**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the EHR for R2 revealed she was admitted to the facility with diagnoses that included but not limited to, need for assistance with personal care, unspecified dementia with mood disturbance, chronic systolic (congestive) heart failure, chronic respiratory failure with hypoxia, fracture of body of sternum, subsequent encounter for fracture with routine healing and fracture of manubrium, subsequent encounter for fracture with routine healing and neuropathy. A review of the 5-day Minimum Data Set (MDS) dated [DATE] for R2 revealed, Section B (Hearing, Speech and Vision) revealed, R2 had moderate difficulty in hearing and that the speaker must increase volume and speak distinctly; Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 14, which indicated little to no cognitive impairment. A record review of R2's care plan with onset date of 12/12/2024, updated on 1/14/2025 revealed, a care plan for a communication, hearing related to (r/t) hears with moderate difficulty as evidence by hears best in left ear and having hearing aids in left and right ear; The care plan goal for R2 was that she will hear communication during interactions during review period. The care plan interventions included, to assist with hearing aid placement as resident allows. An interview and observation conducted on 1/14/2025 at 11:28 am with R2 revealed, she was not wearing her hearing aids. R2 stated that she had hearing aids, which she was able to put in herself in the morning, but no one was available to assist her with taking them out. R2 revealed, that some staff members were helpful while others were not. R2 explained that her hands were numb, and she was unable to remove the hearing aids on her own due to neuropathy. The resident expressed feeling helpless and stated that she tries to communicate using the call light speaker, but she was unable to hear the staff's responses. An interview conducted on 1/15/2025 at 9:55 am with Certified Nursing Assistant (CNA) CC revealed, that she was not aware that R2 had hearing aids, but she learned about it the previous day. CNA CC explained that she does not typically check the Activities of Daily Living (ADLs) unless necessary, such as when documenting care. CNA CC clarified that protocol requires CNAs to review the ADLs before providing care. An interview and observation conducted on 1/15/2025 at 10:32 am with Licensed Practical Nurse (LPN) DD revealed that CNAs were expected to review the ADL plan of care (POC) to understand what assistance the resident required. LPN CC confirmed that it is expected for CNAs to consult the ADL POC before delivering care. LPN CC acknowledged that she was aware R2 has hearing aids but was uncertain if this was included in the resident's ADL POC. After reviewing the ADL POC together, it was confirmed that R2 required assistance with both hearing aids. LPN CC stated that both the CNA and nurse were responsible for assisting the R2 with hearing aids and that staff should be aware of this need. An interview was conducted on 1/16/2025 at 11:44 am with the Director of Nursing (DON) confirmed that staff were expected to review the ADL POC to understand the services a resident need and to ensure their preferences were respected. The DON highlighted that failing to provide services could lead to missed care, potentially resulting in a negative experience for the resident. Cross Reference F689, F677 Based on observations, staff interviews, record review, and review of the facility's policy titled Patient's Plan of Care, the facility failed to implement care plans for two of 20 sampled residents (R) (R42 and R2). Specifically, the facility failed to provide proper supervision for R42 and to assist with hearing aid placement for (R2). This deficient practice had the potential to affect the residents' health and safety. Findings include: A review of the facility's policy titled, Patients Plan of Care dated 12/29/2023 under section titled Guideline revealed, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patients' medical, physical, mental and psychological needs. 1. Review of the Electronic Medical Record (EMR) revealed R42 was admitted to the facility with diagnoses that included but not limited to Alzheimer's/Dementia, Traumatic Brain Injury (TBI), and history of pedestrian on foot injured in collision with car, pick-up, or van. Review of R42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 9, which indicated moderate cognitive impairment. Review of R42's care plan dated 11/23/2024 revealed, a care area/problem for risk of elopement. Goals included but not limited to patient will have no injuries during any attempts to leave the grounds during the review period. Interventions included but not limited to, supervision while outside. An interview on 1/14/2025 at 3:48 pm with [NAME] FF confirmed that he accidentally opened the door for R42 allowing him to be outside unsupervised on 1/13/2025 at 4:01 pm. An interview on 1/16/2025 at 2:22 pm with Licensed Practical Nurse (LPN) DD confirmed close supervision to monitor the location of residents with high elopement risk should be completed in intervals. An interview on 1/15/2025 at 10:15 am with the Director of Nursing (DON) revealed that Certified Nursing Assistants (CNA)s should constantly be rounding to ensure safety of residents. An interview on 1/15/2025 at 10:15 am with the Administrator revealed, that R42 left the faciity on 1/13/2025 through the dining room doors. She confirmed and verified that the care plan was not followed due to [NAME] FF opened the door allowing him to go outside unsupervised. The Administrator revealed, her expectations of staff to not leave residents unsupervised or allow residents to leave the indoors without questioning nurses. She revealed, staff had been warned against letting residents outside without being accompanied by nursing staff. An interview on 1/15/2025 at 10:15 am with the Minimum Data Set (MDS) Coordinator revealed, all residents should be 1:1 on the outside as stated by the changes made yesterday, January 14, 2025. She also stated that sometimes when a nurse assesses a resident, the data will create new interventions on the care plan that will be later reviewed by an interdisciplinary team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policies titled Patient Plan of Care and Care of Hearing Aids, the facility failed to assist one out of four sampled residents (R) (R2) with the use of hearing aids. Specifically, the facility failed to assist with the proper use of hearing aids by not placing them in and removing them. This failure to provide the necessary support could result in communication barriers. Findings include: A review of the facility's policy titled, Care of Hearing Aide dated 12/29/2023 under section titled Intent revealed, The primary intent of caring for a hearing aid is to maintain the patients hearing aid in good order. A review of the Electronic Health Record (EHR) for R2 revealed, she was admitted to the facility with diagnoses that included but not limited to, need for assistance with personal care, unspecified dementia with mood disturbance, chronic systolic (congestive) heart failure, chronic respiratory failure with hypoxia, neuropathy, and fracture of body of sternum. A review of R2's 5-day Minimum Data Set (MDS) dated [DATE] revealed, Section B (Hearing, Speech and Vision) revealed, R2 had moderate difficulty in hearing and that the speaker must increase volume and speak distinctly; Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 14, which indicated little to no cognitive impairment. A record review of R2's Activities of Daily Living (ADLs) Plan of Care on 1/15/2025 revealed, under section Resident Caution and Diagnosis hearing aids to both ears. Assist with placement in the morning and remove after supper and place on charger. An interview and observation conducted on 1/14/2025 at 11:28 am with R2 revealed, she was not wearing her hearing aids. R2 stated that she had hearing aids, which she was able to put in herself in the morning, but no one was available to assist her with taking them out. R2 revealed, that some staff members were helpful while others were not. R2 explained that her hands were numb, and she was unable to remove the hearing aids on her own due to neuropathy. The resident expressed feeling helpless and stated that she tries to communicate using the call light speaker, but she was unable to hear the staff's responses. An interview and observation conducted on 1/15/2025 at 9:51 am with R2 revealed, she still did not have her hearing aids in, which made communication difficult. R2 indicated that nurses had been in and out of her room to administer medications but had not assisted with hearing aids. An interview conducted on 1/16/2025 at 12:34 pm with a Family Representative (FR) revealed, R2 has voiced concerns about the staff not being able to assist her with her hearing aids. FR also stated that when speaking to R2, he notices that she does not have her hearing aids in, which makes communication difficult. FR emphasized that R2 having her hearing aids properly in place would significantly improve R2's quality of life and ability to hear. An interview conducted on 1/15/2025 at 9:55 am with Certified Nursing Assistant (CNA) CC revealed, that she was not aware that R2 had hearing aids, but she learned about it the previous day. CNA CC explained that she does not typically check the Activities of Daily Living (ADLs) unless necessary, such as when documenting care. CNA CC clarified that protocol requires CNAs to review the ADLs before providing care. However, due to a busy workload, CNA CC sometimes cannot check them beforehand but does so after providing care. An interview and observation conducted on 1/15/2025 at 10:32 am with Licensed Practical Nurse (LPN) DD revealed that CNAs were expected to review the ADL plan of care (POC) to understand what assistance the resident required. LPN CC confirmed that it is expected for CNAs to consult the ADL POC before delivering care. LPN CC acknowledged that she was aware R2 has hearing aids but was uncertain if this was included in the resident's ADL POC. After reviewing the ADL POC together, it was confirmed that R2 required assistance with both hearing aids. LPN CC stated that both the CNA and nurse were responsible for assisting the R2 with hearing aids and that staff should be aware of this need. An interview was conducted on 1/16/2025 at 11:44 am with the Director of Nursing (DON) confirmed that staff were expected to review the ADL POC to understand the services a resident need and to ensure their preferences were respected. The DON highlighted that failing to provide services could lead to missed care, potentially resulting in a negative experience for the resident. An interview was conducted on 1/16/2025 at 12:07 pm with Administrator revealed, that staff should regularly review the ADL POC to ensure they are providing the appropriate services and meeting the resident's needs. The Administrator stated staff were also involved in care plan meetings, where they learn what ADLs should be provided. The Administrator noted that failure to follow the resident's ADL POC could result in neglecting the resident's needs, and staff should use nurses as a resource to ensure proper care. Cross Reference F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility's policy titled Skilled Nursing Services - Elopement, the facility failed to closely monitor one of 13 residents (R) R42 for elopement potential. This deficient practice had the potential to place residents at risk for safety concerns including but not limited to physical and/or mental distress. Findings include: Review of the policy titled Skilled Nursing Services - Elopement dated 12/29/2023 revealed, the intent is to promote person-centered care for patients at risk for elopement. Guideline documented the center implements mechanisms and procedures for monitoring and managing patients at risk for elopement to minimize the risk of a patient leaving a safe area without authorization and/or appropriate supervision. Procedure revealed the center will take a proactive approach for new patients and assess new admissions for elopement risk. The licensed nurse will re-assess patient at least quarterly, annually, with any significant change, and re-admission to the center. Elopement risk factors and appropriate interventions will be identified and implemented into the patients plan of care. Implement interventions to prevent recurrence and maintain patient safety. Review of the Electronic Medical Record (EMR) revealed, R42 was admitted to the facility with pertinent diagnoses including but not limited to Alzheimer's/dementia, Traumatic Brain Injury (TBI), and history of pedestrian on foot injured in collision with car, pick-up, or van. Further review of the EMR revealed an Elopement Risk assessment dated [DATE] documented a score of 11 out 20, which denotes a moderate risk for elopement. The latest Elopement Risk Assessment was completed on 1/14/2025, the day after R42's 1/13/2025 elopement from the facility. R42'Elopement Risk was 14 out of 20, which denotes moderate risk for elopement. There was no evidence that quarterly Elopement Risk Assessments were completed. Review of R42's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) of nine, which indicated moderate cognitive impairment. Section E (Behaviors) revealed, the resident did not exhibit wandering behaviors. Observations on 1/14/2025 to 1/16/2025 during the three-day survey revealed R42 alone in his room. Interview on 1/14/2025 at 10:45 am, R42 appeared to be alert, but not oriented to his surroundings. He did not recall going outside the facility on 1/13/2025. Interview on 1/14/2025 at 3:48 pm with [NAME] FF, confirmed that he was the one who opened the door for R42 allowing him to leave the facility unsupervised on 1/13/2025 at approximately 4:01 pm. Interview on 1/14/2025 at 3:56 pm, the Maintenance Director revealed he discovered R42 wheeling himself down the back sidewalk and returned the resident inside the facility. Interview on 1/15/2025 at 10:15 am with the Director of Nursing (DON) revealed that an elopement risk assessment is performed with input from the resident and family members upon admission. She further stated that the Certified Nursing Assistants (CNAs) should constantly be making rounds to ensure the safety of the residents. Interview on 1/15/2025 at 10:16 am with the Administrator revealed that R42 left the faciity on 1/13/2025 via the exit door in the dining room. She stated that [NAME] FF opened the door for the resident around 4:01 pm and the Maintenance Director found him outside around the maintenance shop at approximately 4:10 pm. During further interview, she stated the expectations are that staff do not leave residents unsupervised or allow any residents to leave the facility without checking with the nurses. She stated staff has been educated against letting residents outside the facility without being accompanied by nursing staff. On 1/16/2025 the Administrator further revealed that the facility did not have a policy on Supervision as it pertains to residents. Interview on 1/16/2025 at 2:22 pm, the Licensed Practical Nurse (LPN) DD confirmed that close supervision of a resident means to monitor the location of residents who are at risk for elopement. Cross Reference F656

Based on observation, staff interviews and review of facility's policy titled, Infection Prevention Plan, the facility failed to prevent the spread of infections by not properly securing and storing clean linen in one out of three halls (Hall A). This deficient practice had the potential to cause the spread of infection throughout the facility. The facility census was 76 residents. Findings include: Review of facility's policy titled Infection Prevention Plan dated 12/29/2023 under section titled Goals revealed, The goals of the infection prevention program are as follows: To prevent and control the transmission of infectious and communicable diseases; To prevent healthcare associated infections . Under the section titled Scope revealed, The center provides services on an in-patient basis to a geriatric population with various medical conditions, including hospice, hemodialysis and other special needs .Implementation of Preventive Measures: Prevention of a spread of infections is accomplished by use of standard precautions and other barriers. An observation and interview conducted on 1/16/2025 at 11:08 am on Hall A revealed, an opened bag of chips found on the inside of the clean linen cart, which was also used for storing personal protective equipment (PPE) gowns. When asked about the opened bag of chips, Certified Nursing Assistant (CNA) AA revealed, it was hers and confirmed that it was not supposed to be stored on the clean linen cart. CNA AA acknowledged the potential risks of cross contamination, resident safety and that storing food inside the clean linen cart could compromise its cleanliness. An interview conducted on 1/16/2025 at 11:37 am with Registered Nurse/Infection Prevention Nurse (RN/IPN) BB when asked about the opened bag of chips found on the inside of the clean linen cart revealed, that anyone could have grabbed the food and consumed it, which could lead to infection risks, particularly if the food was contaminated by someone with an infectious condition. An interview conducted on 1/16/2025 at 11:44 am with the Director of Nursing (DON) confirmed that the opened bag of chips should not have been stored on the cleaned linen cart. The DON expressed concern that the contamination of food in the clean linen cart could result in the transfer of germs to the linens and PPE, which could negatively impact residents, especially those with open wounds or compromised immune systems. An interview conducted on 1/16/2025 at 12:11 pm with the Administrator confirmed that incidents like this should not occur. The Administrator revealed that food in the clean linen cart could contaminate the linens and PPE, posing risks to resident safety. The Administrator confirmed that CNAs had received in-service training on infection control practices to help prevent such occurrences.

Based on observation, staff interview, and review of facility policy titled Menus, the facility failed to properly prepare foods to conserve nutritive value during the preparation of puree food for nine residents who received a puree diet. The deficient practice had the potential to place nine of nine residents who received a pureed diet at risk of decreased nutritional intake. Findings include: Review of the facility policy titled Menus, review date 12/29/2023, revealed, Menu items should be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. Observation and interview on 1/15/2025 at 10:16 am with Dietary [NAME] EE revealed he was preparing pureed carrots for nine residents. Dietary [NAME] EE added water and thickener to the puree machine along with the carrots and blended until he stated it was the correct consistency. Dietary [NAME] EE revealed that he did not use vegetable broth when preparing puree and wasn't sure if they had any vegetable broth. A review of the recipe for Carrots Herb Pureed Thick revealed that low-sodium chicken base should have been used to ensure a smooth consistency. In an interview on 1/15/2025 at 11:07 am, the Dietary Kitchen Manager (DKM) revealed Dietary [NAME] EE should have used broth when mixing the pureed carrots to give it flavor. In an interview on 1/15/2025 at 11:33 am, the Registered Dietician (RD) confirmed that chicken broth should have been added to the recipe for carrot glazed puree. She stated that she would have staff pull the puree carrots from the line and have the broth added and tested to ensure proper consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two residents (R), (R#36 and R#65) of 23 sampled residents. Findings Include: 1. R#36 was admitted to the facility on [DATE] with diagnoses including but not limited to Huntington's disease, dementia, dysphagia, and aphasia. Review of Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns resident is rarely/never understood and has both short and long-term memory problems. Section G-Functional Abilities revealed R#36 is dependent on one-person physical assistance with activities of daily living (ADLs). Section P-Restraints revealed R#36 does not use physical restraints. Observation on 9/27/22 at 11:48 a.m. revealed R#36 lying in bed with full size bedrails in the up position on both sides of bed. Observation on 9/28/22 at 9:46 a.m. revealed R#36 in bed with full size bedrails in the up position. Observation on 9/29/22 9:33 a.m. revealed R#36 lying in bed with full size bedrails in the up position. 2. R#65 was admitted to the facility on [DATE] with diagnoses including but not limited to senile degeneration of the brain, dementia, mood disorder, and anxiety. Review of R#65's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section G-Functional Abilities revealed R#65 was dependent on one to two-person physical assistance with activities of daily living (ADLs). Section P-Restraints revealed R#65 does not use physical restraints. Observation on 9/28/22 at 9:47 a.m. R#65 was observed in reclined broda chair resting quietly. Observation on 9/28/22 at 10:40 a.m. R#65 was observed attempting to get out of the broda chair. CNA CC raised the footrest on the chair to prevent resident from getting out of the chair. Observation on 9/29/22 at 8:58 a.m. revealed R#65 in broda chair with chair reclined and footrests raised. During interview on 9/29/22 at 11:22 a.m. MDS Coordinator revealed she did not code the residents MDS Assessments to reflect use of full-size bed rails or the broda chair on the MDS assessments because R#36 and R#65 cannot get up independently. During further interview, she stated both the bed rails and broda chair were added following falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled Skilled Inpatient Services Patient's Plan of Care dated 12/4/21, the facility failed to evaluate and revise the care plan interventions and/or determine the need to identify additional interventions for fall prevention for one resident (R) (#64) who had been assessed to be at risk for falls and who sustained additional falls. The sample size was 26 residents. Findings include: Review of the facility policy titled Skilled Inpatient Services Patient's Plan of Care with a revision date of 12/4/21 reads: The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive car plan should also be updated as ongoing clinical assessments identify changes. Review of the clinical record for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to orthostatic hypotension, unsteadiness on feet, difficulty in walking and unspecified dementia without behavioral disturbance The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated resident was unable to complete the assessment. Section G revealed resident requires total assistance with transfers. Review of the care plan updated 9/27/22 revealed that R#64 is at risk for falls due to history of syncope, transfer: extensive assist, mobility: needs assistance, assistive devices: wheelchair, and cognitive status: severely impaired. R# 64 has had several actual falls since admission to the facility. Interventions include assist patient with ADL's and mobility as needed, bed in low position, mat at bedside, non-skid well-fitting shoes, keep personal items within reach, dycem added to wheelchair, assist patient to a quite location, physician to do a medication review and therapy to evaluated and treat as needed. Further review revealed that there was not any evidence that new interventions were put in place to prevent any future falls after R#64 experienced falls and there was no evidence that previously implemented interventions were evaluated for effectiveness. Interview on 9/29/22 at 9:32 a.m. the Registered Nurse (RN) MDS Coordinator stated that she is not responsible for updating residents care plans with appropriate interventions to reduce the risk of a fall reoccurring. She stated that the Resident Care Coordinators (RCC) are responsible for updating the care plans with new fall interventions. She reviewed the record and verified that the nurses on duty at the time of the falls did not put an immediate intervention in post fall. Interview on 9/29/22 at 10:01 a.m. with RCC Licensed Practical Nurse (LPN) FF, stated that the nurses are responsible for putting the new interventions on the care plans at the time of the fall, and her role is to assure that the interventions are appropriated and updated. The RCC reviewed each documented fall and verified there was not a new or appropriate intervention for intervention for seven of the twelve documented falls reviewed. Interview on 9/29/22 at 10:51 a.m. with Director of Nursing (DON) and Regional Nurse Consultant (RNC), the DON stated that her expectations are that there are interventions put in place after the falls. She further stated that the facility has a care plan committee which reviews each resident's falls to determine if the intervention entered initially by the nurse needs to be revised. The nurse who is caring for the resident at the time of the fall is responsible for updating the care plan at the time of the fall. The RNC verified that there were interventions initiated after each fall, but the nurses failed to revise the care plan with the new interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to obtain a Physician order for use of full size bedrails for one resident (R)#36. The sample size was 26. Findings include: Review of the electronic medical record (EMR) revealed that the facility admitted R#36 on 5/3/13. He was admitted with multiple diagnosis that included, but was not limited to Huntington's disease, dementia, dysphagia, and aphasia. Review of R#36's Significant Change Minimum Data Set (MDS) dated [DATE], revealed the R#36 is rarely/never understood and has both short and long-term memory problems. He is dependent on one-person physical assistance with activities of daily living (ADLs). The MDS also revealed that R#36 does not use physical restraints. Observation on 9/27/22 at 11:48 a.m. revealed R#36 was in bed. Both sides of the bed had full size bedrails in the up position. Observation on 9/28/22 at 9:46 a.m. revealed R#36 was in bed. The full size bedrails in the up position on both sides of the bed. Observation on 9/29/22 9:33 a.m. revealed R#36 was in bed. Both sides of the bed had full size bedrails in the up position. Review of R#36 Physician orders did not reveal an order for use of full-size bed rails. Review of care plan intervention dated 3/3/21 revealed 'full bedrails for safety due to diagnosis'. Interview on 9/29/22 at 9:46 a.m. with Certified Nursing Assistant (CNA) CC revealed she was unsure why R#36 had full size bed rails. She stated that R#36 may have the full size bedrails to prevent him from falling out of the bed. Interview on 9/29/22 at 9:53 a.m. with the Director of Nursing (DON) revealed the facility does not use restraints. She stated that R#36 moves around involuntarily which puts him at risk for falls. She revealed that R#36 has a diagnosis of Huntington's disease. Interview on 9/29/22 at 9:55 a.m. with Senior Nurse Consultant (SNC) revealed that the facility only conducts assessments for the use of devices. She stated R#36 is not able to get up on his own. She further stated that because of this, the full-size bedrails are not a restraint. Interview on 9/29/22 at 10:51 a.m. the DON stated that the facility does not complete a formal assessment to determine if the device is a restraint or an enabler prior to resident using the device. The DON further stated that the facility utilizes a mobility care plan and Quarterly Comprehensive Assessment. Interview on 9/29/22 at 11:34 a.m., the Regional Nurse stated that residents are assessed when there is a change in the devices. This information is taken to Patients At Risk weekly meeting with the Interdisciplinary Team. The changes are discussed. She further stated that there is not a formal titled device assessment completed to determine or classify devices such as Geri chair, broada chairs, or bolsters. There is not an assessment completed when resident gets bolsters or goes from a wheelchair to a Geri chair. Follow-up interview on 9/29/22 at 12:17 p.m. with the SNC revealed the facility does not have a policy on the use of bedrails. She stated that they utilize the Center for Medicare and Medicaid Services (CMS) guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the policy titled 'Restraints', the facility failed to ensure three residents (R) (R#36, R#64 and R#65) were free from the use of physical restraints. The sample size was 26. Findings include: Review of the undated policy titled 'Restraints' revealed under procedural guidelines- Prior to use of a restraint, the following should be completed: 1. Patient's need for restraint assessed. 2. Restraint Consent. This includes the patient and/or responsible party consent, as well as reason for restraint and type of device. 3. Physician order for device (to include type of device, and when it may be used).' 1. Review of the electronic medical record (EMR) revealed that R#36 was admitted to the facility on [DATE] with diagnoses including but not limited to Huntington's disease, dementia, dysphagia, and aphasia. Review of Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns resident is rarely/never understood and has both short and long-term memory problems. Section G-Functional Abilities revealed R#36 is dependent on one-person physical assistance with activities of daily living (ADLs). Section P-Restraints revealed R#36 does not use physical restraints. Observation on 9/27/22 at 11:48 a.m. revealed R#36 was in bed with full size bedrails in the up position on both sides of bed. Observation on 9/28/22 at 9:46 a.m. revealed R#36 was in bed with full size bedrails in the up position. Observation on 9/29/22 at 9:33 a.m. revealed R#36 was in bed with full size bedrails in the up position. Review of R#36 Physician orders did not reveal an order for use of full-size bed rails. Review of care plan intervention dated 3/3/21 revealed 'full bedrails for safety due to diagnosis'. Interview on 9/29/22 at 9:46 a.m. with Certified Nursing Assistant (CNA) CC revealed she was unsure why R#36 had full size bed rails. She stated that she thinks the resident has the full-size bedrails because he jerks a lot, and they will prevent him from falling out of bed. Interview on 9/29/22 at 9:53 a.m. with the Director of Nursing (DON) revealed the facility does not use restraints. She stated that the resident has full size bedrails because he has Huntington's disease, which causes him to move around involuntarily and puts him at risk for falls. Interview on 9/29/22 at 9:55 a.m. with Senior Nurse Consultant (SNC) revealed the full-size bedrails are not a restraint because resident cannot get up on his own. States the facility does not write orders for the use of these devices but only does an assessment. Follow-up interview on 9/29/22 at 12:17 p.m. with the SNC revealed the facility does not have a policy on the use of bedrails. Stated they go by the Center for Medicare and Medicaid Services guidelines. 2. Review of the EMR revealed that R#65 was admitted to the facility on [DATE] with diagnoses including but not limited to senile degeneration of the brain, dementia, mood disorder, and anxiety. Review of R#65's quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section G-Functional Abilities revealed R#65 was dependent on one to two-person physical assistance with activities of daily living (ADLs). Section P-Restraints revealed R#65 does not use physical restraints. Observation on 9/27/22 at 1:49 p.m. revealed R#65 in a reclined broda Chair. Alert but disoriented. CNA CC reports this is usual for resident. Resident observed attempting to get out of chair independently. CNA CC observed reclining chair back to prevent resident from getting out of chair independently. Observation on 9/28/22 at 9:47 a.m. R#65 was observed in reclined broda chair resting quietly. Observation on 9/28/22 at 10:40 a.m. revealed R#65 attempting to get out of broda chair. CNA CC raised the footrest on the chair to prevent resident from getting out of the chair. Observation on 9/29/22 at 8:58 a.m. revealed R#65 in the broda chair with chair reclined and footrests raised. Interview on 9/29/22 at 9:46 a.m. with CNA CC revealed resident has had this chair approximately one month because of a fall. She further revealed she had not received training on this type of chair. CNA CC stated R#65 attempts to get up when agitated and she reclines him when he is attempting to get up. Once reclined, resident is unable to get up. Interview on 9/29/22 at 9:53 a.m., the DON revealed the facility does not consider the broda chair a restraint because R#65 cannot walk. She sates the chair is an enabler and that facility does not use restraints. The DON also revealed R#65 is in the broda chair to prevent falls. Interview on 9/29/22 at 9:55 a.m. with the SNC revealed the broda chair is not a restraint because R#65 cannot walk. The SNC stated the facility does not write orders for the use of these types of devices but only does an assessment. Review of R#65's medical record did not reveal an assessment for the use of the Broda chair. 3. Review of the EMR for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to orthostatic hypotension, unsteadiness on feet, difficulty in walking, displaced intertrochanteric fracture of right femur and unspecified dementia without behavioral disturbance. Review of the most recent MDS dated [DATE], revealed a BIMS was coded as 99, which indicated resident was unable to complete the assessment. Section G revealed resident requires total assistance with transfers. Review of a care plan revised on 9/6/22, revealed the resident was at risk for falls related to falls x 3. Interventions - Assist patient with ADL's and mobility as needed, assist pt to quite location, and md to do med review, bed in low position, dycem added to wheelchair, encourage patient to call when needing assistance, footwear, provide non-skid socks as needed, mat at bedside: left, moved resident to room [ROOM NUMBER]c to be closer to the nurses station, non-skid shoes, well-fitting shoes, placed resident in Geri chair and brought to nurses station for observation, remind patient to call when needing assistance, Resident is still weak at this time from covid diagnosis. Currently working with therapy to regain her strength. Continue with therapy and encourage resident to call for assistance, therapy referral, therapy referral made for unsteady gait, wheelchair with anti-tippers. Review of a Resident's Consolidated Order revealed R#64 did not have a physician's order for the reclined Geri-chair. A review of the resident's medical record revealed no evaluations or follow up for the use of the restraint (Geri-chair). Observation on 9/28/22 at 9:38 a.m. revealed R#64 sitting in a Geri Chair reclined in her room. Observation 9/28/22 at 11:54 a.m. R#64 is sitting up in a reclined Gerichair. An unidentified staff member is in the room with resident conversing with resident as she prepares her bed to assist resident in the bed. Observation 9/29/22 at 9:10 a.m. R#64 was out of bed in a reclined Geri chair in her room. Observation 9/29/22 at 11:14 a.m. R#64 was in her room sitting in a reclined Geri chair with a blanket covering her face. Interview on 9/28/22 at 9:38 a.m., CNA CC stated R#64 constantly tries to get up when she's in the bed so she keeps resident in the reclined Geri chair because it is hard for her to get out of the chair. CNA pushed resident to the nurses' station in the Geri chair to be monitored by staff. CNA CC further stated that she keeps the chair reclined to keep resident from getting up. Interview on 9/29/22 at 8:48 a.m., Licensed Practical Nurse (LPN) DD stated R#64 was placed in the Gerichair due to recent falls. LPN DD further stated that she is not sure when resident was placed in the Gerichair, but she has been utilizing the Gerichair for about 2 weeks. Interview on 9/29/22 at 10:51 a.m. with the DON stated that the facility does not have a formal assessment which is completed prior to resident using devices to determine if the device is deemed a restraint or an enabler. DON further stated that the facility has a mobility care plan and Quarterly Comprehensive Assessment. DON stated that R#64 uses the Gerichair for mobility to get from one place to another place and that the gerichair is a mobile device. Surveyor questioned DON as to whether resident could self-propel the Gerichair or the wheelchair. DON responded; no R#64 cannot move the reclined Gerichair on her own, but she was able to self-propel the wheelchair. DON told surveyor that she considers R#64's gerichair it a device for safety and mobility, and she does not think of it as a restraint. Interview on 9/29/22 at 11:34 a.m., the Regional Nurse stated that residents are assessed when there is a change in the devices. This information is taken to Patients At Risk weekly meeting with the Interdisciplinary Team. The changes are discussed. She further stated that there is not a formal titled device assessment completed to determine or classify devices such as Geri chair, broada chairs, or bolsters. She stated that they follow Centers for Medicare and Medicaid (CMS) guidelines and utilize them to determine the classification of the device. There is not an assessment completed when resident gets bolsters or goes from a wheelchair to a Geri chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to assess cognitively impaired residents related to inappropriate sexual behavior for 3 residents (R) (R#75, R#61, and R#43). The census was 102 residents. Findings Include: Review of the Minimum Data Set Quarterly review dated 7/2/19 for R#75 revealed a Basic Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. Mood with a total severity score of zero indicating no mood disorder. Behavior of wandering daily. Functional Status of limited one-person assistance with bed mobility, transfers, dressing, bathing, and moving off and on the toilet and personal hygiene; Not steady but able to stabilize without human assistance for walking. Frequently incontinent of bowel and bladder. Active Diagnosis of, including but not limited to, dementia, anxiety disorder, and depression. Medications of an antianxiety and antidepressant 7 out of 7 days a week. Review of the Care Plan for R#75 revealed he is at risk for mood/behavior problems, has a history of compulsive disorder with inappropriate sexual behaviors, and rejects care at times. R#75 has a diagnosis of dementia with behaviors and mood disorder. Interventions include: R#75's behavior will not adversely affect self or others through next review date. Explain procedures/cares prior to beginning. If patient is upset leave and allow time to calm, then approach and offer again later. Notify MD of changes in status as needed. Observe patient for inappropriate behaviors. Provide meds as ordered and observe effectiveness. Psychiatric consult as needed. Redirect patient as needed. The following nurse notes from 7/21/18- 4/13/19 revealed: On 7/21/18, it was reported by staff that R#75 was touching another resident (R#61) inappropriately. Resident was redirected successfully [Completed by LPN AA]. On 9/10/18 reads: Another resident (R#43) reported that over weekend R#75 came into her room while she was brushing her teeth and urinated in toilet and shook his penis at her. He wanders into other rooms during day and at night. [Completed by LPN AA]. On 10/12/18 nurse note reads: R#75 up walking, nurse took him back to room, she put him on bed, and he grab her between the legs. Nurse instruct R#75 not to do that it was wrong. He told her to go to hell. [Completed by LPN JJ] On 2/15/19 nurse note reads: Found R#75 in R#61's room. R#61 was sitting in her wheel chair and R#75 was standing in front of her with his pants unbuttoned and unzipped. Refused to leave room. Was fighting staff. [Completed by LPN II]. On 3/3/19 nurse note reads: R#75 had sexual behaviors during shift. He had another resident (R#61) hand on him and was using it to rub himself. He had other behaviors of this kind during day. R#75 redirected and other resident (R#61) moved to another location. Will continue to monitor R#75 during day. [Completed by LPN AA]. On 3/19/19 nurse note reads: Yesterday resident followed CNA around the building and tried to get her to kiss him. Inappropriate actions. Resident difficult to redirect at that time. [Completed by Director of Nursing (DON)]. On 3/27/19 nurse note reads: R#75 has been up since 3:30 a.m. walking around and then sitting in dining room. He became frisky with a lady (R#61) from b hall. Asked patient to leave her alone, he stopped, then later a Certified Nursing Assistant (CNA) came to separate him from her. [Completed by LPN JJ] . Review of the medical record for R#75 revealed the 4/13/19 nurse note reads: About 2:55 p.m. R#75 pulled his penis completely out of his pants in front of nursing station beside another resident (R#61). [Completed by LPN AA]. During an observation on 8/6/19 at 10:50 a.m. R#75 was observed wandering down the 200 hall. He was observed to try and exit through the door to the outside at the end of the hall. R#75's wander guard locked the door and prevented him from exiting. The maintenance supervisor was observed redirecting R#75 momentarily then he was observed to turn and walked back over to the door and stare out the window on the door but did not attempt to open the door this time. R#75 was observed to stand at the door for a minute then a staff member brought him back down to the nurses station to the bench. During an interview on 8/6/19 at 11:00 a.m. with LPN AA she stated that R#75 has ongoing sexual behaviors and cannot have Provera (hormone)because it was tried in the past and he developed a blood clot. She stated that all that is being done at this point is monitoring and redirecting him when he has sexually inappropriate behaviors. Nurse stated that, prior to R#75 and R#61's decline, they liked each other and she, R#61, liked for R#75 to touch her. She stated that R#61 would look around and see if anyone was looking, place a hat or a sweater over her lap while R#75 placed his hand underneath, so they didn't get caught. She stated we try to put them in areas where they aren't so close together. LPN AA stated that R#75 goes in and uses other resident's bathrooms, but she has never saw or heard of him going into a room and then have a sexual abuse complaint made on him. She stated that they have placed STOP signs across some of the doors to prevent Residents who wander from going into rooms that aren't theirs and it has really helped with R#75. She stated in the last few months he has tried kissing staff but does not feel he is a danger or would hurt anyone. LPN AA stated that the incident on 4/13/19 R#75 was at the nurse's station and R#71 was sitting in a wheelchair in front of him. She stated she observed R#75 to have his penis out, his back arched with his hips protruding forward toward R#61's face. She stated she reported this incident to the Resident Care Coordinator (RCC) for the 100 hall and to the RCC for the 200 hall. LPN AA stated that she put in the Nurse Practitioner (NP) book for her to see R#75 when she came in for increased behaviors but did not notify the daughter, call the Medical Doctor (MD), or the NP. During this time the behaviors for R#75 was reviewed on the Electronic Medication Administration Record (EMAR) with LPN AA and on 3/3/19 there was no behaviors noted to be documented. On 3/2/19 LPN AA had documented 4 sexual behaviors but there was no documentation as to what kind of sexual behavior was observed. She stated all that is documented is how many behaviors and if the medication worked or not, but they do not document the type of sexual behavior the resident exhibited. She stated that on 3/3/19 she must not have gone back and documented that R#75 had a behavior that day. LPN AA stated that on 3/15/19 the NP increased R#75's Zoloft (used for depression,obsessive-compulsive behavior) due to increased sexual behaviors. She stated she doesn't remember if she reported the incident on 3/3/19. During an interview on 8/6/19 at 11:49 a.m. with CNA CC she stated that when she sees R#75 having sexually inappropriate behaviors, she will redirect him and tell him he can't do that and ask him to keep his hands to himself. She stated she then will separate him from the person he is touching. She stated she has only been here for 2 months and has not had any in-services regarding sexual behaviors and how to approach that as a care giver. CNA stated that she witnessed R#75 touch a female resident's leg in front of the nurse's station and Medical Records (MR) staff DD quickly redirected him. During an interview on 8/6/19 at 11:50 a.m. with CNA BB she stated if she sees R#75, who wanders and/or has sexually inappropriate behaviors, she will tell him his behavior is not appropriate and try to take him out of the situation. She stated she will report it to the charge nurse. CNA BB stated that R#75 will usually listen to her and might get upset but he will usually come back and apologize. She also stated that they get the Hand in Hand training for abuse and dementia and have on-line courses and town hall meetings where different people will talk to them about abuse and other things. CNA BB stated that R#75 usually has inappropriate behaviors towards other female residents. During an interview on 8/6/19 at 11:53 a.m. with MR DD revealed she had to redirect R#75 a month ago and she cannot remember the resident he was being inappropriate with, but he was blowing kisses and said, I'll get you girl. She stated she told R#75 he can't do that and then stated she took him to the dining room. She stated that she has had in-services on how to intervene and redirect with any resident exhibiting any behaviors from fighting, yelling, and sexual behavior. During an interview on 8/6/19 at 11:55 a.m. with CNA EE revealed if he sees a resident wandering in and out of other resident's rooms he tries to distract them and re-direct them. He stated they have a man here who wanders and has inappropriate behaviors and if he sees the resident doing this, he reports it to the Unit Manager (UM) or the DON. He stated he has been at the facility for five months and did receive the Hand in Hand training when he was hired which talked about dementia and abuse. During an interview on 8/6/19 at 12:30 p.m. with CNA EE, he verified the male resident he was talking about that wanders and has inappropriate behaviors is R#75. During an interview on 8/6/19 at 12:05 p.m. with the Administrator and the DON, they were asked to read the nurse notes dated 4/13/19, 3/27/19, 3/19/19, 3/3/19, 2/15/19, 10/12/18, 9/10/19, and 7/21/19. The DON stated she feels sure that LPN AA told she and the Administrator about the incident on 3/3/19. They stated the documented behavior is a common behavior for R#75. The Administrator stated they have placed STOP signs over the doors of the women he, R#75, likes to assist in stopping him from going into their room. He stated because R#75 wanders, the staff try different things like take him outside, do one on one with him, and stated they placed a bench at the nurse's station because he likes to sit there and it helps staff be able to monitor him more closely. The DON stated she does not know why residents name has not been seen by Psych services since December of 2018 but added he has an appointment for some time in August. She stated for the incident related to 4/13/19 LPN AA most likely reported this to the RCC for the 100 hall but it was not reported to her. She stated that the families of R#61 and R#43 who have had sexual inappropriate behaviors toward them by R#75 were not notified and the daughter of R#75 was not notified. Administrator stated that the facility would have notified the family for R#75 for any falls or change in condition, things like that, but their policy is to notify the family of both parties and the physician. DON stated that she would expect any out of the ordinary behaviors for R#75 to be documented but, if it is the same sexual behavior as always, she would not expect them to document every single one of those behaviors. She stated that the relationship between R#75 and R#61 was consensual. She stated they knew each other a long time ago when they went to school together and reconnected here. The Administrator stated the staff have had Dementia training, and some of the monthly required training has some abuse and other things that are related to Dementia. He stated they have a monthly Town Hall Meeting where the topic is generalized, and they discuss a little of everything. He stated that they do not mention any names of any resident but sometimes a staff member may mention an incident. He stated he remembers R#75 being mentioned but cannot recall the specifics. The DON stated when R#75 is sexually inappropriate his nurse reports the behavior to the RCC then she in turn reports it at the morning meeting the following morning. She stated she would not expect staff to call the NP but put the incident in the NP book and have her see them on Monday morning. The Administrator stated that he defines the word Frisky, mentioned in the nurse note on 3/27/19 to be flirty. He stated that he began working at this facility in 2011 as a floor tech and R#75 was here at that time and he has always known R#75 to be flirty. He stated that he interprets the separation of the residents on 3/27/19 to mean that staff felt the need to separate the residents so nothing more happened. He stated he does not recall this incident being reported. Administrator stated that the incident on 2/15/19 was typical for R#75 because he will leave his zipper undone after using the restroom. The DON stated there was no background check done on R#75, prior to his admission, because he was admitted [DATE] and the current owners took over in April 2014 and that is when all new residents began receiving background checks. The DON stated that the facility will protect the other residents from R#75's inappropriate behavior with global education. The Administrator stated that they are using STOP signs and that seems to work for R#75. DON stated that most residents call R#75 by name and tell him to leave right away when he comes into their room. She and Administrator both agree that R#75 coming into other resident's room is more of an aggravation and they have not had any complaints that other residents fear him. Administrator stated that, knowing R#75, he would not consider any of the documented incidents to be abuse except for possibly 3/3/19. The DON stated that there is no specific monitoring in place for R#75. The Administrator stated that none of the incidents have been reported to the State Agency and stated he is the Abuse Coordinator. He stated, by reading from the Facility Abuse Policy, that sexual harassment, sexual coercion, and sexual assault is defined as abuse but stated he would only consider the documented incident on 3/3/19 cause to further investigate but stated, knowing R#75, none of this jumped out at him enough to concern him that further investigation was needed. During an interview on 8/6/19 at 5:00 p.m. with the DON she stated by consensual she means that they had a touchy feely relationship and gave the example that R#61 would cover her lap with a purse or sweater and allow R#75 to continue to do whatever to her that he does. During a telephone interview on 8/6/19 at 1:59 p.m with the CEO of Psych Services revealed they work with the facility for ongoing clinic. She stated R#75 had not been scheduled for Services at the clinic since December 2018. CEO stated she would like for the facility to notify them and inform them on any behaviors/changes in the resident and stated the facility will set up the clinics by giving the care now services a list of residents to be seen by psych services. She stated if the facility doesn't schedule a clinic for a resident then services aren't provided. CEO stated the initial assessment for R#75 was in 2015 and the reason was for inappropriate behaviors. An associate of Psych Services, also on the call, stated she calls the facility every month and the facility have regular clinics as requested per the facility. She stated the process of care now services tele-psych is typically held on Tuesday and Thursday weekly. She stated the facility NP reviews the resident's medical records to include medications, labs, and Medication Administration Record (MAR), and will inform them of changes. Associate stated R#75 has an appointment with the tele-psych on August 16, 2019. During a telephone interview on 8/6/19 at 2:22 p.m. with the Daughter of R#75 she stated R#75 has been in the facility for 5 ½ years and she visits him 2 - 3 times per week. She stated she is very happy with her Father's care thus far and the facility will contact her of any changes or concerns with her father including falls, hospitalizations, infections, changes in medications, or behaviors. She stated to her knowledge her father does not have any infections, pressure sores, or has fallen recently but her father tends to wander around the building and try to get outside. Daughter stated that her father can become very agitated at times and occasionally will get physical. She stated she is invited to the family care plan meetings quarterly and her last meeting was last week, July 29th and during the meeting there was no mention of sexual or inappropriate behaviors exhibited by her father. She stated that during the meeting they stated, R#75 is being R#75 and he has not had any changes in status and is doing well. Daughter stated that the people in attendance for her father's care plan meeting was the two social services ladies, dietary, his CNA for the week, and his nurse for the week. She stated if there are any changes in her Father or any incidents that involve him, she would expect to be notified and in fact always stresses to staff, especially his nurses, to contact her if there are any issues because she is always available 24/7. Daughter stated that she had not been contacted in the last 6 months regarding any sexual or inappropriate behaviors that her Father was displaying but stated she was contacted over a year ago regarding her father being fresh with females in the facility but she has not been informed of any of the documented incidents of her father displaying sexual or inappropriate behaviors. She stated that she would expect to have been contacted about them and it mentioned during the care plan meeting. She stated she assumed that her father had not displayed anymore sexual or inappropriate behaviors since she was last notified 1 year ago. Daughter stated she does not want anyone else's rights in the facility to be infringed upon and wants her father to be comfortable as well. She stated that her Father has not received Psych or therapy services since he has been in the facility and stated she has not been contacted about referring her Father to Psych or therapy services but would not be opposed to her father receiving psych services if it meant ensuring the safety of others and himself. Daughter stated she is very involved in her father's care and the medications that he is being prescribed ad stated a few years ago she requested for them to reduce some of his medications for dementia because she felt that he was being over medicated but has not had that problem recently. During an interview on 8/6/19 at 1:57 p.m. with the Administrator and the DON. The Administrator was asked: At what point would you get concerned for your female residents related to the sexual behaviors of R#75? The Administrator stated that if the sexual behaviors got to the point of being more widespread for other female residents that he would be concerned, or if there was a change in the type of behavior R#75 was having he would be concerned. He stated that right now R#75's behaviors were pretty much isolated to R#61, whom he has had a relationship with for quite a while. He stated he would take each incident case by case, and if there was an increase in behaviors or a change in the type of behavior, he would address it. He stated that he felt that they had a pretty good reporting system. When the Administrator was asked if it had to be an increase in behaviors, wouldn't even one sexual behavior be too many? He stated that he was not notified of all the incidents brought to his attention by the survey team, and/or the staff did not give enough details of the incidents for him to be concerned, such as what part of the body the resident was rubbing on 3/3/19. He stated that R#75 was just being R#75. He stated that if he had known all the details of the incident on 3/3/19, that he would have done a self-report to the State. The Administrator further stated that from what he had learned today, that his plan was to re-educate the staff on reporting, and on sexual abuse. He stated that he felt the staff had just gotten used to R#75's sexual behaviors and had become lax at reporting them. He stated that there needed to be more of an evaluation of each incident to know all the details. He stated that a (psych) evaluation would be appropriate, and referral to inpatient psychiatric services would be considered. He stated that R#75's behavior was discussed with the daughter in care plan meetings, and that the daughter wanted to keep her father here. He said that another care plan meeting needed to be held not only with R#75's family, but with R#61's family as well. The Administrator further stated that if R#75's needs could not be met here, that he would have to be sent out to another facility. During an interview on 8/6/19 at 2:16 p.m. with the ADON she verified that she did the psych scheduling, which she stated was done by Tele-Health (remotely) and not directly in the facility. She stated that the Tele-Health was usually done every other month, and that the psych service company would send her a list of residents on their services and when they were last seen. She stated that she thought R#75 was recommended to be seen by the psych service every 1 to 4 months, but that they have had a heavy schedule of other residents that needed to be seen and verified R#75 had not been assessed by psych since December 2018. She stated that she tried to schedule the psych reviews with the residents with the oldest follow-up reviews to be seen first, and then any residents that were currently having behavioral issues. She stated that psych services had contacted her today to schedule the next group of residents to be seen, and that R#75 was on the list to be seen 8/16/19 at 1:00 p.m. During an interview on 8/6/19 at 2:29 p.m. with the Administrator he stated he has already educated first shift on sexual abuse. He stated he felt that what staff had reported to him was not abuse due to the lack of information given to him but when he processes this in his mind, after getting more of the details, he will probably go ahead and do a thorough investigation and a self-report for the incident on 3/3/19, which stands out most to him. He stated at this point, any sexual behavior would be reported to the physician and stated if he had more information about the incidents brought to his attention today, he would have contacted psych services to see R#75. Administrator stated any physical touching would be considered two types of abuse: physical and sexual. He stated R#75's flirtatious comments would have to be taken on a case by case basis but had staff made him aware that R#75 was showing his penis to another resident, he would have contacted psych, but that no detailed information had been given to him. He stated that staff had become complacent in R#75's behaviors, and that R#75 was being R#75; they were just used to him being like that. During a telephone interview on 8/6/19 at 2:45 p.m. with the Medical Director, and R#75's physician, he stated he was aware of R#75's behavior in March 2019 and that his NP saw R#75 and increased his Zoloft. Medical Director further stated he wasn't aware that R#75 had exposed himself to a female resident or took a female resident's hand and rubbed his groin area with it. He stated he was aware that R#75 had been seen by psych services in December and he spoke with the facility today and asked them to put him back on the psych schedule. He also stated he had spoken to the Unit Manager today and had ordered a low dose of Depakote for R#75 as well. During a telephone interview on 8/6/19 at 3:30 p.m. with the NP she stated that if there is a concern she needs to address the nurses put that information in the book and when she comes in on Mondays she reviews the book and see's the residents. She stated the nurses put the name of the resident, their concerns and she then see's the resident. NP stated that staff told her R#75 was exhibiting sexually inappropriate behaviors but stated that she was not aware he was touching residents or pulling out his penis or she would have ordered a Psych consult and check to see if he had a urinary tract infection to see if this was causing his increased behaviors. She stated she would also check the side effects of each of his medications as well as any possible interactions and after she had collected all the information, she would discuss the situation with the Medical Director, and physician for R#75, but would definitely tell the facility to stick to their policies. She stated if R#75's behavior is repetitive it wouldn't be inappropriate to send him out, but she doesn't know what their policy is for that. NP stated if the staff had called her with these concerns about R#75 she would not have objected to sending him out if that is what they wanted to do but stated she honestly would not expect staff to have called her for behaviors documented on 3/3/19 and 4/13/19 but would have expected them to put s note in the book for her to see the resident on her next visit. During an interview on 8/7/19 at 12:32 p.m. with the Administrator, DON, and the Corporate Nurse the Administrator stated that his definition of sexual relationship as it relates to R#75 and R#61 is one of boyfriend and girlfriend, holding hands, kisses on the cheek, putting his arm around her, and stated it has never been any more than that. He stated that they have never been in bed together and no sexual intercourse. The Administrator stated, regarding R#61 pulling a sweater or hat over her lap to hide the hand of R#75, he doesn't recall an incident like that, and he hasn't witnessed that but stated he is sure it was just hands on her clothing underneath the hat or sweater. The DON stated that R#75 did not put his hand down in her (R#61's) clothing but just under the sweater or the hat she pulled over her lap. Administrator stated that the incident on 4/13/19 was inappropriate behavior but couldn't say if it was sexual without doing an investigation, he stated the incident on 3/27/19 was flirting and described the term frisky as nudging, putting his arms around someone, saying things like, Hey pretty lady but he would not consider that being sexually inappropriate, Administrator stated the incident on 3/19/19 he would also consider flirtatious and would not consider that sexual abuse and stated out of all the nurses notes brought to his attention today the only one that stands out to him as a possibility would be 3/3/19. During an observation on 8/7/19 at 1:00 p.m. R#75 was observed to wander into the conference room and stand in the doorway. A staff member immediately came in and redirected him back out to the nurses station. Review of the facility Abuse Policy dated February 2019 revealed sexual harassment, sexual coercion, and sexual assault is defined as abuse. Review of the Associate Recognition Programs within the Facility, example of orientation revealed, on hire, employees have (including but not limited to) Patient's Rights, Abuse Reporting, and Elder Justice Act. 2. Review of resident (R) #61's clinical record revealed that she had diagnoses including Alzheimer's disease, anxiety disorder, insomnia, and major depressive disorder. Review of a hospital History and Physical dated 8/6/19 revealed that R#61 had severe dementia at baseline. Review of a Monthly Nursing Summary dated 7/19/19 revealed that R#61's cognition varied throughout the day, and she was disoriented to place, situation, and time. Further review of this Summary revealed that she had short term and long term memory problems, had delusions, wandered and intruded on others, and had poor safety awareness. Review of a Social Services Quarterly assessment dated [DATE] revealed very close, supportive, regular interaction with family and friends, but no mention of any type of relationship with R#75. Review of R#61's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicates that the staff conducting the interview was unable to complete one or more questions of the interview. Further review of this MDS revealed that a staff assessment for mental status was done, and they assessed R#61 as having short-term and long-term memory problems, and moderately impaired cognitive skills for daily decision making. Further review of the Cognitive Patterns section of the MDS revealed that R#61 had disorganized thinking, the severity of which fluctuated. Review of R#61's care plans last reviewed on 5/9/19 revealed: (R#61) has severe cognitive impairment related to Alzheimer's dementia. She is noted with confusion, disorientation, and forgetfulness. She has a history of wandering which has declined due to her decline in functional mobility. Her mental status is noted to vary throughout the day. (R#61) has impaired communication skills related to Alzheimer's dementia. She is noted with confusion and disorientation. Her speech rambles and she has difficulty in finding the right words or making sentences. She sometimes understands and is sometimes understood. Interventions to this care plan revealed one to maintain a consistent, relaxed environment and encourage social contact with people. (R#61) has a history of wandering which has declined due to her decline in functional mobility. She is at risk for injury related to impaired safety awareness. Review of the interventions to this care plan revealed to observe for patient's location to ensure safety. (R#61) is a risk for mood/behaviors related to diagnosis of Alzheimer's. She has a history of wandering throughout the facility all day at times. (R#61) is invited and attends group activities. She attends church, music, Bingo, bean auction, food socials and special events. She also enjoys spending time with her husband who is also a resident in this facility and another male friend who is also a resident in this facility. She interacts well with others and is very friendly. She doesn't play bingo anymore R/T (related to) cognitive deficit. Review of the interventions to this care plan revealed to encourage family/friend involvement and socialization. Review of R#61's electronic health record (EHR) Nurse's Notes from July 2018 to 8/6/19 revealed no documentation of any physical contact with R#75. Review of R#75's Nurse's Note dated 2/15/19, completed by Licensed Practical Nurse (LPN) II, revealed that he was in R#61's room. Further review of this Nurse's Note revealed that R#61 was sitting in her wheelchair, and R#75 was standing in front of her with his pants unbuttoned and unzipped, he refused to leave room and was fighting staff. During interview with LPN II on 8/7/19 at 8:47 a.m., she stated that R#61 and R#75 stayed together all the time, and that R#75 had sexual behaviors that they had to monitor all the time, including between him, R#61, and the staff. She further stated that to the best of her recollection, she observed R#75 in close proximity to R#61 in her room on 2/15/19 with his pants unzipped, but did not remember any direct physical contact. During interview with the Administrator on 8/6/19 at 1:57 p.m., he stated that he would be concerned if R#75's behaviors changed or were more widespread to other female residents, but that right now his behaviors were pretty much isolated to R#61, for whom he has had a relationship with for quite a while. The Administrator further stated that he was not aware of the details of all the interactions between R#75 and R#61 for him to be concerned, and thought that (R#75) was just being (R#75). The Administrator stated during continued interview that R#75's behavior had been discussed with his responsible party (RP) in care plan meetings, but that another care plan meeting to discuss R#75's behaviors needed to be held not only with R#75's RP, but with R#61's RP as well. During interview with the Assistant Director of Nursing (ADON) on 8/6/19 at 2:16 p.m., she verified that she scheduled the residents to be seen by the facility's TeleHealth (remote) psychiatric services provider, and thought that R#75 was recommended to be assessed by psychiatric services every one to four months. The ADON further stated that they have had a heavy schedule of residents that needed to be seen by psych services, and she was scheduling the residents that were furthest behind in their reviews. She verified that R#75 had not been seen by the psychiatric provider since December of 2018. During interview with the Social Services Director and Social Worker/admission Director on[TRUNCATED]

Based on record review, staff interview, and review of the policy Reporting and Investigating Abuse the facility failed to report documented sexually inappropriate behaviors for one resident (R) (R#75) to the Abuse Coordinator. The census on 8/5/19 was 102 residents. Findings include: Review of the medical record for R#75 revealed the following incidents of inappropriate sexual behavior: On 7/21/18 nurse note reads: It was reported by staff that R#75 was touching another resident (R#61) inappropriately. Resident was redirected successfully [Completed by LPN AA]. 9/10/18 nurse note reads: Another resident (R#43) reported that over weekend R#75 came into her room while she was brushing her teeth and urinated in toilet and shook his penis at her. He wanders into other rooms during day and at night. [Completed by LPN AA]. 10/12/18 nurse note reads: R#75 up walking, nurse took him back to room, she put him on bed, and he grab her between the legs. Nurse instruct R#75 not to do that it was wrong. He told her to go to hell. [Completed by LPN JJ] 2/15/19 nurse note reads: Found R#75 in R#61's room. R#61 was sitting in her wheel chair and R#75 was standing in front of her with his pants unbuttoned and unzipped. Refused to leave room. Was fighting staff. [Completed by LPN II]. 3/3/19 nurse note reads: R#75 had sexual behaviors during shift. He had another resident (R#61) hand on him and was using it to rub himself. He had other behaviors of this kind during day. R#75 redirected and other resident (R#61) moved to another location. Will continue to monitor R#75 during day. [Completed by LPN AA]. 3/19/19 nurse note reads: Yesterday resident followed CNA around the building and tried to get her to kiss him. Inappropriate actions. Resident difficult to redirect at that time. [Completed by Director of Nursing (DON)]. 3/27/19 nurse note reads: R#75 has been up since 3:30 a.m. walking around and then sitting in dining room. He became frisky with a lady (R#61) from b hall. Asked patient to leave her alone, he stopped, then later a Certified Nursing Assistant (CNA) came to separate him from her. [Completed by LPN JJ] . 4/13/19 nurse note reads: About 2:55 p.m. R#75 pulled his penis completely out of his pants in front of nursing station beside another resident (R#61). [Completed by LPN AA]. During an interview on 8/6/19 at 11:00 a.m. with LPN AA. She stated she reported the incident on 4/13/19 to the Resident Care Coordinator (RCC) for the 100 hall and to the RCC for the 200 hall. LPN AA stated that she put in the Nurse Practitioner (NP) book for her to see R#75 when she came in for increased behaviors but did not notify the daughter, call the Medical Doctor (MD), or the NP. She stated she doesn't remember if she reported the incident on 3/3/19. During an interview on 8/6/19 at 11:50 a.m. with CNA BB she stated if she sees R#75, who wanders and/or has sexually inappropriate behaviors, she will tell him his behavior is not appropriate and try to take him out of the situation. She stated she will report it to the charge nurse. CNA BB stated that R#75 will usually listen to her and might get upset but he will usually come back and apologize. She also stated that they get the Hand in Hand training for abuse and dementia and have on-line courses and town hall meetings where different people will talk to them about abuse and other things. CNA BB stated that R#75 usually has inappropriate behaviors towards other female residents. During an interview on 8/6/19 at 11:55 a.m. with CNA EE revealed if he sees a resident wandering in and out of other resident rooms, he tries to distract them and re-direct them. He stated they have a man here who wanders and has inappropriate behaviors and if he sees the resident doing this, he reports it to the Unit Manager (UM) or the DON. He stated he has been at the facility for five months and did receive the Hand in Hand training when he was hired which talked about dementia and abuse. During an interview on 8/6/19 at 12:30 p.m. with CNA EE, he verified the male resident he was talking about that wanders and has inappropriate behaviors is R#75. During an interview on 8/6/19 at 2:29 p.m. with the Administrator he stated at this point, any sexual behavior would be reported to the physician and stated if he had more information about the incidents brought to his attention today, he would have contacted psych services to see R#75. Administrator stated any physical touching would be considered two types of abuse: physical and sexual. He stated R#75's flirtatious comments would have to be taken on a case by case basis but had staff made him aware that R#75 was showing his penis to another resident, he would have contacted psych, but that no detailed information had been given to him. He stated that staff had become complacent in R#75's behaviors, and that R#75 was being R#75; they were just used to him being like that. Upon review of the grievances by the Administrator there had been no grievances filed regarding sexually inappropriate behavior by R#75. Review of the policy Reporting and Investigation Abuse dated February 2018 revealed it is the intent of this Center to establish standards of practice for investigation and reporting abuse, neglect, mistreatment, exploitation, and misappropriation of property. There was no documentation by the Facility that the sexual inappropriate behaviors of R#75 was reported to the Abuse Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update and revise the person centered comprehensive care plan for 2 Residents (R) (R#75 and R#61) related to sexual behaviors. The sample size was 35 Residents. Findings Include: 1. Minimum Data Set Quarterly review dated 7/2/19 for R#75 revealed a Basic Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. Mood with a total severity score of zero indicating no mood disorder. Behavior of wandering daily. Functional Status of limited one-person assistance with bed mobility, transfers, dressing, bathing, and moving off and on the toilet and personal hygiene; Not steady but able to stabilize without human assistance for walking. Frequently incontinent of bowel and bladder. Active Diagnosis of, including but not limited to, dementia, anxiety disorder, and depression. Medications of an antianxiety and antidepressant 7 out of 7 days a week. Review of the Care Plan for R#75 revealed he is at risk for mood/behavior problems, has a history of compulsive disorder with inappropriate sexual behaviors, and rejects care at times. R#75 has a diagnosis of dementia with behaviors and mood disorder. Interventions include: R#75's behavior will not adversely affect self or others through next review date. Explain procedures/cares prior to beginning. If patient is upset leave and allow time to calm, then approach and offer again later. Notify MD of changes in status as needed. Observe patient for inappropriate behaviors. Provide meds as ordered and observe effectiveness. Psychiatric consult as needed. Redirect patient as needed. During an interview on 8/6/19 at 12:05 p.m. with the Administrator and the DON, the DON stated that if a new intervention was tried with R#75's behaviors his care plan should have been updated but stated there is a care plan in place related to his sexual behaviors. She stated that each intervention is dated according to the time it was implemented but she would not expect each incident with R#75, being sexually inappropriate, to be placed on the care plan. The Administrator stated that there is Patient At Risk (PAR) note on 3/15/19 stating the Zoloft dose for R#75 was increased for increased sexual behaviors toward staff and other residents but there are no recommendations on the PAR. The DON stated that in the PAR meetings the nurse, usually the MDS nurse, would be responsible for updating the care plan. She stated in May the intervention that should have been added to R#75's care plan is Review Medications, but upon review of the Care Plan it was not added. During this time the DON verified that the Care Plan has not been updated or revised since November 2018. Review of the policy Patient's Plan of Care dated July 2018 revealed it is the intent of this center to develop and maintain an individualized plan of care for each patient. Number 4 states: PAR- the care plan should be updated during the PAR meetings. 2. Review of resident (R) #61's clinical record revealed that she had diagnoses including Alzheimer's disease, anxiety disorder, insomnia, and major depressive disorder. Review of R#61's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicates that the staff conducting the interview was unable to complete one or more questions of the interview. Further review of this MDS revealed that a staff assessment for mental status was done, and they assessed R#61 as having short-term and long-term memory problems, and moderately impaired cognitive skills for daily decision making. Further review of the Cognitive Patterns section of the MDS revealed that R#61 had disorganized thinking, the severity of which fluctuated. Review of R#61's care plans last reviewed on 5/9/19 revealed that they included severe cognitive impairment; impaired communication skills; wandering and impaired safety awareness; and risk for mood/behaviors related to diagnosis of Alzheimer's. Further review of the care plans revealed they included one for activities, and that R#61 enjoyed spending time with another male friend who was also a resident in this facility. Further review of all of the care plans revealed that there was no mention of any sexual behaviors between R#75 and R#61. Review of Care Plan Conference meeting notes dated 4/24/19, 11/14/18, 8/29/18, and 6/6/18 revealed that R#61 attended all the meetings except the one on 11/14/18, that the responsible party (RP) was invited but did not attend, and none of the notes mentioned any relationship between R#61 and R#75. During interview with the Social Worker/Admissions Director on 8/8/19 at 12:53 p.m., she verified that she spoke with R#61's RP yesterday, and the conversation included R#61's relationship with R#75. She verified that she did not discuss any sexual interactions or behaviors between the two residents, including R#75 pulling his penis out in front of R#61 (on 4/13/19), or R#75 putting R#61's hand on his pelvic area (on 3/3/19). The Social Worker/Admissions Director stated that she had never discussed the interactions between the two residents in detail with R#61's RP as to include the sexual behaviors. Cross-refer to F 600.

Based on record review, staff interview, and review of the facility's Abuse policy dated February 2019 The Administrator failed to ensure cognitively impaired residents were assessed for appropriateness of sexual relationships and to ensure that relationships were carried out in a private setting for 2 residents (R) (R#75 and R#61). The census on 8/5/19 was 102 residents. Findings Include: Review of the medical record for R#75 revealed : 7/21/18 nurse note reads: It was reported by staff that R#75 was touching another resident (R#61) inappropriately. Resident was redirected successfully [Completed by LPN AA]. 9/10/18 nurse note reads: Another resident (R#43) reported that over weekend R#75 came into her room while she was brushing her teeth and urinated in toilet and shook his penis at her. He wanders into other rooms during day and at night. [Completed by LPN AA]. 10/12/18 nurse note reads: R#75 up walking, nurse took him back to room, she put him on bed, and he grab her between the legs. Nurse instruct R#75 not to do that it was wrong. He told her to go to hell. [Completed by LPN JJ] 2/15/19 nurse note reads: Found R#75 in R#61's room. R#61 was sitting in her wheel chair and R#75 was standing in front of her with his pants unbuttoned and unzipped. Refused to leave room. Was fighting staff. [Completed by LPN II]. 3/03/19 hand on him and was using it to rub himself. He had other behaviors of this kind during day. R#75 redirected and other resident (R#61) moved to another location. Will continue to monitor R#75 during day. [Completed by LPN AA]. 3/19/19 nurse note reads: Yesterday resident followed CNA around the building and tried to get her to kiss him. Inappropriate actions. Resident difficult to redirect at that time. [Completed by Director of Nursing (DON)]. 3/27/19 nurse note reads: R#75 has been up since 3:30 a.m. walking around and then sitting in dining room. He became frisky with a lady (R#61) from b hall. Asked patient to leave her alone, he stopped, then later a Certified Nursing Assistant (CNA) came to separate him from her. [Completed by LPN JJ] . 4/13/19 nurse note reads: About 2:55 p.m. R#75 pulled his penis completely out of his pants in front of nursing station beside another resident (R#61). [Completed by LPN AA]. During an interview on 8/6/19 at 12:05 p.m. with the Administrator and the DON, they were asked to read the nurse notes dated 4/13/19, 3/27/19, 3/19/19, 3/3/19, 2/15/19, 10/12/18, 9/10/19, and 7/21/19. Administrator stated the documented behavior is a common behavior for R#75. He stated they have placed STOP signs over the doors of the women he, R#75, likes to assist in stopping him from going into their room. He stated because R#75 wanders, the staff try different things like take him outside, do one on one with him, and stated they placed a bench at the nurse's station because he likes to sit there, and it helps staff be able to monitor him more closely. DON stated they, R#75 and R#61, knew each other a long time ago when they went to school together and reconnected here. Administrator stated that he defines the word Frisky, mentioned in the nurse note on 3/27/19 to be flirty. He stated that he began working at this facility in 2011 as a floor tech and R#75 was here at that time and he has always known R#75 to be flirty. He stated that he interprets the separation of the residents on 3/27/19 to mean that staff felt the need to separate the residents so nothing more happened. Administrator stated that the incident on 2/15/19 was typical for R#75 because he will leave his zipper undone after using the restroom. The DON stated that the facility will protect the other residents from R#75's inappropriate behavior with global education. She stated that most residents call R#75 by name and tell him to leave right away when he comes into their room. She and Administrator both agree that R#75 coming into other resident's room is more of an aggravation and they have not had any complaints that other residents fear him. Administrator stated that, knowing R#75, he would not consider any of the documented incidents to be abuse except for possibly 3/3/19. The DON stated that there is no specific monitoring in place for R#75. The Administrator stated that none of the incidents have been reported to the State Agency and stated he is the Abuse Coordinator. He stated, by reading from the Facility Abuse Policy, that sexual harassment, sexual coercion, and sexual assault is defined as abuse but stated he would only consider the documented incident on 3/3/19 cause to further investigate but stated, knowing R#75, none of this jumped out at him enough to concern him that further investigation was needed. During an interview on 8/6/19 at 1:57 p.m. with the Administrator and the DON. The Administrator was asked: At what point would you get concerned for your female residents related to the sexual behaviors of R#75? The Administrator stated that if the sexual behaviors got to the point of being more widespread for other female residents that he would be concerned, or if there was a change in the type of behavior R#75 was having he would be concerned. He stated that right now R#75's behaviors were pretty much isolated to R#61, whom he has had a relationship with for quite a while. He stated he would take each incident case by case, and if there was an increase in behaviors or a change in the type of behavior, he would address it. He stated that he felt that they had a pretty good reporting system. When the Administrator was asked if it had to be an increase in behaviors, wouldn't even one sexual behavior be too many? He stated that he was not notified of all the incidents brought to his attention by the survey team, and/or the staff did not give enough details of the incidents for him to be concerned, such as what part of the body the resident was rubbing on 3/3/19. He stated that R#75 was just being R#75. He stated that if he had known all the details of the incident on 3/3/19, that he would have done a self-report to the State. The Administrator further stated that from what he had learned today, that his plan was to re-educate the staff on reporting, and on sexual abuse. He stated that he felt the staff had just gotten used to R#75's sexual behaviors and had become lax at reporting them. He stated that there needed to be more of an evaluation of each incident to know all the details. He stated that a (psych) evaluation would be appropriate, and referral to inpatient psychiatric services would be considered. He stated that R#75's behavior was discussed with the daughter in care plan meetings, and that the daughter wanted to keep her father here. He said that another care plan meeting needed to be held not only with R#75's family, but with R#61's family as well. The Administrator further stated that if R#75's needs could not be met here, that he would have to be sent out to another facility. During an interview on 8/6/19 at 2:29 p.m. with the Administrator he stated he has already educated first shift on sexual abuse. He stated he felt that what staff had reported to him was not abuse due to the lack of information given to him but when he processes this in his mind, after getting more of the details, he will probably go ahead and do a thorough investigation and a self-report for the incident on 3/3/19, which stands out most to him. He stated at this point, any sexual behavior would be reported to the physician and stated if he had more information about the incidents brought to his attention today, he would have contacted psych services to see R#75. Administrator stated any physical touching would be considered two types of abuse: physical and sexual. He stated R#75's flirtatious comments would have to be taken on a case by case basis but had staff made him aware that R#75 was showing his penis to another resident, he would have contacted psych, but that no detailed information had been given to him. He stated that staff had become complacent in R#75's behaviors, and that R#75 was being R#75; they were just used to him being like that. Review of the Job Title : Administrator, revised 10/14, revealed the Administrator Job Description reads: Directs the day to day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. Under Essential Demonstration of Facility Core Values, the Administrator assumes responsibility for and honors patients' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints and, assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Essential Managerial Functions of the Administrator include, but is not limited to, makes routine inspections of the Center to assure that established policies and procedures are being implemented and followed. Cross Reference F600