director of Nursing (ADON) voiced, after pulling up a Resident's E-MAR profile that was displaced on the screen of the unlocked computer, that the Resident's date of birth , picture, name, code status, physician orders, physician's name, room number, allergies, diet, and vital signs could have noted and an unauthorized individual was familiar with electronic facility computer software system other confidential information could have been obtained. On 05/16/24 at 09:58 AM, a policy titled Confidentiality of Social and Medical Record Information was presented to the Surveyor that documented Privacy and Confidentiality Resident/Elders' personal and medical records are protected to assure confidentiality. An in-service titled General In-Service-HIPPA [Health Insurance Portability and Accountability Act] .Examples of failure to comply with HIPPA 1. Leaving resident information out in the open for anyone walking by to see. a.Nurses Not minimizing the computer screen on med cart. Leaving charts opened out in the common area/nurses desks .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure a sink was properly attached to a bathroom wall, for one bathroom sink of two sinks observed. This failed practice had the potential to affect 1 Resident who had access to room [ROOM NUMBER]. Findings included: a. During an observation on 05/13/2024 at 01:14 PM, the bathroom sink in room [ROOM NUMBER] was not flush with the wall. [NAME] caulking type material, partially covered with paint, spread in globs across top and sides of the sink with an open gap on right side behind the cold-water knob. b. During an interview on 05/14/2024 at 10:37 AM, the Maintenance Director was asked to accompany the surveyor to room [ROOM NUMBER]. The Maintenance Director was asked if there was a gap between the wall and the back of the sink. The Maintenance Director stated, there is a bracket on the wall, screwed into the wall, the sink sits on the bracket, and it would not come off. When asked why the sink was not flush with the wall, the Maintenance Director stated, it gets loose due to residents using them (the sink) to push up when standing back up. The Maintenance Director denies the sink would fall from the wall, It is sturdy. The Maintenance Director grabbed the sink and moved the sink in a side-to-side motion. The sink shifted making a grating noise. The Maintenance Director exited room [ROOM NUMBER], faced the wall in hallway and said, this is the bracket, (moved hands outward in a horizontal line), it is held with screws to the wall and bolts to the sink. It cannot come off the wall. When asked if the screws were coming loose from the wall, the Maintenance Director said, Yes. I guess it could fall. c. During an observation on 05/15/2024 at 08:43 AM, the sink in room [ROOM NUMBER] did not move when touched, no gap appeared between wall and sink, and caulk type material was white without paint covering area to right of faucet, behind the cold-water knob. d. The Administrator was interviewed on 05/16/2024 at 02:55 PM. The Administrator stated there is a preventative maintenance program and the Maintenance Director will be able to provide specifics, he rounds the facility all day long. Correction of any maintenance issues are done as time allows and if it is urgent, it is done immediately. A resident sink that is not properly fastened to the wall would possibly be considered a hazard and needs to be fixed. e. On 05/16/2024 at 03:18 PM, the Maintenance Director stated he does round every day with the renovations going on and he picks a hall and does a different resident room every week. If a Certified Medical Assistant sees an issue or a resident says they need something fixed, there is a notification book at each nurse station that is filled out and I check those daily. There are urgent needs and basic needs, the information they fill out in the book gives those choices. Urgent needs are done right away and the basics are as time allows. The Maintenance Director acknowledged the Resident sink in room [ROOM NUMBER] and was addressed right away.

Based on record review and staff interview, the facility failed to ensure a referral for Pre-admission Screening and Resident Review (PASRR) was made for one (Residents #72) sampled resident reviewed for PASARR. Specifically, the facility failed to ensure Resident #72's PASRR Level 1 pre-screening was completed prior to admission. The findings include: 1. A review of the Care Plan revealed the facility admitted Resident #72 on 03/30/2024 with diagnoses that included bipolar II disorder. 2. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/2024, revealed Resident #72 had a Brief Interview for Mental Status [BIMS] score of 15 which indicated the resident is cognitively intact. 3. A review of Resident #72's Care Plan, revised 04/10/2024, revealed the resident had bipolar disorder and depression, would exhibit indicators of depression, anxiety, or sad mood, and had interventions in place that included administering medications as ordered and observing the resident for signs of depression. 4. A review of a Level I Preadmission Screen for Resident #72 revealed the screening was completed on 05/14/2024 and indicated the resident had a Diagnosable Major Mental Disorder identified as Bipolar Disorder. 5. During an interview on 05/15/2024 at 2:16 PM, the Assistant Director of Nursing [ADON] was asked who completed the PASRR screenings in the facility. The ADON indicated she started working in the facility on April 12, 2024, and that she has been responsible for the PASRR screenings since that date. The surveyor asked the ADON when a PASRR Level 1 screening is required to be completed. The ADON indicated the screening should take place before residents are admitted to the facility. The surveyor asked ADON when Resident #72's PASRR Level 1 was completed. The ADON indicated the screening took place on 05/14/2024. 6. During an interview on 05/16/2024 at 3:00 PM, the ADON stated the facility did not have a policy for Minimum Data Set [MDS] or PASRR.

Based on observations, interviews, record review and review of facility policy and procedures, the facility failed to provide perineal care in accordance with professional standards of care, for 2 (Resident #14 and Resident #52) of 2 residents observed. This failed practice had the potential to affect 7 residents residing in 300 hall who required assistance with perineal care. The findings are: 1. a. A review of an admission Record, indicated the facility admitted Resident #14 with diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting left, non-dominant side, interstitial pulmonary disease, pulmonary edema, cerebral vascular disease, and cerebrovascular disease. b. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. Resident was dependent on staff for toileting hygiene, lower body dressing, sitting to lying and lying to sitting, sit to stand and chair to bed transfers. Resident required substantial assistance with rolling from left to right. c. A review of Resident #14's Care Plan, revised 02/02/2024, revealed the resident was dependent on staff for toileting hygiene. Interventions included 1 or more staff members to complete the activity. d. During an observation and interview, on 05/13/2024 at 01:27 PM, Certified Nursing Assistant (CNA) #3 and CNA #4 entered Resident's room, closed the door, pulled the curtain, explained procedure to Resident #14, transferred from wheelchair to bed. CNA #3 pulled back foreskin and used 1 wipe to clean private area using one swipe across the tip of the private area. Pulled skin back over tip of the private area. CNAs rolled Resident #14 onto the right side, 1 wipe used to clean both buttocks. CNA #3 placed a clean brief under resident. Resident was rolled onto left side. CNA #4 adjusted brief under resident. Resident rolled onto back as both CNAs fastened back of brief to front. CNAs put Resident #14's pants back on. Resident transferred from bed back into wheelchair. e. CNA #3 did not know if Resident #14 was circumcised, I just know there is a lot of skin there and I had to keep pulling it up to clean it. CNA #3 stated gloves should be changed and hands sanitized during brief changes, I just forgot to bring in extra gloves. 2. a. A review of an admission Record, indicated the facility admitted Resident #52 with diagnoses that included Ataxic Cerebral Palsy, hypertension, iron deficiency anemia, polyosteoarthritis, and urinary incontinence. b. The quarterly MDS, with an ARD of 04/16/2024, revealed Resident #52 had a BIMS score of 2 which indicated the resident had severe cognitive impairment. Resident was dependent on staff for toileting hygiene, personal hygiene, upper and lower body dressing, sitting to lying and lying to sitting, and rolling from left to right. c. A review of Resident #52 ' s Care Plan, revised 04/17/2024, revealed the resident was dependent on staff for toileting hygiene. Interventions included 1 or more staff members to complete the activity. d. On 05/13/24 at 01:52 PM, CNA #3 and CNA #9 entered Resident #52 s room, explained procedure, provided privacy by closing door, and pulling privacy curtain between door and bed and between bed A and B. No hand hygiene was performed, both aides gloved. Resident #52 was transferred to the bed using a lift. CNA #3 explained brief change process to resident. CNA #9 assisted with lift movement, legs of device not spread during transfer to fit under bed, wheels remained unlocked. Resident lowered into bed, Resident's head was positioned against headboard causing chin to be at chest, shoulders on pillow. CNA #9 left room after transfer. No hand hygiene performed. CNA #3 placed two clear trash bags at the foot of bed, rolled Resident onto left side, providing explanation of removing sling. CNA #3 removed Resident's pants and placed them into the clear trash bag near wall. CNA then unfastened brief and lowered front of brief exposing Resident's lower body. One wipe used to wipe for personal care in circular motion one time. Wipe placed in clear trash bag close to the edge of bed away from wall. 1 wipe used to wipe downward motion on left groin. Wipe placed in clear trash bag. One wipe used in downward motion on right groin. Disposed of in clear trash bag. Resident rolled onto right side, away from CNA, sling removed. One wipe used upward motion to lower back. Two wipes used to clean stool from gloves. Five more wipes used to clean lower back in upward motion. One wipe used to clean left and right buttock, swipe up on right across back and down on left. Clean brief placed under Resident and Resident rolled to left side to brief could be positioned under Resident. Resident rolled onto back and brief fastened. Resident moaning and grimacing. CNA #3 removed glove from left hand, placed package of wipes in drawer of bedside table. No hand hygiene done. Covered resident with blanket, held clear trash bags in, still gloved, right hand. e. At 02:03 PM, Resident # 52 was positioned to comfort, raising head of bed, clipping call light to blanket in reach, bed placed in low position. No hand hygiene performed during brief change and no glove change performed. Trash and soiled pants taken to hallway and placed in appropriate bins. f. 05/13/24 02:07 PM CNA #3 stated gloves should be changed, and hands sanitized during brief changes, I just forgot to bring in extra gloves. Hands should be sanitized before providing a beverage and after, I just didn't think about it. g. Review of the facility's undated document titled, Peri Care Check Off, instructed to Gather all supplies . Use the overhead table for your items. Put gloves on. Undo soiled brief and roll up and tuck under resident. Start at the waist (belly button is landmark) and work your way down to the knees. At the belly button line farthest away from you (hip bone) start with your first swipe. Takes approximately 3 swipes, maybe more depending on size. Be sure to get under the belly roll. Make sure to get the . pubis area. Next outer long leg toward pubis are on inner thigh on both sides. Male: pull the foreskin back and clean the head in a circular motion. Depending on how dirty make take a couple of times cleaning. Then the shaft to the base (away from the [male private area]). Clean the scrotum and under the scrotum. Be sure to pull the foreskin back over the {private area].Clean the thighs (inner and outer) to the knees. Be sure to get all areas of the legs. Take towel longways and lay on resident from waist to the knees and pat dry. Do not move towel while pat drying When finished place in bag. Change gloves from front to back. (both people change gloves clean and dirty person) Hand gel between glove change. (state says had gel not required) (optional only if soiled) Reposition resident on side. Start on the back at the waist. Make the swipe across. Then butt cheek up/butt cheek up. /Crack up. Ensure area is clean. Male (ensure under scrotum is clean). Clean both legs down to the knees be sure to get all area of the leg. Change gloves. Place clean brief. Roll resident toward you. Then the other person will finish cleaning resident on opposite side of bed. Pat dry. Changes gloves and apply cream.Wash hands. Offer fluids etc.Comments: .Always 2 people to do peri-care with sate in the building. One person be clean, and one does care. When in doubt change gloves. Always one swipe with 1 wipe. Front to back. h. A review of the Peri Care Check Off for Certified Nursing Assistant (CNA) #3, provided by the Assistant Director of Nursing (ADON) on 05/16/2024 at 03:14 PM, revealed the facility evaluated CNA #3 on 08/01/2023 and a Y was documented for each area of the check off. i. A review of the Peri Care Check Off for CNA #4, provided by the Assistant Director of Nursing (ADON) on 05/16/2024 at 03:14 PM, revealed the facility evaluated CNA #4 on 08/04/2023 and a Y was documented for each area of the check off. j. A review of the Peri Care Procedure for CNA #3, provided by the ADON on 05/16/2024 at 03:14 PM, revealed CNA #3 was evaluated on 03/26/2024 and given a check mark under the heading PASS for each item in the procedure. The first step in procedure indicated Prepare . GATHER SUPPLIES: Knock before entering . Provide privacy . set up supplies and work area named moisture shield etc. On towel . Explain . Position resident . Spray peri-cleanser ./ or pre-moistened wipes. Wash area from lower abdomen to pubic bone including waist and hips (anywhere a wet brief may have been in contact with the skin). Place dirty cloth in linen trash bag. Use dry cloth and dry this area. Place this cloth in linen trash bag. Clean front of resident using one wipe for each swipe (left side, middle, right side) utilizing front to back procedure. Please remember to pull back foreskin on male residents that are not circumcised gently and clean the head of the [male private area].Catheters: . Pat dry using clean, dry wash cloth. Put on clean gloves and turn resident over to expose buttocks. Clean back side front to back, wash entire buttocks area - pat dry Apply named moisture shield - (named) ointment - (named) - skin barrier as needed, remove gloves sanitize hands Make resident comfortable .Offer fluids . Close trash bags and dispose of properly . Wash hands with soap and water . k. A review of the Peri Care Procedure for CNA #3, provided by the ADON on 05/16/2024 at 03:14 PM, revealed CNA #3 was evaluated on 03/26/2024 and given a check mark under the heading PASS for each item in the procedure. l. A review of the Peri Care Procedure for CNA #4, provided by the ADON on 05/16/2024 at 03:14 PM, revealed CNA #4 was evaluated on 03/26/2024 and given a check mark under the heading PASS for each item in the procedure. m. Review of the facility document titled, All Staff Inservice Education Report, dated 05/01/2024, with a topic Importance of Good Hand Hygiene specified, . 1. When properly washing hands the correct way it helps to reduce and prevent the spread of germs 2. Hand washing helps protects . the resident . from getting sick . 4. One should wash hands before/after the use of gloves, .before and after peri-care of resident . The signature page contained CNA #3's signature and did not contain CNA #4 ' s signature. n. A review of a facility document titled, All Staff Inservice Education Report, dated 05/01/2024, with a topic Use of Hand Sanitizer instructed, 1.can be used when soap and water is not available. 2. Sanitizers can quickly reduce the number of germs on hands . The signature page contained CNA #3's signature and did not contain CNA #9's signature. o. Review of the facility undated policy and procedure titled, Hand Hygiene, specified, Perform Hand Hygiene When: 5. After contact with inanimate objects in immediate vicinity of the patient. Alcohol-based Hand Rub: is the preferred method of decontamination if hands are not visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids. Alcohol Based Hand Rub Procedure: 1. Apply dime-sized amount of product into the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. This usually takes 15 seconds of less.

Based on observation, interview, record review and policy review, the facility failed to follow manufacturer guidance to transfer a Resident from the wheelchair to the bed and from the bed back to the wheelchair for 1 Resident (Resident #14) of 1 Resident observed during a transfer. This failed practice had the potential to affect 3 residents (Resident #14, #42, and #45) who are transferred using a sit to stand lift. Findings include: a. A review of an admission Record, indicated the facility admitted Resident #14 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left, non-dominant side, other reduced mobility, cerebral vascular disease, and cerebrovascular disease. b. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. Resident was dependent on staff for toileting hygiene, lower body dressing, sitting to lying and lying to sitting, sit to stand and chair to bed transfers. Resident required substantial assistance with rolling from left to right. c. A review of Resident #14's Care Plan, revised 02/02/2024, revealed the Resident is dependent on staff for activities of daily living. Interventions included . Sit to stand with 2 staff assistance for transfers. d. On 05/13/2024 at 01:27 PM, Certified Nursing Assistant (CNA) #3 and CNA #4 explained to Resident #14 they were going to do a transfer from wheelchair to bed to perform a brief change. Resident #14 did not want to remain in bed. CNA #3 stated they would return Resident to the wheelchair after the brief change. CNA #3 placed a sling around Resident's back, under both arms, with the opening and loops at the chest. CNA #3 and CNA #4 attached loops to the device, placed Resident's feet on what is identified as the footplate on page 6. Resident #14 has a left-hand that will not fully open, fingers are stiff, and index finger not able to curl around the handle. Resident was able to grip the right-side handle. CNA #3, took resident's left hand and strained to open the hand to allow fingers to hook on the left side handle, talking to Resident, Let's get your hand up here, hold on. The strap for the leg was not on device and no leg stabilization was done. Resident #14 was not standing, the assist sling, around upper torso, was suspending Resident's upper body, Resident's feet were on the footplate, knees bent, Resident's body was in a bent position with chest above feet and buttocks sticking outward past footplate. Buttocks was not supported. Resident #14 was transferred to bed. After the care Resident was transferred back to wheelchair using same method, left hand unable to grip handle, CNA #3 hooked fingers on handle, sling applied to upper torso, no buttock strap used. e. On 05/14/2024 at 02:01 PM, the named lift, sit to stand device, was on 300 hallway, to the left of Resident #14's room. The Caution label documented, . 2. This equipment shall be operated by trained caregivers only.5. For details of operation of this equipment, please refer to your Owner's Manual. f. Review of the (named) lift manufacturer packet dated 2021.09, provided by the Director of Nursing (DON) on 05/14/2024 04:00 PM, when policy was requested. The packet was identified as the policy facility uses by the Assistant Director of Nursing (ADON) on 05/16/202024 at 02:55 PM. Page 21, Fitting Stand Assist Buttock Strap, documented a triangle with exclamation point in the center, the Buttock strap MUST be used with the Stand Assist sling. These slings are designed to complement one another in providing the greatest comfort and security for the patient being transferred. Page 3 listed the symbol explanation as Warning! Failure to heed this warning may result in damage to the product or serious injury to the operator and/or user. On page 22, Lift and Transfer from Bed, number 5, instructed, Have the patient's hands holding the handles. For patients who cannot hold the handles, have them hold their arms around chest. g. During an interview on 05/15/2024 at 09:35 AM, the Director of Nursing (DON) indicated staff should follow manufacturer safety guidance when operating a lift to prevent injury. h. During an interview on 05/16/2024 at 02:55 PM, the Assistant Director of Nursing indicated staff should follow the safety guidelines, and the Administrator stated, I would think so. i. Review of SABINA Sit to Stand Lift Skills Checklist, dated 02/05/2024, revealed CNA #3 was evaluated by the DON, and received check marks on all eleven items reviewed. This checklist was not specific for the (named) lift.

Based on observation, record review and interview, the facility failed to ensure peg tubes were flushed with the appropriate amount of tap water as ordered by the physician to prevent peg tube complications in 1 (Resident #53) of 2 Residents that received tube feeding, and flushes. The findings are: a. A Physician Order (dated, 12/20/2021) documented, Flush feeding tube with 60 cc of water before and after medication administration. b. A Care Plan documented, .Resident #53 has potential for nutritional deficits related to dysphagia, aphasia, dependent of g-tube for nutrition. (Revision on: 02/03/2024) .2/20/24-tube feeding changed, see orders. Administer feedings as ordered Check g-tube for placement as ordered. Cleanse g-tube site as ordered . c. A Physician Order (dated, 02/23/2024) documented, Zenpep Oral Capsule Delayed Release Particles 5000-24000 UNIT (Pancrelipase (Lipase-Protease-Amylase)) Give 1 capsule via G-Tube before meals related to EXOCRINE PANCREATIC INSUFFICIENCY d. A Physicians Order (dated, 03/14/2024) documented, NPO diet NPO texture. e. On 05/15/24 at 11:39 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 check for tube placement on Resident #53. LPN #1 flushed with 30 cc of tap water, administered Zenpep crushed in water, and flushed with 30 cc after. f. On 05/15/24 at 11:42 AM, LPN #1 was asked to check the orders on peg tube flushes before and after medications. LPN #1 confirmed that Resident #53 should receive 60 cc of water before and after medications. LPN #1 was asked to explain the process of confirming the amount of flush before and after medications are given. LPN #1 said, We should check the order before giving medicine. LPN #1 said that getting too little water flushes could cause stomach contents to not clear, and a medication may not be absorbed correctly. g. On 05/15/24 at 12:02 PM, the Surveyor asked the Assistant Director of Nursing (ADON) if there is a process staff are expected to follow prior to administering medications and flushes to residents with a peg tube. The ADON confirmed that nursing should check the physician orders prior to administering medication and flushes. The Surveyor asked if there were any concerns if a resident did not get the ordered amount of water flushes. The ADON said it could cause the peg tube to not be cleared of stomach content, keeping the peg tube patent, and it could cause nutritional issues. h. 05/15/24 01:33 PM, the ADON provided an In-service (dated, 05/31/2023) titled Medication Administration documenting, .Verification of Order All medications MUST be administered according to the physicians order. Every medication given must be checked against the eMAR . In-service titled G tube orders did not provide documentation of material that was covered. No policies on peg tubes or medication administration were provided.

Based on observation and interview, the facility failed to ensure medications were stored and labeled in accordance with state laws and accepted standards of pharmacy practice, failed to ensure nasal spray was administered appropriately for 1 (Resident #178), and failed to ensure medications were secured in 1 medication cart of 2 medication carts observed. This failed practice had the potential to affect 47 residents residing in the facility with the ability to ambulate independently or propel in a wheelchair independently. Findings include: Resident #27's Care Plan identifies Resident #27 with impaired cognitive function r/t Dementia Date Initiated: 08/10/2023. Resident #62 Care Plan identifies Resident #62 with impaired cognitive function due to cerebral vascular accident. Date Initiated: 12/30/2022. On 05/13/24 at 11:40 AM, a medicine cup containing a solid-tubular clear substance was found sitting on the dresser of Resident #27 and a second medicine cup containing a solid-tubular white substance was found sitting on the nightstand of Resident #62. The surveyor asked the Director of Nursing (DON) to identify the substances. The DON stated, I can only guess, maybe zinc, but it should not have been left in the room. The DON asked Resident #62, What is this the resident responded, I don't know, what is it. The DON asked Resident #62, When was this left in your room? Resident #62 stated, yesterday. The DON stated the substances were dried and they were probably left in the room yesterday. On 5/14/24 at 3:25 PM, the surveyor interviewed the DON. The surveyor asked, did you determine what medications were in the two medication cups in the resident's rooms? The DON stated, No, the white was probably zinc and the clear probably ointment. The surveyor asked why is it important to keep medication stored per facility pharmacy and state laws regarding storage. The DON stated, So other residents don't get into them. The surveyor asked what is the danger of medication being left at bedside? The DON stated Another resident could ingest it. Or it could be put in the wrong area or misused or inappropriately used. On 5/14/24 at 3:25 PM, the DON provided the facility Medication Storage in the Facility policy. The policy states: . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 5/14/24 at 4:00 PM, the DON provided a copy of an in-service the facility started on Do Not leave Meds in the room. 05/15/24 09:05 AM, the Surveyor observed LPN #3 pass Resident #178's Fluticasone Propionate nasal spray and the resident self-administered. Resident #178 administered 2 sprays in the right nostril and 1 spray in the left nostril. The order documented Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 1 spray in both nostrils one time a day. On 05/15/24 at 09:05 AM, the Surveyor and LPN #3 entered Resident #178's room for medication administration. The Surveyor noted medication cart was unlocked with keys in the lock, the resident's medication was left on the cart, the screen open to display Resident #178's personal information (including date of birth , picture, orders etc.) On 05/16/24 09:00 AM, the DON confirmed the nurse's key should not be left unattended because someone not authorized could get them and have access to the medication. During an observation on 05/15/24 at 10:05 PM, medication cart for the left side of 300 hall, 400 hall and 600 hall, being used by Licensed Practical Nurse (LPN) #2, rolled cart to the nurses station and parked it, to the right side of the door, of the medication room, located between 300 and 400 hall. LPN #2 then moved to the nurses' station and sat facing 500 and 600 hall. LPN was unable to see the medication cart over the counter while seated. During an interview on 05/15/2024 at 10:12 PM, the DON stated the medication cart should not be left open and unattended. The DON instructed LPN #2 to secure the medication cart. On 05/15/2024 at 10:15 PM, during an interview, LPN #2 stated the medication cart should be locked when unattended and out of sight, so no one can access the medications including confused residents or staff. During an interview on 05/15/2024 at 10:30 PM, the Assistant Director of Nursing (ADON), stated the medication cart should be locked at all times if out of sight of the nurse. It is a safety concern if someone opens the cart and removes something, drinks it or consumes it. Review of a facility policy titled, Medication Storage in the Facility, with an effective date of 01/01/2015, stated, . Policy Medications and biologicals are stored safely, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures .B. Only licensed nurses, .permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.E. Except for those requiring refrigeration . medications intended for internal use are stored in a medication cart.

Based on observation, record review and interview, the facility failed to prevent the misappropriation of narcotics for 2 Residents (Resident #72 & #74) to prevent possible complications of pain management. This failed practice had the potential to affect all residents taking narcotics in the facility. The findings are: 1. a. On 05/14/2024 at 10:26 AM, the Surveyor noted the controlled medication on hand did not match what was documented in the narcotic book for 2 Residents. b. On 05/14/2024 at 10:35 AM, the Surveyor noted the following discrepancies in the controlled medication book: 1. Resident #72 Pregabalin 75 mg there were 23 pills documented and 22 on hand. 2. Resident #72 Oxycodone 20 mg there were 2 pills documented and 1 on hand. 3. Resident #74 hydromorphone 2 mg 47 documented and 45 on hand. c. On 05/14/2024 at 10:35 AM, Licensed Practical Nurse (LPN) #4 voiced she had gotten sidetracked with an Incident and Accident report along with other things and had forgotten to sign them out. d. On 05/14/2024 at 03:00 PM, a review of the electronic records documented that the last administration was 05/13/2024 at 7:00 AM. e. On 05/14/2024 at 03:03 PM, LPN #4 confirmed she knew a controlled substance should be signed out immediately after administration and documented on the Medication Administration Record (MAR). LPN #4 stated she had administered the hydromorphone at 08:40 AM and at 10:15 AM. The Surveyor informed LPN #4 the order (Hydromorphone 2 mg give 2 mg by mouth every 4 hours as needed for pain) did not state every 2 hours as need and LPN #4 changed the 10:15 AM to 12:15 PM and stated she gave the 2nd does at 12:15 PM (12:15 PM was after the time discrepancies was noted by the Surveyor). LPN #4 confirmed not documenting in the MAR neither administration of the hydromorphone and that she would fix it. f. On 05/14/2024 at 03:12 PM, the Surveyor notified the Director of Nursing (DON) of the discrepancies with the narcotic count and the administration have not been documented in the MAR. The Director of Nursing (DON) voiced she had in-serviced the nurse. The DON also voiced she knew there was a problem, but she did not know how to handle it that it depended on how the Surveyors were investigating it. g. On 05/14/2024 at 03:30 PM, the Resident #74 voiced he had not received or asked for any pain medication today. Resident #74 voiced he was having pain earlier in the day during therapy and had told the therapist and rated the pain at a 7 on a 0-10 pain scale. h. On 05/14/2024 at 03:43 PM, the therapist said Resident #74 did voice he was in pain and rated his pain as a 7, but she did not inform the nurse because she did not believe he was a true 7 due to the lack of grimacing and other signs of pain.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets and 15 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The menu for lunch documented residents who received pureed diets were to receive a #8 scoop (1/2 cup) of pureed Spanish rice. The menu also specified for each resident on the mechanical soft diets to receive one tortilla bread each. 2. On 05/13/2024 at 12:51 PM, the following observations were made during the noon meal service: a. The residents who required pureed diets were served pureed beef enchilada, pureed vegetable blend and pureed flour tortilla. There was no pureed Spanish rice served to the residents on pureed diets. There were no substitutes given to the residents on pureed diets, in place of rice not served. b. The residents on mechanical soft diets were served beef enchilada, Spanish rice, and vegetable blend. There was no tortilla bread served to them as specified on the menu. c. On 05/13/2024 at 12:53 PM, the surveyor asked the Dietary Employee (DE) #3 the reason the residents on pureed diets were not served pureed rice. DE #3 stated, I overlooked it. d. On 05/14/2024 at 09:22 AM, the surveyor asked the DE #3 the reason the residents on mechanical soft diets were not served tortilla bread with their lunch meal on 05/13/24. DE #3 stated, I overlooked it.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets. The findings are: 1. On 05/13/2024 at 11:17 AM, Dietary Employee (DE) #3 used a #6 scoop (2/3) cup to place 6 servings of beef enchilada into a blender, added chicken broth pureed, and poured into a pan. At 11:21 AM DE #3 poured the pureed beef enchilada into a pan. The consistency of the pureed beef enchilada was gritty. 2. On 05/13/2024 at 11:24 AM, DE #3 used a #8 scoop (1/2 cup) to place 6 servings of vegetable blends, chicken broth and thickener into a blender, pureed, and poured into a pan. The consistency of the pureed vegetable blend was not form. 3. On 05/13/2024 at 11:41 AM, DE #3 placed 6 servings of flour tortilla into a blender, added chicken broth and pureed. At 11:43 AM, DE #3 poured the pureed flour tortilla into a pan. The consistency of the pureed flour tortilla was thick, sticky, and lumpy. At 12:53 PM, the surveyor asked DE #3 to describe the consistency of the pureed flour tortilla served to the residents for lunch. DE #3 stated, It was thick, sticky, and lumpy. 4. On 05/13/2024 at 12:56 PM, the surveyor asked a certified nursing assistant #1 who was assisting resident in the dining room to describe the consistency of the pureed flour tortilla served to the residents on pureed diets. She stated, It was thick, sticky and lumpy. 5. 05/14/2024 07:40 AM, the pureed sausage served to the residents on pureed diets for breakfast meal was lumpy and not smooth. At 08:10 AM, the surveyor asked Certified Nursing Assistant (CNA)#2 who was assisting residents in the dining room to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It was not smooth. The Director of Nursing stated, It was more like mechanical. She asked CNA #2 to ask the kitchen for another pureed sausage. The kitchen did and she showed the comparison to the CNAs. On 05/14/24 at 08:17 AM, the surveyor asked the DE #3 to describe the consistency of the pureed sausage served to the residents on pureed diets. DE #3 stated, It was not smooth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, document review and policy and procedure review, it was determined the facility failed to ensure hand hygiene and gloves were changed during perineal care for 2 residents (Resident #14 and Resident #52) of 2 residents observed for perineal care. This failed practice had the potential to affect 7 residents who required assistance with perineal care. The facility failed to ensure hand hygiene was performed during clean laundry delivery, before and after entry into room [ROOM NUMBER]. The facility failed to ensure doors for 3 (Resident #18, #28, #54) on droplet precautions remained closed, and COVID positive residents wore the appropriate protection when leaving the room. The Facility failed to ensure staff followed droplet precautions to prevent cross contamination and the spread of disease affecting all 78 residents in the building. Findings include: Review of the facility undated policy and procedure titled, Hand Hygiene, specified, Perform Hand Hygiene When: 5. After contact with inanimate objects in the immediate vicinity of the patient. Alcohol-based Hand Rub: is the preferred method of decontamination if hands are not visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids. Alcohol Based Hand Rub Procedure: 1. Apply dime-sized amount of product into the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. This usually takes 15 seconds or less. During an interview on 05/13/2024 at 02:39 PM, the Infection Preventionist stated the last Inservice on hand hygiene was week before last. Review of the facility's undated, document titled, Peri Care Check Off, instructed to Gather all supplies (box of gloves, 2 packages of wipes, hand sanitizer, 3 towels, brief, butt cream, 2 plastic bags, linens if bed needs changed) and place all items in clean trash bag to bring to the room. Close the blinds and pull your curtain then wash your hands before starting peri-care. Place a towel over the table to set up a field. 2 plastic bags at the end of the bed. One for dirty wipes and the other for dirty linen. Put gloves on. Undo soiled brief and roll up and tuck under resident. Change gloves if you touch any area soiled. Start at the waist . and work your way down to the knees. Takes approximately 3 swipes, maybe more . Make sure to get the . pubis area. Male: pull the foreskin back and clean the head in a circular motion. Then the shaft to the base (away from the head of [private]). Clean the scrotum and under the scrotum.Clean the thighs .to the knees.Take towel longways and lay on resident .pat dry.When finished place in bag. Change gloves from front to back. (both people change gloves clean and dirty person) Hand gel between glove change. (state says had gel not required) (optional only if soiled) Reposition resident on side. Start on the back at the waist. Make the swipe across. Then butt cheek up/butt cheek up. /Crack up. Ensure the area is clean. Male (ensure under scrotum is clean).Change gloves. Place clean brief. Roll resident toward you. Then the other person will finish cleaning the resident on the opposite side of bed.Changes gloves and apply cream.Wash hands. Offer fluids etc.Comments: .Always 2 people to do peri-care with sate in the building. One person be clean, and one does care. When in doubt change gloves. Always one swipe with 1 wipe. Front to back. A review of the Peri Care Check Off for Certified Nursing Assistant (CNA) #3, provided by the Assistant Director of Nursing (ADON) on 05/16/2024 at 03:14 PM, revealed the facility evaluated CNA #3 on 08/01/2023 and a (Y) was documented for each area of the check off. A review of the Peri Care Check Off for CNA #4, provided by the ADON on 05/16/2024 at 03:14 PM, revealed the facility evaluated CNA #4 on 08/04/2023 and a (Y) was documented for each area of the check off. A review of the Peri Care Procedure for CNA #3, provided by the ADON on 05/16/2024 at 03:14 PM, revealed CNA #3 was evaluated on 03/26/2024 and given a check mark under the heading PASS for each item in the procedure. The first step in the procedure indicated Prepare . GATHER SUPPLIES: . GEL HAND SANITIZER, . GLOVES (SEVERAL PAIRS) . The third step listed is, KNOCK BEFORE ENTERING AND WAIT FOR RESPONSE . The fourth step in the procedure indicated, PROVIDE PRIVACY . CLOSE BLINDS . A review of the Peri Care Procedure for CNA #4, provided by the ADON on 05/16/2024 at 03:14 PM, revealed CNA #4 was evaluated on 03/26/2024 and given a check mark under the heading PASS for each item in the procedure. The first step in procedure indicated . PROVIDE PRIVACY . CLOSE BLINDS . Review of the facility document titled, All Staff Inservice Education Report, dated 05/01/2024, with a topic Importance of Good Hand Hygiene specified, showed . 1. When properly washing hands the correct way it helps to reduce and prevent the spread of germs 2. Hand washing helps protect . the resident . from getting sick . 4. One should wash hands before/after the use of gloves, .before and after peri-care of resident . The signature page contained CNA #3's signature and did not contain CNA #4's signature. Review of the facility document titled, All Staff Inservice Education Report, dated 05/01/2024, with a topic Use of Hand Sanitizer instructed, 1.can be used when soap and water is not available. 2. Sanitizers can quickly reduce the number of germs on hands . The signature page contained CNA #3's signature and did not contain CNA #9's signature. A review of an admission Record, indicated the facility admitted Resident #14 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left, non-dominant side, interstitial pulmonary disease, pulmonary edema, cerebral vascular disease, and cerebrovascular disease. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. Resident was dependent on staff for toileting hygiene, lower body dressing, sitting to lying and lying to sitting, sit to stand and chair to bed transfers. Resident requires substantial assistance with rolling from left to right. A review of Resident #14's Care Plan, revised 02/02/2024, revealed the Resident was dependent on staff for toileting hygiene. Interventions included 1 or more staff members to complete the activity. During an observation on 5/13/2024 at 01:27 PM, CNA #3 and CNA #4 entered Resident # 14's room, and closed the door, pulled the room dividing privacy curtain, and explained to Resident #14 they were going to perform a brief change. CNA # 3 pulled back Resident's sheet and comforter. CNA #3 and CNA # 4 donned gloves. No hand hygiene was done upon entering the Resident's room or prior to beginning care. During the transfer of Resident #14 from wheelchair to bed, the Resident's call light fell to floor and was picked up by CNA #4. The call light fell a second time landing as if draped over the legs of the sit to stand, touching floor between device legs and button end on floor. The call device remained on floor from 01:30 PM to 01:32 PM when picked up by CNA # 4 and placed on Resident's bedside table. At 01:33 PM, CNA # 3 removed Resident's brief. A window to the left side of the Resident's bed had a window shade open. A window was behind CNA # 4, who was standing on the left side of Resident's bed. CNA # 4 turned around and looked out window twice and did not close the window shade. CNA # 3 removed Resident # 14's pants, unfastened and lowered Resident's brief, exposing abdomen, private area, and legs. CNA # 3 used 1 wipe to clean the tip of the private area wiping in a straight line. At 01:35 PM, CNA #4 turned around and closed the window shade. CNAs rolled Resident onto the right side. CNA #3 used 1 wipe to clean both buttocks, swiping up on left buttock and down on right buttock. CNA # 3 placed a clean brief behind Resident and tucked edge under Resident's right side. Resident was rolled to the left side and CNA #4 adjusted the brief under the Resident. Resident was rolled onto their back and both CNAs fastened the brief on each side. At 01:38 PM, CNA # 3 pushed clean wipes, sticking out of the top of the soft pack, back into the package using the tips of her pointer and middle fingers and resealed the top. CNAs put Resident #14's pants back on. At 01:45 PM, CNA # 3 using gloved right hand, straightened Resident 14's pillow, removed the soiled bed pad, straightened the top sheet, and comforter, while holding bed pad in left hand. Resident 14's call light placed on top of comforter. CNA #3 was still wearing gloves from the start of the brief change. No hand hygiene or glove change was done during peri-care or the brief change. The call light was not sanitized prior to placing it on the bedside table or on Resident's bed. During an interview, on 05/13/2024 at 01:47 PM, CNA # 4 stated the window shade should have been closed before brief was removed to provide privacy. During an interview on 05/13/2024 at 02:07 PM, CNA # 3 stated privacy should have been provided prior to care of Resident #14, and gloves should be changed, and hands sanitized during brief changes, I just forgot to bring in extra gloves. A review of an admission Record, indicated the facility admitted Resident #52 with diagnoses that included Ataxic Cerebral Palsy, hypertension, iron deficiency anemia, Poly osteoarthritis, and urinary incontinence. The quarterly MDS, with an ARD of 04/16/2024, revealed Resident #52 had a BIMS score of 2 which indicated the Resident had severe cognitive impairment. Resident is dependent on staff for toileting hygiene, personal hygiene, upper and lower body dressing, sitting to lying and lying to sitting, and rolling from left to right. A review of Resident #52's Care Plan, revised 04/17/2024, revealed the resident was dependent on staff for toileting hygiene. Interventions included 1 or more staff members to complete the activity. During observation on 05/13/2024 at 01:52 PM, CNA #3 and CNA #9 brought Resident #52 into room and provided privacy. No hand hygiene was performed. Both aides donned gloves. Resident #52 was placed in bed by using a lift. CNA #3 explained the process to the Resident. Resident lowered into bed, Resident's head was positioned against headboard causing chin to be at chest, shoulders on pillow. CNA #9 left room. No hand hygiene done. CNA #3 placed two clear trash bags at the foot of bed, rolled resident onto left side, providing explanation of removing sling. CNA #3 removed Resident's pants and placed them into the clear trash bag near wall. CNA then unfastened brief and lowered front of brief exposing the Resident's abdomen, private area, and lower body. One wipe used to wipe the private part, in circular motion, one time. Wipe placed in clear trash bag, closest to the edge of bed, away from wall. One wipe used to wipe in a downward motion on left groin. Wipe placed in the clear trash bag. One wipe used in a downward motion on right groin. Disposed of in clear trash bag. Resident rolled onto right side; sling removed. One wipe is used in an upward motion to gluteal cleft which then becomes soiled. CAN #3 used 2 wipes to clean soiled area from gloves. Five more wipes used to clean gluteal cleft, 1 swipe each. One wipe used to clean left and right buttock, swipe up on right across back and down on left. CNA #3 placed a clean brief under Resident and Resident rolled to left side to allow brief to be positioned under Resident. Resident rolled onto back and brief fastened. CNA #3 removed glove from left hand, placed package of wipes in drawer of bedside table. No hand hygiene observed. CNA covered Resident with a blanket, while holding clear trash bags in, still gloved, right hand. On 05/13/2024 at 02:03 PM, CNA #3 re-positioned Resident #52 to comfort, raising head of bed, clipping call light to blanket in reach of Resident, placed the bed in low position. No hand hygiene performed during brief change and no glove change performed. Trash and soiled pants taken to hallway and placed in appropriate bins. On 05/13/2024 at 02:04 PM, CNA #3 returned to Resident #52's room and held a water cup and straw providing resident a drink. No hand hygiene performed prior to re-entering Resident's room or after exiting resident room. In an interview on 05/13/2024 at 02:07 PM, CNA #3 stated gloves should be changed and hands sanitized during brief changes, I just forgot to bring in extra gloves. Hands should be sanitized before providing a beverage and after, I just didn't think about it. On 05/14/2024 at 10:07 AM, Housekeeping #1 was observed entering room [ROOM NUMBER], delivering a blue and gray colored folded blanket. No hand hygiene was done while going into room [ROOM NUMBER]. Housekeeping #1 knocked on the room door and announced entry. Housekeeping #1 delivered blanket and stood in doorway of room speaking with residents. Housekeeping #1 exited room and did not perform hand hygiene. During an interview with Housekeeping #1, stated they were never told to sanitize going into rooms only coming out. Housekeeping #1 stated their hands were sanitized, and there is no sanitizer on the laundry cart as they cannot keep them on the cart, only a small bottle in their pocket if they want. Housekeeping #1 stated they did not have a small bottle of sanitizer. On 05/14/2024 at 10:16 AM, observation of the wall sanitizer dispenser, hanging on the wall in room [ROOM NUMBER], to the left of the television, was checked and contained sanitizer. Review of the facility document titled, All Staff Inservice Education Report, dated 05/01/2024, with a topic Importance of Good Hand Hygiene specified, . 1. When properly washing hands the correct way it helps to reduce and prevent the spread of germs 2. Hand washing helps protects . the resident . from getting sick . 4. One should wash hands before/after the use of gloves, .before and after peri-care of resident . Signature page did not contain Housekeeping #1's signature. Review of the facility document titled, All Staff Inservice Education Report, dated 05/01/2024, with a topic Use of Hand Sanitizer instructed, 1.can be used when soap and water is not available. 2. Sanitizers can quickly reduce the number of germs on hands . The signature page did not contain Housekeeping #1's signature. In an interview on 05/14/2024 at 09:35 AM, the Director of Nursing (DON) indicated staff should be changing gloves when going from dirty to clean, when gloves become visibly soiled, and performing hand hygiene with glove change to avoid cross contamination. On 05/15/2024 at 09:45 AM, the Administrator stated there was not a different hand hygiene policy for laundry, and there was not a policy for clean laundry handling. In an interview on 05/15/2024 at 10:15 AM, CNA #5 stated gloves should be changed during care if they are soiled or if doing peri care and always sanitize. During an interview on 05/16/2024 at 02:55 PM, the Administrator indicated gloves should be changed during peri care per policy. On 05/13/2024 at 02:39 PM, interview with the Infection Preventionist (IP); Isolation confirmed that residents with COVID should remain in their room with the door closed if they test positive for COVID. On 05/14/24 at 08:30 AM, while walking down 300 Hall the Surveyor observed the doors to room [ROOM NUMBER] and 305 open with droplet precaution signs, and personal protective equipment (PPE) sitting outside of the rooms. room [ROOM NUMBER] had appropriate droplet signs and the door was closed. Residents were observed sitting at the bedside in wheelchairs without masks. On 05/14/24 at 02:01 PM, The Surveyor observed the doors to room [ROOM NUMBER] and 305 open with droplet precaution signs, and PPE sitting outside the rooms. On 05/14/2024 at 03:18 PM, the Surveyor was standing at the nurses' station and observed Resident #28, who was on droplet precautions walking down the hall with a rolling walker and no mask in place. As Resident #28 walked past a room, Resident #18 who was also on droplet precautions was observed without a mask coming out of the room and spinning around 3 times in a specialty chair and going back to the room. The Surveyor walked down hall and observed the door to Resident #18's room was open with resident sitting near the bedside table. Resident #54, who was also on droplet precautions, was resting with eyes closed with the door open. The Surveyor observed Registered Nurse (RN) #2 walking to the open door of Resident #28's room and shut the door and removed an isolation gown from the PPE hanging on the outer door. The Surveyor asked RN #2 if the doors to isolation rooms are supposed to be left open, and why. RN #2 told the Surveyor the rooms should be closed because the residents have COVID. The Surveyor asked RN #2 to explain their isolation process for the hall. RN #2 confirmed that the doors to the room of residents with COVID should remain closed because COVID is an airborne disease, and it puts others at risk. On 05/14/2024 at 10:58 AM, Nurses note documented, . (Resident #28) Continues on isolation r/t to COVID+ diagnosis . On 05/15/2024 at 00:50 AM, Nurses note documented, . (Resident #18) Remains on droplet isolation precautions for COVID-19 . On 05/15/2024 at 01:16 AM, Hot Rack Charting note documented, . (Resident #54) Remains on droplet isolation precautions for COVID-19 . On 05/13/24 at 2:28 PM, Surveyor observed the Maintenance Man pushing a cart down the 600 hall, he was wearing a blue mask over his nose and mouth. He stopped at the end of the hall and pushed open the door of room [ROOM NUMBER] which had signage on the door to wear personal protect equipment Personal Protection Equipment (PPE) due to droplet precautions. Surveyor asked the Maintenance Man if he knew he was supposed to wear PPE into the room? The Maintenance Man stated: I don't know what she has, I was just taking her about her Mother's Day present. On 05/15/24 at 10:25 PM, the DON indicated they do not have a mask policy, they can ask staff to wear them, but they cannot make them wear them. Infection Prevention and Control policy submitted by the Administrator on 05/15/24 at 4:00 PM indicates, .The nursing facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .All persons shall adhere to the infection prevention and control program by referencing said resources. COVID-19 Guidance policy submitted by Administrator on 05/15/24 at 4:00 PM indicates, .Staff will be alert to signs of COVID-19.

Based on observation, record review and interview, the facility failed to ensure the dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen, ensure leftover foods were not used to maintain food quality; food items stored in the refrigerator/freezer were covered, sealed, and foods were dated when opened to ensure first in, first out usage to prevent potential for food bone illnesses: ceiling vents and lights were maintained in clean, sanitary conditions for food preparation These failed practices had the potential to affect 76 residents who received meals from the Kitchen. The findings are: 1. On 05/13/224 09:15 AM, Dietary Employee (DE) #1 was standing by the clean area of the dish washing machine when she pulled an apron around her waist and tied it in a knot. She picked up a coffee cup, placed her finger inside the cup and removed the debris inside the cup, then placed the cup on the tray to be used in serving coffee to the resident for lunch. 2. 05/13/24 At 09:16 AM, DE #1 picked up a clip board from the counter and gave it to DE #2. She touched her mask contaminated her hands. Without washing her hands, she picked up glasses by their rims and stacked them on the trays to be used in serving beverages to the residents for lunch meal. DE #1 picked up plates from the rack in the dish washing machine room and when DE #1 was ready to place them on the plate warmer, the surveyor immediately asked DE #1 what should you have done after touching dirt object and before handling clean or food items? DE #1 stated, I should have washed my hands. 3. On 05/13/24 at 09:18 AM, DE #1 turned on the hand washing sink faucet and washed her hands. She used her bare hands to turn off the faucet, contaminating her hands. Without washing her hands, DE #1 picked up glasses by their rims and stacked them on the trays to be used in serving beverages to the residents for lunch. 4. On 05/13/24 at 09: 22 AM, DE #2 was on the dirty side of the dish machine. He picked up a water hose and used it to remove leftover food items from the plates. Without washing his hands, he picked up plates and placed them on the rack to be used in portioning food items to be served to the residents for noon meal. The surveyor asked the DE #2 what should you have done after touching dirty objects before handling clean equipment? DE #2 stated, I should have washed my hands. 5. On 05/13/24 at 09:25 AM, the following dented cans were observed on a rack with non-dented cans to be used. a. A can of dented pumpkin. b. A can of peach pie filling. 6. On 05/13/24 at 09:36 AM, the following observations were made on a shelf in the walk-in refrigerator. a. A plastic lock bag that contained leftover sausage, leftover scrambled eggs, and leftover bacon. At 10:37 AM the surveyor asked DE #3 what do you use the leftover scrambled eggs, sausage, and bacon in the refrigerator for? DE #3 stated, We use them for the residents we go to dialysis in the morning, residents who received mechanical soft diets and residents on pureed diets the next day. b. There were 4 bags of shredded lettuce with a received date of 05/08/2024. The shredded lettuce leaves were discolored. The surveyor asked the Dietary Supervisor to describe the appearance of the shredded lettuce. She stated they were discolored. We just got them in on 05/08/2024. 7. On 05/13/24 at 09:39 PM, the following observations were made in the walk-in freezer. a. An opened box of beef patties was on a shelf in the freezer. The box was not covered or sealed. 8. On 05/13/24 at 09:52 AM, an opened bottle of lemon juice was on a rack in the storage room. The manufacturer's specification on the bottle documented, Refrigerator after opening. The surveyor asked the Dietary Supervisor what do you use lemon juice for? She stated, We use it when we have a food or dessert that calls for it. 9. On 05/13/24 at 10:14 AM, DE #3 opened a box that contained bags of flour tortilla and placed them on the counter. She united the bags of flour tortilla. At 10:16 AM, DE #3 picked up a spray bottle and sprayed it inside the pan. She pulled the gloves out of the glove box and placed them on her hands, contaminating them. She removed slices of tortilla from the bag and placed each slice in a pan to be used in making beef enchilada to be served to the residents for lunch. The surveyor immediately asked the Dietary Employee what should you have done after touching dirty object and before handling equipment and or food items? (DE) #3 stated, I should have removed gloves and washed my hands. 10. On 05/13/24 at 10:40 AM, the following observations were made in the dish washing room: a. The ceiling/wall above a metal rack on the dirty side of the dish machine had a gray/black residue on it. b. The door frames leading to the dish washing machine room were rotted out and chipped. The areas that were chipped were exposed to the metal. c. The right-side corner of the door leading to the dishwashing machine was missing the baseboard. The area where base board was missing had an accumulation of gray/black residue on it. d. The ceiling air conditioning wood cover had brown stains on it. e. The wall above the counter on the clean side of the dish machine was peeling paints, exposing the cement. f. The areas around the 3-compartment sink, oven, and the corners of the fluorescent lights had rust stains and black stains on them. g. The door frame leading to the outside was pushed in, exposing the metal. h. The floor leading to the janitor's closet was chipped, the area that was exposed had black stains on it. i. The door frames leading to the storage room were chipped exposing the metal. j. The walls in the kitchen, around the food preparation counter, storage room and dishwashing area had black stains that had dried in a drip formation, running down the wall in different areas. k. The ceiling tile by the 3-compartment sink was broken, exposing the concrete. l. Throughout the Storage Room, the corners where the wall and the ceiling meet had a discoloration of black residue. The Surveyor asked the Dietary Supervisor to describe the appearance of the area. She stated, It looks like mildew. 11. On 5/13/24 at 12:01 PM, the Certified Nursing Assistant (CNA) #1 picked up tray card and placed them on the food trays. Then, pulled the utility cart that contained opened tray covers to be used in covering food plates to be served to the residents for lunch towards her. Without sanitizing her hands, she picked up plate covers with her fingers touching the inside of the covers and covered the plates of food items. 12. The facility policy titled, Handwashing and glove usage in food service .When food handlers must wash their hands. Document, Before starting work. After leaving and returning to the kitchen/pre area and after touching anything else such as dirty equipment, work surfaces or cloths. 13. The following observations were made: a. 05/13/24 12:15 PM, thumb touching inside of dome cover with thumb of CNA #1 b. 05/13/24 12:17 PM, CNA #1 thumb touching inside of dome cover. c. 05/13/24 12:17 PM, CNA #1 pulling cart with dome lids - not sanitizing hands then picking up dome lid with hands touching inside of lid with fingers. 14. On 5/13/24 at 12:22 PM, Registered Nurse (RN) #1 confirmed hands should be sanitized after touching a cart and should not have fingers or thumbs touching the inside of the food dome cover.

Based on observation and record review, it was determined that the facility failed to ensure resident dignity was maintained by failure to cover urinary catheter collection devices for 1 (Resident #37) of 1 (sampled resident who had an indwelling urinary catheter. The findings are: Resident #37 had diagnoses of Quadriplegia, Unspecified, Other Specified Disorders of Bladder, and Chronic Obstructive Pulmonary Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not have an indwelling catheter. a. A Care Plan with a revision date of 04/13/23 documented, .has an Indwelling Suprapubic Catheter r/t [related to] Neuromuscular Dysfunction of bladder . Position catheter bag and tubing below the level of the bladder . b. On 05/22/23 at 11:06 AM, Resident #37 was lying in bed. A catheter bag with light yellow urine was hanging from the foot of the bed, not covered and easily visible from doorway. c. On 05/22/23 at 4:11 PM, Resident #37 was lying in bed. A catheter bag was hanging from the foot of the bed, not covered and was easily visible from doorway. d. On 05/26/23 at 9:06 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if a catheter collection bag should be visible. CNA #1 stated, No. It should be in a privacy bag. e. On 05/26/23 at 9:09 AM, the Surveyor asked the Administrator if a catheter collection bag should be visible. The Administrator stated, No. We have privacy bags to put them in. f. On 05/26/23 at 9:10 AM, the Surveyor asked CNA #2 if a catheter collection bag should be visible. CNA #2 stated, It's supposed to be in a bag. The Surveyor asked what the purpose of the bag was for. CNA #2 stated, So you can't see it.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual 3.0, the facility failed to accurately record the assessment for 1 (Resident #50) of 24 (Residents #1, #5, #8, #10, #13, #15, #25, #26, #28, #37, #40, #49, #50, #51, #52, #60, #62, #68, #72, #73, #74, #75, #176 and #278) sampled residents. The findings are: Resident #50 had diagnoses of Nontraumatic Intracerebral Hemorrhage in Hemisphere, Cortical, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, and Unspecified Sequelae of Unspecified Cerebrovascular Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/2023 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Annual MDS with an ARD of 03/02/2023 documented under Section I2000 a diagnosis of Pneumonia coded for the look back period. b. The Quarterly MDS with an ARD of 12/01/2022 documented in Section I2000 a diagnosis of Pneumonia coded for the look back period. c. The Quarterly MDS with an ARD of 09/02/2022 documented in Section I2000 a diagnosis of Pneumonia coded for the look back period. d. On 05/04/23 at 1:33 PM, the Surveyor asked the MDS Coordinator to navigate to the MDS with an ARD of 03/02/23 for Resident #50. The Surveyor asked the MDS Coordinator to identify the response coded under Section I2000, for the diagnosis of Pneumonia. She stated, It says yes. The Surveyor asked if Resident #50 had an active diagnosis to collaborate with that response. She stated, Yeah, I don't see pneumonia in there. I'll go in now and correct those. e. The Resident Assessment Instrument (RAI) Manual, Chapter 1, 1.8 Protecting the Privacy of the MDS Data documented, .Medicare and Medicaid participating LTC [Long Term Care] facilities are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functionable capacity and health status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to review and revise the Care Plan to meet the residents' needs for 1 (Resident #68) of 6 (Residents #25, #27, #40, #52 and #176) sampled residents whose care plans were reviewed. This failed practice had the potential to affect 12 residents who had weight loss in the last 3 months per a list provided by the Director of Nursing (DON) on 05/25/23 at 10:02 AM. The findings are: 1. Resident #68 was admitted on [DATE] with diagnoses of Nondisplaced Fracture of Lateral Malleolus of Right Fibula, Dementia, Depressive Episodes and Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/23 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had a weight loss of loss 5% or more in the last month and was not on a physician prescribed weight loss program. a. A Care Plan initiated on 1/18/23, with a goal to receive adequate nutrition as evidenced by weight stable, with an initiated date of 1/18/23 and a goal revision date of 04/24/23 documented, .has a potential for nutritional deficits related to at risk for malnutrition as evidenced by mini-nutritional assessment . receives a Regular diet . Add Ice cream to Lunch and Dinner, initiated on 1/25/23 . Offer substitutes for foods not eaten, initiated on 1/20/23 . RD [Registered Dietician] to evaluate and make diet change recommendations PRN [as needed], initiated on 1/25/23 . Weigh resident monthly and PRN. Report concerns with changes in weight to MD [Medical Doctor], initiated on 1/20/23 . There were no additional interventions added after the initiation date. b. Resident #68's Medical Record documented her admission weight as 150.5 pounds on 01/18/23, on 02/21/23 her weight was documented as 139.0 pounds, on 04/19/23 her weight was documented as 118.0 pounds and on 05/23/23 her weight was documented as 118.0 pounds. c. On 05/22/23 at 12:25 PM, Resident #68 was sitting in a geri-chair in the Dining Room being fed by a family member. The family member said Resident #68 came to the nursing facility due to a fracture. She has lost a lot of weight, she was home with me till this happened, that is why we are here. I come every day at lunch to feed her, and they feed her the other meals. d. On 05/25/23 at 8:40 AM, the Surveyor asked the Dietary Manager, Can you tell me the interventions or treatments that have been added to [Resident #68's] Care Plan to decrease her ongoing weight loss? She stated, I know she has a weight loss and I know we have added Mighty Shake or maybe it's the house supplement to her trays to try and help with it. I am not sure which one it is right now. The Surveyor asked, Have you revised [Resident #68's] Care Plan with any interventions regarding her weight loss? She stated, No, I have not, we talk about the weights in our meetings, and I tell the DON about any concerns I have. I do assess the residents monthly and we talk about any that have losses, but I myself, I have not revised her Care Plan, we work together to do that. e. On 05/25/23 at 8:45 AM, the Surveyor asked the Assistant Director of Nursing (ADON), Who is responsible for Care Plan revisions on the residents? She stated, We work together on them. The MDS Nurse takes care of the Care Plans with the MDSs, but we can go in and revise them anytime that one needs to be. Any of the nurses or the care staff can revise a Care Plan. The Surveyor asked, Should a residents Care Plan be revised if she has lost over 30 pounds in 4 months? She stated, Yes, it should have been. We can revise at any time, and we can review the Care Plans for needs and put in for the MDS Nurse to make the changes to the Care Plan as well. f. On 05/25/23 at 12:40 PM, the Surveyor asked the MDS Nurse, If a resident had a weight loss of over 30 pounds in 4 months, should the Care Plan reflect interventions to decrease the weight loss? She stated, Yes, it should be. The Surveyor asked, Who is responsible for revising the Care Plans for the residents that are residing on the 100 Hall? She stated, I am. The Surveyor asked, Can anyone revise the interventions on a residents Care Plan if they need to? She stated, Well they could if they wanted to, but we have recently been told that we are responsible for all the Care Plan revisions now. The Surveyor asked, Who uses the Care Plan to provide care to the residents and who has access to the Care Plans of the residents? She stated, The CNAs [Certified Nursing Assistants] and the Nurses. The Surveyor asked, Why should the Care Plan interventions be revised for a resident that has had significant weight loss? She stated, Maybe they need to be fed or on a different diet to prevent further weight loss. g. On 05/25/23 at 11:00 AM, the DON stated, We do not have a policy we use for the Care Plan revision; we use the RAI [Resident Assessment Instrument] manual. h. The RAI Manual, Section 4.7 titled, The RAI and Care Planning, documented, .The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving .

Based on observation, interview, and record review, the facility failed to ensure adequate nail care was provided for 1 (Resident #62) of 15 (Residents #8, #15, #25, #26, #37, #40, #49, #50, #51, #52, #60, #62, #68, #176 and #278) sampled residents who relied on the facility for assistance with nail care. The findings are: Resident #62 had diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Nondominant Side, Rhabdomyolysis, and Other Lack of Coordination. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person for personal hygiene. a. A Care Plan with a revision date of 04/13/23 documented, [Resident #62] is at risk for Impaired Skin Integrity r/t [related to] impaired mobility . Keep nails trimmed / filed to minimize jagged edges . b. On 05/22/23 at 9:46 AM, Resident #62 was sitting in a wheelchair in the hallway. His fingernails extended 1/3 inch past the end of his fingertips and were uneven. The Surveyor asked Resident #62 if he would like them cut. He stated, Yeah. I'd like them cut short. The Surveyor asked who typically cuts his nails. He stated, The people working here. c. On 05/22/2023 at 8:27 AM, Resident #62 was sitting in a wheelchair in his room. His fingernails continued to extend 1/3 inch past the the fingertips. d. On 05/24/2023 at 3:50 PM, the Surveyor asked the Administrator to provide a copy of the facility's policy and procedures regarding nail care. She stated, We don't have one.

Based on observation, interview, and record review, the facility failed to ensure sufficient treatment and services were provided to prevent a decreased range of motion for 1 (Resident #1) of 24 (Resident #1, #5, #8, #10, #13, #15, #25, #26, #28, #37, #40, #49, #50, #51, #52, #60, #62, #68, #72, #73, #74, #75, #176 and #278) sampled residents. The findings are: Resident #1 had diagnoses of Cerebral infarction, Unspecified, Metabolic Encephalopathy, and Fibromyalgia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and had no functional limitation in Range of Motion (ROM). a. A Physician Order dated 05/11/23 documented, Norco Oral Tablet 5-325 MG [milligrams] (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 12 hours as needed for PAIN . b. A Physician Order dated 06/28/22 documented, Voltaren Gel 1% (Diclofenac Sodium) Apply to Left shoulder topically every 6 hours as needed for Pain *2 Grams using dosage card* . c. The Care Plans with an initiated date of 09/09/19 and the latest revisions made on 04/28/23 did not address pain management or maintaining range of motion. d. On 05/22/23 at 10:35 AM, Resident #1 was sitting in a wheelchair in her room. Resident #1 stated, My shoulder is really hurting. She clutched her right shoulder with her left hand and stated, I can't lift it more than halfway and I can't use it to move in my bed. I can't lie on that side. The Surveyor asked if she was receiving therapy. Resident #1 shook her head no. The Surveyor asked if she had reported her pain and the lack of mobility in that arm. She stated, Yes I've told them. e. On 05/23/23 at 9:10 AM, Resident #1 was in the hallway sitting in a wheelchair. The Surveyor asked if she was still in pain from her shoulder. She stated, Yes., and attempted unsuccessfully to lift her arm past horizontal. f. On 05/24/23 at 11:33 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if Resident #1 had reported pain in her shoulder or difficulty performing ADLs (activities of daily living). She stated, She's been complaining about that for about a week. She's getting Norco and they increased her dose from 8 to 12 (milligrams). She's also got a cream I can apply whenever she wants. g. On 05/24/23 at 3:50 PM, the Surveyor asked the Administrator and the Director of Nursing (DON) if they had been made aware of Resident #1's report of persistent pain and difficulty performing transfers and self-care. The DON stated, No I haven't heard anything about it.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a sanitary environment in 1 of 1 medication storage room to prevent potential cross contamination. This failed practice had the potential to affect 1 resident (Resident #72) who had medications stored in the refrigerator as documented on a list provided by the Director of Nursing (DON) on 05/26/23. The findings are: 1. On 05/22/23 at 11:45 AM, in the Medication Storage Area of the 700/800 Halls Nurses Station was a refrigerator designated for resident medications. On the second shelf of the refrigerator below the narcotics lock box, was a white Styrofoam container with 2 pieces of fried fish, coleslaw and french fries. There was no date or name on the food container and the nurse on duty threw out the container of food. In a tray in the door of the refrigerator was four, two tablespoon containers containing a congealed white substance with green flakes. A locked narcotic box was in the refrigerator. There were 1-2 bottles of medication sitting on the shelf with the narcotic box, and 2 bottles of [Nutritional Drink] sitting on a shelf in the door of the refrigerator. 2. On 05/25/23 at 11:24 AM, the Surveyor asked Infection Prevention (IP) #1, Should staff food containers be in refrigerator that the resident's medications are stored in? She stated, No, it should not be. The Surveyor asked, Does anyone have the responsibility to maintain the refrigerators that store the resident's medications? She stated, I go around every morning and check the refrigerators and document the temperatures of them. The Surveyor asked, What days do you work? She stated, I only work Monday through Friday. The Surveyor asked, Why should the staff's food not be stored in the same refrigerator with resident medications? She stated, Cross contamination. 3. On 05/25/23 at 11:30 AM, the Surveyor asked Infection Prevention #2 if staff food should be in refrigerator that resident's medications are stored in. She stated, No. The Surveyor asked, Does anyone have the responsibility to maintain the refrigerators that store the resident's medications? She stated, The weekend nurse supervisor checks the refrigerators on the weekends. The Surveyor asked, Why should the staff's food not be stored in the same refrigerator with resident medications? She stated, Cross Contamination. 4. On 05/25/23 at 11:39 AM, the Surveyor asked the DON, Should the staff's food be in the same refrigerator that the resident's medications are stored in? She stated, No, I did not know it had been done. The Surveyor asked, Why should the staff's food not be stored in the same refrigerator with resident medications? She stated, Because it should not be in the refrigerator with the resident's medications because it could cause cross contamination. 5. A facility policy titled, Pharmaceutical Services, provided by the DON on 05/25/24 at 3:31 PM documented, .Storage of drugs. All drugs and biologicals are stored in locked compartments under proper temperature controls . The policy did not address the potential for cross contamination of storing food with medications.

Based on observation, interview, and record review, the facility failed to ensure a Physician's Order for a dietary supplement was followed for 1 (Resident #8) of 7 (Residents #8, #15, #28, #50, #60, #62 and #68) sampled residents who received a dietary supplement according to a list provided by the Director of Nursing (DON) on 05/25/23 at 10:02 AM. The findings are: Resident #8 had diagnoses of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Dysphagia, Oral Phase. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/23 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with eating and received a therapeutic mechanically altered diet. a. A Physicians Order dated 09/25/19 documented, Glucerna four times a day 8 ounces . b. A Physicians Order dated 11/22/21 documented, Regular diet, Pureed texture, Nectar consistency. Mighty shakes with all meals. 11/7/19 Add ice cream Breakfast/Lunch/Dinner. May have Mech [mechanical] Soft snacks r/t [related to] diet refusal signed 12/19/22 . c. A Care Plan with a revision date of 04/14/23 documented, .receives a Regular pureed diet . takes routine diuretics. Nectar thick liquids . 9/25/19 Glucerna 8 ounces four times daily . 9/26/19 Sugar free mighty shake with all meals . Give the resident supplements as ordered . d. On 05/22/23 at 12:50 PM, Resident #8's lunch tray contained pureed ham, pureed sweet potato, pureed angel food cake with strawberries, pureed bread, mighty shake, thickened cranberry cocktail, 2 servings of whipped spread and 2 sugar packets. e. On 05/24/23 at 8:55 AM, the Surveyor asked the Dietary Manager to review Resident #8's lunch tray served on 05/22/23 and identify what if any items were not present. The DM stated, She is missing her ice cream. We used to do Magic Cups, but I guess the company stopped using those. The Surveyor asked why it is important to follow the diet as ordered. She stated, If they are getting the right parts of the meal then they get what they need for their weight and nutrition. f. On 05/24/23 at 12:30 PM, Resident #8's lunch tray contained pureed sausage, pureed cabbage, pureed cornbread, creamed potatoes, pureed peach cobbler, mighty shake, 2 thickened cranberry cocktails, thickened lemon-flavored water, whipped spread, and condiments. Ice cream was not present on the tray as ordered.

Based on interview, and record review, the facility failed to ensure resident funds were placed in an interest-bearing account and the interest earned was prorated per individual on the basis of actual earnings or their end-of quarter balance. The failed practice had the ability to affect 11 sampled residents (Residents #1, #5, #8, #10, #15, #40, #50, #52 #60, #62 and #176) who had trust accounts managed by the facility according to a list provided by the Business Office Manager (BOM) on 05/25/23 at 9:51 AM. The findings are: 1. The March 2023 and April 2023 Trust Account Bank Statements indicated No interest was paid in 2022 and no interest has been paid to date, in 2023. 2. On 05/24/23 at 3:09 PM, the Surveyor asked the Administrator to address the fact that no interest was reflected on the monthly statements. The Administrator stated, There is no interest. They switched the account around, changed the name and it was just messed up. The Surveyor asked the Administrator to identify, they. The Administrator stated, Corporate. The Surveyor asked the Administrator to provide the date the current account was opened, and she reported that it was opened on 02/12/21. The home switched names and went from non-profit to profit.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one of one meal observed. The failed practice had the ability to affect 74 residents who received their meals from 1 of 1 kitchen according to a list provided by the Infection Preventionist (IP) #1 on 05/25/23 at 3:38 PM. The findings are: 1. The Lunch Menu provided by the Dietary Manager (DM) on 05/22/23 at 11:00 AM documented the lunch meal consisted of 3 ounces of Baked Ham, 1 Baked Sweet Potato, 1/2 Cup Seasoned Carrots, 1 Slice of Bread, 1 Margarine Spread, Angel Food Cake 2x3 inch square, 1/2 cup Strawberries with whipped topping and 1 cup of coffee/tea. 2. On 05/22/23 at 12:00 PM, as the lunch meal was being served, each tray received a bowl with a 2x3 inch slice of angel food cake. On top of the cake were 2 to 3 previously frozen strawberries. 3. On 05/22/23 at 12:30 PM, of the residents who elected to eat their meal in the Dining Room, 7 of the trays did not contain a baked sweet potato or substitute. 4. On 05/24/23 at 8:55 AM, the Surveyor asked the DM to observe multiple trays from the lunch meal served on 05/22/23. Upon review she stated, They are missing their sweet potato. The Surveyor asked if there were not enough potatoes prepared for lunch and what should take place if they run out of an item. The DM stated, When I was the cook, I always made sure I had some extra to avoid times like this. If I did run out, I would make the resident a salad if they could have it or make them another vegetable. The Surveyor asked why it is important to follow the menu as written. She stated, They need all the parts for their nutrition. 5. On 05/24/23 at 9:00 AM, the Surveyor asked the Dietary Manager to review the menu for the lunch meal on Monday (05/22/23). The menu called for a 2x3 inch angel food cake and 1/2 cup strawberries. The Surveyor asked the DM to review multiple trays which contained a piece of angel food cake with strawberries. The Surveyor asked if she thought there was 1/2 cup of strawberries present on top of the cake. The DM stated, That's not 1/2 cup, that's probably not even an ounce. The Surveyor asked why it was important to serve the serving size according to the menu. The DM stated, If they are getting the right parts of the meal then they get what they need for their weight and nutrition.

Based on observation, and interview, the facility failed to utilize standard precautions when processing clean laundry and failed to process clean laundry in a manner to maintain cleanliness. The failed practice had the ability to affect 77 residents according to the Census by Hall provided by the Administrator on 05/22/23 at 10:25 AM. The findings are: 1. On 05/22/23 at 12:42 PM, laundry staff was rolling a laundry basket containing clean laundry in the lower basket and hanging from the upper rod on the 600 Hall. There was no covering over the clean clothes on the top rod or the lower basket. 2. On 05/23/23 at 10:44 AM, laundry staff was rolling a laundry basket containing clean laundry folded in the lower basket on the 200 Hall. The laundry basket was not covered. 3. On 05/23/23 at 12:45 PM, laundry staff was rolling a laundry basket containing clean laundry on the 300 Hall with clean clothing hanging on the upper hanging rod, in the lower basket uncovered. 4. On 05/24/23 at 11:15 AM, laundry staff were walking down the 400 Hall pushing a laundry cart with clean laundry. The residents' clothes hanging from the top hanging rack were exposed and not covered. The clothes in bottom basket were folded and covered with a sheet. The Surveyor asked Laundry Employee #1, Are those the residents clean laundry? She replied, Yes they are. The Surveyor asked, Is that how you always bring the clean laundry down the halls to return them to the residents? She stated, Yes. I have the bottom clothes covered. I put this sheet over them, but I don't cover the top part because, see I have them separated by the resident ' s room numbers and if I cover it, I can't see the numbers and it gets too confusing. 5. On 05/24/23 at 11:25 AM, the Surveyor asked the Director of Nursing (DON), Should the clean laundry be covered when being taken down the hallways to the residents by staff? She stated, Yes it should be. The Surveyor asked, Why should it be covered? She stated, Infection control. 6. On 05/24/23 at 11:28 AM, the Surveyor asked the Laundry Supervisor, Should the resident ' s clean laundry be covered when the staff are taking it down hallways to give back to the residents? She stated, Yes. The Surveyor asked, Why should it be covered? She replied, Cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to maintain a safe environment for 4 (Rooms #206, #207, #208 and #209) rooms and failed to avoid utilizing power strips to operate medical devices for 1 (Rooms #209) of 9 (Rooms #201, #202, #203, #204, #205, #206, #207, #208 and #209) resident rooms on Hall 2. The findings are: 1. On 05/23/23 at 11:17 AM, Resident Rooms #207 and #209 shared a conjoined restroom. The Ground Fault Circuit Interruption (GFCI) outlet situated on the restroom wall immediately over the sink was broken, with a spring protruding from the reset button. There was an unsecured outlet cover that did not match the outlet resting over the broken outlet. The outlet was not secured to the wall. 2. On 05/23/23 at 11:55 AM, Resident Rooms #206 and #208 shared a conjoined restroom. The GFCI outlet situated on the restroom wall immediately over the sink was broken, with a large crack extending vertically the full length of the outlet. The Surveyor pressed the test button on the outlet to verify that it was functioning properly. Sparks immediately flew from the outlet, landing in the sink accompanied by a loud buzzing sound. After 2 to 3 seconds the lights and TV in the restroom and in the resident's room went off. The Surveyor exited the room and requested that the Maintenance Supervisor accompany him to the room. The Surveyor informed the Maintenance Supervisor of the occurrence and the electrical outage. He stated, No, I turned the breaker off across the hall. The Surveyor restated the outage immediately following the electrical short. He stated, Well let me check The Maintenance Supervisor left to verify that the breaker had been thrown. He returned and stated, You were right, it's thrown. The Surveyor asked what the potential outcome of this malfunctioning outlet being left in service. He stated, Shock someone. 3. On 05/23/23 at 12:09 PM, the Maintenance Supervisor was asked to describe the condition of the outlet in the restroom shared by Rooms #207 and #209. He stated, It's broke, looks like someone put a screw through it. No, that's the spring. The Surveyor asked if the outlet should be in this condition. He stated, No. The Surveyor asked how frequently the outlets should be tested. He stated, I don't know, we do test them. The Surveyor asked if the Maintenance Supervisor kept logs of the GFCI testing. He stated, No. The Surveyor asked what the outcome could be with a broken GFCI outlet. He stated, Someone could get shocked. 4. On 05/22/23 at 12:07 PM, Resident room [ROOM NUMBER] had a low-pressure air mattress plugged into a power strip, currently running. Sequential Compression Devices (SCD) were hanging on the wall at the bedside, also plugged into the power strip. An oxygen concentrator was plugged into a second power strip. 5. On 05/23/23 at 8:44 AM, Resident room [ROOM NUMBER] had a low-pressure air mattress plugged into a power strip, currently running. SCDs were hanging on the wall at the bedside, also plugged into the power strip. An oxygen concentrator was plugged into a second power strip. 6. On 05/24/23 at 7:32 AM, Resident room [ROOM NUMBER] had a low-pressure air mattress plugged into a power strip, currently running. SCDs were hanging on the wall at the bedside, also plugged into the power strip. An oxygen concentrator was plugged into a second power strip. 7. On 05/26/23 at 8:34 AM, the Surveyor asked the Administrator if medical devices should be plugged into power strips. She stated, Oh .no.

Based on observation, and interview, the facility failed to ensure expired food items were promptly removed and discarded on or before the expiration or use by dates, foods were dated and/or utilized prior to their expiration date, equipment was sanitized between clean and dirty tasks to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, food was prepared and served in a manner to minimize the risk of food borne illness and staff did not consume personal beverages while in the kitchen. The failed practice had the ability to affect 73 residents who receive their meals from one of one kitchen according to a list provided by the Infection Preventionist, LPN on 05/25/23 at 3:38 PM. The findings are: 1. On 05/22/23 at 10:35 AM, on a bottom shelf of the Dry Storage Room there was a box of tortillas that contained 4 packs of 12 tortillas with an expiration date of 05/16/23. 2. On 05/22/23 at 10:40 AM, two one half cup glasses of tomato juice were sitting on top of the drink cart in the kitchen. The tops of the glasses were covered with plastic wrap and were not dated. The Dietary Manager (DM) stated, They were poured this morning. On the same cart was a pitcher of tomato juice that was three quarters full. A sticker on the side of the pitcher was dated 04/30/23. The DM reported that the juice was actually opened yesterday (Sunday). The Surveyor asked how she knew when the pitcher was filled. The DM stated, I know the weekend cook watches that for us and fills it when it gets low. The lid on the pitcher of juice was open to air and contaminates. 3. On 05/22/23 at 10:44 AM, a tray containing 12 sandwiches was sitting on the second shelf of the walk-in refrigerator. Only one sandwich contained the date of preparation. The DM reported that the sandwiches had been prepared for snack. The Surveyor asked how the viability of the sandwiches could be identified if only one sandwich bore the date of preparation. She stated, We just know they will all be eaten today. 4. On 05/22/23 at 10:46 AM, a box containing two 5-pound plastic containers of sour cream had a use by date of 05/13/23. 5. On 05/22/23 at 10:53 AM, a rolling plastic tub containing powdered milk was observed in the kitchen. The DM removed the lid, and the tub had what appeared to be a liquid that had run down the side and had come into contact with the dry mix. Located on top of the mix were multiple clumps of milk/liquid mixture. The Surveyor asked the DM if she was aware of how the liquid came into contact with the dry mix. The DM stated, I bet it was Dietary Aide #1. I bet she used a scoop that was still wet. The DM stated, This needs to be thrown out. 6. On 05/22/23 at 11:57 AM, on a shelf located above a worktable in the kitchen there was a box of salt open to air and contaminates. 7. On 05/22/23 at 12:02 PM, Dietary Aide #1 was standing next to the tray line in the middle of the kitchen drinking a beverage. 8. On 05/22/23 at 12:03 PM, while placing lids on bowls of carrots, Dietary Aide #2 placed her fingers inside of each clear plastic lid as she placed the lids on the bowls. 9. On 05/22/23 at 12:05 PM, a 10-pound tube of ground beef was in a shallow pan of standing water to thaw. 10. On 05/22/23 at 1:00 PM, a 6-ounce bottle of hot sauce was on a table in the resident dining area. The bottle did not have a lid which left it open to air and contaminates. 11. On 05/24/23 at 9:30 AM, a 6-ounce bottle of hot sauce was on a table in the resident dining area. The bottle did not have a lid which left it open to air and contaminates. The Surveyor asked the DM to identify the issues that could arise from an open container. The DM stated, That bugs could have gotten in it, and it is all dried out and that it needs to be thrown out. 12. On 05/24/23 at 11:55 AM, Dietary Aide #3 had two bags of dry brownie mix. Prior to mixing, the bags were placed inside the mixing bowl and then moved to the baking pan contaminating both the bowl and the pan. 13. On 05/24/23 at 12:10 PM, Dietary Aide #4 was pushing a rolling cart that contained multiple breakfast trays retrieved from resident rooms. Dietary Aide #4 placed the contaminated trays into the window of the dish room. The cart remained outside of the dish window in the resident dining area. At approximately 12:15 PM, a Certified Nursing Assistant retrieved the cart to transport lunch trays to the resident rooms. The cart was not sanitized between uses. 14. On 05/25/23 at 1:54 PM, the Surveyor asked the Dietary Manager (DM) to describe the proper way to put a lid on a bowl. The DM stated, You would have them in the holder with the tops up so you could grab one from the top and put it straight on the bowl without touching the inside. The Surveyor asked why it is important to avoid touching the inside of the lids. The DM stated, To avoid cross contamination. The Surveyor asked what the proper way to thaw meat was. She stated, It is best to set it out in the refrigerator three days in advance if you have the room or you can set it in the refrigerator one day before then in water to finish thawing. The Surveyor asked if water should be still or running. The DM stated, Running. The Surveyor asked if dietary employees should consume beverages in the kitchen area. She stated, No. The Surveyor asked what should happen to the carts that bring dirty trays from the resident's rooms/hall to the kitchen. The DM stated, They should be sanitized before being used again.

Based on observation, and interview the facility failed to ensure that the exit doors were locked and would alarm for 2 (End of 400 Hall and end of 600 Hall) doors of 10 doors when tested. This failed practice had the potential to affect 3 (Resident #1, R #2, and R #3) residents residing in the building who were at risk for elopement according to the list given by Licensed Practical Nurse (LPN) #1 on 11/17/2022 at 3:00 PM. The findings are: 1. On 11/17/22 at 3:55 PM to 4:25 PM, with the assistance of the Director, all the exit doors in the building were checked the to see if they were locked and alarmed. There were no residents near the doors. a. On 11/17/22 at 4:10 PM, the exit door at the end of the 400 Hall was locked but did not sound an alarm. There were no residents near the door. b. On 11/17/22 at 4:20 PM, the exit door at the end of the 600 Hall was locked but did not sound an alarm. There were no residents near the door. c. On 11/17/22 at 4:25 PM, Maintenance Personnel was summoned by the Director of Nursing (DON) to check both doors. The alarms on both doors sounded after he adjusted them.