Based on record review, staff and physician interviews, and policy review the facility failed to document routine assessment and interventions completed by the facility for 1 of 6 residents reviewed (Resident #8). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated 11/24/2023 documented a Brief Interview for Mental Status (BIMS) of 14 indicating he was cognitively intact. The MDS informed he was independent with toileting and walking. The MDS documented a primary diagnosis of other neurological conditions and also diagnoses of diabetes, anemia, malnutrition, and Parkinson's. Record review of Resident #8 Assessments in his Electronic Health record (EHR) lacked documentation of complete assessments related to a decline in condition from 12/13/23 to 12/17/23. Record review of Resident #8 Progress Notes and Point of Care Records in his EHR revealed the following: 12/13/23 - Resident #8 had a medium formed bowel movement. 12/14/23 - Resident #8 had an emesis and the facility notified his Doctor of his decline with no new orders. 12/15/23- Resident #8 abdomen was assessed and soft. Resident #8 had a medium loose bowel movement. 12/16/23 - Resident #8 had a headache 12/17/23 - Facility gave him magnesium laxative in the morning, and sent him to the local hospital to be evaluated due to a decline in condition. Record review of the local hospital Emergency Department (ED) Provider Note on 12/17/2023 at 10:14 AM revealed he was diagnosed with a small bowel obstruction, acute respiratory failure, acute renal failure, aspiration pneumonia due to gastric secretions, and sepsis. During an interview on 5/22/24 at 9:45 AM the Director of Nursing (DON) revealed the facility would notify the physician if adverse symptoms occurred depending on the severity, if there was a further change in condition like a decline, they would either call or fax the physician depends on the situation. During and interview on 5/22/24 at 3:30 PM With Staff E, Licensed Practical Nurse (LPN) revealed Resident #8 would always tell staff if there was a problem and he was normal all night the last night she worked with him on 12/16/23 going into 12/17/23. Last time I was with him, he was acting normal and went out to church. Last night I worked with him and he was normal all night long. He was very with it, but was slow to act, I think he would have told someone if he wasn't having BM's because he would always tell someone. During an interview on 5/22/24 at 4:35 PM With Staff D, Registered Nurse (RN) revealed resident #8 was independent around the facility and able to take himself to the bathroom. He would let us know if he went, his normal bowel movements were loose and large. She then revealed he had a previous bariatric surgery and if he ate too much of the wrong food it could upset his stomach and make him kind of sick. She informed his symptoms would be lots of phlegm, upset stomach, and dry heaving. She then informed he would not normally vomit food substance, just saliva not bile. She revealed she was working on 2/16/23 before he went to the hospital and assessed him. He was under the weather, but very adamant he didn't want to go to the hospital and just wanted to wait it out. She then informed on 12/17/23 she went and check on him in the morning and he had sunken in eyes and a low blood pressure and she suspected he was dehydrated, she informed she attempted to keep him comfortable in the beginning, she then informed he would want to go to the hospital if his POA was ok with it. During an interview on 6/4/24 at 11:04 AM with Staff C, Physician revealed in his line of work bowel obstructions can form very rapidly and sometimes in a matter of hours (3-4 hours). He then revealed a bowel obstruction does not have to evolve slowly over days. He revealed Resident #8 Advance Directives was comfort care (control pain and other symptoms so the patient can be as comfortable as possible) while living at the facility. Record review of the facilities undated policy titled Bowel Management Program instructed the following: a. Each resident will use the toilet/commode/urinal bedpan as per care plan. b. The nursing staff, (CNA's) will record the bowel movements. Residents that are independent with toileting will be asked if they have had a bowel movement (BM) by the CNA's every shift. If the resident does not have a bowel movement, that will be documented. c. The 10:00 - 6:00 AM nurse will run a BM list towards the end of his/her shift. Residents will be identified who have not had a bowel movement in two (2) or more days. d. The 6:00 - 2:00 PM Nurse or Certified Medication Aide (CMA) will administer an oral laxative or stool softener as ordered to the residents who have been identified as not having had a bowel movement in two days. e. Following administration, Nurse/CMA will monitor which residents have not had a bowel movement. f. If a resident has not had a BM by morning of the 3rd day, the night shift or day shift Nurse will administer a suppository or an additional laxative aide as ordered for elimination needs. g. If no results from the second intervention, the nurse will complete an abdominal assessment. Document assessment. Notify the physician in a timely manner. h. Nurses and CMAs are to document any medication or treatment interventions given on the Medication Administration Record or Treatment Record. i. Document on the 24-hour Nurse Hand off sheets and communicate in change of shift nurse report when bowel aides are needed and given as well as the results. j. Residents who are getting PRN bowel management medications on a frequent basis should be considered to have any scheduled bowel management medications re-evaluated.

Based on observations, clinical record review, staff and resident interviews and facility policy review, the facility failed to assess for the safety and competency of self-administration of inhalant medications for 1 of 7 residents observed during medication administration (Resident #25) . The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 9/06/23, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of indicating intact cognition. The MDS included diagnoses of chronic respiratory failure with hypoxia, shortness of breath, dyspnea, and generalized muscle weakness. The Care Plan, revised 08/30/23, revealed a focus area for impaired Activities of Daily Living (ADLs) and mobility independence related to chronic respiratory failure with hypoxia. The Care Plan lacked focus area or intervention for the self administration of medications. The Medication Administration Record (MAR), dated November 2023, revealed the following medication orders: a. Breyna (Budesonide-Formoterol Fumarate Dihydrate) Inhalation Aerosal 160-4.5 micrograms (mcg) per actuation (ACT), inhale 2 puffs orally twice a day. Rinse mouth after use. b. Symbicort Aerosol 180-4.5 mcg/ACT, inhale 2 puffs orally twice a day. Rinse mouth after use. c. Ipratropium-Albuterol inhalation solution 0.5-2.5 milligrams (mg) per 3 milliliters (ml), inhale 3 ml orally four times a day; d. Albuterol Sulfate inhaled aerosol solution 108 mcg/ACT, inhale 2 puffs orally every two hours as needed for shortness of breath or wheezing. Use inhaler when away from nebulizer. On 11/08/23 at 9:04 AM, observed Staff G, Certified Medication Aide (CMA), enter Resident #25's room with three vials of Ipratropium-Albuterol (also known as Duoneb) inhalation solution, typically used with a nebulizer as a breathing treatment. The order instructed inhalation of one vial (3 ml) four times a day related to Chronic Obstructive Pulmonary Disease (COPD). Staff G placed the three vials of Duoneb solution into a plastic container in Resident #25's room, on the overbed table. The container label indicated Ipratropium-Albuterol and listed the times: 7:30 AM, 11:30 AM, 3:30 PM, 7:30 PM, 11:30 PM, and 3:30 AM. Staff G stated Resident #25 received three vials to complete breathing treatments independently though the shift. Three additional medicated inhalers located on Resident #25's nightstand. Staff G informed that Resident #25 performed all inhalant medications independently. On 11/08/23 at 9:45 AM, Resident #25 verified he performed self-administration of all inhaled medications kept at bedside. Resident #25 stated he used the Duoneb nebulizer treatment every 4 hours; two puffs of the albuterol inhaler as needed; two puffs of the Breyna inhaler twice per day; and two puffs twice per day of the Symbicort inhaler, but notified he is not currently utilizing this inhaled medication. Resident #25 denied need to rinse mouth after use of Breyna or Symbicort inhaler as indicated in the Physician's orders. On 11/08/23 at 10:00 AM, the Director of Nursing (DON) stated she expected these inhaled medications be in a lock box in Resident #25's room, due to a roommate. The DON confirmed she expected an assessment for self-administration of medication completed prior to a resident self-administering. The DON confirmed she failed to complete the assessment for Resident #25. The facility policy titled Self-Administration of Medications, no date, revealed that medications kept in the resident's room must be in a locked container. The policy informed that the Interdisciplinary Team will assess the resident's cognitive, physical, and visual ability to determine if it is safe for the resident to self-administer medications. The facility policy further instructed to document all teaching and instruction provided to the resident and give the resident copies of instruction.

Based on clinical record review, observations, resident and staff interviews, review of a Maintenance Work Order, the facility failed to maintain good repair of a floor heating register in resident room for 1 of 8 resident's rooms screened for a homelike environment (Resident #21). The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 7/07/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed diagnoses of late-onset cerebellar ataxia, multi-system degeneration of the autonomic nervous system, adjustment disorder with anxiety, and depression. The MDS, revealed Resident #21 required extensive assistance of two staff for bed mobility, transferring, and toileting and non-ambulatory. Review of facility form titled Maintenance Work Order revealed on 8/02/23, the Administrator requested a work order for a heat register cover off in Resident #21's room. Order signed and marked as done by Maintenance staff on 8/02/23. On 11/06/23 at 11:50 AM, half of floor heating register cover sat on the floor just under Resident #21's bed. The bed, located next to wall, had left side parallel to wall, cover for floor register observed in disrepair underneath the length of the bed. Noted sheets, blankets, and a tissue near the exposed heating unit underneath resident bed. On 11/06/23 at 12:00 PM, Facility Administrator arrived at Resident #21's room to view disrepair of heating register cover. Administrator notified that the heat in Resident #21's room does work and informed that Maintenance Staff would be made aware to provide repair of the floor heating cover. On 11/07/23 at 8:29 AM, the cover to the floor heat register lied on the floor underneath the head of bed. The head of bed alongside the wall perpendicular to wall with original floor heat register cover in disrepair. On 11/08/23 at 8:42 AM, the cover to floor heat register lied on the floor underneath the head of Resident #21's bed. Resident #21 reported the heat register sat in disrepair for a couple of months and stated she noticed the heat unit sounded loud. On 11/08/23 at 9:50 AM, Staff J, Housekeeping Staff, informed the facility had Maintenance Work Order Forms to be completed with any requested repairs. Staff J reported she had witnessed heat register covers off and lying on the floor before and that she will put them back on unless they get too bent then the facility will order a new one. Staff J indicated she had witnessed Resident #21's heat register cover off before as her bed bumps it. On 11/08/23 at 10:12 AM, the Director of Nursing (DON) arrived at Resident #21's room to view disrepair of the heat register cover. The DON stated the cover should not be left like that and informed he would find out if the broken register cover would be fixed or replaced. On 11/08/23 at 10:32 AM, the DON reported that Maintenance Staff was working on fixing the broken cover at this time.

Based on clinical record review, staff interviews, employee file review, and facility policy review, staff failed to report to the facility and the facility failed to identify situations as an alleged violation involving abuse and to report allegations within required regulatory time frames for 3 of 3 residents reviewed (Residents #9, #26 and #28). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #9 signed 10/12/23 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Section I signed 10/24/23 documented diagnoses of cancer, anxiety disorder, and encephalopathy (change in brain function). A document titled Self-Report dated 2/1/23 revealed another resident touched and patted Resident #9 on the breast on 1/12/23 in a common area of the facility. The report indicated Staff H, Licensed Practical Nurse (LPN), and the former Director of Nursing (DON), Staff B, were aware of the incident on 1/12/23. Staff B investigated the incident, and she did not find the other resident had intentionally had inappropriate contact with Resident #9. On 1/31/23 Staff I, Health Services Supervisor, learned of the incident and determined it should have been reported regardless of the investigation results. The time frame between the incident and the report was 20 days. On 11/08/23 at 10:15 AM, the Administrator confirmed he was not here when this incident occurred. He stated at the time of this incident the resident received 15-minute checks for safety. He expected staff would report potential abuse within 2 hours. On 11/08/23 at 10:41 AM, Staff H stated the 15-minute checks started when the other resident began touching female residents. She revealed she witnessed this incident and it upset her the most because she believed the individual needed a higher level of care and 15-minute checks were a start but were not enough. Staff B stated the resident knew what he was doing when he touched Resident #9. On 11/08/23 at 2:33 PM, Staff B stated the other resident's behaviors became more aggressive and territorial over time. She believed he knew staff were watching him because he was aware of the checks and they upset him. He had to be redirected and walked away from the area after he touched Resident #9. 2. The MDS Assessment for Resident #26 dated 8/25/23 revealed the resident scored 12 out of 15 on a BIMS exam, which indicated moderate cognitive impairment. Section I of the MDS listed diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety disorder. A Care Plan area dated 5/6/22 documented Resident #26 became confused and easily over-stimulated due to Parkinson's and dementia, and staff should assess and anticipate needs. Another Focus Area with the same date indicated the resident was at risk for falls. On 7/18/22 an intervention was added that the resident was easily startled and needed time to become aware of someone's presence. A Progress Note dated 2/8/23 created by Staff K, labeled MD/Nursing Communications, with the return fax signed by Staff H, LPN documented Resident #26 was found laying on his back with his head on the closet door. He reported he did not hear his roommate come up behind him, and the roommate made a loud noise that scared me to death. The roommate admitted he came up behind the resident and clapped his book together loudly to be 'funny'. A Progress Note dated 3/9/23 by Staff H, revealed Resident #26 was standing in his room without assistance when his roommate startled him causing him to sit next to his bed on the floor. A document titled Self-Reports documented no self-reports were completed between 2/1/23 and 7/24/23. On 11/08/23 at 10:15 AM, the Administrator stated at the time of this incident the resident who caused Resident #26 to fall received 15-minute checks for safety. He expected staff would report potential abuse within 2 hours and did not have documentation these resident-to-resident incidents were reported. On 11/08/23 at 10:41 AM, Staff H confirmed the 15-minute checks were in place. She believed the resident who caused the falls was high risk and needed a higher level of care. She did not believe 15-minute checks were effective because his behaviors would happen when staff walked away. She stated Resident #26 startled easily and the other resident would make him fall. Staff H stated there were two incidents they knew of where the other resident made Resident #26 fall, but indicated there could have been more they didn't know about because the residents shared a room. She stated the resident causing the falls knew what he was doing, and that staff later heard him laugh with another resident about what he did. On 11/08/23 at 2:33 PM, Staff B, Registered Nurse (RN)/Former Director of Nursing (DON) stated the other resident's behaviors became more aggressive and territorial over time. She believed he knew staff were watching him because he was aware of the checks and they upset him. Staff B indicated the resident should have had 1:1 intervention in place sooner to prevent additional incidents. 3. The MDS for Resident # 28 dated 8/8/23, included diagnoses of dementia and anxiety disorder. The BIMS for Resident #28 showed a score of 6 out of 15, indicating severe cognitive impairment. The MDS reflected Resident # 28 required extensive assist of two staff for bed mobility, transfer, dressing and personal hygiene. The Care Plan for Resident # 28 dated 8/06/23, directed she needed help from one staff to dress. Totally dependent on one staff for personal hygiene, bed mobility and a full body lift for transfers. The Incident Report note dated 9/3/23, described a situation on 8/23/23 Staff C, Certified Nurses Aide (CNA) reported as they cared for Resident #28 she screamed in distress. She revealed she witnessed Staff D, CNA grab Resident #28's hand from her and told Resident #28 to shut up. Staff D continued to hold Resident #28's wrists and forced her arms through her clothes to get her ready for bed. The note continued Staff C failed to report this incident to her supervisor until 9/3/23. The Employee Performance Expectation Disciplinary Action for Staff D, CNA dated 9/7/23, reflected staff reported on 9/4/23 she witnessed physical and verbal abuse along with some disturbing behavior. The Employee file for Staff C included a document titled New Hire Acknowledgement Receipt dated 8/23/23, indicated she received a copy of the facility policy on Reporting Suspected Crimes under the Federal Justice Act. The Reporting Suspected Crimes under the Federal Justice Act dated 2010, directed at point # 2 All new staff, as part of their orientation to work at the facility shall receive a copy of their obligation to comply with the law and this policy and procedure. The Nursing Schedule dated 8/27/23, showed Staff A, LPN worked on the 2-10 shift. On 11/08/23 at 1:23 PM, Staff A denied knowledge that Staff C reported any incidents with Staff D. Staff A stated she expected staff to report such incidents and concerns to her. On 11/08/23 02:23 PM, Staff B, Registered Nurse (Director of Nursing at the time of the report) stated she expected the CNA to report concerns like this to Management immediately. On 11/09/23 at 11:15 AM, the DON reported he expected staff to report any concerns with other staff interaction with residents to him immediately. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy dated October 2022 documented that all residents had the right to be free from abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Sexual exploitation included touching of a clothed or unclothed breast. Resident-to-resident physical contact that occurred is considered resident-to-resident abuse. Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility would presume instances of abuse caused physical harm, pain, or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to complete a thorough investigation of alleged violations of abuse, maintain documentation, and prevent further incidents. (Residents #9 and #26). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #9 signed 10/12/23 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Section I of the MDS signed 10/24/23 documented diagnoses of cancer, anxiety disorder, and encephalopathy (change in brain function). A document titled Self-Report dated 2/1/23 revealed another resident touched and patted Resident #9 on the breast on 1/12/23 in a common area of the facility. The report indicated Staff H, Licensed Practical Nurse (LPN), and the former Director of Nursing (DON), Staff B, were aware of the incident on 1/12/23. Staff B investigated the incident, and she did not find the other resident had intentionally had inappropriate contact with Resident #9. On 1/31/23 Staff I, Health Services Supervisor, learned of the incident and determined the incident should have been reported regardless of the investigation results. The time frame between the incident and the report was 20 days. A fax sent 2/1/23 and returned 2/2/23 confirmed the incident had not been reported to the other resident's provider. That resident was documented as oriented to person, place, and time with impaired memory. On 11/08/23 at 10:15 AM, the Administrator confirmed he was not here when this incident occurred. He stated at the time of this incident the resident received 15-minute checks for safety. He expected staff would investigate immediately and report potential abuse within 2 hours. On 11/08/23 at 10:41 AM, Staff H stated the 15-minute checks started when the other resident began touching female residents. She revealed she witnessed this incident and 15-minute checks were a start but were not enough. Staff B stated the resident knew what he was doing when he touched Resident #9. On 11/08/23 at 2:33 PM, Staff B stated the other resident's behaviors became more aggressive and territorial. She believed he knew staff were watching him because he was aware of the checks and they upset him. He had to be redirected and walked away from the area after he touched Resident #9. 2. The MDS Assessment for Resident #26 dated 8/25/23 revealed the resident scored 12 out of 15 on the BIMS exam, which indicated moderate cognitive impairment. Section I of the MDS listed diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety disorder. A Care Plan area dated 5/6/22 documented Resident #26 became confused and easily over-stimulated due to Parkinson's and dementia, and staff should assess and anticipate needs. Another focus area with the same date indicated the resident was at risk for falls and had poor safety awareness. On 7/18/22 an intervention was added that the resident was easily startled and needed time to become aware of someone's presence at his door. A Progress Note dated 2/8/23 created by Staff K, labeled MD/Nursing Communications, with the return fax signed by Staff H, LPN documented Resident #26 was laying on his back with his head on the closet door. He reported he did not hear his roommate come up behind him, and the roommate made a loud noise that scared me to death. The roommate admitted he came up behind the resident and clapped his book together loudly trying to be funny. A Progress Note dated 3/9/23 by Staff H, labeled MD/Nursing Communications revealed Resident #26 was standing in his room without assistance when his roommate startled him causing him to sit next to his bed on the floor. The Progress Notes failed to address this as a possible cause for other Resident #26 falls. An untitled Quality Assurance and Performance Improvement (QAPI) document dated 4/14/23 failed to provide a Root Cause Analysis for resident falls or resident to resident interactions. On 11/08/23 at 10:15 AM, the Administrator stated at the time of this incident the resident who caused Resident #26 to fall received 15-minute checks for safety due to inappropriate behavior with other residents. He expected staff would report potential abuse within 2 hours. On 11/09/23 at 12:22 PM the Administrator indicated the QAPI Committee had not been very good at monitoring, had not been consistent with documentation, and had not been documenting follow up. He indicated the program needed to be revamped to include documentation of resident care and quality of life topics. On 11/08/23 at 10:41 AM, Staff H stated she believed Resident #26's roommate was high risk and needed a higher level of care. She did not believe 15-minute checks were effective because his behaviors would happen when staff walked away or in his room. She stated Resident #26 startled easily and his roommate would make him fall. Staff H stated there were two incidents staff knew of where the other resident made Resident #26 fall, but there could have been more they didn't know about because they shared a room. She stated he knew what he was doing when he caused the falls, and that staff later heard him laugh with another resident about what he did. On 11/08/23 at 2:33 PM, Staff B stated the other resident's behaviors became more aggressive and territorial. Staff B indicated the resident should have had 1:1 intervention in place sooner to prevent additional incidents. A policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy dated October 2022 documented that following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals. This written report shall be forwarded to the Department within five days of the initial report. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to conduct a Comprehensive Assessment of a resident in accordance with the timeframes specified for 1 of 1 residents reviewed (Resident #138). The facility reported a census of 34. Findings Include: A Minimum Data Set (MDS) 3.0 Assessment Summary in the Electronic Health Record, labeled Entry with a target date of 10/26/23, revealed 33 questions remained with a status of 'in progress' and 7 days overdue. An MDS Assessment for Resident #138 dated 11/1/23, revealed an unsigned document with Section K completed 11/7/23, Section F completed 11/8/23, and Sections C and D completed 11/8/23. The remaining assessment sections were incomplete. The MDS summary revealed 365 questions remained with a status of 'in progress' and 1 day overdue. The Baseline Care Plan for Resident #138 dated 10/26/23 indicated the resident was oriented to person, place, and time and communication was within normal limits. A document titled Clinical Physician Orders dated 11/8/23 documented that the resident's next order review was 3 days overdue. An interview with the Director of Nursing (DON) on 11/08/23 at 10:26 AM, revealed that a former employee was responsible for MDS completion and the facility was going through a transition. He stated that he and Staff E, Registered Nurse (RN) were responsible for MDS completion as needed during this time. An interview with Staff F, Facility Consultant, on 11/9/23 at 9:09 AM, confirmed the resident's MDS assessments were in process but not completed. She acknowledged the assessments were late. An undated policy titled Resident Assessment Instrument and Care Planning documented that the Resident Assessment (identified as MDS 2.0) would be used to identify areas that needed further evaluation and develop a Plan of Care. Guidelines included the initial assessment must be completed by the 14th day of a resident's stay.

Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to implement interventions, monitor for effectiveness, and modify interventions to minimize the likelihood of falling for 1 of 2 residents reviewed for accidents (Resident #12). The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 8/28/23, revealed Resident #12 required limited assistance of one staff for transfers, locomotion and required extensive assistance of one staff for toileting, dressing, and personal hygiene. The MDS indicated Resident #12 unsteady with transfers or ambulation but able to stabilize without staff assistance. The Care Plan, initiated 8/21/23, listed diagnoses of dementia and anxiety initiated. The Care Plan, revealed a Focus Area for impaired activities of daily living (ADL's) and mobility independence related to impaired safety awareness and recent decline at home. Interventions included: assist of one with transfers and resident to use a walker with tray, staff to provide assistance with her walker and help direct the walker to keep it near the center of the hallway. The Care Plan revealed a Focus Area, initiated 9/03/23, for risk of falls related to injuries from a history of fall with fracture, impaired safety awareness related to dementia and indicated resident will get up without calling for help. Interventions related to risk of falls included: a. Ensure bed is in low position prior to leaving room. b. Frequent staff checks - staff to check on resident when in bed in the morning to see if resident needs assistance, staff to assist resident out of the dining room as close to the time she's finished eating to prevent resident from getting up on her own, and frequent checks of resident while in the common area to help prevent getting up unassisted. The Morse Fall Scale Assessment completed on 8/15/23, revealed Resident #12 at a high risk for falling. Subsequent Morse fall Scale Assessments completed 10/20/23 and 11/05/23 revealed resident remained at high risk for falling. Facility provided Incident Reports from Resident #12's fall occurrences, dates included: 08/18/23, 09/17/23, 09/18/23, 10/10/23, 10/20/23, 10/25/23, 10/27/23, and 11/05/23. Incident Reports included date, time, location, description of incident, and immediate action taken. The Incident Reports failed to include a root cause analysis, indicate an intervention to prevent future falls, or evaluate for effectiveness of fall interventions. On 11/06/23 at 11:55 AM, Resident #12 attempted to get up from her bed. The resident leaned forward reached for shoes with blanket wrapped around waist and walker turned backwards near the foot of bed. The staff stated resident technically independent and entered her room and provided assistance. On 11/07/23 at 9:06 AM, Resident #12 walked in hallway independently with her walker, shuffled gait and veered to the left nearly missed the mechanical lifts and walls of hallway. On 11/07/23 at 10:33 AM, the Director of Nursing (DON) reported Resident #12's current transfer status as independent with transferring and ambulation. The DON determined this status from a recommendation from Therapy, initiated 10/03/23, and confirmed the conflict between current transfer status and resident's Care Plan. DON stated the Care Plan would be updated to reflect current status. When asked for interventions put into place following the independent transfer status for the following falls on 10/10/23, 10/20/23, 10/25/23, 10/27/23, and 11/05/23, the DON informed that all interventions related to falls would be located within the Incident Reports and resident's Care Plan. On 11/09/23 at 10:35 AM, the DON provided Incident Reports and wrote on the reports the intervention implemented for the corresponding fall. The DON informed there was no intervention implemented for fall on 10/10/23 and stated that not all interventions on Resident #12's Care Plan were still applicable. DON indicated an expectation that interventions be removed from Care Plan when no longer applicable. The undated facility policy titled Falls, revealed the purpose of the policy is to ensure that if a resident falls, a thorough assessment is completed and appropriately documented with interventions identified to prevent future falls. Policy instructed responsible staff: Charge Nurse, DON, and Administrator, to determine potential causes for the fall and add teaching and/or interventions to the plan of care to prevent another fall from occurring. The facility policy titled Incident Report Policy, revised 7/15/23, revealed incidents to be assessed in 24 hours, and 1 week, unless needed more frequently. The policy instructed that the DON will monitor documentation and completion of incident reporting, Health Services Supervisor will review Care Plan and update as appropriate within 72 hours, and Administrator will sign and lock incidents upon full completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based clinical record review, staff interview, and facility policy review, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) Program that focuses on indicators of the outcomes of care and quality of life. The facility reported a census of 34 residents. Findings Include: A review of the Summary Statement of Deficiencies and provider's Plan of Correction (POC) dated 7/18/22, with corrections initially dated 8/18/22 and revised to 10/1/22, identified the following deficiencies: a. F609 - Reporting of Alleged Violations. b. F657 - Care Plan Timing and Revision. c. F684 - Quality of Care. d. F689 - Free of Accident Hazards/Supervision/Devices. e. F727 - Sufficient Nursing Staff. f. F868 - QAA Committee. The POC documented a plan to audit Incident Reports according to a schedule and to report and address identified concerns in QAPI Committee Meetings. The POC revealed training that instructed staff to immediately report allegations of abuse to the Administrator who would use the facility reportable decision tree to determine reportable occurrences. Staff were trained through Relias (computer program) on preventing, recognizing, and reporting abuse. A new schedule of quality assurance meetings was put in place. A document labeled [NAME] Manor QAPI dated 1/13/23, documented the topics of the QAPI meeting as quality measures, facility focus, clinical review (mock), re-hospitalizations, Pharmacy Report, recruitment/retention, staff satisfaction, Therapy, Environmental, and Dietary. The facility failed to assign a responsible party to topics of quality measures, clinical review, re-hospitalizations, recruitment/retention, and staff satisfaction. Infection control, nursing home compare, policies, orientation, incident reports/safety, resident council, and complaints/concerns remained blank. An untitled document dated 4/14/23, revealed topics of the QAPI Meeting included medication errors, new hire retention, turnover, Pharmacy, and call offs. The committee failed to review resident care outcomes, quality of life indicators, audit results, or reportable incident topics. A document titled QAPI, dated 10/13/23, documented the topics of the QAPI meeting included medication errors, new hire retention, agency hours, a medication storage inspection, and hazardous drug review. The committee failed to review resident care indicators, quality of life, audit results, or reportable incident topics. A document titled Self-Identification and Correction Form dated 11/6/23, revealed that on 9/18/23 the facility identified Care Plan reviews not being kept up to date as a deficient practice. This was not reviewed at the 10/13/23 QAPI meeting. On 11/09/23 at 12:22 PM, the Administrator stated he expected the QAPI Committee to review prior survey results at the first meeting after a survey and discuss approaches to ensure deficiencies did not happen again. Tasks should be assigned to the correct department head. Those staff monitored for compliance and revisited the issue until they found a solution that worked. The Administrator indicated the committee had not been very good at monitoring, had not been consistent with documentation, and had not been documenting follow up. He indicated the program needed to be revamped to include documentation of resident care and quality of life topics. There were no surveillance documents available for review. A policy titled Quality Assurance and Performance Improvement (QAPI) Plan approved and adopted 8/2017 documented the company-wide performance improvement process included identifying and implementing opportunities to improve the quality of resident care and quality of life. Section V. 6) documented that performance improvement was an ongoing cycle of measuring resident outcomes and that monitoring results was essential.

Based on clinical record review, staff interviews, and facility document review the facility failed to notify the Physician and the Resident's Representative of resident to resident incidents for 3 out 3 residents reviewed (Resident # 3, #18 and #28). The facility reported a census of 32 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) Assessment for Resident #18 dated 5/27/22, documented a BIMS of 13, indicating she is cognitively intact. The MDS documented diagnosis including heart failure, non-Alzheimer's dementia and depression. Resident #18's Clinical Record lacked any documentation of an incident between the resident and another resident occurring on 6/30/22. The Clinical Record also failed to contain a set of vital signs or physical assessment of Resident #18 on the date of the incident. The Clinical Record failed to contain documentation of notification to Resident #18's healthcare provider or responsible party regarding the incident. 2. The Minimum Data Set (MDS) Assessment for Resident #3 dated 4/8/22, listed diagnoses of Alzheimer's Disease, depression, and anxiety. The MDS further listed Resident #3 with a Brief Interview of Mental Status (BIMS) of 9 (moderately impaired cognition). The Care Plan for Resident # 3 dated 6/26/22, reflected a Power of Attorney for health matters. Resident # 3's Progress Note printed 7/12/22, failed to reflect notification of the Power of Attorney, and the Physician after an incident on 6/28/22 and an incident on 7/7/22. 3. The MDS Assessment for Resident #28 dated 6/15/22, listed diagnoses of peripheral vascular disease and chronic obstructive pulmonary disease (COPD). The MDS documented Resident # 28's BIMS of 9 (moderately impaired cognition), and Resident #28 required extensive assist of 1 staff for bed mobility, transfers, dressing and personal hygiene. The Care Plan for Resident # 28 dated 4/6/22, reflected a Power of Attorney for health matters. Review of Resident # 28's Progress Notes printed 7/12/22, failed to include notification to the Physician, and the Power of Attorney about the resident to resident incident that occurred on 6/28/22 and 7/7/22. On 7/14/22 at 1:37 PM, the Director of Nursing (DON) stated when an incident occur, she expected notification to the family and the Physician done within 24 and documented in the resident's chart. The undated Incident Report and Follow-up Sheet, directed at point # 3: Notify on-call phone to report incident. Notify Family and Physician within 24 hours.

Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to report resident to resident contact 2 out of 3 times it occurred (Resident #3, #18 and #28) to the State Agency. The facility reported a census of 32 residents. Findings included: 1. The Minimum Data Set (MDS) Assessment for Resident #3 dated 4/8/22, listed diagnoses of Alzheimer's Disease, insomnia, depression, anxiety and atrial fibrillation. The MDS further listed Resident #3 with a Brief Interview of Mental Status (BIMS) of 9 (moderately impaired cognition), and independent with ambulation and transfers. The Progress Note printed on 7/12/22, revealed on 6/30/22 at 8:38 AM, Staff B, Licensed Practical Nurse, (LPN) walked up the hallway toward the common area and observed Resident #3 rubbing his left hand on Resident #18's breast on top of her shirt. Resident #18 said, Get your hands off of me. Staff B told Resident #3, you can't touch people like that and he said - She said she did not have a bra on. The Progress Note read all staff aware of inappropriate behavior and educated to notify the Nurse of any situations regarding Resident #3, and another resident. 2. The Quarterly MDS for Resident #18 dated 5/27/22, documented a BIMS of 13, indicating she is cognitively intact. The MDS documented diagnosis including heart failure, non-Alzheimer's dementia and depression. The Resident #18's Clinical Record lacked any documentation regarding the incident on 6/30/22. 3. The Minimum Data Set (MDS) assessment for Resident #28 dated 6/15/22, listed diagnoses of peripheral vascular disease and chronic obstructive pulmonary disease (COPD). The MDS documented Resident #28's BIMS of 9 (moderately impaired cognition), and required extensive assist of 1 staff for bed mobility, transfers, dressing and personal hygiene. Review of the Facility's Self-Report dated 6/28/22, read Review of the Self-Reported incident to the State Agency reflected on 6/28/22 at 3:25 PM, Staff found Resident #3 in the room of Resident #28 leaning over her rubbing her thigh staff believed he was kissing her on her face due to the close proximity, and the noises that were heard. Resident #28 was noted to be laughing and fully clothed with no complaints to the staff. Resident #3 was removed from the room. The Health Services Supervisor notified immediately who then called the Administrator. Observation on 7/12/22 at 3:37 PM, as Resident #28 wheeled herself down the hall by the Nurse's Station, Resident # #3 walked by and with his fingers tickled her elbow. On 7/13/22 at 12:21 PM, Staff A, Registered Nurse (RN)/Instructor reported as she walked down the hall on 7/7/22, she saw a man facing Resident #28. She said, the man held Resident #28's hand and Resident #3 reached/leaned down into her face in a very intimate way. Staff A, revealed she thought that must be her husband. She saw Staff C, Therapy Director in the hall and reported it to her. Staff C, went to the Nurse Supervisor after she removed Resident #3 from the room. On 7/13/22 at 12:36 PM, Staff C, Therapy Director, stated Staff A, RN/Instructor asked her about the 2 residents in a room together. She went in the room on 7/7/22, and saw Resident #3 held both hands/arms of Resident #28 out to the sides with his face right by hers approximately an inch or 2 apart, while the resident sat in her chair. She removed Resident #3 from the room, and reported the incident to Nursing Supervisor. On 7/13/22 at 12:02 PM, the Administrator, said she knew of one event with Resident #3 and Resident #28, and 1 event with Resident #18. She said, they reported to the Long Term care Ombudsman about the 1st incident, and the State Agency. The Administrator said, they were unsure about reporting the incident with Resident #18. On 7/13/22 at 1:35 PM, the Director of Nursing (DON) reported, she thought there is another incident dated 7/7/22 while she was on vacation, she found a note in her mail box that she shares with the Nurse Supervisor. She reported the note was from Staff C about Resident #3 found in Resident #28's room over her. The DON confirmed she and the Administrator were out of the building last week. The DON revealed, she is surprised the incident with Resident #18 failed to be reported to the State Agency (SA). On 7/13/22 at 1:35 PM, the DON confirmed, she expected the incident with Resident #18 and Resident # 3 be reported to the SA. The Facility Reportable Decision Tree dated 11/16/26, reportable allegations to the Survey Agency (required of Skilled Nursing Facilities (SNF) and Intellectually Disabled (ID) programs under federal conditions of participation). Against any resident by any other person including another resident, family member, visitor, employee, or service provider: mistreatments abuse (verbal, sexual, physical, or mental) notification is required through online reporting to the SA within 24 hours of discovery of the occurrence including weekends and holidays. The facility's Mandatory Reporting policy dated 1/2022, directed at point # 4: Upon receiving a claim of abuse of a dependent adult in a facility or program, the facility or program shall separate the victim and alleged abuser immediately and shell maintain the separation until the abuse investigation is completed and abuse determination is made.

4. The Quarterly MDS for Resident #18 dated 5/27/22, documented a BIMS of 13, indicating she is cognitively intact. The MDS documented diagnosis including heart failure, non-Alzheimer's dementia and depression. The Clinical Record lacked any documentation regarding a resident to resident incident involving Resident #18 on 6/30/22. The Care Plan with a printed date 7/14/22, failed to include interventions documented to prevent the incident from reoccurring. On 7/14/22 at 7:30 AM, the DON reported the facility lacked a Care Plan policy for updating Care Plans. She reported the MDS Care Plan Coordinator told her, they try to updated Care Plans in 72 hour to 7 days. The undated Facility's Incident Report and Follow-Up Sheet, directed at point 3: Have details ready and interventions implemented. Based on observation, clinical record review, facility document, and staff interviews the facility failed to address the use of an anticoagulant (AC) blood thinning medication, antidepressant medication, and failed to direct the staff to monitor for the side effects of the medications for 2 out of 5 residents reviewed (Resident #3 and #8), and failed to add interventions to the Care Plan after resident to resident interactions occurred for 3 out of 3 resident reviewed (Resident #3, #18 and #28). The facility reported a census of 32 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #3 dated 4/8/22, listed diagnoses of Alzheimer's Disease, insomnia, depression, anxiety and atrial fibrillation. The MDS reflected Resident #3 with a Brief Interview of Mental Status (BIMS) of 9 (moderately impaired cognition), and independent with ambulation and transfers. The Care Plan for Resident #3 dated 4/10/19, listed a focus area: The resident is/has potential to be physically aggressive related to diagnosis of dementia and complicated interpersonal relationship with his wife. The Care Plan intervention read: monitor, document, report as needed and any signs or symptoms of resident posing danger to self or others. The Care Plan failed to address Resident #3's sexual behaviors towards other residents. The Care Plan for Resident #3 dated 2/27/19, failed to address the use of an anticoagulant (AC) blood thinning medication and failed to identity the side effects for staff to monitor. The Care Plan lacked the resident's use of antidepressant medication and failed to reflect the side effects staff needed to monitor. The Medication Administration Record (MAR) for Resident #3 dated 7/22, reflected the antidepressants for daily use included: a. Sertraline 50 milligrams (mg) started on 1/25/22. b. Trazadone 50 mg started on 2/18/19. c. Bupropion 5 mg started on of 4/5/22. The MAR continued to direct Resident # 3 to take Eliquis (a blood thinning medication) 5 MG two times a day started on 7/12/2019. On Observation 7/12/22 at 3:37 PM, Resident # #3 walked next to Resident # 28, and with his fingers tickled her elbow. 2. The Minimum Data Set (MDS) assessment for Resident #8 dated 4/15/21, listed diagnoses of stroke, deep venous thrombosis (DVT), depression and aphasia (loss of ability to understand or express speech, caused by brain damage). The MDS reflected Resident #8 rarely or never understood. The Care Plan for Resident # 8 dated 5/19/21, failed to identify the use of antidepressant medication and AC medications, and failed to identify the side effects to monitor for. The Medication Administration Record (MAR) for Resident #8 dated 7/22, reflected antidepressant medications included: a. Fluvoxamine extended release 100 mg daily with the order date of 04/06/2022, and a discontinuation date of 7/06/2022. b. And reflected a new antidepressant started on 7/6/22, fluoxetine 10 MG daily for depression. The MAR directed the resident took apixaban (Eliquis) (a blood thinning medication) 2.5 mg, 1 tablet two times a day for blood clot started 4/6/22. 3. The Minimum Data Set (MDS) assessment for Resident #28 dated 6/15/22, listed diagnoses of peripheral vascular disease and chronic obstructive pulmonary disease (COPD). The MDS documented Resident # 28's BIMS of 9 (moderately impaired cognition), and required extensive assist of 1 staff for bed mobility, transfers, dressing and personal hygiene. The Care Plan for Resident #28 that included a print date of 7/12/22, failed to identify intervention to address inappropriate resident to resident interaction. On 07/12/22 at 3:37 PM, as Resident #28 wheeled herself down the hall by the nurses station, Resident #3 walked by and with his fingers tickled her elbow. On 07/14/22 07:30 AM, the Director of Nursing, (DON) said the facility lacked a policy on updating Care Plans. She reported she would expect Care Plans updated in 72 hours to 7 days when changes occur. On 7/14/22 at 1:37 PM, the DON, confirmed she expected the Care Plan to address AC and antidepressant medications and the side effects to monitor the resident for.

Based on Clinical Record review, staff interview, and policy review the facility failed to assess 2 of 2 residents after being touched by a resident on 2 of 3 occasions (Resident #18 and #28). The facility reported a census of 32 residents. Findings Include: 1. The Quarterly MDS for Resident #18 dated 5/27/22, documented a BIMS of 13, indicating she is cognitively intact. The MDS documented diagnosis including heart failure, non-Alzheimer's dementia and depression. Review of a Progress Note printed on 7/12/22, revealed on 6/30/22 at 8:38 AM, Staff B, Licensed Practical Nurse, (LPN) walked up the hallway toward the common area and observed Resident #3 rubbing his left hand on Resident #18's breast on top of her shirt. Resident #18 said, Get your hands off of me. Staff B told Resident #3, you can't touch people like that and he said - She said she did not have a bra on. The Clinical Record for Resident #18 lacked any documentation regarding a resident to resident incident involving Resident #18 on 6/30/22. The Clinical Record also failed to contain a set of vital signs or any physical assessment of Resident #18 on the date of the incident. 2. The Minimum Data Set (MDS) Assessment for Resident #28 dated 6/15/22, listed diagnoses of peripheral vascular disease and chronic obstructive pulmonary disease (COPD). The MDS documented Resident #28's BIMS of 9 (moderately impaired cognition), and required extensive assist of 1 staff for bed mobility, transfers, dressing and personal hygiene. The Care Plan for Resident #28 that included a print date of 7/12/22, lacked interventions to address inappropriate resident to resident interaction. Resident #28's Progress Notes printed on 7/12/22, failed to include an assessment note about resident to resident contact on 6/28/22 and 7/7/22. The Clinical Assessment printed on 7/12/22, failed to include assessments on 6/28/22 and 7/7/22. Observation on 7/12/22 at 3:37 PM, as Resident #28 wheeled herself down the hall by the Nurse's Station, Resident #3 walked by and with his fingers tickled her elbow. On 7/13/22 at 9:37 AM, Staff B Licensed Practical Nurse (LPN), said Staff C, Therapy Director observed Resident #3 kissing Resident # 28 in her room. Staff B reported she also observed Resident #3, when she came up the hall as his hand rubbed a crossed Resident #18 breasts. Staff B, stated Resident #18 yelled at Resident #3 don't' touch me. Staff B, reported she moved Resident #3 away from Resident # 18, and told him he can't touch people like that. Staff B, said she reported the incident to the Nurse Supervisor right away, and told the Supervisor that the resident should not be here, he needed Assisted Living. Staff B, revealed the intervention is staff are to monitor where Resident #3 is when he is not in the lounge. Staff B, denied scheduled checks on Resident #3, she confirmed 3 resident to resident evens involving Resident #3 had occurred. On 7/13/22 at 9:55 AM, Staff C, Therapy Director, reported on 6/28/22 she observed Resident #3 in the room of Resident #28 as his hand rubbed her thigh and as he kissed her. She said she went and told the nurse right away and let her staff know to keep an eye out for that behavior from Resident #3. She said, she expected the facility to follow up and do what they needed to do, but hasn't heard what they did. Staff C, confirmed Staff A, Registered Nurse (RN)/Instructor here last Thursday and Friday 7/7 // and 7/8/22, reported to her seeing Resident #3 in Resident #28's room kissing her. On 7/13/22 at 12:21 PM, Staff A, reported as she walked down the hall she saw a man facing Resident #28. She said, the man held Resident #28's hand and Resident #3 reached/leaned down into her face in a very intimate way. Staff A, revealed she thought that must be her husband. She saw Staff C in the hall and reported it to her. Staff C, went to Nurse Supervisor after she removed Resident #3 from the room. The Administrator confirmed staff failed to complete an incident report event between Resident #3 and # 28. 7/13/22 at 1:35 PM, the Director of Nursing (DON) said, she expected charting every shift on any behavior on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). She stated it directed to document yes or no on the MAR, and if yes, a behavior was noted, then add a note in the Progress Notes about the situation. On 7/13/22 at 1:46 PM, the Director of Nursing DON said, she expected assessments completed by the nurses after incidents. The undated Incident Report and Follow-Up Sheet, directed Nursing Staff to take the resident's initial vitals, then assess the resident for injury and use Fall Scene Investigation form to collect data needed to complete the Incident Report.

Based on observations, clinical record review, staff and resident interviews the facility failed to supervise and prevent 1 out of 1 residents (Resident #3) from kissing and touching 2 out of 2 other residents (Resident #18, #28), 3 different times. The facility reported a census of 32 residents residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) Assessment for Resident #18 dated 5/27/22, documented a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating the resident cognitively intact. The MDS documented diagnoses including heart failure, non-Alzheimer's dementia and depression. The Clinical Record lacked any documentation regarding an incident occurring on 6/30/22, when Resident #3 touched Resident #18 inappropriately. The Care Plan with a printed date of 7/14/22, failed to have interventions documented in regards to supervision to prevent the incident from reoccurring. 2. The Minimum Data Set (MDS) assessment for Resident #3 dated 4/8/22, listed diagnoses of Alzheimer's Disease, insomnia, depression, anxiety and atrial fibrillation. The MDS further listed Resident #3 with a BIMS score of 9 out of 15 (moderately impaired cognition), and independent with ambulation and transfers. The Care Plan dated 4/10/19, listed a focus area: The resident is/has potential to be physically aggressive related to diagnosis of dementia and complicated interpersonal relationship with his wife. The Care Plan intervention read: monitor, document, report as needed any signs or symptoms of the resident posing danger to self or others. Review of the Medication Administration Record (MAR) dated 7/2022, directed to monitor vital signs (VS) each shift x 72 hours, then every shift Monitor VS for 3 Days, also notify the doctor after 72 hours. Order Dated 7/11/2022 at 6:03 PM. The Facility's Self Report to the State Agency (SA) dated 6/28/22, reflected on 6/28/22 at 3:25 PM Staff found Resident #3 in the room of Resident #28 leaning over her rubbing her thigh. Staff believed he was kissing her on her face due to the close proximity and the noises that were heard. Staff removed Resident #3 from the room. The Progress Notes for Resident #3 printed on 7/12/22, lacked a note dated 6/28/22 addressing the resident to resident incident. The Progress note lacked any incident note dated 7/7/22, when another incident occurred. The Progress Note printed on 7/12/22, revealed on 6/30/22 at 8:38 AM, Staff B, Licensed Practical Nurse, (LPN) walked up hallway toward common area and observed Resident #3 rubbing his left hand on Resident #18's breast on top of her shirt. Resident #18 said, Get your hands off of me. Staff B told Resident #3, you can't touch people like that and he said,She said she did not have a bra on. The Progress Note documented all staff aware of inappropriate behavior and educated to notify nurse of any situations regarding Resident #3 and any other resident. On 7/13/22 at 4:24 PM, observed Resident #3 walked down to the Conference Room and walked in and said oh you are all a lone in here. He then turned and walked out of the room. 3. The MDS Assessment for Resident #28 dated 6/15/22, listed diagnoses of peripheral vascular disease and chronic obstructive pulmonary disease (COPD). The MDS documented Resident #28 with a BIMS score of 9 out of 15 (moderately impaired cognition), and required extensive assist of 1 staff for bed mobility, transfers, dressing and personal hygiene. The Care Plan for Resident # 28 with a print date of 7/12/22, lacked interventions to address inappropriate resident to resident interactions. The Care Plan dated 9/21/21, identified a history of trauma and a risk for trauma related symptoms. The Care Plan read the resident lost her husband unexpectedly. Resident #28's Progress Notes printed on 7/12/22, failed to include a note about resident to resident contact on 6/28/22 and 7/7/22. The Statement from Staff A, Registered Nurse (RN)/Instructor, read on 7/8/22 at 11:45 AM she observed a male in Resident #28's room holding her hands. Review of the Statement from Staff C, Therapy Director, dated 7/7/22, at 11:45 AM she walked in the hall and Staff A told her she saw a resident in Resident #28's room. The statement continued to read Resident #3 is not to be in that room. Resident #3 with his back to the doorway, bent over Resident #28 as he held her arms out and placed his head in her chest area. Observation on 7/12/22 at 3:37 PM, noted Resident #28 wheeled herself down the hall by the Nurse's Station, Resident #3 then walked by and with his fingers tickled her elbow. On 7/13/22 at 9:37 AM, Staff B, LPN, said Staff C observed Resident #3 kissing Resident #28 in her room. Staff B reported she also observed Resident #3, when he came up the hall as his hand rubbed a crossed Resident #18 breasts. Staff B, stated Resident #18 yelled at Resident # 3 don't' touch me. Staff B, reported she moved Resident #3 away from Resident #18, and told him he can't touch people like that. Staff B, said she reported the incident to the Nurse Supervisor right away, and told the supervisor that the resident should not be here, he needed Assisted Living. Staff B, reported the intervention is they are to monitor where Resident #3 is when he is not in the lounge. Staff B, denied scheduled checks on Resident #3, she confirmed there had been 3 resident to resident incidents involving Resident # 3. On 7/13/22 at 9:55 AM, Staff C, Therapy Director, reported on 6/28/22 she observed Resident #3 in the room of Resident #28 as his hand rubbed her thigh and as he kissed her. She said she went and told the nurse right away and let her staff know to keep an eye out for that behavior from Resident #3. She said, she expected the facility to follow up and do what they needed to do, but hasn't heard what they did. Staff C, confirmed the Staff A RN/Instructor here last Thursday and Friday 7/7/22 and 7/8/22, reported to her she seen Resident #3 in Resident #28's room kissing her. On 7/13/22 at 9:45 AM, Resident #28, reported that man comes in her room every night and helps her to bed, but he doesn't sleep with her, his son takes him up in the elevator. She said they snuck off and got married, but failed to recall Resident #3's name or any kissing or touching. She confirmed he was her husband. On 7/13/22 at 12:02 PM, the Administrator, said she knew of one event with Resident #3 and Resident #28, and 1 event with Resident #18. She said they reported to the Long Term Care Ombudsman and the State Agency (SA) about the 1st incident. The Administrator said, they were unsure about reporting the incident with Resident #18. She reported the intervention after the 1st event to monitor closely, and they got an urinalysis test (UA) that turned out negative, she said after the second event checking his BP she said the Dr. may adjust his medications. She confirmed staff failed to complete an incident report event between Resident #3 and #28. On 7/13/22 at 12:21 PM, Staff A, RN/Instructor reported as she walked down the hall she saw a man facing Resident # 28. She said, the man held Resident #28's hand and Resident #3 reached/leaned down into her face in a very intimate way. Staff A, revealed she thought that must be her husband. She saw Staff C in the hall and reported it to her. Staff C, went to Nurse Supervisor after she removed Resident # 3 from the room. On 7/14/22 at 11:20 AM, Resident # 3 reported, he only holds hands with woman here, or touches their arms. He denied touching anyone breasts, or kissing anyone. He said, he got chewed out for being in a resident room so no more of that. During the conversation he smiled and laughed. On 7/13/22 at 1:35 PM, Director of Nursing (DON) said, when the sexual inappropriate behavior was noted, the intervention was not to let Resident #3 go down the hall past his room. (Resident #28's room is 4 doors down on the right of his). The DON stated, the incident with Resident #18, Resident #3 wanted to verify that Resident #18 didn't have bra on. The DON said, Resident #3 had increased confusion and they thought the resident may have an urinary tract infection (UTI). We directed Therapy to watch Resident #28's room when they went by, and nursing watched the lobby when Resident #3 is out there, and intervene as needed. The DON voiced, she wondered if the relationship was consensual or not between Resident #3 and #28. Resident # 28 would engage him by waving at him in the Dining Room, and she mumbled under her breath due to separation of him in the Dining Room. The staff are expected to keep eyes out for any inappropriate interaction with females. She stated we needed to take this more seriously, she thought there is another incident dated 7/7/22, while she was on vacation. She revealed, she found a note in her mail box that she shares with the Nurse Supervisor. She reported the note came from Staff C, about Resident #3 found in Resident #28's room over her. She confirmed, she and the Administrator were out of the building last week (1st week in July) and the Nurse Supervisor took charge. The DON confirmed, she expected the incident with Resident #18 and Resident #3 be reported to the SA. On 7/13/22 at 1:46 PM, the Director of Nursing (DON) said, she expected incident reports and assessments completed by the nurses after incidents. She reported, also expected statements with the investigation and interventions implemented, along with family and Physician notification after each event. She said, in Resident #3, and Resident #28's situation, it depended on the residents' cognitive abilities. The DON, revealed she needed to look at the BIMS score for cognition, she thought Resident #28 was question able at times. On 7/14/22 at 7:30 AM, the DON reported the facility failed to have a policy directing staff for what to do with resident to resident incidents or unusual occurrences other then in the Abuse policy. The facility list of the Residents BIMS dated 7/12/22, that included 9 woman with a BIMS less than 13. The Resident Assessment Instrument (RAI) Manual, read a patient can score 0 to 15 points on the BIMS test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. The facility Abuse policy dated 12/30/20, directed staff at the following points: a. Point #23 - Employees are required to report incidents anything unusual or unexpected at the time of the occurrence to their supervisor or person in charge of the facility for further investigation regardless of whether the incident results in obvious or visible injury. b. Point # 29 - Employees are required to immediately intervene to distract, halt, and/or prevent harm to the extent that they can do so without placing themselves at risk of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, Facility Schedule review and Facility Assessment Review, the facility failed to provide the required 8 hours a day Registered Nurse (RN) coverage for 9 out of 30 days reviewed. The facility reported a census of 32 residents. Findings Include: Review of the Nursing Schedule from June 12 through July 12, 2022, lacked an RN in the facility 9 out of 30 days (6/12/22, 6/18/22, 6/19/22, 6/26/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/10/22). On 7/14/22 at 7:25 AM, The Director of Nursing (DON), said she worked Monday, Tuesday, Thursday, Fridays and another RN works Wednesdays. The DON said she worked the weekends to make the RN coverage. The DON further confirmed she failed to work the 1st week in July and the DON stated she tried to work some hours on the weekends for the RN coverage. On 7/14/22 at 11:49 AM, the DON, said she punched in and out when she worked. She confirmed she is not always at the facility the full 8 hours a day, but tried to put in some time in the building on the weekends. She confirmed she was off the first week in July 2022. On 7/15/22 at 10:28 AM, the Administrator reported she based the staffing for the facility on the census and various acuity levels/diagnoses found in our Facility Assessment. She said, we strive to provide daily nursing coverage Licensed Practical Nurse(LPN)/RN and daily Oral Medication Technician (OMT) coverage. The Facility assessment dated [DATE], reflected a lack of the number of staff and hours needed to care for the residents.