**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an authorization signature from one sampled resident (Resident #291) to allow the facility to open and maintain a resident trust account out of four sampled residents sampled for resident trust accounts. The facility census was 46 residents. 1. Review of Resident #291's trust account on 8/2/24 showed: -The resident was admitted to the facility on [DATE]. -The resident had a balance of $0.0 in his/her account -The absence of an authorization form that was signed by the resident. During an interview on 8/2/24 at 10:21 A.M. the Regional Business Office Manager (BOM) said he/she gave the form to the new facility BOM, but the new facility BOM did not have the resident sign the authorization form. During a telephone interview on 8/8/24 at 2:42 P.M., the previous BOM said: -He/she worked as the BOM until 7/15/24 then became the Activity Director. -The resident's account was opened on 7/22/24.

Based on interview and record review, the facility failed to ensure the funds of one discharged resident (Resident #93) was forwarded to the resident within 5 days of the resident moving to a new facility; and failed to ensure that Third Party Liability (TPL- a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account) forms were completed and sent to Missouri (MO) Healthnet (a state agency which administers the provision and payment of services for Missouri's Medicaid program) within 30 days of death for two discharged residents (Resident #91 and #92). The facility census was 46 residents. 1. Review of Resident #93's medical record, showed: -He/she was discharged from the facility to a hospital on 1/25/24. - The residents' fund account, showed he/she had $80.24 in his/her resident trust account at the time of discharge. - The resident was discharged from the hospital to another facility on 2/6/24. -There was no documentation that showed the resident's money was sent to the resident at the new facility. During an interview on 8/2/24 at 10:51 A.M., the Regional Business Office Manager (BOM) said: -The facility BOM was only in his/her job for a short time and was not trained yet, so he/she conducted the resident trust fund review. -The facility was waiting for approval for the FA465 (a form which is sent to the nursing home, which included the effective date a participant is eligible for vendor payments the level of care for a participant and the surplus amounts and dates) to come from the family support division after the resident was approved for Medicaid to let the facility know what the patient's share of expenses were. -He/she closed the account on 7/30/24 (176 days after the resident was admitted to a different Long Term care Facility). During a telephone interview on 8/8/24 at 2:23 P.M., the Former BOM said: -He/she was not trained well on the new resident trust management program. -In order to forward money from this facility to the next facility, he/she would have to submit a request and he/she was not trained in how to enter that request properly into the system. -He/she had not requested a refund. 2. Review of Resident #91's medical record showed the resident passed away on 3/28/24 and $121.79 was in his/her trust fund account account. During an interview on 8/2/24 at 11:15 A.M., the Regional BOM said the former BOM did not complete a TPL form for the resident. 3. Review of Resident #92's medical record showed the resident passed away on 9/7/23 with $50.00 in his/her account. During an interview on 8/2/24 at 11:17 A.M., the Regional BOM said the former BOM did not complete a TPL form for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a timely advanced directive for one sampled resident (Resident #291) when he/she elected to be a Do Not Resuscitate (DNR, an election to have Cardio-Pulmonary Resuscitation [CPR] withheld in the event of cardiac arrest) out of 14 sampled residents. The facility census was 46 residents. Review of the undated facility policy titled Advanced Directives showed the facility was to: -Inform and offer the resident a choice to elect to be a DNR on admission. -Assist the resident in obtaining an advanced directive. -Ensure coordination with the physician to enact the advanced directive. -Update the plan of care and place orders in the medical record. 1. Review of the resident's medical record showed: -An admission to the facility on [DATE]. -An out of hospital DNR form signed by the resident on [DATE] with no other signatures. Review of the resident's Physician Order Summary (POS) on [DATE] showed an order for the resident to be a full code (an election to receive CPR in the event of cardiac arrest). During an interview on [DATE] at 9:41 A.M., the resident said he/she signed a DNR order on admission and would not want facility staff to perform CPR in the event his/her heart stopped. During an interview on [DATE] at 2:33 P.M., Registered Nurse (RN) A said: -The resident had an order to be a full code. -He/She would have performed CPR on a resident with a full code order in the medical record. -It should have taken a week or less to get the physician to sign a DNR order. -Two staff members could have witnessed the resident sign the DNR to enact it while waiting for the physician to sign the order. -The resident wished to be a DNR and this should have been followed up on by nursing or social services. During an interview on [DATE] at 10:16 A.M., the Minimum Data Set (MDS) Coordinator said: -Residents who wished to be a DNR would sign a DNR form. -The form would then be signed by either the resident's physician or two staff members to be verified. -Medical records would scan the verified order into the resident's medical record and nursing staff would input a physician's order for the DNR. -He/She would like the DNR to be enacted within 72 hours of the resident signature to ensure the resident's wishes were followed in the event of cardiac arrest. -A DNR should not go from [DATE] to [DATE] without being verified by the physician or two staff witnesses. During an interview on [DATE] at 11:58 A.M., the Director of Nursing (DON) said: -Staff were to ensure DNR orders were signed by the physician to ensure the resident's wishes were carried out. -He/She would expect the DNR to be verified and enacted within 24 hours of initiation. -Follow up on an unsigned DNR would be a team effort from admissions, nursing and social services. -A DNR signed by the resident on [DATE] should have been verified prior to the time of this interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete Minimum Data Set assessments (MDS-a federally mandated comprehensive assessment) in a timely manner (within 14 calendar days after admission) for two sampled residents (Resident #291 and Resident #292); and failed to complete an accurate MDS assessment for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 46 residents. Review of an undated facility policy titled MDS Completion and Submission Timeframes showed the facility was to complete and submit MDS assessments within federal requirements but lacked mention of the specific guidelines. No other policies for MDS assessments were received. The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, showed facilities were to complete and submit resident admission assessments within 14 calendar days of admission to the facility. 1. Review of Resident #291's face sheet on 8/1/24 showed: -An admission on [DATE]. -Diagnoses including femur fracture, depression, and chronic kidney disease (longstanding disease of the kidneys). Review of the resident's medical record on 8/1/24 showed a lack of a comprehensive MDS admission assessment. 2. Review of Resident #292's face sheet on 8/1/24 showed: -An admission on [DATE]. -Diagnoses including malnutrition, asthma (a restrictive disease of the airway), dysphagia (difficulty swallowing), and reduced mobility. Review of the resident's medical record on 8/1/24 showed a lack of a comprehensive MDS admission assessment. 3. During an interview on 8/01/24 at 10:14 A.M., the MDS Coordinator said: -He/She was responsible for completing residents' MDS assessments. -admission assessments should be completed within 14 days of admission. -He/She was behind on completing MDS assessments. -The assessments for Resident #291 and Resident #292 have not been completed and are past due. During an interview on 8/2/24 at 11:58 A.M., the Director of Nursing (DON) said: -The MDS Coordinator was responsible for ensuring timely completion of MDS assessments. -admission MDS assessments were to be completed within 14 days of admission. -The facility was behind on MDS assessments. -He/She expected staff to ensure all MDS assessments were completed on time. 4. Review of Resident #1's face sheet showed he/she admitted to the facility with the diagnosis of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's Quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's Annual MDS dated [DATE] showed: -Section C- Cognitive Patterns had not been filled out/completed. -Section D- Mood had not been filled out/completed. Review of the resident's CHC-PHQ-2 to 9 (inquires about the degree to which an individual had experienced depressed mood and anhedonia (the inability to experience joy or pleasure) over the past two weeks) dated 3/24/24 showed: -The resident had little pleasure in doing things. --The resident experienced these 12-14 days (nearly every day) during the assessment period. -The resident had felt down, depressed, or hopeless. --The resident experienced these 7-11 days (half or more of the days) during the assessment period. -The resident had felt down or had little energy. --The resident experienced these 7-11 days during the assessment period. -The resident felt like he/she was moving or speaking so slowly that other people had noticed. --The resident experienced these 12-14 days during the assessment period. Review of the resident's Quarterly MDS dated [DATE] showed: -Section C- Cognitive Patterns had not been filled out/completed. -Section D- Mood had not been filled out/completed. Review of the resident's CHC-PHQ-2 to 9 dated 6/24/24 showed: -The resident had little pleasure in doing things. --The resident experienced these 7-11 days during the assessment period. -The resident had felt down, depressed, or hopeless. --The resident experienced these 7-11 days (half or more of the days) during the assessment period. -The resident had felt down or had little energy. --The resident experienced these 2-6 days (several days) during the assessment period. -The resident had trouble concentrating on things, such as reading the newspaper or watching the television. -The resident felt like he/she was moving or speaking so slowly that other people had noticed. --The resident experienced these 12-14 days during the assessment period. During an interview on 8/1/24 at 11:19 A.M. Certified Medication Technician (CMT) B said the MDS Coordinator was responsible for submitting the MDS assessments. During an interview on 8/1/24 at 11:41 A.M. Licensed Practical Nurse (LPN) B said the MDS Coordinator was responsible for submitting the MDS assessments. During an interview on 8/1/24 at 12:42 P.M. the MDS Coordinator said: -The cognitive and mood assessments were to be completed during each MDS assessment. -He/She was not the MDS Coordinator at the time of the previous MDS submissions. During an interview on 8/2/24 at 11:58 A.M. the DON said: -The MDS Coordinator was responsible for completing the MDS submissions timely and accurately. -He/She would have expected the MDS assessments to be completed accurately for Resident #1 including the sections for cognition and mood, especially with Resident #1's diagnosis of depression. -He/She would be responsible for overseeing that the MDS assessments were completed and accurate.

Based on interview and record review, the facility failed to create person-centered comprehensive care plans to guide facility staff in resident care of new admissions for two sampled residents (Residents #291 and #292) out of 14 sampled residents. The facility census was 46 residents. Review of an undated facility policy titled Comprehensive Person-Centered Care Plans showed the facility was to: -Complete a person-centered care plan for all residents. -Complete the care plan within seven days of a comprehensive Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff for care planning) admission assessment. --The policy lacked direction for staff on when to complete the comprehensive care plan without completion of the comprehensive assessment. The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, showed facilities were to complete a comprehensive, person-centered care plan within seven days of completion of the MDS admission assessment but no later than 21 days after admission. 1. Review of Resident #291's face sheet showed: -Diagnoses including femur fracture (broken thighbone), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and chronic kidney disease (a gradual loss of kidney function over time). Review of the resident's care plan dated 7/22/24 showed: -A focus on Activities of Daily Living (ADL) assistance with no goals and incomplete interventions. -A focus on limited physical mobility with no goals or interventions. -A focus of a nutritional problem with no goals but included interventions. -A focus of impaired vision, complete with goals and interventions. --The care plan lacked information on the diagnoses of depression and chronic kidney disease as well as surgical site care related to the resident's recent surgical intervention of the femur fracture. 2. Review of Resident #292's face sheet showed: -Diagnoses including malnutrition (not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), asthma (a restrictive disease of the airway), dysphagia (difficulty swallowing), and reduced mobility. Review of the resident's care plan dated 7/29/24 showed the care plan lacked information regarding the resident's reduced mobility and ADL assistance. 3. During an interview on 8/1/24 at 10:14 A.M., the MDS Coordinator said: -He/She was responsible for completing residents' comprehensive care plans. -He/She liked the care plans to be completed within 14 days from admission but was unsure on what the regulation was. -He/She was behind on completing comprehensive assessments. During an interview on 8/2/24 at 11:58 A.M., the Director of Nursing (DON) said: -The MDS Coordinator was responsible for completing comprehensive care plans. -The facility was behind in completing comprehensive care plans. -He/She was unsure of how soon comprehensive care plans had to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure bathing was completed per choice for one sampled resident (Resident #2) and failed to ensure the resident's care plan showed the resident's care needs and abilities regarding Activities of Daily Living (ADL-bathing, dressing, toileting, eating and mobility) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's ADL policy and procedure dated March 2018, showed: -Residents would be provided with care, treatment and services to ensure their ADLs do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLS are unavoidable. -Appropriate care and services would be provided for resident's who were unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care. -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning). 1. Review of Resident #2's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including stroke, arthritis (an inflammatory condition of the joints), history of falling, muscle weakness and obesity (excessive weight). Review of the resident's Care Plan dated 11/3/22, showed there was no documentation showing the resident's abilities and need for assistance regarding his/her bathing status. There were no updates to the resident's care plan after this time. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was cognitively intact. -Had no upper or lower body limitations. -Needed partial to moderate assistance with bathing and dressing. Review of resident's Electronic Bathing/Shower record showed resident received bathing on 7/2, 7/3, 7/4, 7/6, 7/7, 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, and 7/21. There were no further bathing/showers documented after 7/21/24. Review of the resident's handwritten Bath Sheets showed the resident received bathing on 7/1, 7/3, 7/12 and 7/15. There were no bath sheets documented after 7/15/24, showing bath/showers were completed. None of the bath sheets were signed by the nurse. Observation and interview on 7/29/24 at 8:02 A.M. showed the resident was sitting in his/her recliner dressed for the weather watching television. He/She was alert and oriented and said: -He/She had a concern with receiving his/her showers. -Nursing staff assisted him/her to the shower and he/she could assist with bathing but needed help. -He/She usually was supposed to shower twice weekly on Sunday and Thursday, but he/she did not receive his/her shower yesterday (on Sunday) and had not had a shower for 8 days as of today. Observation and interview on 7/29/24 at 11:28 A.M., showed the resident was sitting in his/her recliner with his/her eyes closed, resting comfortably. There was no outstanding odors coming from the resident. The resident woke and said he/she still had not received a shower today and was hoping to receive one by the days end. Observation and interview on 7/31/24 at 9:22 A.M., showed the resident was sitting up in his/her wheelchair in his/her room watching television. There were no outstanding odors coming from the resident or his/her room. He/she said that he/she had not gotten a shower this week at all and it had been 10 days now since his/her last shower. The resident said staff was assisting him to change his/her clothes, but he/she would really like to receive a shower today. Observation and interview on 8/1/24 at 9:50 A.M., showed the resident was dressed for the weather and sitting in the dining room in his/her wheelchair. He/she said he/she still had not received a shower and it had now been 11 days since his/her last shower. He/she said in the morning, to keep from having body odor, he/she has been using a wet cloth to wipe himself/herself off at the sink but he/she wanted to take a bath/shower. He/she said the shower aide that usually gave the showers was unable to give it because he/she had been working on the floor and had not been able to give his/her shower. During am interview on 8/01/24 at 9:58 A.M., Certified Nursing Assistant (CNA) A said: -The shower aide was supposed to give the resident baths/showers and residents were supposed to receive showers at least twice weekly. -The other nursing staff were also able to give baths/showers. -It has been rough getting the resident baths completed but the shower aide had been pulled to work on the floor and was not able to give the showers daily. -The nursing staff was trying to get the resident showers completed as they were able. -They usually document the showers under tasks in the electronic medical record for each resident. -They also documented on the bath sheets when they saw a skin issue and provided that documentation to the nurse. -He/She has tried to assist with giving showers and had given some on occasion. -When the shower aide was not working on the floor, he/she was able to get all of the resident showers completed. During an interview on 8/01/24 at 10:13 A.M., CNA B said: -He/She was the shower aide in the facility and this was his/her primary job when he/she was not assisting with providing cares on the floor. -Residents are supposed to get baths at least twice weekly but some residents get baths more often if they choose. He/She said they try to accommodate the residents. -He/She has not been able to get all of the showers done recently because he/she has been pulled to work on the floor. -When he/she had down time, he/she was able to get some showers completed, maybe three to four daily if possible. -He/She usually bathes 12 to 14 people per day and kept a shower assignment sheet that has all of the residents he/she has to bathe. -His/Her normal schedule is Monday through Friday and every other Sunday but it has changed recently. -He/She has been pulled to work on the floor for the past two weeks due to call ins and lack of staff. -When he/she gives showers, he/she documented them in the resident's electronic record and also completed the shower sheet to document if the resident has any skin issues. -On days that he/she was not working, the CNAs were supposed to split giving the showers on each shift. -He/She was working on the floor today so he/she would not be able to get many showers completed. -Management staff have tried to call in staff to assist but usually they don't have anyone to come in. -Regarding Resident #2, he/she had not been able to get his/her showers completed and it had been at least a week since he/she completed his/her shower. -He/She would try to get it done today. During an interview on 8/2/24 at 10:18 A.M., Licensed Practical Nurse (LPN) A said: -They have a shower schedule and residents were supposed to get showers twice weekly, but the shower aide has been pulled to the floor recently due to staffing and it may be that all of the resident showers had not been given as normal. -All of the nursing staff are crossed trained to assist with bathing, so any of the CNA staff can give showers. -When the shower aide was pulled to work on the floor, all of the nursing staff have tried to give showers when able, but they have not been able to get all of the showers completed. -He/She only worked on Fridays so she/he was not there during the week to know what showers were/were not given, but he/she tried to keep up with what showers were being given when he/she is in the building and when they have a shower aide available to give the resident showers. -Staff should try to ensure residents are bathed at least once weekly when staffing was low. -They have been trying to hire and retain staff but it had been difficult at times. During an interview on 8/2/24 at 11:58 A.M., the Director of Nursing (DON) said: -Bathing was to be given twice weekly or per resident preference. -He/She was aware baths haven't been given twice weekly. -They have a shower aide, but the shower aide has been pulled to work on the floor a lot lately. -When the shower aide is pulled to the floor, he/she is supposed to track who was being given showers and who has not been given a shower. -They have not been getting showers completed as they should due to staff call ins and lack of staff but they were working to try to improve this. -Residents should receive bathing at least weekly and should not go 11 days without having a bath/shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to address one sampled the resident's behavioral symptoms in order to manage known behaviors, failed to ensure the resident's behaviors were monitored and documented by staff as they occurred and failed to ensure actions and interventions were implemented upon the first aggressive behavior and subsequently followed up on to ensure resident behaviors toward his/her roommate did not continue for sampled resident (Resident #141) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy and procedure dated March 2019, showed: -As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder or mental disorder. -As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of the resident's medical record and general observations the resident's usual pattern of cognition, mood and behavior, usual method of communicating needs, typical or past responses to stress, fear, anxiety, frustration and other triggers, and patterns of coping with stress, anxiety and depression. -Nursing staff would identify, document and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition. -New onset or changes in behaviors would be documented regardless of the degree of risk to the resident or others. -The Interdisciplinary Team would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a care plan. Safety strategies would be implemented immediately if necessary to protect the individual and others from harm. -Interventions would be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. If the resident was being treated for altered behavior or mood the team would seek and document any improvements or worsening in the individual's behavior, mood and function. -Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. 1. Review of Resident #141's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). The document did not include the resident's behavior diagnoses from his/her hospital discharge. Review of the resident's Hospital Medical Record dated 6/7/24 showed the resident: -Had a diagnosis of adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with mixed anxiety and depressed mood, and history of stroke with left side weakness. -Had been receiving psychiatric medications for symptoms related to anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus)and depression. -Had a mental health evaluation that showed the resident was referred for adjustment concerns at his/her current placement. The resident reported that he/she was taking his/her psychiatric medications daily and they seemed to be working well. The evaluation showed the resident was alert and oriented, demonstrated adequate judgement and insight and had no ideations of hallucinations, delusions, suicidal or homicidal ideations at that time. The resident was provided supportive consultation. Review of the resident's Entry Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/11/24, showed the resident was admitted to facility on 6/28/24. ARD dated 7/11/24 showed the MDS was incomplete showed 20 days overdue. Documentation showed the resident: -Was cognitively intact with no delirium, disorganized thought or altered level of consciousness. -Had little interest, feeling bad about self, trouble concentrating and sleeping and social isolation. -Had no verbal or physical behavioral symptoms, hallucinations or delusions. Review of the resident's Care Plan dated 6/30/24, showed the resident had potential to be verbally/ physically aggressive to staff related to ineffective coping skills, and mental/emotional illness. Interventions showed staff would: -Monitor behaviors (specify the frequency) and document observed behavior and attempted interventions. -Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. -Provide a Psychiatric/Psychogeriatric consult as indicated. -When the resident became agitated, staff would intervene before agitation escalates; guide the resident away from the source of distress; engage calmly in conversation; If response was aggressive, staff were to walk calmly away, and approach the resident later. -The care plan did not show the resident had adjustment disorder, anxiety and depression and what symptomatic behaviors were exhibited when the resident was distressed, it did not show interventions to address the resident's adjustment disorder and how the facility was managing these behaviors, based on the information provided in his/her hospital discharge records. Review of the resident's admission Trauma Neglect Screening dated 7/1/24 showed a score of 7.0 (on a scale of zero to 7, zero was no trauma). The screening showed the resident: -Had exposure to any form of trauma (including natural disaster, community violence/war, serious injury or illness, serious accident, assault with a weapon, impoverishment, homelessness, persistent bullying). -There were factors that increase the resident's vulnerability (dementia, confusion, disorientation, poor insight/poor judgement, poor communication skills, poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, history of being exploited, for example, giving away money or personal items). -Had a history of substance use/abuse (alcoholism, drug abuse including prescription drug abuse/narcotic seeking) and/or compulsive behavior (uncontrolled or poorly controlled gambling, overeating, exercise, obsessions). -Had a psychiatric history and/or present mental health diagnosis, including psychotic and possible misinterpretation of events and the intentions of others. -Had a depressive illness and/or present signs/symptoms of depression/mood distress. Low self-esteem, isolation and withdrawn behavior. Complaints of chronic pain, illness, fatigue and/or persistent anger, fear and/or anxiety. -Had a history or presence of dysfunctional behavior (provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior) including roaming/wandering into peer's rooms/personal space. -Had a history of mistreating others and/or information presented by a reliable source indicates a history of mistreating others. -The document showed the risk measure for likelihood for psychiatric, behavioral and/or physical symptomology related to trauma showed the resident had some symptomology. Notes showed the resident had a long history of making poor decision in life. He/She had expressed that he/she has abused both alcohol and drugs which has contributed to him/her being incarcerated for years. Review of the resident's Behavior Notes showed: -On 7/23/24, staff documented the resident was verbally aggressive, cursing, making derogatory statements and speaking in a forceful tone. The resident said motherfucker fucking fuck and making statements I am going to lose my shit and get the fuck out of here referencing himself/herself and making statement to nurse, after the resident's roommate (Resident #21) reported the resident had been mishandling his/her food items in the refrigerator in their room and had been leaving the bedroom door open during the night while he/she was trying to sleep. Non-pharmacological interventions showed the nurse attempted to mediate the situation with both roommates advising both speak to each other kindly and respectfully. The resident refused to speak to his/her roommate regarding having door closed at night stating, I don't talk, I lose my shit! You can't keep me in this cell like this. The nurse explained to resident, resident rights and this was not prison. The resident continued to curse at the nurse regarding his/her roommate and the situation and stated, You are just a fucking nurse, you have nothing to do with this. I wanna talk to the director. The resident also reported no preference to the room door being opened and admitted to leaving the door open at night to intentionally irritate his/her roommate. The resident was also upset regarding his/her roommate having a recliner and requested the facility provide a recliner for him/her as well. The nurse explained to the resident that the facility does not provide lounge furniture and the resident would need to provide his/her own recliner. The nurse advised both resident's he/she would notify the facility management staff of this conflict and for this night, the nurse would not close the door but would recommend the resident to close door. The nurse documented he/she left the resident's room due to the resident's ongoing verbal aggression and volatility. The resident did not close the door and his/her roommate did not express any further frustration this night. Intervention failed. Duration of Time for Non-Pharmachological Intervention to determine success or failure: This nurse spent approximately 10 minutes with resident and roommate attempting to mediate this conflict. -On 7/25/24, staff documented the resident was calling his/her roommate derogatory names such a [NAME]. The nurse entered the resident's room to provide his/her roommate's evening medications. The nurse greeted the resident upon entering and upon leaving the room he/she spoke to the resident stating, Sleep well, have a good night. The resident said it is kinda hard to sleep with [NAME] over there banging around. The nurse stated to resident, Do not call him/her names, that is not nice. He/She is going to bed. Stop calling him/her names and proceeded to leave room. The resident's reaction to attempted intervention was further behaviors. The Intervention failed. -On 7/25/24 at 12:30 A.M., staff documented the resident intentionally provoked conflict toward his/her roommate. The nurse documented the resident's roommate called for the nurse due to resident had opened the door. Upon entering the room, the resident's roommate told the nurse that upon completion of the meeting earlier in the day it was agreed that their room door would be closed from 11:00 P.M. to 11:00 A.M. and kept open at all other times. When the nurse questioned the resident on opening door, the resident again began calling his/her roommate [NAME] and complaining regarding his/her roommate going to bed late. Non-pharmacological interventions showed the nurse asked the resident to stop provoking his/her roommate and stated if the agreement was the door was to be closed from 11:00 P.M. to 11:00 A.M., then that is when the door will be closed. The nurse told the resident to stop calling names, and stop being mean. The nurse told the resident he/she would close the door and it would stay closed. The nurse then left and closed the door. The door remained closed this shift. The intervention was successful. -On 7/27/24, staff documented the resident was making derogatory remarks, using abusive language and disturbing other residents. The resident was loudly drawing attention to himself/herself while in the hallway while residents were sleeping. The nurse advised the resident to return to his/her room if he/she continued to be disrespectful and disruptive to other residents. The resident returned to his/her room and did not leave his/her room again. The intervention was successful. Observation and interview on 7/29/24 at 7:43 A.M., the resident was laying on his/her bed. He/She was dressed for the weather, alert and oriented. There was a privacy curtain pulled between him/her and his/her roommate (who was not in the room). The resident said: -He/She and his/her roommate did not get along and both him/her and his/her roommate have approached staff to get them to separate them or to move to another room but management staff told him/her there were no other rooms available (he/she said he requested to move to another room last week). -He/She tried to stay out of his/her roommate's way and did not interact with him/her much. Review of the resident's Social Services Note dated 8/1/24, showed: -On 7/29/24 the Administrator and other management staff spoke with the resident in an attempt to find a way to resolve the issue between the resident and his/her roommate. A discussion was had about the option to move to another room, but the resident did not want to move to any of the available beds. The resident and his/her roommate decided that they would prefer to remain together and each apologized for their behavior. They were both instructed to leave the room and to seek assistance from staff if a conflict were to develop again. Both agreed to do so. Review of the resident's Care Plan on 8/1/24 showed there were no updates to the resident's care plan from 6/30/24. The care plan did not show the resident's prior psychiatric history, substance abuse, prior dysfunctional behaviors, current behaviors and specifically those behaviors the resident had toward his/her roommate and interventions implemented to mitigate those behaviors. There were no indications that a psychological referral for counseling services was implemented or any supportive services to assist with managing his/her anger and volatility on an ongoing basis. Review of the resident's Medical Record on 8/1/24 showed there was no additional documentation showing any referrals for behavior management, counseling/therapeutic services, or outside supportive behavioral services were implemented once the resident began expressing dysfunctional behaviors. There was no documentation showing any attempts to intervene timely after the resident's first behavioral incident with his/her roommate. Observation and interview on 8/01/24 at 9:39 A.M., showed the resident was in his/her wheelchair in the hallway. The resident said: -The issues that he/she had with his/her roommate had to do with him/her being able to sleep at night and his/her roommate making noise at night because he/she liked to stay up late. -His/Her roommate would stay up late typing at 1:00 A.M., and it wakes him/her up and keeps him/her up. -The nursing and management staff spoke with him/her about how they were getting along. He said some days were good and there were no problems, and other days it would occur again. -He/She and his/her roommate have had verbal incidents I get hot headed I do have a temper but they have not had any physical incidents. -Where he/she comes from, you don't make a lot of noise at night when you see someone was sleeping. He/She said it was hard for him/her to sleep at night and he/she was also having pain that was finally addressed. -Earlier this week, on 7/29/24, they had an incident and he/she threw a shoe at the privacy curtain in the direction of his/her roommate, but it did not hit his/her roommate. He/She threw the shoe because the resident was typing at 2:00 A.M. and he/she was letting his/her roommate know that he/she was trying to sleep and to stop. He/she said he/she knew that it would not hit his/her roommate. -A couple days after this incident, the administrative staff spoke with him/her and told him/her that he/she could not have that type of aggression in the facility. -He/She said he/she still wanted to change rooms. 2. Review of the Resident #21's quarterly MDS dated [DATE], showed the resident was cognitively intact. During an interview on 7/30/24 at 12:57 P.M., the resident said: -Regarding his/her roommate, Resident #141. -He/She and his/her roommate had had a problem last week when his/her roommate slammed his/her wheelchair against his/her tray table for no reason and against his/her bed. He/She had not provoked Resident #141, but the resident has some anger problems and behaviors and does not get along with people. -On Monday at around 6:30 A.M., he/she was laying down in bed resting and the privacy curtain was pulled. Resident #141 threw a book at him/her which hit the curtain, but it did not hit him/her. -He/She had not provoked his/her roommate or said anything to him/her to warrant his/her behavior. -Most of their issues had to do with keeping the room door closed. He/She likes the door closed between 11:00 P.M. and 11:00 A.M. and his/her roommate wants the door open. -They decided to compromise and will keep the door open between 11:00 A.M. to 11:00 P.M. and closed between 11:00 P.M. to 11:00 A.M. 3. During an interview on 8/1/24 at 9:58 A.M., Certified Nursing Assistant (CNA) A said: -He/She was aware that Resident #141 had problems with his/her roommate. -The issues between the roommates usually occurred at night and he/she was not aware of any incidents regarding the resident occurring during the day. -Usually they received information about any resident incidents during resident rounds at shift change. -It had been reported that the resident had been calling his/her roommate names and was keeping his/her roommate awake at night. -Usually if there are any incidents or behaviors regarding residents, they notify the Charge Nurse and management (DON and Administrator). -The facility management staff have spoken with both the resident and his/her roommate and he/she was told their conflict had been resolved. -He/She had not seen the resident have any negative behaviors toward any of the other residents, his roommate or staff. -One of the interventions was to move the resident's bed to be placed against the wall to cut down on conflict with his/her roommate and this seemed to resolve some of the resident's concerns. -Additional interventions they have been given is to try to separate him/her from the conflict and try to talk to him/her to get him/her to calm down when he/she becomes irritated/angry. -He/She was not aware if the resident participated in any counseling services. During an interview on 8/02/24 at 10:18 A.M., Licensed Practical Nurse (LPN) A said: -He/She was notified that Resident #141 and his/her roommate had been having disagreements and different preferences regarding their room and lighting. -There were only a couple of incidents between the resident and his/her roommate that were more verbal in nature. -He/She was not aware of exactly what had occurred between the resident and his/her roommate on 7/29/24. -He/She knew that management staff spoke with both residents about their conflicts and tried to mitigate, but he/she was not sure that there was anything that had formally been put in place behaviorally for either resident. -The resident had also had inappropriate behaviors with female staff and management staff determined that the female staff would need to go in to provide care to him two at a time. -These behavioral interventions should have been in the resident's care plan. -He/She did not think that the resident was receiving any counseling/therapy or behavioral management. -(After looking in the resident's medical record) he/she did not see anything in the resident's care plan about any referrals for or actual therapy/counseling services and there was no information regarding his behaviors with his/her roommate. -He/She was unaware of the resident's request to move to another room. -He/She would expect to see documentation about the resident's behaviors in his/her care plan. -If the resident's behaviors continued, they should look at separating the resident from his/her roommate. -On 7/29/24 there was a note showing the Social Service Director and Administrator met with the resident to discuss a room change. During an interview on 8/2/24 at 10:52 A.M., the Social Service Designee (SSD) said: -He/She was familiar with the resident and his/her roommate. -The resident's roommate had several roommates before the resident was admitted to the facility, but at the time the resident came, the roommate was in a room by himself/herself. -Once the resident was admitted , they found they had similarities and asked to room together. -After the resident moved into the room they began having conflicts related to their sleep patterns and preferences and they would complain about each other and instigate each other. -He/She was made aware of the resident's behaviors since his/her admission and was not aware that any interventions had been put in place regarding conflicts with his/her roommate. -He/She was out of the facility from 7/2/24 through 7/23/24 and returned to work on 7/29/24. -On 7/29/24, staff informed him/her that the resident's roommate reported that earlier that morning or the night before, the resident had thrown a book at him/her and the book had hit the privacy curtain. -He/She went to talk with the resident's roommate and he/she told him/her that he/she did not want to room with the resident anymore, that the resident had done several things since moving into his/her room like rearranging his/her food in his/her personal refrigerator, banging his/her wheelchair against his/her bed, keeping the door open at night and the roommate gave him/her a handwritten paper with these complaints documented (the complaints started on 7/17/24). The roommate also reported that the resident had thrown a book that hit the privacy curtain this morning. He/She advised the roommate to stay away from Resident #141 and to report any additional conflict to the management staff. -He/She went to speak with the resident about the incident and he/she acknowledged throwing the book. The resident said he/she would stay away from his/her roommate and agreed to report any conflict to management staff. -He/She then informed the Director of Nursing (DON) and Administrator about the issue and they spoke with both residents. At that time they were looking at moving one of them out of the room. -The incident should have been documented in the resident's medical record at the time it occurred and there was an incident report documented but he/she could not find it currently. -Both residents were offered the choice to move to another room and they both declined to move. They apologized to each other and said they would not have further difficulties and would talk with management staff if they had further conflicts. -Since this mediation occurred, the residents seemed to have resolved their issues and there have been no further behaviors from either resident. -He/She was not sure what additional action they could have taken other than to keep them away from each other on 7/29/24. -To his/her knowledge, they did not document any behavior monitoring on either resident and he/she did not take any further action to ensure the resident was monitored to ensure there was no further behaviors. -The resident had mental health diagnoses, but he/she was unaware if there have been any therapy or counseling referrals set up for him/her. -They have a vendor for counseling services that comes in weekly and the resident had signed the consent to receive services but Resident #141 had not seen the therapist. -They probably should have monitored the residents after the incident occurred and it should have been care planned. During an interview on 08/02/24 at 11:58 A.M., the DON said: -He/She was aware of the resident and his roommate having conflicts prior to this but did not know in detail what occurred before 7/29/24. -On 7/29/24, the resident threw something towards his/her roommate and had banged his/her wheelchair against his/her roommate's bed. -He/She was aware of the resident's diagnoses and his behavioral history was documented in his/her medical record related to his/her history of aggression and adjustment disorder. -If you know of the residents diagnoses and of (him/her) having an incident of aggression, he/she would probably want to implement psychiatric services and counseling services after the first behavioral incident. -On 7/29/24, he/she would have expected staff to separate the residents and to implement behavior monitoring of both residents to begin immediately and on every shift for at least three days after the incident occurred. -The incident should have been documented in the resident's medical record. -He/She would have expected staff to put a behavior plan in place to try to mitigate to resident's behaviors and prevent the escalation of his/her behaviors. -All of these interventions should have been documented in the resident's care plan in detail.

Based on interview and record review, the facility failed to ensure residents' monthly Medication Regimen Review (MRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) were completed by the pharmacy to ensure irregularities were identified so they could be acted upon for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's policy titled MRRs dated May 2019 showed: -The goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. -The MRR involved a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medications errors, and other irregularities. -Copies of MRR reports, including physician responses, were maintained as part of the permanent medical record. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Malignant Neoplasm of Unspecified Site of Left Breast (breast cancer). -Personal History of Transient Ischemic Attack (TIA- a mini stroke which happens when there is a temporary disruption in the blood supply to part of the brain). -Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). Review of a Listing of Residents Reviewed with No Recommendation dated 2/5/24 completed by the Pharmacy Consultant (PC) A showed the resident was not on this list, indicating a recommendation for the resident was made for the month of January 2024. Review of a Listing of Residents Reviewed with No Recommendations dated 3/31/24 completed by PC A showed the resident was not on this list, indicating a recommendation for the resident was made for the month of March 2024. Review of a Listing of Residents Reviewed with No Recommendations dated 4/30/24 completed by PC A showed the resident was not on this list, indicating a recommendation for the resident was made for the month of April 2024. Review of the resident's Electronic Medical Record (EMR) on 7/30/24 showed: -No documentation was found related to the MRRs for the months of January 2024, March 2024, and April 2024. -No documentation was scanned into the resident's EMR related to the months of January 2024, March 2024, and April 2024. During an interview on 8/1/24 at 11:42 A.M. Licensed Practical Nurse (LPN) B said: -The nurses were in charge of completing the MRRs. -He/She would fax the recommendations, if needed, and once a response was received by the physician, then he/she would put in a nurse's note and change orders if indicated. -The DON was responsible for ensuring completion of the MRRs. -If there was not a note in place or the MRR was not scanned into the resident's EMR, then there would be no way to verify the completion of the recommendation. -The facility was playing catch-up with the MRRs. During an interview on 8/2/24 at 11:58 A.M. the Director of Nursing (DON) said: -The PC was responsible for emailing the MRRs to the facility. -Once received, he/she was responsible for printing the MRRs and would give or send a copy to the facility's physicians. -Once completed, the staff person in charge of medical records was responsible for scanning the recommendations into the residents' EMRs. -The nurses were responsible for making any order changes related to the MRRs. -He/She expected the nurses to document a note for any order that was made or changed. -He/She expected staff to keep better documentation and record of the MRRs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete recommended Gradual Dose Reduction (GDR- involves the stepwise tapering of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose or the medication can be discontinued altogether) and/or (MRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for psychotropic medications (drugs which affect psychic function, behavior, or experience) for three sampled residents (Resident #1, #18 and #33) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's policy titled MRRs dated May 2019 showed: -The goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. -The MRR involved a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medications errors, and other irregularities. -Copies of MRR reports, including physician responses, were maintained as part of the permanent medical record. Review of the facility's policy titled Tapering Medications and Gradual Dose Reduction (GDR) dated April 2007 showed: -Residents who used antipsychotic drugs should receive GDRs and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the medications. -Within the first year after a resident was admitted on an antipsychotic medication or after the resident had been started on an antipsychotic medication, the staff and practitioner should attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the diagnosis of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/16/23 showed the resident was cognitively intact. Review of a Physician Recommendation dated 5/30/24 completed by Pharmacy Consultant (PC) A showed: -The resident had been taking Venlafaxine (Effexor- used to treat depression) Extended Release (ER) 24 hour 150 milligrams (mg), since September 2023 and a GDR needed to be attempted. -The facility had not responded to this recommendation. Review of the resident's Physician Order Sheet (POS) dated July 2024 showed the resident had an order for Venlafaxine ER 24 hour 150 mg, give one tablet by mouth one time a day. 2. During an interview on 8/1/24 at 11:45 A.M. Licensed Practical Nurse (LPN) B said: -When a GDR was recommended, he/she would reach out to the doctor and verify the recommendation. -He/She would then place a note in the resident's medical record with the pertinent information related to the GDR. -He/She had not remembered a GDR recommendation for the resident. -He/She reviewed the resident's chart and could not verify the recommendation had been completed or signed off by the physician. -The Director of Nursing (DON) was responsible for verifying the completion of all pharmacy recommendations. During an interview on 8/1/24 at 12:48 P.M. the MDS Coordinator said: -There would be notes in place in a resident's medical record if a GDR was followed-up on and the physician's response. -He/She was unsure if the resident's GDR had been completed or what the physician's response had been. -If the GDR had been completed, he/she would have expected to see a nurse's note in the resident's medical record. -The DON was responsible for ensuring all pharmacy recommendations were completed. During an interview on 8/2/24 at 11:58 A.M. the DON said: -Once a GDR recommendation was made, he/she would give a copy to the doctor and monitor for the completion of the recommendation. -Medical records was responsible for scanning the signed recommendations into the residents' medical charts. -The nurses were expected to make a note in the residents' medical charts once a recommendation was completed and if any new orders were received. -He/She could not find the documentation of the resident's GDR completion. 2. Review of Resident #18's admission Face Sheet showed the following diagnosis: -Had diagnoses including Depression (is classified as a mood disorder. It may be described as feelings of sadness, loss, or anger that interfere with a person's everyday activities). -Autism (refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech). -Affective Mood Disorder-is a mental disorder characterized by dramatic changes or extremes of mood. Review of the undated facility list of residents from the consulting pharmacy's MRRs showed there was no documentation found for the resident's MRR for February 2024. Review of the resident's care plan revised on 2/12/24 showed: -Administer psychotropic medication as ordered by physician. -Consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly. Review of resident's MRR dated 4/30/24 with recommendations showed: -The resident had a recommendation to the physician related to Risperdal (an atypical antipsychotic drug. It is sometimes used to treat depression), the medication lacked the allowable diagnosis to support use. -This was faxed to the resident's physician and there was no written response from physician. Review of the resident's Quarterly MDS dated [DATE], showed the resident: -Was severely cognitively impaired. -Had diagnoses including Depression, Autism and stroke. Review of resident's MRR dated 5/30/24 with recommendations showed: -The pharmacist had a recommendation to the physician, which required an allowable diagnosis for use of Divalproex, (is anticonvulsant, is used to treat seizure disorders, certain psychiatric conditions, such as manic phase of bipolar disorder) and it was listed for mood disorder. -There was no documentation from the resident's physician related to the pharmacy's request. Review of the resident's MRR dated 5/30/24 with recommendations showed: -The resident had a recommendation to the physician, required a allowable diagnosis for use of Risperidone. -There was no documentation from the resident's physician related to the pharmacy's request. Review of the resident's Physician Order Sheet (POS), July 2024 showed: -Risperidone 1 millagram (one tablet, Give 1 tablet orally at bedtime related to Depression. -Divalproex SOD DR 500 mg, give one tablet orally every 12 hours related to Affective Mood Disorder. -Divalproex SOD DR Give with 250 mg tab to equal 750 mg). -Divalproex SOD DR 250 mg TA Give 1 tablet orally every 12 hours related to Mood Disorder. 3. Review of Resident #33's admission Face Sheet, showed the resident: -Had diagnoses including dementia with behavioral disturbance (is commonly associated with memory loss) Alzheimer's dementia (is a type of dementia that affects memory, thinking, and behavior), depression, and anxiety (Feelings of panic, doom, or danger , Sleep problems or feeling tired). Review of the undated facility list of residents from the consulting pharmacy's MRRs showed there was no documentation found for the resident's MRR for February 2024. Review of resident's a MRR dated 3/31/24 with recommendations showed: -The resident had a recommendation to the physician related to Zyprexa, the medication lacks the allowable and appropriate diagnosis to support use. Had signature of the physician as reviewed on 4/14/24. Had no documentaion related to a change of diagnosis was made. Review of the resident's care plan on revised on 5/29/23 showed: -The resident uses antidepressant and antipsychotic medications related to depression and mood disorder. -The resident will be free from discomfort or adverse reactions related to antidepressant/antipsychotic therapy through the review date. -Administer medications as ordered by physician. -The pharmacy consultant to review medication monthly. Review of the resident Quarterly MDS dated [DATE], showed the resident: -Severely cognitive impaired. -Had diagnoses including dementia with behavioral disturbance, Alzheimer's, depression, and anxiety. Review of the resident's POS, dated 8/1/24, showed the following physician's orders: -Zyprexa Oral Tablet 7.5 milligrams (mg) (an antipsychotic medication) Give one tablet by mouth at bedtime related to Anxiety disorder. (no change in diagnosis per pharmacy MRR request): 4. During an interview on 7/31/24 at 9:16 A.M., LPN B said: -The pharmacist came to the facility monthly and completed MRRs for all residents. -He/she would then call the physician or fax pharmacy recommendation to the resident physician for review. -Once a response was received by the physician, then he/she would put in a nurse's note with any change in medication orders or if no changes at this time. -The DON was responsible for ensuring completion of the MRRs. -The resident had not had any recent changes to his/her medication. During an interview on 8/2/24 at 11:58 A.M. the DON said: -MRRs were completed monthly by a contracted pharmacy consultant company. -The reports and recommendation were to be emailed to DON for review. -He/she would then print and send to the resident's physician for review for any recommendation. -The physician would write his/her response and sign the form. -The medical records staff and DON would be responsible for ensure have recommendation were documented and to ensure have current physician orders scan into the resident medical record. -He/she was not aware the pharmacy MRR/GDR recommendations were not acted upon for Resident #18 and Resident #33's medication.

Based on interview and record review, the facility failed to maintain evidence (via receipts or signatures) for monetary transactions in the resident trust fund accounts for two sampled residents (Resident #2 and #3) out of four sampled residents; and failed to maintain a proper accounting of the end of month petty cash (the amount of cash that is accessible for residents with resident trust that residents can request funds from) amounts from July 2023 through April 2024. This practice potentially affected 22 residents with resident trust. The facility census was 46 residents. 1. Review of Resident #2's resident trust fund transactions list dated 4/1/24 through 7/31/24 showed: - A transaction dated 5/6/24 for $40.41 without a receipt or signature for that transaction. - A transaction dated 6/14/24 for $18.97, without a receipt for that transaction. 2. Review of Resident #3's resident trust fund transaction list dated 4/1/24 trough 7/31/24, showed a transaction for $28.56, without a receipt or a signature for that transaction. During an interview on 8/2/24 at 10:32 A.M. the Regional Business Office Manager (BOM) said: -The previous BOM placed multiple transactions on one receipt and that made the transactions hard to distinguish. -The previous BOM did not keep specific receipts for each grocery store transaction. 3. Review of the resident trust records from July 2023 through June 2024, showed the absence of petty cash records from July 2023 through April 2023. During an interview on 8/2/24 at 10:18 A.M., the Regional BOM said there was not an actual form that was used, to do the petty cash calculations for the petty cash.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the ambient (pervasive quality of the surrounding environment) temperature of Resident #291's room, and resident rooms [ROOM NUMBERS], within the required Centers for Medicaid and Medicare Services (CMS) regulatory requirement of 71-81 ºF (degrees Fahrenheit) failed to monitor temperatures of those rooms when those rooms felt warm, failed to ensure all staff knew where the locations of the thermometers and failed to ensure that two of the facility thermometers were properly operating. The facility also failed to maintain the restroom floor in resident room [ROOM NUMBER] free from a pungent urine odor; failed to maintain the floors in resident rooms [ROOM NUMBER] free from a buildup of debris; failed to maintain the filter of the climate control unit in resident room [ROOM NUMBER] free of dust and mildew; failed to maintain the fans in resident rooms [ROOM NUMBERS] and the therapy room free of a heavy buildup of dust; failed to maintain the shower curtain in the North Hall shower room free from red colored stains; and failed to maintain the ceiling vent in the South Hall shower room, free from buildup of dust inside the vents. This practice potentially affected at least 6 residents with temperatures in their room above 81 ºF and at least 25 residents in other areas of the facility. The facility census was 46 residents. Review of the Ambient Temperature Checks section of the facility's policy entitled Emergency Electrical Outage Procedure, dated 3/30/23, showed: -The ambient temperatures of all residents spaces will be monitored every 30 minutes and documented on flow sheets provided in this section. -The acceptable range of temperature is 71-81 ºF. -There are wall thermometers placed above the fire extinguishers on each hall and one in the dining room outside the kitchen door. -Staff will also check temperatures in two resident rooms on each hall every 30 minutes. -Probe thermometers for this use are in the Maintenance Director's Office. -Notify the charge nurse, Administrator and Maintenance Director immediately, if monitored temperatures, range beyond 71-81 ºF. 1. Review of Resident #291's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/11/24, showed: -The full MDS was not completed. -Section C cognitive function was completed and it indicated the resident was cognitively intact. During an interview on 7/30/24 at 9:03 AM, the resident said it was hot in his/her room. Observation on 7/30/24 at 9:13 AM, showed the ambient temperature in the resident's room was 82.4 ºF. Observation on 7/30/24 at 12:08 P. M, showed the ambient temperature in the resident's room was 84.3 ºF. Observation on 7/30/24 at 1:01 P. M, showed the ambient temperature in the resident's room was 84.2 ºF. Observation on 7/30/24 at 1:39 P.M. showed the ambient temperature in the resident's room was 85 ºF. During an interview on 7/31/28 at 9:54 A.M., the resident said 7/30/24 was not a good day because the air conditioning was out and his/her room was hot and he/she felt miserable. 2. Observation on 7/30/24 at 1:35 P.M. showed the ambient temperature in resident room [ROOM NUMBER] was 82 ºF. 3. Observation on 7/30/24 at 1:44 P.M. showed the ambient temperature in resident room [ROOM NUMBER] was 82 ºF. 4. During an interview on 7/30/24 at 2:03 P.M. the Maintenance Director (MD) said: -He/she did not know of anyone who took temperatures of those rooms. -There was not a thermometer at the nurse's station. -If a facility staff member needed to monitor room temperatures they would have to ask him/her for the other thermometers. Observation on 7/30/24 at 2:07 P.M., showed: -The MD brought three thermometers out to the Main dining room to verify how they recorded temperatures. -The following temperatures were recorded from all three of the facility's thermometers and one of the surveyor's thermometer. -Facility thermometer A recorded a dining room temperature of 41.2 ºF. -Facility thermometer B recorded a temperature of 35.2 ºF. -Facility thermometer C recorded a temperature of 76.6 ºF. -The surveyor's thermometer recorded a temperature of 77.3 ºF. During an interview on 7/30/24 at 2:16 P.M., the MD said: -It had been since 4/24 or 5/24, since he/she had checked the thermometers to verify the thermometers worked properly. -He/she did not document the maintenance of the thermometers. -He/she did not know that facility thermometers A and B were so far out of range. During an interview on 7/31/24 at 9:14 A.M., Licensed Practical Nurse (LPN) C said: -On 7/30/24, Resident #291's room was the worst, but resident room [ROOM NUMBER] and 30 were warm, but not as hot as Resident #291's room. -He/she did not check temperatures in the rooms. -He/she shut the curtain in rooms [ROOM NUMBERS]. -The Maintenance Assistant had to clean out the climate control units in those rooms. During an interview on 7/31/24 at 9:21 A.M., Certified Nursing Assistant (CNA) B said: -On 7/30/24, he/she felt that Resident #291's and resident room [ROOM NUMBER] were warm. -The climate control units were on, but the air did not blow out cool. -He/she told the Director of Nursing (DON). -He/she did not take any temperatures of the rooms. -None of the residents said anything regarding the warm temperatures in their rooms. -He/she did not notice any warm temperatures in room [ROOM NUMBER]. During an interview on 7/31/24 at 9:39 A.M., the MD said: -The coils (heat exchangers that transfer heat to and from the refrigerant running in the loop between the outdoor A/C condenser and the cooling equipment inside a building) were filled with dirt and lawn debris. -The maintenance staff sprayed a cleaning chemical on the coils and then power washed the coils. -If the coils were filled with dust and lawn debris and that debris would affect how well they worked. -How often he/she and the Maintenance staff cleaned the coils in the individual room climate control units, depended on how hot it got. -In the past three months, the maintenance staff had to pull the individual units for cleaning, at a rate of 10 units at a time. -He/she had to replace the climate control unit in Resident #291's room. During an interview on 7/31/24 at 9:46 A.M., the DON said: -He/she asked facility staff to ask residents in those rooms if they wanted to go to the dining room, where it was cooler. -He/she did not do any monitoring and he/she did not ask the staff to do any monitoring. -He/she did not know where the thermometers that would be used for monitoring temperatures, were located. During an interview on 7/31/24 at 12:49 P.M., the Administrator said: -He/she expected the charge nurse to be notified if the resident rooms were hot. -He/she expected the facility staff to monitor the thermometer in the hallway. -If it felt overly hot or cold and voiced by the residents, then the employees should notify their immediate supervisor or charge nurse and offer residents the opportunity to come out to the dining room. -He/she would expect that an employee would get a thermometer to monitor the temperatures. -He/she would expect new employees to be oriented to the locations of the thermometers. During a phone interview on 8/8/24 at 11:19 A.M., the Care Plan Coordinator said during the orientation, he/she did not go over the location of thermometers with the new DON when the new DON started at the facility about two weeks prior to the survey. 5. Observation on 7/30/24 at 11:01 and on 8/1/24 at 9:30 A. M, 10;20 A.M., 11:52 A.M. and 1:06 P.M., showed a pungent urine odor emanating from the restroom in resident room [ROOM NUMBER]. During an interview on 8/1/24 at 1:07 P.M., the MD said: -He/she could remove the epoxy (a material incorporating such ingredients as carbon and aramid fibers, graphite, epoxies and ceramics, which are corrosion-resistant and used for building materials) paint and clean the floor underneath. -He/she could still smell the urine odor in that room, even though the floor looked like it had been mopped earlier that day. 6. Observation on 7/30/24 with the MD showed: -At 11:02 A.M. there was a buildup of dust on the fan and a buildup of debris under the nightstand in resident room [ROOM NUMBER]. -At 11:15 A.M., there was a buildup of dust and mildew in the filter of the climate control unit in resident room [ROOM NUMBER]. -At 11:16 A.M. there was the presence of a brown substance on the leg of the commode riser in room [ROOM NUMBER]. -At 11:24 A.M., there was a buildup of debris on and cobwebs (spider webs) behind the furniture in resident room [ROOM NUMBER]. -At 11:43 A.M., there was a heavy buildup of dust in the fans in resident room [ROOM NUMBER]. During an interview on 7/30/24 at 11:44 A.M., the MD said the housekeepers were supposed to clean the fans. 7. Observation on 7/30/24 at 12:02 P.M., in the shower room across from the sprinkler room showed: -There were red colored stains on the shower curtain. -The presence of debris and papers under the tub. -A heavy buildup of dust inside the ceiling vent. During an interview on 7/30/24 at 12:06 P.M., the MD said he/she did not know about the stains on the shower curtains. During an interview on 7/30/24 at 12:08 P.M., CNA B said he/she saw the stains on the shower curtain for the first time that morning. 8. Observation on 7/30/24 at 2:21 P.M., showed there was a heavy buildup of dust in the fan in the therapy room. One resident was president in the therapy room at that time. During an interview on 7/30/24 at 2;22 P.M., the Certified Occupational Therapist Assistant (COTA) said the therapy staff have not been on top of cleaning the fans like they needed to. 9. Observation on 7/30/24 at 2:29 P.M., showed at 2:52 P.M., there was a buildup of dust in the vent in the South Hall shower room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications brought in by one sampled resident's (Resident #33) family member was labeled and stored correctly in the Certified Medication Technician (CMT) cart out of 14 sampled residents; failed to ensure other medications in the CMT cart were stored and labeled appropriately and failed to dispose of expired medical supplies found in the medication room which had the potential to affect all residents in the facility. The facility census was 46 residents. Review of the facility's policy titled Labeling of Medication Containers dated [DATE] showed: -Medication labels were to be legible at all times. -Labels for individual resident medications included all necessary information, such as: --The resident's name. --The prescribing physician's name. --The name, address, and telephone number of the issuing pharmacy. --The name, strength, and quantity of the drug. --The prescription number, if applicable. --The date the medication was dispensed. --Appropriate accessory and cautionary statements. --The expiration date, when applicable. --Directions for use. -Medications were not to be transferred between containers. Review of the facility's policy titled Medications Brought to the Facility by the Resident/Family dated [DATE] showed: -The facility discouraged the use of medications brought in from outside and would inform residents and families of that policy as well as applicable laws and regulations. -If a medication was not otherwise available and/or it was determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing (DON) services and nursing staff, with support of the attending physician and consultant pharmacist, should check to ensure that: --State laws and regulations allow such use. --The contents of each container were labeled in accordance with established policies. --The contents of each container had been verified by a licensed pharmacist. Review of a facility policy titled Pharmacy Services-Role of the Consultant Pharmacist dated [DATE] showed the consultant pharmacist should provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services, including procedures to support resident quality of life such as safe, individualized medication administration programs. 1. Review of Resident #33's face sheet showed he/she admitted to the facility with the following diagnoses: -Neurocognitive Disorder with Lewy Bodies Disorder (a type of dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions). -Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed: -The resident was severely cognitively impaired. -The resident had a short term and long-term memory problem. Review of the resident's Physician Order Sheet (POS) dated [DATE] showed: -An order for Causticum (used in homeopathy (a medical system based on the belief that the body can cure itself) for a broad spectrum of conditions) 200c, 10 drops under the tongue twice daily for incontinence). -SeaBD one capsule (a homeopathic medication used as an antioxidant and has anti-inflammatory benefits), chew and then spit out every night at bedtime then mouth wash. -Nuadapt one capsule (a unique blend of botanicals and nutrients that supports the stress response, improves cognition and in particular, promotes cortisol (a hormone that assists in regulating the body's stress response, helping control metabolism, and suppressing inflammation) balance), open and mix with applesauce at least 30 minutes before breakfast and supper daily. -Hyoscyamus (used in the ancient times to treat pain or insomnia (persistent problems falling and staying asleep) 30 milliliters (ml), give 10 drops under the tongue three times a day. -NuxVom (a homeopathic medication with purported benefits for a wide range of conditions including heart disease and cancer) 200c drops, administer 10 drops under the tongue every night at bedtime. -Cardiovascular (referring to the heart and blood vessels) Research Magnesium (used for heart health), one teaspoon (tsp.) mixed with applesauce at least 30 minutes before breakfast daily. Observation on [DATE] at 1:53 P.M. of the resident's medications stored in the CMT cart showed: -A dropper bottle of Causticum inside a pill bottle with the label indicating the medication had five refills available before [DATE]. -A SeaBD bottle with no label or expiration date. -A Nuadapt bottle with no label and the expiration date was illegible. -A dropper bottle of Hyoscyamus only labeled with pharmacy name and use as directed. -A dropper bottle of Nux Vomica only labeled with the pharmacy name and use as directed. -A bottle of Magnesium solution, unlabeled, and had expired [DATE]. During an interview on [DATE] at 1:53 P.M. CMT A said the resident's family had just brought in the magnesium solution and someone should have checked the expiration date before accepting the medication. 2. Observation on [DATE] at 1:53 P.M. of the CMT medication cart showed: -A budesonide and formoterol fumarate (used to help control symptoms of asthma (a condition in which a person's airways become inflamed, narrow, and swell which makes it difficult to breath) and improve lung function) unlabeled and not in any storage bag/box/or container. -A fluticasone propionate (used to treat allergies or non-allergic nasal symptoms) nasal spray stored outside of its original container without a visible expiration date on the bottle. -A bottle of whole produce fruits balance of nature dietary supplements (used to support general well-being) without a resident label or expiration date. -A bottle of whole produce veggies balance of nature dietary supplements (used to support general well-being) without a resident label or expiration date. 3. Observation on [DATE] at 2:21 P.M. of the medication storage room showed: -Four intravenous (IV) start kits that expired on [DATE]. -Four IV start kits that expired on [DATE]. -One box of safety blood collection sets and [NAME] adapters (connection between syringes and needles) which expired on [DATE]. 4. During an interview on [DATE] at 11:20 A.M. CMT B said: -All medications were to stay in the original container. -Medications should be labeled with the medication name, resident's name, quantity, and expiration date. -Any unlabeled medications or supplements should be discarded. -If the expiration date of a medication could not be found or was illegible, then the medication should be disposed of. -If a family member brought in medication for the resident to use while at the facility and was expired, he/she would inform the nurse and have the nurse speak with the family. -There should not be any expired supplies stored in the medication room. During an interview on [DATE] at 11:48 A.M. Licensed Practical Nurse (LPN) B said: -All medications were to stay in the original container. -Any unlabeled medication or supplements should be discarded because there would be no way to verify who the medication was for or if it's the correct medication for the resident. -Any medications brought in by family members needed to be labeled and have a verification slip. -Medications should be labeled with the resident's name, dose, frequency of use, description of use, expiration date, and the quantity. -If a resident's family member brought in an expired medication, he/she would not accept the medication. -There should not be any expired supplies in the medication room. During an interview on [DATE] at 12:51 P.M. the MDS Coordinator said: -Any medications brought in by family members needed to be approved by the physician and verified by the pharmacy. -All medications needed to be stored in the original container. -If he/she found an unlabeled medication in the medication cart, then he/she would discard the medication. -All medications and supplements needed to be labeled with the resident's name, route of administration, directions of use, expiration date, and open date. -Any medications that did not have an expiration date or the expiration date was illegible needed to be discarded and re-ordered. -A staff person that accepts medications brought in by families needed to verify that it was labeled appropriately and not expired. -Expired medical supplies should not be stored in the medication room. During an interview on [DATE] at 11:58 A.M. the DON said: -The facility allowed family members to bring over the counter and prescription medications to the facility. -Any medications brought in by family members needed to be verified and unopened. -Resident #33's medication usually came from a different pharmacy and was sealed in a prescription bag when given to the facility by Resident #33's family member. -All medications should be stored in the original container. -Medications brought in my families needed to be labeled just like a pharmacy label. -He/She expected staff to discard and reorder any medications that were not labeled appropriately. -He/She expected staff to discard and reorder any medications that were expired or if the expiration date was illegible. -The staff person should not have accepted the bottle of Magnesium Solution brought in by Resident #33's family member due to it being unlabeled and expired. -Expired medical supplies should not be stored in the medication room.

Based on observation, interview and record review, the facility failed to ensure recipes were available for dietary staff to use while making pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) waffles, chicken tenders and pureed mixed vegetables; and the facility failed to ensure the recipes for the pureed versions of those items were detailed enough to include the amounts of liquids and/or thickener that were needed to make the recipe properly. This practice potentially affected five residents with pureed diets. The facility census was 46 residents. 1. Observation on 7/29/24 at 8:17 A.M., showed Dietary [NAME] (DC) A made pureed waffles without having the recipe book open. During an interview on 7/29/24 at 8:41 A.M. the Dietary Director said he/she was not able to print off the recipe for pureed waffles because the computer was down. Review of the pureed recipe for waffles on 7/29/24 showed: -The recipe was dated 9/15/17. -Remove desired number of servings and add nutritive liquid (milk, broth, etc.). Blend until desired consistency and add approved thickener to achieve desired consistency if needed. During an interview on 7/29/24 at 8:46 A.M., the Dietary Director said the recipe was inadequate because the recipe did not state how much liquid or how much thickener to add per the number of servings of waffles. 2. Observation on 7/29/24 at 10:59 A.M., showed DC A made pureed chicken tenders without having the recipe book open. DC A added an unmeasured amount of chicken base to the processed chicken, then added water to the food processor. DC A processed the chicken into a pureed form. Review of the pureed recipe for chicken tenders on 7/29/24 showed: -The recipe was dated 9/15/17. -Remove desired number of servings and add nutritive liquid (milk, broth, etc.). Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. The recipe did not state how much liquid or thickener to add per the number of servings that needed to be pureed. 3. Observation on 7/29/24 at 11:11 A.M., showed: - DC A was making pureed french fries. - DC A added cold milk to pureed fries. - DC A did not have the recipe book opened to look at the recipe for pureed french fries. 4. Observation on 7/29/24 at 11:31 A.M., showed: - DC A pureed the mixed vegetables - DC A did not have a recipe book open. Review of the pureed recipe for the mixed vegetable on 7/29/24 showed: -The recipe was dated 11/11/15. -Remove desired number of servings and add nutritive liquid (milk, broth, etc.). -Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. The recipe did not state how much liquid or thickener to add per the number of servings that needed to be pureed. During an interview on 7/29/24 at 12:08 P.M., the Dietary Director said: -He/she did not have printed recipes for pureed french fries. -There was a little bit of chunk in the pureed french fries. -He/she did not know why they did not have a recipe for the pureed french fries. and -He/she expected facility staff to use the recipes if they were available for use. During an interview on 7/29/24 at 12:43 P.M., DC A said he/she did dnot use the recipe book to make the pureed items. and the Dietary Director could taste some of the pureed items. During a phone interview on 8/5/24 at 3:45 P.M., the Consultant Registered Dietitian (CRD) said: -He/she expected the dietary cooks to use the recipe book, while they made pureed food. -It has been difficult to have an in-service because gathering the dietary staff was difficult to get together for a functional in-service. -Most of the time, he/she spoke with the cook regarding food consistency and temperatures. During a phone interview on 8/6/24 at 2:21 P.M., the Consultant RD said the recipes for the pureed items did not provide enough information and the recipes for the pureed items could be made more specific.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the pureed french fries were palatable and failed to ensure the dinner rolls were cooked properly for the lunch meal on 8/2/24. The facility census was 46 residents. 1. Review of Resident #15's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 12/20/23, showed the resident was cognitively intact. Review of Resident #31's quarterly MDS dated [DATE], showed the resident was cognitively intact. Review of the Resident Council minutes dated 12/5/23 showed: -Resident #15 said the food was not good. -Resident #31 said the food was bad. Review of the Resident Council Minutes dated 1/2/24 showed Resident #15 said the food was still not good. 2. Observation on 7/29/24 at 11:16 A.M., showed DC A pureed French Fries in the food processor, DC A added cold milk to the fries in the food with no recipe book used at that time. DC A did not taste the pureed fries after the fries were finished being processed. During a taste test on 7/29/24 at 11:57 A.M., showed the pureed fries with a chunky texture. During an interview on 7/29/24 at 12:01 P.M., DC A said the pureed fries had a bland taste because the fries had a bland taste. During an interview on 7/29/24 at 12:08 P.M., the Dietary Director said he/she did not have printed recipes for pureed fries. During an interview on 8/1/24 at 2:39 P.M., Resident #15 said: -The part of the food that was not good, was the taste. -The French Fries served on Monday (7/29/24) were not crispy, but mushy and -The food was undercooked. and the French Fries were too mushy. 3. Review of Resident #21's quarterly MDS, dated [DATE], showed Resident #21 was cognitively intact. During an interview on 8/2/24 at 12:10 P.M., Resident #21 said the dinner rolls, which were served for lunch, were undercooked. Observation on 8/2/24 at 12:11 P.M., showed the resident was able to pull the roll apart and the dough able to be stretched for an inch (in.) or more. Observation on 8/2/24 at 12:15 P.M., in the kitchen showed the dinner rolls were cooked on the outside but it was not done on the inside because the roll was able to be pulled the dough was able to be stretched. During an interview on 8/2/24 at 12:16 P.M., Dietary [NAME] (DC) A said the dinner rolls were not completely cooked. During an interview on 8/2/24 at 12;24 P.M., the Dietary Director said he/she noticed the rolls were not cooked because he/she was not working in the kitchen on that day.

Based on observation, record review and interview, the facility failed to ensure the pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) chicken tenders and french fries were pureed to smooth consistency. This practice potentially affected 5 residents with pureed diets. The facility census was 46 residents. 1. Review of the pureed recipe for chicken tenders dated 9/5/17, showed: -Remove desired number of servings and add nutritive liquid (milk, broth, etc.). -Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. The recipe did not state how much liquid or thickener to add per the number of servings that needed to be pureed. Observation on 7/29/24 at 10:59 A.M., showed: - Dietary [NAME] (DC) A pureed the chicken, by adding an unmeasured amount of chicken base, and added water to the food processing container which contained the chicken and the base and pureed the ingredients together. - DC A did not have a recipe book opened. - DC A did not taste the pureed chicken tenders and placed the pureed product in a metal pan and placed it into oven to maintain food warmth. During a taste test on 7/29/24 at 11:54 A.M., the texture of the pureed chicken was grainy (contained small bits). 2. Observation on 7/29/24 at 11:16 A.M., showed DC A pureed french fries in the food processor, DC A added cold milk to the fries in the food with no recipe book used at that time. DC A did not taste the pureed fries after the fries were finished being processed. During a taste test on 7/29/24 at 11:57 A.M., showed the pureed fries with a chunky texture. During an interview on 7/29/24 at 12:01 P.M., DC A said he/she should have pureed the fries a little longer to make it or smooth. During an interview on 7/29/24 at 12:08 P.M., the Dietary Director said: - He/she did not have printed recipes for pureed fries. - There was a little bit of chunk in the pureed fries. - He/she did not know why they did not have a recipe for the pureed fries. - He/she did not discuss the recipes with the Consultant Registered Dietitian (RD) - He/she expected facility staff to use the recipes if they were available for use. During an interview on 7/29/24 at 12:43 P.M., DC A said he/she did dnot use the recipe book to make the pureed items. and the Dietary Director could taste some of the pureed items.

Based on observation, interview, and record review, the facility failed to ensure the facility's policy regarding the proper storage was followed, when food was stored in the resident use refrigerator. This practice potentially affected at least 4 residents who had food stored in the resident use refrigerator. The facility census was 46 residents. Review of the policy entitled Foods Brought by Family/Visitors dated 10/17, showed: -Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format he/she can understand. -Food brought by family/visitors that is left with the resident to consume later, will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. -Non perishable foods will be stored in resealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. -Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator. The container will be labeled with the resident's name, the item and the use by date. -Nursing staff will discard perishable foods on or before the use by date. -The nursing staff and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due expiration dates.) 1. Observation on 8/1/24 from 11:56 A.M. to 12:11 P.M., showed: -A sign, which stated the following, on the resident use refrigerator: --Resident's food only, Must have name and any prepared food needed to be dated, (expires and discard after 3 days). --Any food that was not a resident's food would be discarded daily. --Please put a name and date all food items; If not named and dated, it will be thrown away. -The following food items were in the resident use refrigerator: --A container with food that was later identified as food belonging to a staff member. --A container of French Onion Dip which was without a resident's name or a date that it was received. --Another container of French Onion Dip with an expiration date of 7/7/24. --A container of cottage cheese which expired 6/12/24. --A package of hot dogs which was received on 6/17/24, a without a resident's name on it. --A container of creamy mayo which expired on 7/5/23, without a name or the date that the package was received. --A package of humus (a dip, spread, or savory dish made from cooked, mashed chickpeas blended with tahini, lemon juice, and garlic) without a name of a resident or a date that it was received. --A package of boiled eggs without a name of a resident or a date that it was received. --A package of peanut butter without a name of a resident or a date that it was received. --Food in a black foam container without a name of a resident or a date that it was received. --Food in an aluminum container without a name of a resident or a date that it was received. --The presence of applesauce and yogurt containers, and several bottles of nutritional supplements without a name of resident or a date those items were received. During an interview on 8/1/24 at 12:13 P.M., the Director of Nursing (DON) said: -The supplements were for general use by all residents. -The applesauce and yogurt were used for the medication administration. -The fridge should be cleaned weekly. -He/she expected staff to place the date the item was received, and the name of the resident the item was for. During an interview on 8/1/24 at 12:16 P.M., the Dietary Director said: -Staff food should be placed in the staff refrigerator located in a different area of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pneumococcal pneumonia vaccines (a vaccine to protect against pneumococcal disease caused by the bacteria Streptococcus pneumoniae) were offered, administered, or documented for three sampled residents (Residents #10, #141, #241) out of five residents sampled for vaccination provision. The facility census was 46 residents. Review of an undated facility policy titled Pneumococcal Vaccines showed: -All residents would be offered pneumococcal vaccines to aid in preventing pneumococcal infections. -Upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine and, if eligible, receive the vaccine within 30 days of admission. -Assessments of the residents' vaccination status would occur within five days of admission. -Any vaccine refusals or administrations would be documented in the residents' medical record. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, revised 2/9/24, showed the CDC recommended pneumococcal vaccination for adults [AGE] years old and older as well as for adults between 19 and [AGE] years old with certain medical conditions or risk factors including chronic (including end stage) renal disease and chronic liver disease, and any adult over 65 who received a single dose of the PPSV23 vaccine should have a dose of either PCV20 or PCV15 after one year of administration. 1. Review of Resident #10's face sheet showed: -The resident was older than [AGE] years old. -The resident had an admission date of 10/28/22. Review of the resident's immunization report on 8/1/24 showed: -No evidence of pneumococcal vaccination administration dates. -The report lacked documentation of education, consent or refusal and administration of the pneumococcal vaccine for which the resident was recommended per the CDC due to chronic renal disease. 2. Review of Resident #141's face sheet showed: -The resident was younger than [AGE] years old. -The resident had a diagnosis of chronic hepatitis C (a chronic liver disease). -The resident had an admission date of 6/28/24. Review of the resident's immunization report showed: -No evidence of pneumococcal vaccination administration dates. -The report lacked documentation of education, consent or refusal and administration of the pneumococcal vaccine for which the resident was recommended per the CDC due to chronic liver disease. 3. Review of Resident #241's face sheet showed: -The resident was older than [AGE] years old. -The resident had a diagnosis of chronic renal disease. -The resident had an admission date of 6/20/2024. Review of the resident's immunization report on 8/1/24 showed: -Resident #241 received a pneumococcal vaccine (PPSV 23) on 6/1/22. -The report lacked documentation of education, consent or refusal and administration of the PCV20 or PCV15 pneumococcal vaccine for which the resident was recommended per the CDC due to diagnosis of chronic renal disease and age. 4. During an interview on 8/01/24 at 10:00 A.M., the Infection Preventionist (IP) said: -Residents should have been screened for pneumococcal immunizations on admission. -All administered immunizations should have been documented in the resident medical record. -Any refusals should have been signed and documented in the resident's medical record. -Residents that were recommended pneumococcal vaccines should have been offered the vaccine by the facility. -He/She was responsible for ensuring resident's vaccine status along with refusals were documented and they were offered recommended vaccines. During an interview on 8/2/24 at 11:58 A.M., the Director of Nursing (DON) said: -Residents should have been screened for pneumococcal immunizations on admission. -All administered immunizations should have been documented in the resident medical record. -Any refusals should have been signed and documented in the resident's medical record. -Residents that were recommended pneumococcal vaccines should have been offered the vaccine by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the kitchen area and resident rooms [ROOM NUMBERS], free of ants. This practice affected the kitchen and affected 4 residents who resided in those rooms. The facility census was 46 residents. Review of the policy entitled Foods Brought by Family/Visitors dated 10/17, showed: -Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Non perishable foods will be stored in resalable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. 1. Observations on 7/29/24 at 11:06 A.M., showed the presence of ants at the 3-compartment sink location. During an interview on 7/29/24 at 11:49 A.M., the Maintenance Director said he/she was unaware of ants in the kitchen before today. 2. Observation on 7/30/24 at 11:12 A.M., showed the presence of ants in resident room [ROOM NUMBER]. Observation on 7/30/24 at 11:33 A.M., showed the presence of ants in resident room [ROOM NUMBER] behind the nightstand and the presence of snacks which were not in containers. During an interview on 7/30/24 at 11:40 A.M. the Social Service Designee said he/she needed to speak with the resident in resident room [ROOM NUMBER], about placing his/her snacks in containers to keep the ants out. During an interview on 8/1/24 at 1:07 P.M., the Maintenance Director said ants have not been an ongoing issue within the rooms and no one had brought it to his/her attention before this week. During an interview on 8/1/24 at 2:48 P.M., Housekeeper A said he/she saw ants in one of the resident rooms approximately a week ago. He/She brought the ants to the attention of the Maintenance Director and the Maintenance Director gave him/her spray for the ants.

Based on observation and interview, the facility failed to remove a buildup of dust and food debris from under the reach-in refrigerator; failed to label items that were not easily identifiable in the containers those items were in; failed to ensure employees washed hands after handling non-food items then going back to handling food items; failed to prevent the buildup of debris in the window unit air conditioner; failed to check the temperature of food items before placing those items on the steam table; failed to ensure the pot holder was free from damage that could allow fibers to contaminate food; failed to ensure dietary employees handled containers used or serving residents, without contaminating those containers; failed to use a three-step (wash, rinse and sanitize) process to wash the food processor container between foods; failed to store a box of individual packets of butter according to the storage instructions on the box; failed to maintain the lower part of the toaster free from a heavy buildup of crumbs. This practice potentially affected all residents. The facility census was 46 residents. 1. Observation on 7/29/24 from 7:26 A.M. through 8:36 A.M. during the breakfast meal preparation showed: - The presence of dust, food debris, and an old container of yogurt under the reach-in refrigerator - Dietary [NAME] (DC) A handled his/her phone and did not wash his/her hands before going back to the steam table to serve food on a plate. - The presence of grime and dust within the air conditioning unit. - The absence of a label on a shaker with a white granulated substance in the shaker. - DC A pulled broke a waffle a part with his/her ungloved hands and placed the waffle pieces into a plate. - DC A rinsed out the food processor instead of washing the food processor through a 3-step process, before processing the waffles after he/she processed another food. - DC A handled waffles with his/her bare hands from the toaster. 2. Observation on 7/29/24 from 11:05 A.M. through 1:10 P.M. during the lunch meal preparation showed: - Debris and dust in the window air conditioner unit. - A box of personal sized margarine containers that were not refrigerated with many of the margarine containers which lost their covers and the box which stated refrigerate. - DC A placed French fries on steam table did not check the temperature. - DC A used the damaged potholder to take the pan of pureed chicken out of oven and DC A did not check temperature, when he/she placed the pureed chicken on steam table. - DC A handled the dessert cups for the applesauce by using his/her fingers inside of the dessert cups while he/she placed portions of applesauce into the cups. - DC A did not wash the cover of the food processor container that was used previously to puree (to blend, chop, mash or strain a food item until that food turns into a soft and smooth consistency) the chicken, to puree the vegetables. During an interview on 7/29/24, DC A said: - At 11:28 A.M., he/she did not know how long the pot holder had been damaged. - At 12:40 A.M., he/she had been trained to wear gloves and he/she should have worn gloves during the time he/she handled the waffles. - At 12:42 A.M. he/she should have held the dessert cups on the bottom. - At 1:03 P.M., he/she had not cleaned the lower part of the toaster after he/she saw the heavy buildup of bread crumbs at the bottom of the toaster. During an interview on 7/29/24, the Dietary Director (DD) said: - At 12:14 P.M., the small butter condiments should have been refrigerated after he/she saw the box with a lot of missing covers from those containers. - At 12:17 P.M., the dietary employees moved the reach-in refrigerators out, every week, but they should be sweeping under those refrigerators nightly. - At 12:18 P.M., he/she expected the dietary staff to check the temperatures of food items when those food items were placed on the steam table. - At 12:20 P.M., the salt containers should be labeled. - At 12:26 P.M., he/she expected employees to use gloves, when they touched food directly. During an interview on 7/29/24 at 12:19 P.M., Dietary Aide (DA) A said he/she did not know the margarine containers needed to be refrigerated. During an interview on 7/29/24 at 12:52 P.M., the Maintenance Director said the dietary staff had not notified him/her about the grime in the air conditioner unit.

5. Review of Section 19 CSR 20-20.100 (Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities) showed facilities were to screen their residents and staff for tuberculosis using a two-step Mantoux skin test (a test administered under a resident's skin, evaluated within 48 to 72 hours, and repeated one to three weeks afterward). Review of an undated facility policy titled Screening Residents for Tuberculosis showed: -All residents would be screened for tuberculosis. -New admissions would be screened for signs and symptoms of tuberculosis per state and federal regulations. -The admission nurse would be responsible for screening new residents for signs and symptoms of tuberculosis. -Any residents who had been potentially exposed to TB or were at increased risk of TB infection would have been referred for further screening. -Any residents screening positive would be further isolated from other residents and staff. NOTE: The policy lacked information regarding administration of the two step TB skin test for newly admitted residents for screening. 6. Review of Resident #141's Treatment Administration Record (TAR) dated July 2024 showed: -One administration of the TB skin test on 7/1/24 with no documentation of the evaluation of the skin test. -There was no documentation of a second step being completed. Review of the resident's medical record showed no evidence of a two-step TB skin test administration. 7. Review of Resident #241's TAR dated June 2024 showed: -One administration of the TB skin test on 6/30/24 with no documentation of the evaluation of the skin test. -There was no documentation of a second step being completed. Review of the resident's medical record showed no evidence of a two-step TB skin test administration. 8. During an interview on 8/1/24 at 10:04 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) Coordinator said: -He/She was responsible for keeping track of the residents' TB screenings. -Newly admitted residents should have received a two-step TB skin test administered one to three weeks apart. -He/She was responsible for inputting physician orders into the residents' medical record for the two-step skin test. -The nurses who worked the floor on any given day would be responsible for administering the skin test per the physician orders. -If a resident were to miss the window for the second step of the test, the facility staff would have to begin the process from step one. During an interview on 8/2/24 at 11:58 A.M., the Director of Nursing (DON) said: -He/She expected every new admission to have a two-step TB skin test completed on admission, with the second step being done one to three weeks after the first. -He/She expected any resident with a missed second step test to have been restarted in the testing cycle. -The skin test process should have been ensured by audits of residents' medical records. -The MDS Coordinator was the facility infection preventionist and was responsible for ensuring residents had the appropriate orders and received their skin test within the appropriate time frame. Based on observation, interview, and record review, the facility failed to perform adequate hand hygiene during medication pass for three supplemental residents (Resident's #11, #27, and #10) out of nine supplemental residents and failed to create and implement a Tubercolosis (TB, a potentially serious infectious bacterial lung disease) program when staff failed to complete two-step Mantoux skin tests (a test to show potential TB infection) for two sampled residents (Resident #141 and #241). The facility census was 46 residents. Review of the facility's policy titled Handwashing/Hand Hygiene dated August 2019 showed: -The facility considered hand hygiene the primary means to prevent the spread of infections. -All personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -All personnel should follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Hands should be washed with soap (antimicrobial or non-antimicrobial) and water when hands were visibly soiled. -Use an alcohol-based hand rub or alternatively, soap (antimicrobial or anti-microbial) and water for the following situations --Before and after direct contact with residents. --Before preparing or handling medications. --After contact with a resident's intact skin. --After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. --After removing gloves. --Before or after eating or handling food. -Hand Hygiene is the final step after removing and disposing of personal protective equipment (PPE). -The use of gloves did not replace hand washing/hand hygiene. Review of the facility's policy titled Administering Medications dated April 2019 showed Staff were to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 1. Review of Resident #11's face sheet showed he/she admitted to the facility with the following diagnoses: -Permanent Atrial Fibrillation (an irregular heartbeat). -Dysphagia (difficulty swallowing). -Low Back Pain. -Age-Related Physical Debility. Review of the resident's Physician Order Sheet (POS) dated July 2024 showed: -An order for a regular diet with mechanical soft (any foods that could be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or food processor) texture, regular/thin consistency (no additives and considered non-restrictive), crush pills. -Diclofenac Sodium External Gel 1% (Voltaren Gel- used to relieve pain from arthritis in certain joints such as those of the knees, ankles, feet, elbows, wrists, and hands), apply to both shoulders topically three times a day for pain, two grams (gm) each shoulder. -Lidocaine Pain Relief External Patch (a local anesthetic that numbs the nerves in a specific area of your body) 4%, apply to the lower back topically one time a day related to low back pain. Observation of the resident's medication administration on 7/30/24 at 9:52 A.M. completed by Certified Medication Technician (CMT) A showed: -He/She sanitized his/her hands and dispensed the resident's medication into a medication cup. -He/She then put on gloves and placed the medication into a pouch in order to crush the medication. -After crushing the medications, he/she kept his/her gloves on and placed the medication back into the medication cup and mixed the medication in some yogurt. -He/She then left the medication cart and walked down the hall and into the resident's room with the same gloves on. -With the same gloves on, he/she assisted the resident when giving him/her the medications and got some of the yogurt on his/her left glove. -He/She then threw the medication cup in the trash can and opened the Lidocaine Pain Relief External Patch with the same gloved hands. -He/She applied the Lidocaine Pain Relief External Patch to the resident's lower back and went on to use the Voltaren Gel on both of the resident's shoulders with the same gloved hands. -He/She then exited the resident's room and walked back to the medication cart. -He/She then put the Voltaren Gel back into the assigned package and removed his/her gloves. During an interview on 7/30/24 at 10:05 A.M. CMT A said: -He/She would not have done anything different during the medication pass. -He/She was questioning whether or not his/her glove usage had been appropriate and stated that was how he/she had always done the medication pass. -He/She had not realized that yogurt had gotten on to his/her left glove. -If he/she had realized it during the medication pass, he/she would have removed his/her gloves. -If he/she had only been administering one route of medication to a resident, then he/she would sanitize his/her hands before entering and exiting the resident room/area. 2. Review of Resident #27's face sheet showed he/she admitted to the facility with the diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's POS dated July 2024 showed an order for Accu-Chek's (a test that measures glucose in whole blood) before meals and at night daily. Observation on 7/31/24 at 12:11 P.M. of the resident's Accu-Chek showed performed by Licensed Practical Nurse (LPN) B showed: -He/She gathered the supplies needed for the check, sanitized his/her hands, and took the resident to the shower room. -He/She did not sanitize his/her hands upon entry to the shower room. -He/She placed the resident in the center of the room and realized he/she forgot the cotton balls needed for the test. -He/She exited the shower room without sanitizing his/her hands. -After retrieving the cotton balls, he/she re-entered the shower room without sanitizing his/her hands. -He/She donned gloves and performed the Accu-Chek. -After completion of the test he/she removed his/her gloves and took the resident back into the dining room. During an interview on 7/31/24 at 12:32 P.M. LPN B said: -He/She would have sanitized his/her hands more often during the process. -He/She should have sanitized his/her hands before and after donning/doffing gloves. -He/She should have sanitized his/her hands upon entrance and exit of the shower room. 3. Review of Resident #10's face sheet showed he/she admitted to the facility with the following diagnoses: -Heart Failure (a weakness of the heart that leads to a build-up of fluid in the lungs and surrounding tissues). -Hypertension (high blood pressure). -Chronic Obstructive Pulmonary Disorder (COPD- a disease process that decreases the ability of the lungs to perform ventilation). Review of the resident's POS dated July 2024 showed: -Spot check oxygen saturation each shift to assess need for Pro Re Nata (PRN- as needed) oxygen. -Ketoconazole Cream 2% (when in topical form, it can treat scaly areas on the skin or scalp), apply to face topically two times a day for darkening of the skin, apply to dark spots on face. Observation on 8/1/24 at 9:25 A.M. of the resident's medication administration completed by CMT A showed: -He/She grabbed the pulse oximeter (a non-invasive method for monitoring blood oxygen saturation) and entered the resident's room without sanitizing his/her hands. -He/She then exited the resident's room without sanitizing his/her hands. -After dispensing the resident's medication, he/she re-entered the resident's room and donned gloves without sanitizing his/her hands. -After administering the medication to the resident, he/she removed his/her gloves and donned new gloves without sanitizing or washing his/her hands. -He/She then applied the Ketoconazole Cream 2% to the resident's face. During an interview on 8/1/24 at 9:35 A.M. CMT A said he/she would not have done anything differently during the resident's medication administration. 4. During an interview on 8/1/24 at 11:33 A.M. CMT B said: -During medication administration hand hygiene should be completed before and after each resident and washed after every three residents. -Hand hygiene should be performed before and after gloves are worn. -Hand hygiene should also be performed when entering and exiting resident areas including the shower room. -Gloves were not a substitution for hand hygiene. -Gloves were not to be worn in the hallway or into a resident's room. -If his/her gloves were to get soiled during a task, then he/she would remove the gloves, sanitize/wash his/her hands, and put on new gloves. -Resident #11's medication administration was nor performed correctly. -The staff person should have removed his/her gloves before leaving the medication cart. -The staff person needed to remove his/her gloves and sanitize between each route of medication during Resident #11's medication administration. During an interview on 8/1/24 at 12:01 P.M. LPN B said: -Hand hygiene needed to be completed before and after glove usage. -All medications were to be administered with gloves on. -Gloves were not a substitution for hand hygiene. -The staff person had not performed appropriate hand hygiene during Resident #11's or Resident #10's medication administration. -The staff person needed to remove his/her gloves and perform hand hygiene between each route of medication during Resident #11's medication administration. -Gloves were not to be worn outside of resident rooms. During an interview on 8/1/24 at 1:07 P.M. The Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said: -Hand hygiene should be performed before dispensing medications and in between each resident during medication administration. -Hand hygiene should be performed upon entry and when exiting resident rooms/areas. -Hand hygiene should be performed before and after glove usage. -Gloves were not a substitution for hand hygiene. -The CMT had not performed correct hand hygiene during Resident #11's and Resident #10's medication administrations. -The CMT should have removed his/her gloves and sanitized between his/her hands between each route of medication during Resident #11's medication administration. -Gloves needed to be removed when soiled. During an interview on 8/2/24 at 11:58 A.M. the Director of Nursing (DON) said: -During medication administration he/she expected the staff to perform hand hygiene between each resident, upon entering and exiting resident rooms, and between vital sign checks and the dispensing of the medications. -He/She expected staff to perform hand hygiene before and after glove usage. -He/She expected staff to remove their gloves and perform hand hygiene if gloves were to be soiled during a task. -Gloves were not a substitution for hand hygiene. -CMT A had not performed hand hygiene appropriately during Resident #11's and Resident #10's medication administration. -He/She would have expected the CMT to remove his/her gloves and perform hand hygiene between each route of administration during Resident #11's medication administration. -LPN B had not performed appropriate hand hygiene during Resident #27's Accu-Chek. -He/She would have expected him/her to perform hand hygiene when entering and exiting the shower room. -Gloves were not to be worn when going in and out of resident rooms.

Based on interview and record review, the facility failed to obtain a signature from (or maintain a paper receipt) for one discharged sampled resident (Resident #90) when he/she withdrew money at the time of his/her discharge and to prevent the existence of a negative balance for one sampled resident (Resident #31) for 41 days. This practice affected two residents out of six residents selected for the resident fund review. The facility census was 41 residents. 1. Record review of Resident #90's Face Sheet showed he/she was discharged to another facility on 7/20/22 with his/her return not anticipated. Record review of the Resident's Trust Fund Statement dated 7/1/22 through 9/30/22 showed a check was disbursed to the resident on 7/19/222 for $65.02. During an interview on 1/10/23 at 10:23 A.M., the Business Office Manager (BOM) said he/she: -Made a money order for that resident, but he/she did not have record for the money order. -Did not have a signature on any papers that the resident signed when he/she withdrew the $65.02. 2. Record review of Resident #31's trust transaction history dated 11/1/22 through 12/31/22 showed: -On 11/29/22, the resident started off with $0.00, in his/her account. -On 11/29/22 the resident had a negative balance of $50.00 -On 11/30/22, the resident had a balance of $50.00 but a withdrawal of $75.00 was made on 11/30/22, which left a balance of negative $25.00 -Another withdrawal was made on 11/30/22 for $50.00, which left a balance of negative $75.00. -On 12/31/22, the resident had a balance of negative $50.00 and a withdrawal of $75.00 was made which left a negative balance of $125.00, a deposit of $75.00 was made which left a balance of negative $50.00 During an interview on 1/10/23 at 11:17 A.M., the BOM said he/she did not know the resident had $0.00 in his/her account on 11/29/22, when he/she withdrew the $50.00 for the resident. During an interview on 1/13/23 at 11:36 A.M., the BOM said he/she: -Was not sure if the resident's account was actually negative on 11/29/22. -Tried to figure out how he/she caused the negative balance for the resident; in the new system, one has to place the transactions in a batch. -Believed it was a mistake on his/her part which caused the account to be negative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two severely cognitively impaired residents (Resident #26 and #34) from physical and sexual abuse, when Resident #34 hit Resident #26 on or about 12/14/22 causing pain and a raised area on his/her head, and to assess severely cognitively impaired residents for the capacity and ability to consent to consensual sexual expression, when Resident #34 was found kissing and fondling Resident #26 on 10/31/22 and when Resident #34 was found unclothed in Resident #26's bed attempting to have sexual intercourse on 1/6/23. The facility census was 41 residents. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on April 2021 showed: -Residents have the right to be free from abuse, neglect, and exploitation. This includes but is not limited to freedom from verbal, mental, sexual or physical abuse. -Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. -Identify and investigate any allegations within time frames required by federal requirements. -Protect resident from any further harm during investigation. -Establish and implement a quality assurance plan review and analysis of any reports or allegation, findings of abuse or neglect. Record review of the facility's undated Resident Self Determination, Capacity and Consent in Sexual Expression policy showed: -Each resident has the right to sexual expression such as but not limited to: hand holding, flirting or teasing, hugs and or kiss, signs of companionship or romantic affection and intercourse. -Consensual sexual expression with another individual requires consent. The resident must have the mental capacity to consent to sexual expression. Capacity is the ability to understand the nature and effects of one's act in a specific moment in time. To determine capacity related to consent the facility will assess the resident: --The resident was able to exhibit an understanding appreciation for the type of sexual expression they wish to engage in. --The resident was able to realize and rationalize the risk and benefits of engaging in sexual expression. --Inform the resident on how to report sexual abuse and their right to refuse sexual expression at any time and the right to voluntary sexual expression without coercion. -The resident must have mental capacity to consent to sexual expression. Capacity is the ability to understand the nature and effects of one's act in a specific moment in time. To determine capacity related to consent the facility will assess the resident. -Capacity to consent to sexual expression will be monitored and re-evaluated over-time as needed on the individual resident's physical, mental and psychosocial needs. -The facility determining capacity for consent to sexual expression should not be determined by a single individual. --Assessing the resident capacity and ability to consent for sexual expression. --The interdisciplinary team (IDT) and/or physician to determine the resident's capacity, benefits and potential for harm related to sexual expression. --Consulting the resident family member or guardian to assist with determining capacity and consent relate to sexual expression. -The facility will determine appropriate verses inappropriate sexual expression include: --Any sexual expression involving a resident that has been deemed unable to consent or lacks the capacity to consent would be in appropriate sexual expression. Any expression that was involuntary, non-consensual or coerced is inappropriate sexual expression. The facility will consult the resident physician in the event that a resident requested to engage in sexual expression by exhibiting health related barriers. -The facility will document in all involved parties health record, how capacity was determined, consent amongst all parties involved was verbalized and understood and that resident rights and sexual abuse was discussed. -The facility will educate and support the resident rights to sexual expression by educating family, legal representative if resident has cognitive impairment and staff on resident rights, protecting the resident from sexual abuse and reporting to management, safety and risk to include, but not limited to sexually transmitted infection injury or falls and Identify hyper-sexuality (a human's need to express intimacy but, describes a person's inability to control their sexual behavior), sexual disinhibition (is inappropriate sexual behavior, but persons with dementia may not know how to appropriately meet their needs for closeness and intimacy) and other sexually related physical and cognitive issues resident may have an effect on sexual expression. 1. Record review of Resident #26's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses of: -Stroke (mild). -Benign Brain Tumor. -He/she had a legal guardian. Record review of Resident #26's care plan initiated on 11/3/22 showed: -Had a history of brain tumor causing impulsive behaviors. -Resident #26 had a sexual behavior issue on 10/31/22. -He/she will have fewer episodes of sexual behaviors by review date. -The resident's interventions included: --The facility staff were to praise any indication of Resident #26's progress or improvement in the sexual behaviors and was revised on 11/3/22. --Facility staff were to provide a program of activities that was of interest and accommodates the resident's status and was revised on 11/3/22. --The facility staff were to discuss inappropriate behaviors. Explain and reinforce to the resident why behavior was inappropriate and/or unacceptable revised on 11/3/22. --The facility staff were to minimize potential for Resident #26's sexual behaviors by offering tasks that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22. -Resident #26 facility care plan had no indication or documentation with details of how the resident was sexually acting out. Record review of Resident #26's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/2/22, showed: -He/she was severely cognitively impaired and his/her Brief Interview Mental Status (BIMS) score was of 6 out of 15. -Able to understand others and was able to make his/her needs known. -Required limited assistance of one staff member with personal cares and transfers. -He/she no behavior indicated affecting other residents. Record review of Resident #26's facility care plan revised on 1/11/23 showed: -Had history of benign (non-cancerous) brain tumor (is a mass of cells that grows relatively slowly in the brain) causing impulsive behaviors. -Had video monitoring camera in room to alert staff of the resident self-transfers, care plan revised with initiated of the intervention on 1/6/23. -Resident #26's had a sexual behavior issue on 1/6/23. -He/she will have fewer episodes of sexual behaviors by review dated 1/6/23. -The resident's interventions included: --The facility staff were to minimize potential for Resident #26's sexual behaviors by offering tasks that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22 and revised on 1/6/23 facility staff were to redirect the resident as needed. -Resident #26's facility care plan had no indication or documentation with details of how the resident was sexually acting out. Record review of Resident #34's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses of: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -He/she had a guardian. Record review of Resident #34's facility care plan dated 11/2/22 showed the resident: -Had a history of dementia and impaired thought process related to diagnosis of dementia and had impaired decision making. -Had displayed inappropriate sexual behaviors with staff and peers initiated on 11/2/22. -Goal was to have fewer episodes of sexual behaviors by the next review date. -Intervention revised on 11/2/22 included: --Administer medications as ordered. Monitor/document for side effects and effectiveness. --If reasonable, discuss Resident #34's behavior. Facility staff were to explain and reinforce why the behavior was inappropriate and/or unacceptable for the resident and his/her family. --Facility staff were to intervene as necessary to protect the rights and safety of the resident and others residents, the facility staff were to approach and speak in a calm manner to the resident. Facility staff were try to divert the attention of the resident and remove the resident from situation and take the resident to alternate location as needed. Record review of Resident #34's Physician Visit Summary Note dated 12/13/22 at 11:48 A.M., showed the resident: -Had a diagnosis of sexual inappropriateness, dementia and hyper-sexuality. -Continue to have difficulties with sexual inappropriateness. -Medication had been initiated to decrease the libido (is the part of their personality that is considered to cause their emotional, especially sexual, desires) and sex drive. -He/she seems to be inappropriate with male/female resident at the facility. -The plan was medication adjustment, monitor very closely and family members have to be updated and aware of the resident sexual behaviors. Nursing staff will notify the physician of any issues or problems occur. Record review of Resident #34's Care Plan dated 12/14/22 showed: -The resident had become and was at risk for further physically aggression of hitting another resident (Resident #26) related to the resident's anger dementia and poor impulse control. -Intervention include administer dementia medication as ordered (family does not agree to antipsychotic mediation). --When Resident #34 becomes agitated the facility staff was to intervene before agitation escalates, was to guide the resident away for source of distress, engage calmly in conversation. If the resident response was aggressive, staff should walk calmly away and reapproach later. --Resident #34 enjoys coloring, offer color pages as distraction. Record review of Resident #34's Quarterly MDS dated [DATE], showed the resident: -Had diagnosis of dementia. -Had severe cognitive impairment and he/she had a BIMS of 3 out 15. -Was able to understand others and able to make his/her needs known. -Was independent with ambulation and transfers. -No behavior indicated affecting other resident. Record review of Resident #34's Care Plan revised on 1/9/23 showed the resident: -Had displayed inappropriate sexual behaviors on 1/6/23. -The resident's care plan intervention were initiated on 1/6/23 and revised on 1/9/23 and the new interventions were: --Minimize potential for Resident #34's inappropriate sexual behaviors by offering tasks which divert attention such as coloring, group activities. --Provide a program of activities that is of interest and accommodates the resident's status. -Spoke with family, (they) state understanding. Facility staff were to continue to attempt to redirect the resident. Facility staff were to honor the resident's wishes for sexual relationship and provide privacy when needed. 2. Record review of Resident #26's nursing note dated 10/31/22 at 1:35 P.M., showed: -Resident #26's guardian and Public Administrator (PA - court appointed guardian) was called and made aware of Resident #26 attempting to be sexually involved with another resident (Resident #34). -It was explained that he/she had been seen kissing on Resident #34, and Resident #34's had his/her hands in inappropriate places on Resident #26's body. -Both residents have been seen attempting to go to each other's rooms with each other and they have been redirected each time with all these behaviors. -PA did not have any further comments outside of his/her appreciation for them watching and keeping them safe. -The resident's physician was aware as well, had no new orders at that time. Record review of Resident #26's medical record showed: -No documentation related to the resident to resident inappropriate sexual contact had been fully investigated by the facility staff on 10/31/22. -Did not have a comprehensive assessment documented to evaluate his/her capacity to consent for consensual sexual expression. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident inappropriate sexual contact had been fully investigated by the facility staff on 10/31/22. -Did not have a comprehensive assessment documented to evaluate his/her capacity to consent for consensual sexual expression. 3. Record review of Resident #34's Health Status Note date 12/14/22 at 2:34 A.M. showed: -Resident #34 was seen being very intimate and physically close to another resident (Resident #26) at the dining area table. -Resident #26 then propelled himself/herself to the nursing station. -Resident #26 was talking with the nurse when all of a sudden Resident #34 took a baggie full of change and proceeded to hit Resident #26 over the head. -Resident #34 cursed Resident #26 out. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34 family member was notified of the incident. Record review of Resident #26's Health Status Note date 12/14/22 at 2:40 A.M. showed: -Resident #26 was at table kissing another resident (Resident #34). -The nurse separated the residents. Informed them they could not be kissing in dining room. -Resident #26 followed the nurse to the nursing station and was talking to the nurse. Resident #34 walked over to Resident #26 and hit him/her over the head with a baggie of change. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34 then began to curse at Resident #26. -The nurse noticed a knot on top of Resident #26's head. Resident #26 noted to have pain and Tylenol (pain medication) was administered. Record review of Resident #34's Behavioral note dated 12/14/22 at 4:43 P.M. showed: -Resident #34 was seen being very intimate and physically close to another resident (Resident #26). -He/she had recently hit the other resident in the head (on the morning of 12/14/22) for what appeared to be jealousy of Resident #26, who was speaking to another resident. -Resident #34 seemed to not understand due to his/her baseline confusion. -Resident #34 was directed to sit at another table of the same gender and Resident #26 was to sit at a different same gender table. -Resident #34 first followed these instructions, but was soon again repeating these behaviors with the other resident, who was also confused, and he/she was seen following him/her around the dining hall and stepping in between him/her and any other resident he/she was near. -Anytime Resident #26 would speak to another resident, Resident #34's facial expression would turn to anger and he/she would stare that resident down angrily. -Once Resident #34 had begun those behaviors again with Resident #26 after being told to keep his/her distance, this nurse again explained to Resident #34 that he/she needs to not be around this other resident. -Resident #34 then became aggravated and began to raise his/her voice saying that's my boyfriend/girlfriend, you cannot keep me away and you can't have him/her. -This nurse then walked Resident #34 to his/her room to explain to him/her that he/she had recently hurt Resident #26, and the family and his/her physician requesting he/she stay separated from Resident #26. -This nurse called Resident #34's family member to reiterate the above. After the phone call, Resident #34 stated he/she understood why we are asking him/her to stay away from Resident #26 for now. -About 10 minutes later, Resident #34 was seen following Resident #26 back to his/her room and became frustrated again when redirected and explained could not go to other resident's room. -This nurse offered to call Resident #34's family member again to explain. -Resident #34 began asking if he/she was a prisoner here because he/she can't do anything. -This nurse said he/she is only being asked to not be around one resident, and that he/she was free to sit wherever else he/she would like. -Resident #34 then sat down and ate his/her dinner, only after Resident #26 went back into his/her room and was out of sight of Resident #34. During an interview on 1/20/23 at 9:59 A.M., Administrator said: -Resident #34 had a documented behavioral incident on 12/14/22. -The facility was in the middle of a COVID (a new disease caused by a novel (new) coronavirus) outbreak and administration staff did not have time to complete an investigation into that incident. -Administration staff had reviewed the resident's behavioral and incident note from 12/14/22 and at the time of review it was out of the window to investigate or to report. -He/she may have internal documentation related to Resident #34's aggressive behavior on 12/14/22. 4. Record review of Resident #34's nursing incident note dated 1/6/2023 at 2:54 P.M. showed: -Resident #34 was found in Resident #26's room having sexual intercourse. One of the residents had accidentally pressed the call light which caused one of the Certified Nursing Assistants (CNA) to go answer the call light and CNA C found them engaging in sexual intercourse. The resident's family member and guardian had been notified. Record review of Resident #26's nursing incident note dated 1/6/23 at 2:56 P.M. showed he/she was found in his/her room with another resident (Resident #34) having sexual intercourse. One of the residents had accidentally pressed the call light causing CNA C to find Resident #26 and another resident (Resident #34) having sex. The resident's guardians were notified of the incident. Record review of Resident #26's medical record showed: -No documentation related to the resident to resident inappropriate sexual contact had been fully investigated by the facility staff on 1/6/22. -Did not have a comprehensive assessment documented to evaluate his/her capacity to consent for consensual sexual expression. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident inappropriate sexual contact had been fully investigated by the facility staff on 1/6/22. -Did not have a comprehensive assessment documented to evaluate his/her capacity to consent for consensual sexual expression. 5. During an interview on 1/11/23 at 10:48 A.M., Housekeeping A said: -He/she was aware of two residents who may be involved in touch and sexual contact. -He/she was informed to let nursing staff know if he/she found the residents together. -The facility staff are to ensure Resident #26 and Resident #34 do not go onto each other's hallways or bedrooms. -The facility staff were to redirect the residents from touching each other, such as holding hands. During interview on 1/11/23 at 10:59 A.M., the Facility Care Partner said: -He/she was instructed to ensure to monitor Resident #26 and Resident #34 to make sure they do not go into each other's resident room or hallway. During an interview on 1/11/23 at 10:55 AM, Administrator said: -Resident #34 had been in a relationship with Resident #26 for a while. -He/she felt the facility had followed facility policy guidelines to review and determine if either of the residents had capacity to consent to a consensual sexual relationship. -The Interdisciplinary Team (IDT, is a professionals plan, coordinate and deliver of resident's personalized health care), residents' physician, family member and/or guardians had been included in the discussion related to the residents sexual behavior and relationship. -Resident #34 had a history of exposing body parts to the Administrator and other staff members. -Resident #34's sexual behavior had been an issue for a while and that could have started around November 2022. -The facility had documentation of Resident #34's inappropriate sexual behaviors in his/her nursing notes. -Resident #34 had medication changes by his/her physician, but continued his/her ongoing sexual behavior. -The residents' families and Power of Attorney (POA) were aware of Resident #34 and Resident #26's continued relationship. -The resident's physician was aware of Resident #34 behavior. -The resident's families and/or guardians had agreed on how hard it was in discouraging the residents from having a relationship with each other. -Staff have not reported them as having sexual behavior toward other residents. -Resident #34 was the instigator in the two residents' relationship. -The facility has tried to keep Resident #34 and Resident #26 separate as much as possible and to ensure they stay on opposite units. -The sexual incident between Resident #34 and Resident #26 was on 1/6/23. The facility IDT had met regarding the sexual incident and the IDT was working on a plan to assess and ensure that both residents wanted to continue their relationship and assess the safety of the resident and assess if Resident #26 and Resident #34 had the capacity to consent to consensual relationship. -He/she was not aware if the facility had a formal Capacity to Consent assessment form to be complete related to the residents capability to consent to consensual sexual relationship. During interview on 1/11/23 at 2:46 P.M., Licensed Practical Nurse (LPN) C said: -Resident #26 and Resident #34 had been in the dining area for meals and then was separated and instructed by facility care staff to go to their own bedrooms and was directed to their bedrooms. -Resident #26 headed toward his/her room on a different hallway. -The facility staff had assumed both residents were in their own rooms. -During that time somehow Resident #34 made his/her way back to Resident #26's room. -While in Resident #26 room, one of the residents accidentally pressed the call light. -The facility staff were not aware Resident #34 was in Resident #26's room at that time. -CNA C knocked and entered Resident #26's bedroom. -CNA C reported Resident #34 had his/her legs up in the air while laying on Resident #26's bed. -Resident #26 had his/her pants down around his/her ankles and was in between Resident #34 legs. -He/She had been notified and went to Resident #26's room as the residents were getting dressed. -The sexual incident happened on Resident #26's bed, which nursing staff should have been able to see on the video monitor located at the nursing station. -At the time of the sexual incident, he/she was at the nursing station working at the computer entering physician orders. -He/she was not monitoring the camera in Resident #26's room at that time. -When he/she entered the resident's room, CNA C had already separated the residents and CNA C had instructed the residents to get dressed. -After the residents were dressed, CNA C and LPN C redirected Resident #34 go to the main dining area. -Facility staff then redirected Resident #34 to his/her own room. -He/She notified Resident #34's family member and Resident #26's guardian of sexual contact. -The residents' physician was made aware of the incident and had known about both residents past history of sexual behaviors toward each other. -He/She was unsure if he/she completed a detailed incident report related to resident sexual encounter. -He/she documented the sexual incident in both resident's nursing notes. -Resident #34 and Resident #26 had been seen flirting between each other. -The facility staff had been instructed to redirect Resident #26 and Resident #34 from their sexual behaviors and ensure to separate the residents as needed. -Resident #26's was a big flirt and he/she loved the attention of opposite gender. -Resident #34 had taken the flirty behavior too far at times to include trying to touch the resident or take Resident #26 back to his/her room. -Resident #34 was easily upset and could became verbally aggressive when Resident #26 would pay attention to other opposite gender residents. -Resident #34 had hit Resident#26 in past when he/she was not paying attention to Resident #34. -The hitting incident was documented in the resident nursing notes. -He/She was aware of another sexual behavioral incident between Resident #34 and Resident #26 in the past, but he/she was unsure of the date. -Resident #26 and Resident #34 care plan interventions were to redirect the residents and to avoid physical contact between the two resident and to discourage their relationship. During an interview on 1/11/23 at 1:06 P.M., CNA C said: -He/she had been scheduled to work the evening shift on 1/6/23 and came in earlier that day. -He/she noticed Resident #26's call light was on. -He/she knocked on Resident #26's door and called out the resident's name as he/she entered the room. -Upon entering Resident #26's room, he/she found Resident #34 laying on his/her back on Resident #26's bed. -Resident #34 had his/her pants around one ankle and with his/her legs spread apart and feet up in the air. -Resident #34 had his/her shirt on. -Resident #26 had his/her pants down and was in between Resident #34's legs and was leaning over Resident #34 as he/she was starting to have sexual intercourse with Resident #34. -He/she informed both residents that this was not appropriate behavior and both residents needed to get dress. -Another CNA was in the bathroom and heard what was going on and got the facility charge nurse. -Resident #26 had friendly flirty behavior toward other residents including Resident #34 and with staff. (CNA C did not give detail of what meant as flirty.) -Resident #34 had diagnosis of dementia and was confused at times. Resident #34 had thought he/she was in a relationship with Resident #26 as married couple at times. -He/she said on 1/6/23 was not first time Resident #26 and Resident #34 had sexual touching between each other. -He/she had been instructed the residents can sit by each other in main dining area, but not allowed to touch each other. CNAs and other facility staff were to try and redirect the residents and remove the resident from the situation. -Resident #26 had an approved video monitoring camera (non-recording monitor) that had been turned away from Resident #26's bed. During an interview on 1/11/23 at 12:45 P.M., CNA A said: -He/she was walking down the hallway on 1/6/23 when CNA C informed him/her of the sexual incident between Resident #34 and Resident #26. -He/she went to notify the charge nurse. During an Interview on 1/11/23 at 12:26 P.M., CNA B said: -The CNA's had been instructed try to ensure Resident #34 and Resident #26 don't have contact and to redirect the residents as needed. During an interview on 1/11/23 at 2:50 P.M., CNA B and Nursing Assistant (NA) A said: -CNAs would redirect Resident #34 if he/she was upset or close contact with Resident #26 by offering coloring book, looking out window or remove from area. -CNAs would explain to each resident that his/her sexual behaviors were was not appropriate behavior and why staff needed to separate them. -Resident # 26 requires reminders for what he/she needed to do or where he/she needed to be due to his/her short term memory. -Resident #26 was easily redirected or does not always pay attention to Resident #34 (has short attention span). During an interview 1/11/23 at 3:26 P.M., the Director of Nursing (DON) said: -Resident #26 and Resident #34, refer to themselves as the love birds, due to the relationship the residents want to have or think they are in. -At times Resident #26 and Resident #34 call each other as boyfriend/girlfriend and the residents like to play cards and hold hands. -He/she did not feel there was willful intent to harm or take advantage of either resident. -When facility staff would ask the residents each time if they wanted to be in a relationship or in a sexual relationship with each other, they would confirms yes at that time when asked. -The facility interventions did include trying to redirect the residents and provide alternative activity to best of the facility staff abilities. -Resident #26 and Resident #34 have sexual behavior care plans and not a detailed assessment for the ability to consent for a consensual sexual relationship. -Resident #26 and Resident #34 guardian/POA and family were made aware and would prefer the residents not be in a relationship, but know it was not always able to stop the relationship. -Resident #26's PA would prefer sexual relationship not to happen, but again may not be able to stop the relationship. -The facility would provide privacy, if Resident #26 and Resident #34 require to have a sexual relationship and ensure both resident were happy and agreeable to sexual expression. -Resident #26 was forgetful at times, but does tell staff that Resident #34 was his/her girlfriend/boyfriend. -1/6/23 was not the first time of Resident #26 and Resident #34 had physical sexual contact. He/she does not remember when the first sexual contact had happened. -The facility had not reported resident to resident sexual behaviors or interaction due to IDT felt was not abuse of sexual in nature. -The facility did not complete an incident or comprehensive investigation related to sexual contact and had agreed the residents sexual behaviors that both residents consented to at that time. -All was discussed during IDT meeting and discussed with families, POA and physician. During an interview on 1/11/23 at 4:05 P.M., Administrator said: -The facility would discuss the resident's capacity to consent during the IDT meeting with the resident's physician and family or guardians. -IDT meeting would document in the resident's nursing notes and should have included how the determination was made for the residents' relationship. -The facility IDT had determined the residents were able to make that decision at that time. -The facility administration had approached Resident #26 and Resident #34 about the sexual behavior and the residents know what they wanted to do at that time and they wanted to continue to having a personal relationship with each other. This was expressed at that time by the residents. During an interview on 1/12/23 at 9:36 A.M., CNA D: -Resident #26 had known behavior of be flirty with staff and resident. -Resident #26 and Resident #34 will engage each other for conversation. -Resident #26 and Resident #34 are able to make personal needs known. -CNAs complete a behavior monitoring at least daily on the CNA charting and nursing staff have a separate area they would document behaviors. During an interview on 1/12/23 at 10:21 A.M., CNA B said: -Resident #34 has behavior of wandering into Resident #26 room related sexual needs. -He/She w

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and/or report the findings of an investigation of resident to resident physical and sexual abuse between two severely cognitively impaired residents after one supplemental resident (Resident #34) hit another sampled resident (Resident #26) with a bag of coins leaving a knot on his/her head on 12/14/22, and after staff found Resident #34 kissing and touching Resident #26 in an inappropriate sexual manner on 10/31/22 and staff found Resident #26 unclothed from the waist down on top of Resident #34 unclothed from the waist down in bed attempting to have sexual intercourse on 1/6/23, out of 14 sampled residents and nine supplemental residents. The facility census was 41 residents. Record review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on April 2021 showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from verbal, mental, sexual or physical abuse. -Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. -Identify, investigate and report any allegations within time frames required by federal requirements. -Protect resident from any further harm during the investigation. -Establish and implement a quality assurance plan review and analysis of any reports or allegation, findings of abuse or neglect. 1. Record review of Resident #26's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses of: -Stroke (mild). -He/she had a legal guardian. Record review of Resident #26's care plan initiated on 11/3/22 showed: -Had history of brain tumor causing impulsive behaviors. -Resident #26 had a sexual behavior issue on 10/31/22. -He/she will have fewer episodes of sexual behaviors by review date. -The resident's intervention included: --The facility staff were to praise any indication of Resident#26's progress or improvement in the sexual behaviors revised on 11/3/22. --Facility staff were to provide a program of activities that was of interest and accommodates the resident's status revised on 11/3/22. --The facility staff were to discuss inappropriate behaviors. Explain and reinforce to the resident why behavior was inappropriate and/or unacceptable, revised on 11/3/22. --The facility staff were to minimize potential for Resident #26's sexual behaviors by offering task that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22. -Resident #26's facility care plan had no indication or documentation with details on how the resident was sexually acting out. -Did not indicate the resident had the capacity to consent to having consensual sexual relationship. Record review of Resident#26's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/2/22, showed: -He/she was severely cognitively impaired and his/her Brief Interview Mental Status (BIMS) score was of 6 out of 15. -Able to understand others and was able to make his/her needs known. -Required limited assistance of one staff member with personal cares and transfers. -He/she had no behavior indicated affecting other residents. Record review of Resident #26's care plan revised on 1/11/23 showed: -Had history of brain tumor causing impulsive behaviors. -Had video monitoring in room to alert staff to the resident self-transfers care plan revised with initiated of the intervention on 1/6/23. -Resident #26 had a sexual behavior issue on 1/6/23. -He/she will have fewer episodes of sexual behaviors by review, dated 1/6/23. -The resident's interventions included: --The facility staff were to minimize potential for Resident #26's sexual behaviors by offering task that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22 and added to redirect the resident as needed and was revised on 1/6/23. -Resident #26 facility care plan had no indication or documentation with details of how the resident was sexually acting out. Record review of Resident #34's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses of: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -He/she had a guardian. Record review of Resident #34's care plan dated 11/2/22 showed the resident: -Had a history of dementia and impaired thought process related to diagnosis of dementia and had impaired decision making. -Had displayed inappropriate sexual behaviors with staff and peers initiated on 11/2/22. -Goal was to have fewer episodes of sexual behaviors by the next review date. -Intervention revised on 11/2/22 included: --Administer medications as ordered. Monitor/document for side effects and effectiveness. --If reasonable, discuss Resident #34's behavior. Facility staff were to explain and reinforce why the behavior was inappropriate and/or unacceptable for the resident and his/her family. --Facility staff were to intervene as necessary to protect the rights and safety of the resident and others residents, the facility staff were to approach and speak in a calm manner to the resident. Facility staff were try to divert the attention of the resident and remove the resident from situation and take the resident to alternate location as needed. -Did not indicate the resident had the capacity to consent to having consensual sexual relationship. Record review of Resident #34's Physician Visit Summary Note dated 12/13/22 at 11:48 A.M., showed the resident: -Had diagnoses of sexual inappropriateness, dementia and hyper-sexuality. -Continue to have difficulties with sexual inappropriateness. -Medication had been initiated to decrease the libido (is the part of their personality that is considered to cause their emotional, especially sexual, desires) and sexual drive. -He/she seems to be inappropriate with male/female resident at the facility. -Resident #34 was anxious (a feeling of unease, worry or fear), would wander at times and get upset easily. -The plan was medication adjustment, monitor very closely and family members have be updated and aware of the resident sexual behaviors. -Nursing staff will notify the physician if any issues or problem occur. Record review of Resident #34's Quarterly MDS dated [DATE], showed the resident: -Had diagonals of dementia. -Had severe cognitive impairment and he/she had a BIMS of 3 out 15. -Was able to understand others and able to make his/her needs known. -Was independent with ambulation and transfers. -No behavior indicated affecting other resident. Record review of Resident #34's Care Plan revised on 1/9/23 showed the resident: -Had displayed inappropriate sexual behaviors on 1/6/23. -The resident's care plan intervention were Initiated on 1/6/23 and revised on 1/9/23 and the new intervention were; --Minimize potential for Resident #34's inappropriate sexual behaviors by offering tasks which divert attention such as coloring, group activities. --Provide a program of activities that is of interest and accommodates the resident's status. -Spoke with family, state understanding. Facility Staff were continue to attempt to redirect the resident. Facility staff were honor the resident's wishes for sexual relationship and provide privacy when needed. -Did not indicate the resident had the capacity to consent to having consensual sexual relationship. 2. Record review of Resident #26's Nursing Note dated 10/31/22 at 1:35 P.M., showed: -Resident #26's guardian and Public Administrator (PA, court appointed guardian) was called and made aware of Resident #26 attempting to be sexually involved with another resident (Resident #34). It was explained that he/she had been seen kissing on Resident #34 and Resident #34's had his/her hands in an inappropriate places on Resident #26 body. -Both residents have been seen attempting to go to each other's rooms with each other and they have been redirected each time with all these behaviors. -PA did not have any further comments outside of his/her appreciation for us watching them and keeping them safe. -The resident's physician were aware as well, had no new orders at that time. Record review of Resident #26's medical record showed: -No documentation found related to if the resident to resident sexual contact had been fully investigated by the facility staff or reported to the appropriate authorities, including the State Agency, for the alleged resident to resident inappropriate sexual behaviors on 10/31/22. -Did not have comprehensive assessment documented to evaluate Resident #26 capacity to consent for consensual sexual expression or any finding of a evaluation. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident sexual contact had been fully investigated by the facility staff or reported to the appropriate authorities, including the State Agency, for the alleged resident to resident inappropriate sexual behaviors on 10/31/22. -Did not have comprehensive assessment documented to evaluate Resident #34 capacity to consent for consensual sexual expression or any finding of a evaluation. 3. Record review of Resident #34's Health Status Note date 12/14/22 at 2:34 A.M. showed: -Resident #34 was seen being very intimate and physically close to another resident (Resident #26) at the dining area table. -Resident #26 then propelled himself/herself to the nursing station. -Resident #26 was talking with the nurse when all of a sudden Resident #34 took a baggie full of change and proceeded to hit Resident #26 over the head. -Resident #34 had cursed at Resident #26 out. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34 family member was notified of the incident. Record review of Resident #26's Health Status Note date 12/14/22 at 2:40 A.M. showed: -Resident #26 was at table kissing another resident (Resident #34). -The nurse separated the residents. Informed them that they could not be kissing in dining room. -Resident #26 had followed the nurse to the nursing station and was talking to the nurse. Then Resident #34 walked over to Resident #26 and hit him/her over the head with a baggie of change. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34 had than began to curse at Resident #26. -The nurse had notice a knot on top of Resident #26 head. Resident #26 was noted to have pain and Tylenol (pain medication) was administered. Record review of Resident #34 Behavioral Note dated 12/14/22 at 4:43 P.M. showed: -Resident #34 was seen being very intimate and physically close to another resident (Resident #26). -He/she had recently hit the other resident in the head (on the morning of 12/14/22) for what appeared to be jealousy of Resident #26, who was speaking to another resident. -Resident #34 seemed to not understand due to his/her baseline confusion. -Resident #34 was directed to sit at another table of the same gender and Resident #26 was to sit at a different same gender table. -Resident #34 first had followed these instructions, but was soon seen again repeating these behaviors with the other resident, who was also confused, and he/she was seen following him/her around the dining hall and stepping in between him/her and any other resident he/she was near. -Anytime the Resident #26 would speak to another resident, Resident #34's facial expression would turn to anger and he/she would stare that resident down angrily. -Once Resident #34 had begun those behaviors again with Resident #26 after being told to keep his/her distance, this nurse again explained to Resident #34 that he/she needs to not be around this other resident. -Resident #34 became aggravated and began to raise his/her voice saying that's my boyfriend/girlfriend, you cannot keep me away and you can't have him/her. -This nurse then walked Resident #34 to his/her room to explain to him/her that he/she had recently hurt Resident #26, and the family and his/her physician had requested he/she stay separated from Resident #26. -This nurse had called Resident #34's family member to reiterate the above. After the phone call, Resident #34 stated he/she understood why we are asking him/her to stay away from Resident #26 for now. -About 10 minutes later, Resident #34 was seen following Resident #26 back to his/her room and became frustrated again when was redirected and explained could not go to other resident room. -This nurse offered to call Resident #34's family member again to explain. -Resident #34 began asking if he/she was a prisoner here because he/she can't do anything. -This nurse said he/she is only being asked to not be around one resident, and that he/she was free to sit wherever else he/she would like. -Resident #34 then sat down and ate his/her dinner, only after Resident #26 had went back into his/her room and was out of sight of Resident #34. Record review of Resident #26's medical record showed: -No documentation found related to the resident to resident sexual contact and resident to resident altercation had been fully investigated by the facility staff or reported to the appropriate authorities, including the State Agency, for the alleged resident to resident sexual behaviors on 12/14/22. -Did not have comprehensive assessment documented to evaluate Resident #26 capacity to consent for consensual sexual expression or any finding of a evaluation. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident inappropriate sexual contact and resident to resident altercation had been fully investigated by the facility staff or reported to the appropriate authorities, including the State Agency, for the alleged resident to resident sexual behaviors on 12/14/22. -Did not have comprehensive assessment documented to evaluate Resident #34 capacity to consent for consensual sexual expression or any finding of an evaluation. During an interview on 1/20/23 at 9:59 A.M., Administrator said: -Resident #34 had documented behavioral incident on 12/14/22. -The facility was in middle of a COVID (a new disease caused by a novel (new) coronavirus) outbreak and administration staff did not have time to complete an investigation into that incident and did not report the incident state authorities. -Administration staff had reviewed the resident behavioral and incident note from 12/14/22 and at that time of the review it was out of the window to investigate or to report. -He/she may have internal documentation related to Resident #34 aggressive behavior on 12/14/22. 4. Record review of Resident #34's Nursing Incident Note dated 1/6/2023 at 2:54 P.M. showed: -Resident #34 was found in Resident #26's room having sexual intercourse. -One of the residents had accidentally pressed the call light which caused Certified Nursing Assistant (CNA) C to go answer the call light. -CNA C had found the residents engaging in sexual intercourse. -The resident's family member and guardian had been notified. Record review of Resident #26's Nursing Incident Note dated 1/6/23 at 2:56 P.M. showed: -Resident #26 was found in his/her room with another resident (Resident #34) having sexual intercourse. -One of the residents had accidentally pressed the call light causing CNA C to find Resident #26 and another resident (Resident #34) having sex. -The residents' guardians were notified of the incident. Record review of Resident #26's medical record showed: -No documentation found related to the resident to resident sexual contact had been fully investigated by the facility staff or reported to the appropriate authorities, including the State Agency, of alleged resident to resident sexual behaviors on 1/6/23. -Did not have comprehensive assessment completed to evaluate Resident #26 for his/her capacity to consent for consensual sexual expression. -Did not indicate the resident had the capacity to consent to be in a consensual sexual relationship. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident inappropriate sexual contact had been fully investigated by the facility staff or reported to the appropriate authorities, including the State Agency, of the alleged resident to resident sexual behaviors on 1/6/23. -Did not have comprehensive assessment completed to evaluate Resident #34 for his/her capacity to consent for consensual sexual expression. -Did not indicate the resident had the capacity to consent to be in a consensual sexual relationship. 5. During an interview on 1/11/23 at 10:48 A.M., Housekeeping A said: -He/she was aware of two residents who may be involved in touch and sexual contact. -He/she was informed to let nursing staff know if he/she found the residents having sexual contact. During interview on 1/11/23 at 10:59 A.M., Care Partner said: -If he/she had noticed or found a resident in sexual interaction with another resident, he /she would report to the charge nurse. -He/she had not seen Resident #26 and Resident #34 in sexual contact or being aggressive toward each other. -He/she was instructed to ensure to monitoring of Resident #26 and Resident #34 to make sure they do not go into each other resident's room or linger in each other's hallway or wing. During an interview on 1/11/23 at 10:55 A.M., the Administrator said: -Resident #34 had been in a relationship with Resident #26 for a while. -The facility did not report the resident to resident sexual behaviors incident to the appropriate authorities on 10/31/22 or on 1/6/23. -After the administration staff had reviewed and followed the facility Abuse and Neglect policy related to alleged resident to resident abuse, it was determined that the sexual behaviors incident was not abuse, but a was a behavior related to resident's disease process and the resident's desire to have a relationship. -He/she felt the facility had followed guidelines to review and determine if either resident had capacity to consent to consensual sexual relationship with the Interdisciplinary Team (IDT, is a professionals plan, coordinate and deliver of resident's personalized health care), the residents' physician, and family member and/or guardians. -He/she felt was not a reportable incident after discussion with the IDT was the resident to resident sexual incident was not a reportable as alleged sexual abuse. -Resident #34 was the initiator in the resident's relationship. -The facility have try to keep Resident #34 and Resident #26 separate as much as possible and to ensure they stay on opposite units. -The sexual incident between Resident #34 and Resident #26 on 1/6/23, the facility IDT had meet regarding the sexual incident and were working on plan to ensure both residents could make the discussion and/or wanted to continue a relationship. --The facility plan was to reassess Resident #26 and Resident #34 if they had the capacity to consent to consensual sexual relationship. During an interview on 1/11/23 at 12:26 P.M., CNA B said: -The CNA's had been instructed try to ensure Resident #34 and Resident #26 do not have personal contact and were to redirect the resident as needed. -He/she would report any sexual contact or behaviors to the charge nurse, ensure the resident were safe and separated. During an interview on 1/11/23 at 12:45 P.M., CNA A said: -He/she was walking down the hallway on 1/6/23 when CNA C informed him/her of sexual incident between Resident #34 and Resident #26. -He/she went to notify the charge nurse. -He/she did not witness Resident #26 and Resident #34 in the bedroom together. During interview on 1/11/23 at 2:46 P.M., Licensed Practical Nurse (LPN) C said: -Resident #26 and Resident #34 had been up in dining area for meals and then was separated and instructed by facility care staff to go to their own bedrooms and was directed to their bedrooms. -Resident #26 had headed toward his/her room on a different hallway. -The facility staff had assumed both in their rooms. -During that time, somehow Resident #34 had made his/her way back to Resident #26's room. -While in Resident #26 room, one of the residents had accidentally pressed the call light. -The facility staff were not aware Resident #34 was in Resident #26's room at that time. -CNA C had knocked and entered Resident #26's bedroom and had reported that Resident #34 had his/her legs up in the air while laying on Resident #26 bed. -Resident #26 had his/her pants down around his/her ankles and was in between Resident #34's legs. -LPN C had been notified by a CNA of the incident and went into Resident #26's room as the residents were getting dress. -At the time of the sexual incident, LPN C was at the nursing station working at the computer entering physician orders. -CNA C had already separated and redirected Resident #26 and Resident #34. -CNA C and LPN C had redirected Resident #34 go to the main dining area. -Facility staff then redirected Resident #34 to his/her room. -LPN C had called notified Resident #34 family member and Resident #26's guardian of sexual contact. -The resident's physician was made aware of the incident and had known about both resident's past sexual behaviors and Resident #34 easily agitated behavior. -LPN C was unsure if he/she had completed a detail incident report related to resident sexual encounter. -He/she had document the sexual incident in both resident's nursing notes. -He/She reported the incident to the Director of Nursing (DON). -LPN C was made aware of another sexual behavioral incident between Resident #35 and Resident #26 in the past but did not know the date. -Resident #26 and Resident #34's care plan was to redirect the residents and to avoid physical contact between the two residents and to discourage their relationship. During an interview on 1/11/23 at 1:06 P.M., CNA C: -He/she had notice Resident #26's call light was on. -He/she had found that Resident #34 was laying on his/her back on Resident #26 bed. -Resident #34 had his/her pants around one ankle and with his/her legs spread apart and feet up in the air. -Resident #26 had his/her pants down and was in between Resident #34 legs and was leaning over Resident #34 as he/she was starting to have sexual intercourse's with Resident #34. -CNA C felt had just found the resident's together just in time. Before had completed intercourse with the Resident #34. Resident #26 and Resident #34 had turned their head as the CNA C had enter Resident #26 bedroom. -CNA had informed both residents that this was not appropriate behavior and both residents needed to get dress. -Another CNA was in the adjoining bathroom and had heard what was going on and went to get the facility charge nurse. -CNA C was not aware if Resident #26 and Resident #34 were in a relationship either sexual or as friends. -Resident #34 had diagnosis of dementia and was confused at times. Resident #34 had thought he/she was in a relationship with Resident #26 as married couple at times. -CNA C said on 1/6/23 was not first time Resident #26 and Resident #34 had sexual touching between each other. -He/she had been instructed that the resident can sit by each other in main dining area but not allowed to touch each other. CNA's and other facility staff were to try and redirect the residents and remove the resident from the situation. -He/she would report any inappropriate behaviors to the charge nurse. During an interview on 1/11/23 at 2:24 P.M., Resident #26's PA said; -He/she had been made aware of Resident #26 sexual behavioral incident on 1/6/23 and that Resident #26 had other sexual contact with same resident in the past. -He/she would preferred Resident #26 not to be in sexual relationship with another resident. -Resident #26 had required supervision and assistance by facility care staff due to his/her very short memory. -Resident intervention would include to try keep the resident separated to avoid the potential of sexual contact. -PA voiced that he/she does realize the facility may not be able to prevent sexual contact but he/she would hope the sexual relationship would not happen again. During an interview 1/11/23 at 3:26 P.M., the DON said: -The facility had not reported the resident to resident sexual or aggressive behaviors to state authorities, due to IDT felt was not abuse of a sexual in nature. -He/she did not feel there was willful intent to harm or take advantage by either resident. -The facility did not complete an incident or comprehensive investigation related to sexual contact or physically aggressive behaviors and the residents had agreed the sexual contact was something that both residents consented to at that time. -All was discussed during IDT meeting and discussed with families, POA and physician. -Resident #26 and Resident #34, refer to themselves as the love birds, due to the relationship the resident's want to have or think they are in. -At times Resident #26 and Resident #34 call each other as boyfriend/girlfriend and the residents like to play cards and hold hands. -He/she did not feel there was willful intent to harm or take advantage of the either resident. -When facility staff would ask the residents each time if they wanted to be in a relationship or in a sexual relationship with each other, they would confirm by a yes at that time when asked. -1/6/23 was not the first time of Resident #26 and Resident #34 had physical sexual contact. He/She could not remember date when the residents first had sexual contact. --Was not the first time Resident #34 was fascinated with Resident #26 and he/she would get worked up or riled up easily when Resident #26 would talk to other residents. During an interview on 1/12/23 at 9:36 A.M., CNA D: -If he/she had found the resident in a sexual activity or if he/she felt the resident was not comfortable with situation, he/she would separate the residents by redirecting them and would notify and report to the charge nurse immediately. During an interview on 1/12/23 at 10:21 A.M., CNA B said: -Resident #34 has behavior of wandering into Resident #26 room related sexual needs. -Resident #34 had not seen flashing any resident or staff for a while and had never seen going into other resident rooms. -He/She was educated by nursing staff related to resident rights and intervention to try keep resident separated. -He/she would report any behaviors to charge nurse. During an interview on 1/12/23 at 10:35 A.M. LPN D: said: -He/she would report any sexual abuse to the facility charge nurse and to administration. -He/She felt the residents could not make that decision by themselves to have consensual relationship due to their impaired memory. -Facility administration had educated facility staff on the policy related to sexual expression and care plan intervention for each resident. During an interview on 1/12/23 at 11:00 A.M., Registered Nurse (RN) A said: -Resident #26 and Resident #34 were not in right mind to be in a consensual relationship. -He/she was aware of another sexual contact that happen prior to 1/6/23, but unsure of the date. -The facility IDT, physician and guardian would discuss the resident capability to consent and the wishes of the resident and guardian. -He/she would report to Director of Nursing or Administrator any alleged sexual abuse between resident or staff. During an interview on 1/12/23 at 11:14 A.M., Resident #34, guardian said: -He/she felt the resident did not have capacity to consent for consensual relationship. -Resident #34, was not able to make good choices and had poor judgement as a part his/her disease process. During an interview on 1/12/23 at 11:22 A.M., Physician A said: -Resident #34 and Resident #26 did not have capacity to make a consensual discussion to have sex intercourse. -The facility are monitoring Resident #34 and Resident #26 very closely and were to redirect the residents to discourage sexual behavior. -The resident were known to get touchy and hugging prior to 1/6/23. -He/she felt the sexual interaction was not sexual abusive behavior by either resident. -Resident #34 had diagnosis of hyper-sexuality due to dementia that was located at base of temporal lobe causing sexual dysfunction. -They facility had tried keeping the resident's separated and to redirect the residents as needed. -He/she had change Resident #34 and Resident #26 medication by adjustment dose of medication and added medication. -Resident #26 had history of head trauma and other medical issue that would cause decrease of in short memory. -He/she did not feel the facility could prevent the sexual behaviors due to their diagnosis. -Resident #26 and resident #34 have not had a change in their base line mental status, had remain the same. -felt the facility has provide the intervention and care need for the resident. -Resident #34 and resident #26 did not have a mental health evaluation completed before or after the sexual interaction. During an interview on 1/13/23 at 10:59 P.M., DON said: -He/she did not conduct interview with resident for the safety of all residents during the first resident to resident sexual contact incident or on 1/6/23. -The facility should had reported the sexual or behavioral (hitting) incident when had first happen a few months ago. -Resident #34 was easily agitated and would get upset if he/she thought Resident #26 was flirty or talking to the other resident. -Facility IDT did not feel Resident #26 and Resident #34 sexual encounter on 1/6/23 was a Resident to Resident alleged sexual abuse or was an inappropriate sexual relationship. -The facility did not completed investigation and did not reported the resident to resident sexual contact to state agency, due to IDT discussion felt that this sexual contact was not resident to resident sexual abuse. -All behavioral were to be documented in each of the resident's nursing notes. -For any resident to resident altercation to including aggressive behaviors and any inappropriate sexual behavior, he/she would have expected facility nursing staff to have completed a facility risk management report or a incident report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate a resident to resident physical and sexual abuse between two severely cognitively impaired residents after one supplemental sampled resident (Resident #34) hit one sampled resident (Resident #26) on 12/14/22 causing a knot on his/her head, and after staff found Resident #34 kissing and touching Resident #26 in an inappropriate sexual manner on 10/31/22 and after staff found Resident #26 unclothed from the waist down on top of Resident #34 unclothed from the waist down in bed attempting to have sexual intercourse on 1/6/23, out of 14 sampled residents and nine supplemental residents. The facility census was 41 residents. Record review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on April 2021 showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from verbal, mental, sexual or physical abuse. -Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. -Identify, investigate and report any allegations within time frames required by federal requirements. -Protect resident from any further harm during the investigation. -Establish and implement a Quality assurance plan review and analysis of any reports or allegation, findings of abuse or neglect. 1. Record review of Resident #26's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses of: -Stroke (mild) -He/she had a legal guardian. Record review of Resident #26's facility care plan initiated on 11/3/22 showed: -Had history of Brain tumor causing impulsive behaviors. -Had a sexual behavior issue on 10/31/22. -He/she will have fewer episodes of sexual behaviors by review dated. -The resident's interventions included: --The facility staff were to praise any indication of Resident#26's progress or improvement in the sexual behaviors and was revised on 11/3/22. --Facility staff were to provide a program of activities that was of interest and accommodates the resident's status and was revised on 11/3/22. --The facility staff were to discuss inappropriate behaviors. Explain and reinforce to the resident why behavior was inappropriate and or unacceptable revised on 11/3/22. --The facility staff were to minimize potential for Resident #26's sexual behaviors by offering tasks that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22. -The facility care plan had no indication or documentation with details on how the resident was sexually acting out. -Did not indicate the resident had the capacity to consent to having consensual sexual relationship. Record review of Resident #26's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/2/22, showed: -He/she was severely cognitively impaired and his/her Brief Interview Mental Status (BIMS) score was of 6 out of 15. -Able to understand others and was able to make his/her needs known. -Required limited assistance of one staff member with personal cares and transfers. -He/she had no behavior indicated affecting other resident. Record review of Resident #26's personalized care plan revised on 1/11/23 showed: -The resident had a history of brain tumor causing impulsive behaviors. -Had video monitoring in room to alert staff to the resident self-transfers care plan revised with initiated of the intervention on 1/6/23. -Resident #26 had a sexual behavior issue on 1/6/23. -He/she will have fewer episodes of sexual behaviors by review dated 1/6/23. -The resident's interventions included: --The facility staff were to minimize potential for Resident #26's sexual behaviors by offering task that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22 and added to redirect the resident as needed and was revised on 1/6/23. -The facility care plan had no indication or documentation with details of how the resident was sexually acting out. Record review of Resident #34's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses of: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses. -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -He/she had a guardian. Record review of Resident #34's personalized care plan dated 11/2/22 showed the resident: -Had a history of dementia and impaired thought process related to diagnosis of dementia and had impaired decision making. -Had displayed inappropriate sexual behaviors with staff and peers initiated on 11/2/22. -Goal was to have fewer episodes of sexual behaviors by the next review date. -Intervention revised on 11/2/22 included: --Administer medications as ordered. Monitor/document for side effects and effectiveness. --If reasonable, discuss Resident #34's behavior. Facility staff were to explain and reinforce why the behavior was inappropriate and/or unacceptable for the resident and his/her family. --Facility staff were to intervene as necessary to protect the rights and safety of the resident and others residents, the facility staff were to approach and speak in a calm manner to the resident. Facility staff were try to divert the attention of the resident and remove the resident from situation and take the resident to alternate location as needed. -Did not indicate the resident had the capacity to consent to having consensual sexual relationship. Record review of Resident #34's Physician Visit Summary Note dated 12/13/22 at 11:48 A.M., showed the resident: -Had a diagnosis of sexual inappropriateness, dementia and hyper-sexuality. -Continued to have difficulties with sexual inappropriateness. -Medication had been initiated to decrease the libido (is the part of their personality that is considered to cause their emotional, especially sexual, desires) and sex drive. -He/she seems to be inappropriate with male/female resident at the facility. -Resident #34 was anxious (a feeling of unease, worry or fear), would wander at times and get upset easily. -The plan was medication adjustment, monitor very closely and family members have be updated and aware of the resident sexual behaviors. Nursing staff will notify the physician if any issues or problem occur. Record review of Resident #34's Quarterly MDS dated [DATE], showed the resident: -Had diagnosis of dementia. -Had severe cognitive impairment and he/she had a BIMS of 3 out 15. -Was able to understand others and able to make his/her needs known. -Was independent with ambulation and transfers. -No behavior indicated affecting other residents. Record review of Resident #34's Care Plan revised on 1/9/22 showed the resident: -Had displayed inappropriate sexual behaviors on 1/6/2023. -The resident's care plan interventions were initiated on 1/6/2023 and revised on 1/9/22 and the new intervention was: --Minimize potential for Resident #34's inappropriate sexual behaviors by offering tasks which divert attention such as coloring, group activities. --Provide a program of activities that is of interest and accommodates the resident's status. -Spoke with family, state understanding. Facility Staff were continue to attempt to redirect the resident. Facility staff were honor the resident's wishes for sexual relationship and provide privacy when needed. -Did not indicate the resident had the capacity to consent to having consensual sexual relationship. 2. Record review of Resident #26 nursing note dated 10/31/22 at 1:35 P.M., showed: Resident #26's guardian and Public Administrator (PA, court appointed guardian) was called and made aware of Resident #26 attempting to be sexually involved with another resident (Resident #34). It was explained that he/she had been seen kissing on Resident #34 and Resident #34's had his/her hands on inappropriate places on Resident #26 body. -Both resident have been seen attempting to go to each other's rooms with each other and they have been redirected each time with all these behaviors. -PA did not have any further comments outside of his/her appreciation for us watching them and keeping them safe. -The resident's physician were aware as well, had no new orders at that time. Record review of Resident #26's medical record showed: -No documentation found related to the resident to resident sexual contact had been fully investigated by the facility staff for the alleged resident to resident inappropriate sexual behaviors on 10/31/22. -Did not have comprehensive assessment documented to evaluate Resident #26 capacity to consent for consensual sexual expression or any finding of a evaluation. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident sexual contact had been fully investigated by the facility staff for the alleged resident to resident inappropriate sexual behaviors on 10/31/22. -Did not have comprehensive assessment documented to evaluate Resident #34 capacity to consent for consensual sexual expression or any finding of a evaluation. 3. Record review of Resident #34 Health Status Note date 12/14/22 at 2:34 A.M. showed: -Resident #34 was seen being very intimate and physically close to another resident (Resident #26) at the dining area table. -Resident #26 then propelled himself/herself to the nursing station. -Resident #26 was talking with the nurse when all of a sudden Resident #34 took a baggie full of change and proceeded to hit Resident #26 over the head. -Resident #34 had cursed at Resident #26. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34's family member was notified of the incident. Record review of Resident #26 Health Status Note date 12/14/22 at 2:40 A.M. showed: -Resident #26 was at the table kissing another resident (Resident #34). -The nurse separated the residents and informed them that they could not be kissing in the dining room. -Resident #26 had followed the nurse to the nursing station and was talking to the nurse. Then Resident #34 walked over to Resident #26 and hit him/her over the head with a baggie of change. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not an appropriate behavior. -Resident #34 had then began to curse at Resident #26. -The nurse had notice a knot on top of Resident #26's head. Resident #26 was noted to have pain and Tylenol (pain medication) was administered. Record review of Resident #34's Behavioral Note dated 12/14/22 at 4:43 P.M. showed: -Resident #34 was seen being very intimate and physically close to another resident (Resident #26). -He/she had recently hit the other resident in the head (on the morning of 12/14/22) for what appeared to be jealousy of Resident #26, who was speaking to another resident. -Resident #34 seemed to not understand due to his/her baseline confusion. -Resident #34 was directed to sit at another table of the same gender and Resident #26 was to sit at a different same gender table. -Resident #34 first had followed these instructions, but was soon seen again repeating these behaviors with the other resident, who was also confused, and he/she was seen following him/her around the dining hall and stepping in between him/her and any other resident he/she was near. -Anytime Resident #26 would speak to another resident, Resident #34's facial expression would turn to anger and he/she would stare that resident down angrily. -Once Resident #34 had begun those behaviors again with Resident #26 after being told to keep his/her distance, this nurse again explained to Resident #34 that he/she needs to not be around this other resident. -Resident #34 became aggravated and began to raise his/her voice saying that's my boyfriend/girlfriend, you cannot keep me away and you can't have him/her. -This nurse then walked Resident #34 to his/her room to explain to him/her that he/she had recently hurt Resident #26, and the family and his/her physician had requested he/she stay separated from Resident #26. -This nurse had called Resident #34's family member to reiterate the above. After the phone call, Resident #34 stated he/she understood why we are asking him/her to stay away from Resident #26 for now. -About 10 minutes later, Resident #34 was seen following Resident #26 back to his/her room and became frustrated again when was redirected by facility staff and explained could not go to other resident room. -This nurse offered to call Resident #34's family member again to explain. -Resident #34 began asking if he/she was a prisoner here because he/she can't do anything. -This nurse said he/she is only being asked to not be around one resident, and that he/she was free to sit wherever else he/she would like. -Resident #34 then sat down and ate his/her dinner, only after Resident #26 had went back into his/her room and was out of sight of Resident #34. Record review of Resident #26's medical record showed: -No documentation found related to the resident to resident sexual contact and resident to resident altercation had been fully investigated by the facility staff on 12/14/22. -Did not have comprehensive assessment documented to evaluate Resident #26's capacity to consent for consensual sexual expression or any finding of a evaluation. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident sexual contact and resident to resident altercation had been fully investigated by the facility staff on 12/14/22. -Did not have comprehensive assessment documented to evaluate Resident #34's capacity to consent for consensual sexual expression or any finding of an evaluation. During an interview on 1/20/23 at 9:59 A.M., Administrator said: -Resident #34 and Resident #26 had documented behavioral incident on 12/14/22. -The facility was in middle of a COVID (a new disease caused by a novel (new) coronavirus) outbreak and administration staff did not have time to complete an investigation into that incident. -Administration staff had reviewed the resident behavioral and incident note from 12/14/22 and at that time, the review was out of the window to investigate or to report. -He/she may have internal documentation related to Resident #34's aggressive behavior on 12/14/22. 4. Record review of Resident #34's Nursing Incident Note dated 1/6/2023 at 2:54 P.M. showed: -Resident #34 was found in Resident #26's room having sexual intercourse. -One of the residents had accidentally pressed the call light which caused Certified Nursing Assistant (CNA) C to go answer the call light. -CNA C had found the residents engaging in sexual intercourse. -The resident's family member and guardians had been notified. Record review of Resident #26's Nursing Incident Note dated 1/6/23 at 2:56 P.M. showed: -Resident #26 was found in his/her room with another resident (Resident #34) having sexual intercourse. -One of the residents had accidentally pressed the call light causing CNA C to find Resident #26 and another resident (Resident #34) having sex. -The resident's guardian were notified of the incident. Record review of Resident #26's medical record showed: -No documentation found related to the resident to resident sexual contact had been fully investigated by the facility staff of alleged resident to resident sexual behaviors on 1/6/23. -Did not have comprehensive assessment completed to evaluate Resident #26 for his/her capacity to consent for consensual sexual expression. -Did not indicate the resident had the capacity to consent to be in a consensual sexual relationship. Record review of Resident #34's medical record showed: -No documentation found related to the resident to resident sexual contact had been fully investigated by the facility staff of alleged resident to resident sexual behaviors on 1/6/23. -Did not have comprehensive assessment completed to evaluate Resident #34 for his/her capacity to consent for consensual sexual expression. -Did not indicate the resident had the capacity to consent to be in a consensual sexual relationship. 5. During an interview on 1/11/23 at 10:48 A.M., Housekeeping A said: -He/she was aware of two residents who may be involved in touch and sexual contact. -He/she was informed to let nursing staff know if found resident sexual contact. During interview on 1/11/23 at 10:59 A.M. Facility Care Partner said: -If he/she had notice or found a resident in sexual interaction with another resident, he /she would report to the charge nurse. -He/she had not seen Resident #26 and Resident #34 in sexual contact. -He/she was instructed to ensure to monitoring Resident #26 and Resident #34 to make sure they do not go into each other resident's room or hallway. During an interview on 1/11/23 at 10:55 A.M., the Administrator said: -Resident #34 had been in a relationship with Resident #26 for a while. -The facility did document a facility investigation related to the Resident to Resident sexual behaviors on 1/6/23. -The facility had reviewed the facility policy related to sexual abuse. -He/she felt the facility had followed guidelines to review and determine if either resident had capacity to consent to consensual sexual relationship with Interdisciplinary Team (IDT, is a professionals plan, coordinate and deliver of resident's personalized health care) resident's physician, family member and/or guardians and felt was not a reportable incident after discussion with the IDT was the resident to resident sexual incident was not a reportable as alleged sexual abuse. -Resident #34 was the initiator in the resident's relationship. -The facility had been trying to keep Resident #34 and Resident #26 separate as much as possible and to ensure they stay on opposite units. -The sexual incident on 1/6/23 between Resident #34 and Resident #26, the facility IDT had meet regarding the sexual incident and were working on a plan to ensure both residents could make their own discussion and/or wanted to continue a relationship. -The facility were to assess if Resident #26 and Resident #34 had the capacity to consent to consensual sexual relationship. During an Interview on 1/11/23 at 12:26 P.M., CNA B said: -He/she worked the day shift on 1/6/23 when CNA C had found Resident #34 in Resident #26's bedroom. -He/she was in another resident's room at the time of the incident with Resident #26 and Resident #34 in the same room together. -The CNA's had been instructed by administration to try to ensure Resident #34 and Resident #26 do not have personal contact and nursing staff and care staff were to redirect the residents as needed. -He/she would report any sexual contact or inappropriate behaviors to the charge nurse, ensure the residents were safe and would have separated them. During an interview on 1/11/23 at 12:45 P.M., CNA A said: -He/she was walking down the hallway on 1/6/23 when CNA C informed him/her of sexual incident between Resident #34 and Resident #26. -He/she went to notify the charge nurse. -He/she did not witness Resident #26 and Resident #34 in the bedroom together. During interview on 1/11/23 at 2:46 P.M., Licensed Practical Nurse (LPN) C said: -Resident #26 and Resident #34 had been up in dining area for meals and then was separated and instructed by facility care staff to go to their own bedrooms and was directed to their bedrooms. -Resident #26 had headed toward his/her room on a different hallway. -The facility staff had assumed both residents were in their rooms. -During that time, somehow Resident #34 had made his/her way back to Resident #26's room. -While in Resident #26 room, one of the residents had accidentally pressed the call light. -The facility staff were not aware Resident #34 was in Resident #26's room at that time. -CNA C had knocked and entered Resident #26's bedroom and had reported that Resident #34 had his/her legs up in the air while laying on Resident #26 bed. -Resident #26 had his/her pants down around his/her ankles and was in between Resident #34 legs. -LPN C had been notified by a CNA of the incident and went into Resident #26's room as the residents were getting dress. -At the time of the sexual incident, LPN C was at the nursing station working at the computer entering physician orders. -CNA C had already separated and redirected Resident #26 and Resident #34. -CNA C and LPN C had redirected Resident #34 go to the main dining area. -Facility staff then redirected Resident #34 to his/her room. -LPN C had notified Resident #34's family member and Resident #26's guardian of the sexual contact. -The resident's physician was made aware of the incident and had known about both residents' past sexual behaviors. -LPN C was unsure if he/she had completed a detailed incident report related to the residents' sexual encounter. -He/she had documented the sexual incident in both resident's nursing notes and had reported the incident to the Director of Nursing (DON). -LPN C was made aware of another sexual behavioral incident between Resident #34 and Resident #26 in the past but did not know the date. -Resident #26 and Resident #34's care plan was to redirect the residents and to avoid physical contact between the two resident and to discourage their relationship. -Any further investigation would have been completed by the DON. -He/she did not complete a nursing assessment on Resident #26 and Resident #34 related to the sexual contact on 1/6/23. During an interview on 1/11/23 at 1:06 P.M., CNA C said: -He/she had noticed Resident #26's call light was on. -He/she had found that Resident #34 was laying on his/her back on Resident #26's bed. -Resident #34 had his/her pants around one ankle and with his/her legs spread apart and feet up in the air. -Resident # 26 had his/her pants down and was in between Resident #34's legs and was leaning over Resident #34 as he/she was starting to have sexual intercourse with Resident #34. -He/She felt he/she had just found the residents together just in time before had they completed sexual intercourse. -Resident #26 and Resident #34 had turned their heads as the CNA C had enter Resident #26's bedroom. -He/she had informed both residents that this was not appropriate behavior and both residents needed to get dressed. -Another CNA was in the adjoining bathroom and had heard what was going on and went to get the facility charge nurse. -He/She was not aware if Resident #26 and Resident #34 were in a relationship, either sexual or as friends. -Resident #34 had a diagnosis of dementia and was confused at times. Resident #34 had thought he/she was in a relationship with Resident #26 as a married couple at times. -1/6/23 was not first time Resident #26 and Resident #34 had sexual touching between each other. -He/she had been instructed that the resident can sit by each other in main dining area but not allowed to touch each other. CNAs and other facility staff were to try and redirect the residents and remove the residents from the situation. -He/she would report any inappropriate behaviors to the charge nurse. During an interview on 1/11/23 at 2:24 P.M., Resident #26's PA said; -He/she had been made aware of Resident #26 sexual behavioral incident on 1/6/23 and that Resident #26 had other sexual contact with same resident in the past. -He/she would preferred Resident #26 not to be in sexual relationship with another resident. -Resident #26 had required supervision and assistance by facility care staff due to his/her very short memory. -Resident intervention would include to try keep the residents separated to avoid the potential of sexual contact. -He/she realized the facility may not be able to prevent sexual contact but he/she would hope the sexual relationship would not happen again. During an interview on 1/11/23 at 3:26 P.M., the DON said: -The facility had not reported the resident to resident sexual or physically aggressive behaviors to state authorities, due to the IDT felt it was not abuse. -He/she did not feel there was willful intent to harm or take advantage by either resident. -The facility did not complete an incident or comprehensive investigation related to sexual contact or aggressive behaviors and the residents had agreed sexual contact was something that both residents consented to at that time. -All was discussed during the IDT meeting and discussed with families, POA and physician. -Resident #26 and Resident #34, refer to them as the love birds, due to the relationship the resident's want to have or think they are in. -At times Resident #26 and Resident #34 call each other boyfriend/girlfriend and the residents like to play cards and hold hands. -When facility staff would ask the residents each time if they wanted to be in a relationship or in a sexual relationship with each other, they would confirm by a yes at that time when asked. -1/6/23 was not the first time of Resident #26 and Resident #34 had physical sexual contact. He/She could not remember the date when the residents first had sexual contact. -Was not the first time Resident #34 was fascinated with Resident #26 and he/she would get worked up or riled up easily when Resident #26 talked to other residents. During an interview on 1/12/23 at 10:35 A.M. LPN D said: -He/she would report any sexual abuse to the facility charge nurse and to administration. -He/She felt the residents could not make that decision by themselves to have consensual relationship due to their impaired memory. -Facility administration had educated facility staff on the policy related to sexual expression and care plan intervention for each resident. During an interview on 1/12/23 at 11:00 A.M., Registered Nurse (RN) A said: -Resident #26 and Resident #34 were not their in right minds to be in a consensual relationship. -He/she was aware of another sexual contact and inappropriate behaviors that happen prior to 1/6/23, but was unsure of the date. -The facility IDT, physician and guardian would discuss the resident capability to consent and the wishes of the resident and guardian. -He/she would report to director of nursing or administrator any alleged sexual abuse between resident or staff. During an interview on 1/12/23 at 11:14 A.M., Resident #34, guardian said: -He/she felt the resident did not have capacity to consent for consensual relationship -Resident #34, was not able to make good choices and had poor judgement as a part his/her disease process. During an interview on 1/12/23 at 11:22 A.M., Physician A said: -Resident #34 and Resident #26 did not have the capacity to make a consensual discussion to have sexual intercourse. -The facility was monitoring Resident #34 and Resident #26 very closely and were to redirect the residents to discourage sexual behavior. -The residents were known to get touchy and hugging prior to 1/6/23. -He/she felt the sexual interaction was not sexual abusive behavior by either resident. -Resident #34 had a diagnosis of hyper-sexuality due to dementia that was located at base of temporal lobe causing sexual dysfunction. -They facility had tried keeping the residents separated and to redirect the residents as needed. -He/she had changed Resident #34 and Resident #26's medications by adjusting the dosage of medications and added medications. -Resident #26 had history of head trauma and other medical issues that would cause decrease in short memory. -He/she did not feel the facility could prevent the sexual behaviors due to their diagnoses. During an interview on 1/13/23 at 10:59 P.M., the DON said: -He/she did not conduct interviews with other residents for the safety for all residents during the first resident to resident incident or on 1/6/23. -Resident #34 was easily agitated and would get upset with Resident #26, if he/she thought Resident #26 was flirty or talking to the other resident. -Facility IDT did not feel Resident #26 and Resident #34 sexual encounter on 1/6/23 was a Resident to Resident alleged sexual abuse or was an inappropriate sexual relationship at that time. -The facility did not complete an investigation of the resident to resident behaviors including sexual and physically aggressive behaviors due to the IDT discussion felt that this sexual contact was not resident to resident sexual abuse and hitting was not a willful intent to harm, but was a behavior reaction due to the resident's disease process. -For any resident to resident altercation to including aggressive behaviors and any inappropriate sexual behavior, he/she would have expected facility nursing staff to have completed a facility risk management report or a incident report.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of a baseline care plan for one sampled resident (Resident #240) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated December 2016, titled Care Plans-Baseline showed: -The Interdisciplinary Team (IDT) was to review the physician's orders, including medication and treatments, in developing the baseline care plan. -The IDT was to gather information from the resident and their representative that included any services or treatments necessary. 1. Record review of Resident #240's face sheet showed he/she was admitted with the following diagnoses: -Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). -Chronic Obstructive Pulmonary Disease (COPD a chronic inflammatory lung disease that causes obstructed airflow from the lungs). -Acute Respiratory Failure with Hypoxia (when you do not have enough oxygen in your blood). Record review of the resident's Baseline Care Plan Summary, dated 1/7/23 showed the resident required the use of a Continuous Positive Airway Pressure machine (Cpap-a machine that provides positive airway pressure ventilation of ambient air in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person). Observation on 1/9/23 at 1:21 P.M. showed: -The resident had a bilevel positive airway pressure machine (Bi-Pap a type of non-invasive ventilation to support breathing, administered through a face mask. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in or out.) at his/her bedside. -No cpap machine in the resident's room. During an interview on 1/11/23 at 12:35 P.M., the resident said: -He/she had used a bipap prior to admission to the facility. -He/she brought his/her bipap machine from home. -He/she was able to attach oxygen to the bipap machine independently. -He/she required the bipap to sleep each night. -He/she did not use a cpap machine. During an interview on 1/11/23 at 12:58 P.M., Nursing Assistant (NA) A said oxygen orders were found on the resident's care plans. During an interview on 1/11/23 at 3:53 P.M., NA B said the charge nurse had been assisting the resident in using his/her bipap at night. During an interview on 1/12/23 at 10:35 A.M., a representative for the oxygen supplier said: -The resident had been using a bipap machine since before admission to the facility. -He/she had come to the facility to ensure the settings on the machine were accurate on 1/11/23. Record review of the resident's Order Summary Report dated January 2023 showed staff had added an order on 1/12/23 at 7:00 P.M. which stated staff were to ensure the resident was wearing the bipap each night with 3 liters of oxygen connected to the bipap. During an interview on 1/13/23 at 10:10 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -He/she had created the resident's baseline care plan. -He/she had written cpap instead of bipap by mistake. -The resident had brought the machine to the facility upon admission. During an interview on 1/13/23 at 11:03 A.M., the Director of Nursing (DON) said: -Staff were to know the difference between a cpap and bipap machine. -The care plan should have accurately reflected that the resident used a bipap machine.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan addressed oxygen usage for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated April 2009, titled Goals and Objectives, Care Plans showed: -Staff were to include specific resident problems. -Staff were to enter goals and objectives on the resident's care plans so that all disciplines had access to such information. 1. Record review of Resident #5's face sheet showed he/she was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 10/20/22 showed Oxygen use was not marked. Record review of the resident's care plan, dated 12/7/22, showed: -Staff did not address difficulty breathing. -Staff did not address oxygen use. Record review of the resident's Order Summary Report, dated 1/11/23, showed staff were to give 2 liters of oxygen via nasal cannula (medical tubing that has two prongs to enter the nostrils in order to provide supplemental oxygen therapy to people who have lower oxygen levels) to the resident, as needed, for shortness of air or wheezing. During an interview on 1/11/23 at 12:58 P.M., Nursing Aide (NA) A said Oxygen orders were found on the residents' care plans. Observation on 1/11/23 at 1:21 P.M. showed the resident requested a Licensed Practical Nurse (LPN) to assist him/her to put the nasal cannula on to receive supplemental oxygen. During an interview on 1/11/23 at 1:51 P.M., LPN C said he/she was aware the resident frequently used oxygen. During an interview on 1/13/23 at 10:10 A.M., the MDS Coordinator said: -He/she was responsible for creating care plans. -Any resident who used oxygen should have it on their care plan, along with interventions. During an interview on 1/13/23 at 11:03 A.M., the Director of Nursing (DON) said: -Staff were to address oxygen on the care plan for any resident with an oxygen order. -The care plan should have included the physician's order, any monitoring, and reason for use regarding oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician's orders for Hospice services (end of life care) were documented on the Physician's Order Sheet (POS) for two sampled residents (Resident #12 and #35) and to ensure the care plan showed the coordination of services and interventions between Hospice and the facility for one sampled resident (Resident #12) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility Hospice and Palliative Care policy and procedure dated July 2017, showed the facility had an agreement with Hospice to ensure that residents who wish to participate in a Hospice program may do so. Procedures showed: -It is the responsibility of the Hospice to manage the resident's care as it relates to terminal illness and determining the Hospice plan of care. -It is the facility's responsibility to meet the residents personal care and nursing needs in coordination with Hospice and ensure the level of care provided is appropriately based on the individual's needs. -Coordinated care plans for residents receiving Hospice services will include the Hospice most recent plan of care as well as the care and services provided by the facility, including the responsible provider and disciplines assigned to provide specific tasks, in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 1. Record review of Resident #12's Face Sheet showed he/she was admitted on [DATE], with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), vitamin deficiency, insomnia (sleeping disorder), hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), arthritis, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), kidney disease, pain, and stroke. The document showed the resident received Hospice services. Record review of the resident's Physician's Telephone Order dated 3/4/22 showed a physician's order to admit to Hospice due to senile degeneration. Record review of the resident's Hospice Records showed: -The resident was admitted to Hospice on 3/4/22, for senile degeneration of the brain and dementia. -Documentation showed the resident received nursing visits twice weekly, nurse aide visits twice weekly and social service and Chaplin visits once weekly. -Documentation showed medical supplies supplied by Hospice included incontinence supplies and a wheelchair. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 3/14/22, and quarterly MDS's dated 6/12/22 and 9/11/22 showed the resident continued to receive Hospice services. Record review of the resident's POS dated 11/2022 showed there were no physician's orders for Hospice. Record review of the resident's Care Plan updated 11/23/22, showed: -There was no care plan showing Hospice services were being provided or that the facility was coordinating services with Hospice to ensure the resident's care needs were being met. -There were no updates to show the resident was receiving Hospice services or any interventions showing the coordination of care provided between the facility and hospice to address the resident's care needs. -There were no further updates to the resident's care plan. Record review of the resident's Nurse's Notes from 11/1/22 to 1/10/23 showed: -There were no notes showing the nursing staff was coordinating care with Hospice. -There was no documentation showing the resident received Hospice services. Record review of the resident's quarterly MDS dated [DATE] showed the resident continued to receive Hospice services. Record review of the resident's Physician's Notes dated 12/17/22 showed: -The physician visited the resident, completed a physical examination of the resident and reviewed his/her medical record, physician's orders and laboratory results. -There was no documentation showing the resident received Hospice services or that care was being coordinated with Hospice regarding the resident's care. Record review of the resident's Hospice Notes dated 12/28/22, showed: -The resident was recertified for Hospice services again on 10/30/22. -Notes showed the resident continued to receive nursing twice weekly, Certified Nursing Assistant (CNA) care twice weekly and Social Services and Chaplin services once weekly. -Documentation showed the most recent progress report dated 12/28/22, showing the resident was alert to self and family, was sleeping 18 or more hours daily, had a poor appetite, was incontinent and had no skin breakdown. -The resident's most recent nurse's notes showed the nurse visited on 1/11/23. -The most recent nursing aide notes dated 1/11/23, showed the CNA provided bathing to the resident. Record review of the resident's POS dated 12/2022 and 1/2023 showed there were no physician's orders for Hospice. Observation on 1/10/23 at 1:52 P.M., showed the resident was in his/her room in her recliner with his/her eyes closed resting comfortably reclined with a blanket-call light within reach, beverage within reach. He/she was alert but was not oriented. During an interview on 1/11/23 at 10:50 A.M., Licensed Practical Nurse (LPN) C said: -The resident was still receiving Hospice services due to his/her diagnosis and he/she was not eating and had a poor prognosis. -At the time, the resident's re-certification should be assessed, but they had not gotten any information stating the resident would be re-certified due to the resident gaining weight. -He/She said the Hospice nurse came to visit with the resident yesterday and the CNA was here that morning to see the resident. 2. Record review of Resident #35's Face Sheet showed the resident was admitted on [DATE], with diagnoses including cognitive disorder, bladder disorder, anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), insomnia, diarrhea, hallucinations (the apparent perception of something not present), and Alzheimer's disease (a progressive brain disorder that causes a gradual and irreversible decline in memory, language skills, perception of time and space, and vitamin B12 deficiency). Record review of the resident's Hospice Documentation showed he/she was admitted to Hospice on 3/19/22 (prior to admission) for Alzheimer's disease. Documentation showed the resident received nurse case management services, CNA services (bathing, dressing and grooming), and Social Work Case management. Record review of the resident's Care Plan dated 5/2/22, showed the resident chose Hospice care services which included assistance with setting up care services, coordinate his/her care with the Hospice team, providing the resident and family with grief and spiritual counseling as needed, coordinating with the Hospice team to ensure the resident experiences a little pain as possible. Notes did not show Hospice services were discontinued. Record review of the resident's admission MDS dated [DATE], showed the resident was admitted on [DATE] and received Hospice services during the review period. Subsequent quarterly MDS's dated 8/12/22 and 11/7/22, showed the resident continued to receive Hospice services. Record review of the resident's POS dated 11/2022, 12/2022 and 1/2023, showed there were no physician's orders for Hospice services. Record review of the resident's Physician's Notes dated 12/22/22, showed the physician visited the resident, completed an examination and reviewed the resident's physician's orders medical record and laboratory results. There was no documentation showing any coordination of care with Hospice services or orders. Record review of the resident's most recent Hospice Nurse's Notes dated 1/3/23, showed: -The nurse checked on the resident and reviewed his/her pain management and there were no new physician's orders. -Documentation also showed the resident was re-certified for Hospice services most recently on 9/15/22. Record review of the resident's corrected Nurse's Notes dated 1/4/22, showed the nurse contacted Hospice to provide the resident with briefs for incontinence at night and they agreed to do so. Observation on 1/10/23 at 1:46 P.M., showed the resident was laying in his/her bed with his/her eyes closed resting comfortably. There was no sign/symptom of pain or discomfort. 3. During an interview on 1/12/23 at 10:48 A.M., LPN A said: -They coordinated services with Hospice regarding all cares, medications and services provided to the resident. -If they received physician's orders from Hospice, they would notify the facility physician and obtain the order from him/her and place it on the resident's POS. -The order for Hospice is placed on the POS and should be carried over monthly. -The care plan is completed by the MDS Coordinator, who coordinated with the Hospice nurse for completion of the care plan. -At 2:16 P.M., he/she said the process was that the nurse would take an order from the physician and enter it into the computer on the POS as the orders were obtained, and also put the start date and discontinued date as part of the order. -They would also discontinue orders per physician's orders in the computer as they occurred. -They would also update the order on the resident's Medication Administration Record (MAR). -All new physician's orders were discussed and passed along during report (in the morning and at shift change). -The nurse was responsible for double checking to ensure the order was correct. -The Director of Nursing (DON) and MDS Coordinator usually checked to ensure all of the orders were correct and on the POS. During an interview on 1/13/23 at 10:59 A.M., the DON said: -Once an order was given by the physician, the nurse inputs it into the computer on the POS. -If there was a stop date, they input that also otherwise it stayed in the system until the order was discontinued. -The physician reviewed all of the orders monthly. -The nurse would put the orders in to the computer system as he/she received them. -He/She does not complete a monthly review of the physician's orders monthly. -Resident #35 was receiving Hospice services prior to admission. -Resident #12 was admitted to Hospice services after he/she was admitted to the facility. -Both residents were still receiving Hospice services. -The physician's orders for Hospice services must not have been entered into the computer during the change over from their prior computer program to the current one. -The comprehensive care plan should show the residents were receiving Hospice services, what services they were receiving and the supportive services the facility was providing to the resident. -The nurses could update the resident's care plan to show care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reassess smoking safety for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated July 2017, titled Smoking Policy-Residents showed a resident's ability to smoke safely would be reevaluated quarterly, upon a significant change, and as determined by staff. 1. Record review of Resident #5's face sheet showed he/she was admitted with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Muscle spasm (muscle involuntary and forcibly contracts uncontrollably and can't relax). Record review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/4/22 showed: -The resident scored a 10 on his/her Brief Interview for Mental Status (BIMS), which indicated he/she was moderately cognitively intact. -Tobacco use was marked as 'yes'. Record review of the resident's Safe Smoking Evaluation dated 8/30/22 showed: -Staff last assessed the resident's smoking safety 8/30/22. -The resident could not light the cigarette safely or utilize the ashtray properly. -The resident could not extinguish a cigarette properly. -The resident required supervision while smoking. Record review of the resident's Quarterly MDS dated [DATE] showed: -The resident scored a 12 on his/her BIMS which indicated the resident was cognitively intact. -Tobacco use was not marked. Record review of the resident's care plan, dated 12/7/22, showed: -Staff were to complete a smoking assessment quarterly. -The resident required supervision while smoking. During an interview on 1/9/23 at 1:41 P.M., the resident said: -He/she smoked cigarettes. -He/she did not require the use of a smoking apron. Observation on 1/10/23 at 1:06 P.M. showed Certified Nursing Assistant (CNA) A took the resident outside to smoke. During an interview on 1/11/23 at 1:09 P.M., Licensed Practical Nurse (LPN) B said staff were to follow the resident's care plan for frequency of smoking assessments. During an interview on 1/11/23 at 1:51 P.M., LPN C said: -Staff were to perform smoking assessments for each resident every ninety days. -Smoking assessments were to be completed by the nurses. -The MDS Coordinator was responsible for ensuring smoking assessments were done on time. -Staff were to follow the resident's care plan for frequency of a smoking assessment. During an interview on 1/13/23 at 11:03 A.M., the Director of Nursing (DON) said: -Staff were to complete smoking assessments, for each resident that smoked, upon admission and quarterly. -A smoking assessment more than three months old would not be up to date. -Smoking assessments were generally performed by the MDS Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician's orders were accurate, complete, and followed for three sampled residents (Resident #5, Resident #240 and Resident #22) who utilized oxygen and a bilevel positive airway pressure machine (BiPAP, uses two settings with one for inhaling and one for exhaling), and to properly store oxygen equipment when not in use for two sampled residents (Resident #240, Resident #22) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated November 2014, titled Medication Orders showed staff were to record orders for oxygen with the rate of flow, route, and rationale. Record review of the facility's policy, dated April 2019, titled Administering Medications showed: -Staff were to check three times to verify he/she had the right resident, right medication, right dosage, right time, and right method of administration before giving a medication. -Staff were to record in the resident's medical record any complaints or symptoms for which the drug was administered. 1. Record review of Resident #5's face sheet showed he/she was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/25/22 showed the resident used oxygen while at the facility. Record review of the resident's Order Summary Report, dated 1/11/23, showed staff were to give 2 liters of oxygen via nasal cannula (medical tubing that has two prongs to enter the nostrils in order to provide supplemental oxygen therapy to people who have lower oxygen levels) to the resident, as needed, for shortness of air or wheezing. Record review of the resident's Treatment Administration Record (TAR), dated January 2023, showed staff did not sign any dates that month to show oxygen had been administered to the resident. Observation on 1/9/23 at 1:44 P.M. showed: -The resident was using oxygen via nasal cannula with the concentrator delivering 3 liters of oxygen. -NOTE: this was not the dosage of oxygen ordered. Observation on 1/11/23 at 10:21 A.M. showed: -The resident was not in his/her room but the oxygen concentrator was on and set at 3 liters. -NOTE: this was not the dosage of oxygen ordered. Observation on 1/11/23 at 1:21 P.M. showed: -The resident requested Licensed Practical Nurse (LPN) C to assist him/her to put on the nasal cannula to receive supplemental oxygen. -The oxygen concentrator was on and running at 3 liters. -The LPN did not adjust flow rate of oxygen. -NOTE: this was not the dosage of oxygen ordered. During an interview on 1/11/23 at 1:51 P.M., LPN C said: -Staff may have increased the resident's oxygen flow rate if he/she had trouble breathing. -He/she expected the physician to be notified and a new order received before increasing the oxygen flow rate. -He/she did not know the resident's oxygen concentrator was set for the wrong flow rate. 2. Record review of Resident #240's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). -COPD. -Acute Respiratory Failure with Hypoxia (when you do not have enough oxygen in your blood). Record review of the resident's Order Summary Report, dated January 2023, showed: -Oxygen up to 3 liters while at rest and up to 5 liters with activity. -The order did not specify route, reason for use, or parameters for increasing oxygen flow rate. -The resident's Bipap was not listed on the orders. Record review of the resident's Baseline Care Plan Summary, dated 1/7/23 and corrected by the MDS Coordinator on 1/13/23, showed: -The resident required the use of a Bilevel Positive Airway Pressure (Bipap (a type of non-invasive ventilation to support breathing, administered through a face mask. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in or out) . -Staff marked oxygen as a medication for this resident. Observation on 1/9/23 at 1:21 P.M. showed: -The resident was receiving oxygen via a nasal cannula from the oxygen concentrator. -The resident's bipap mask was on his/her nightstand with no dated protective barrier. -The resident's nasal cannula for his/her travel oxygen was wrapped around the traveling case without a barrier and undated. -The nasal cannula attached to the oxygen concentrator was not dated. -No bags were in the resident's room to be used for oxygen equipment storage. Observation on 1/10/23 at 1:39 P.M. showed: -The resident's bipap mask was in the nightstand drawer with no bag or barrier, remained undated. -The resident's nasal cannula attached to the oxygen concentrator had no bag for storage present and remained undated. Observation on 1/11/23 at 10:17 A.M. showed: -The resident's bipap mask was lying directly on the floor with no barrier and remained undated. -The resident was wearing his/her nasal cannula attached to the oxygen concentrator which remained undated and had no bag for storage when not in use. During an interview on 1/11/23 at 3:53 P.M., Nursing Assistant (NA) B said the charge nurse had been assisting the resident in using his/her bipap at night. Record review of the resident's Order Summary Report dated 1/23 showed staff had added an order on 1/12/23 at 7:00 P.M., to ensure the resident was wearing the bipap each night with 3 liters of oxygen connected to the bipap. Observation on 1/13/22 at 9:13 A.M. showed: -The resident's bipap mask was lying on the nightstand with no barrier but was now dated. -Nasal cannula attached to oxygen concentrator was lying against the concentrator with no barrier but bag for cannula was present and dated. 3. During an interview on 1/11/23 at 12:49 P.M., Certified Nursing Aide (CNA) B said: -Staff were to ensure a dated, plastic bag was attached to each oxygen delivery device for each resident. -All oxygen equipment was to be bagged when not in use. -CNA's were not allowed to adjust a resident's oxygen flow rate but were expected to know the flow rate and report to the nurse if machine was set incorrectly. During an interview on 1/11/23 at 12:58 P.M., NA A said: -Oxygen orders were found on the residents' care plans. -Staff were to ensure a dated, plastic bag was attached to each oxygen delivery device for each resident, regardless if in constant use. -Bipap masks were required to be placed in a plastic bag when not in use. -CNA's were not allowed to adjust a resident's oxygen flow rate but were expected to ask the charge nurse what the order was and notify him/her if that was not what the resident was receiving. During an interview on 1/11/23 at 1:09 P.M., LPN B said: -Staff were to ensure a dated, plastic bag was attached to each oxygen delivery device for each resident, regardless if in constant use. -Oxygen masks used for bipap machines were required to be stored in a dated, plastic bag. -He/she expected an order for oxygen use to include how many liters, method of delivery, and if titration was allowed, direction on when and how to titrate the oxygen. -He/she would expect to see directions for titration requiring additional information, such as oxygen saturation level or difficulty breathing. During an interview on 1/11/23 at 1:51 P.M., LPN C said: -Staff were to ensure a dated, plastic bag was attached to each oxygen delivery device for each resident, regardless if in constant use. -Nurses checked each resident's oxygen flow rate at the beginning of every shift to verify the flow rate matched the physician's orders. -He/she expected oxygen titration orders to include specific instructions on when to titrate and how much. During an interview on 1/13/23 at 11:03 A.M., the Director of Nursing (DON) said: -Staff were to ensure oxygen equipment was bagged when not in use. -Staff were to date disposable oxygen tubing (such as a nasal cannula or bipap mask) when he/she opened the packaging. -CNA's and NA's were responsible for ensuring oxygen equipment was put away properly each time they entered a room. -Nurses were responsible for ensuring each resident received the correct amount of oxygen at the beginning of each shift and any time they encountered a resident on oxygen. -Any resident utilizing a bipap should have an order for the bipap. -Oxygen orders were required to include the frequency of use, settings (if applicable), method of delivery, and reason for use. -He/she expected an order to be entered immediately at the start of use or prior to administration for any medication. -He/she expected oxygen orders that allowed titration to include monitoring of oxygen saturation and at what saturation point to increase or decrease the oxygen flow rate. -Staff should never allow a resident to receive more oxygen than is called for in the physician's order. 4. Record review of Resident #22 admission Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: -COPD. -Obstructive sleep apnea (a condition that occurs when the airway becomes narrow as the muscles relax during sleep which reduces oxygen in the blood and causes arousal from sleep). -He/she was his/her own person. Record review of the resident's personalized Care Plan dated 11/8/22 showed: -There was no care plan that addressed the BiPap. -There was no care plan that addressed the monitoring, cleaning and storage of the resident's BiPap. Record review of the resident's TAR dated 12/1/22 to 12/31/22 showed: -Oxygen at four liters via nasal cannula continuously every shift. -Facility staff were to change the oxygen tubing weekly on night shift every Thursday. -No physician's orders were transcribed for the BiPap machine, monitoring, or care for the BiPap oxygen supplies. Record review of the resident's POS dated January 2023 showed the resident: -Had a physician order dated 11/1/22 for oxygen at 4 liters via nasal cannula NC continuous every shift. -Had no physician's orders for the BiPap machine, monitoring, or care for the BiPap oxygen supplies Record review of the resident's TAR dated 1/1/23 to 1/11/23 showed: -Oxygen at four liters via nasal cannula flow continuous and monitor every shift. -Facility staff were change the oxygen tubing weekly during the night shift, on Thursday. -Did not have physician order for Bi-PAP machine, monitoring, or care of the machine or face mask. Observation on 1/9/23 at 10:00 A.M. showed: -The resident was in bed with the Bi-PAP mask in place and eyes closed. -The oxygen concentrator tubing was connected to BiPap machine in the resident's room. During an interview on 1/9/23 at 11:28 A.M., the resident said: -He/she had oxygen in place on a portable tank. -He/she was able to remove and store his/her oxygen nasal cannula and the BiPap machine and mask. -Nursing staff would change the oxygen tubing -He/she was not aware of the staff cleaning his/her BiPap nightly. -His/her oxygen concentrator tubing was connected and runs through the BiPap machine. -He/she had no current issues of shortage of portable tanks. Observation on 1/10/23 at 1:00 P.M., showed the resident's Bi-PAP mask was on top of his/her bed pillow uncovered. During an interview on 1/12/23 at 9:36 A.M., CNA D said: -He/she was unsure how the BiPap mask should be stored or how to care for the machine. -The resident provided most of his/her own care. -The night shift staff were assigned the cleaning task to include oxygen equipment. Record review of the resident's nurse's notes dated 1/12/2023 at 10:26 A.M. showed: -The resident's oxygen level was at 97% with oxygen via nasal cannula. -Had no documentation related to the monitoring of the BiPap machine or cleaning. During interview on 1/12/23 at 10:35 A.M. LPN D said: -The facility night shift staff were responsible for changing oxygen tubing and any cleaning of BiPap machines. -All facility care staff should ensure the storage of the resident's Bi-pap mask in a plastic bag when not in use. -Nursing staff would be responsible for obtaining a physician's order for the resident's BiPap machine and should include the settings, monitoring and cleaning of the machine and face mask daily. Observation on 1/13/23 at 9:54 A.M. showed the resident was sitting in bed with the BiPap mask in place. During an interview on 1/13/23 at 9:54 A.M. the resident said: -The BiPap machine was preset and he/she only had to turn on the machine when needed. -He/she was able to place the face mask on with any difficulty. During an interview on 1/13/22 at 9:58 A.M., CNA A said: -The resident was independent with most of his/her cares including the use of his/her BiPap machine. -He/she would notify nursing staff if he/she had any issues with the BiPap. -The nursing staff were responsible for changing the tubing and face mask for the resident BiPap machine. During interview on 1/13/23 at 10:14 A.M. LPN B said: -The resident was educated on how to setup his/her BiPap and was assessed by nursing staff for his/her ability to apply and remove the BiPap mask and to turn the BiPap machine on and off. -The machine was preset and the resident only had to push a button to turn the machine on or off. -He/she would expect the BiPap mask to be in a plastic bag when not in use. -The resident's BiPap should be cleaned by soaking the mask in warm water then let dry every day. -The BiPap tubing and oxygen tubing should be replaced every week. -The MDS coordinator would be responsible for updating the resident's care plan. -He/she would expect a physician's order for use of a BiPap machine. -The DON or MDS coordinator would complete any medical record audits. -He/she believed the DON was responsible for transcription of physician orders to include the BiPap order to the MAR/TAR. -Monitoring of the BiPap would be documented on the resident's TAR. -He/she did not remember documenting related to monitoring of the resident's BiPap. -The night shift TAR task would have shown as a physician order for monitoring or setup, and cleaning of the resident's BiPap machine. During an interview on 1/13/23 at 11:01 A.M. DON said: -Once a physician's order was given, the nurse would be responsible for inputting the order into the resident's electronic POS. -The physician reviewed all of the orders monthly. -The nursing staff were responsible for transcribing physician's orders received to the resident POS. -He/she did not complete a monthly review or audit of the resident's physician orders. -He/she would be responsible for follow-up on any physician's order for any changes after the POS had been reviewed during the Interdisciplinary Team (IDT) meeting and care plan meeting. -Nursing staff would responsible for ensuring physician orders had been transcribed to the resident's TAR and POS. -There should have been a physician order for his/her BiPap machine and the order should have been transcribed to his/her POS and TAR. -The order should include standard monitoring, care and diagnosis for use of a Bi-PAP machine. -Nursing staff would be expected to document on the residents TAR the monitoring and cleaning of the resident's BiPap. -He/she would expect to have documentation of the resident's ability's to apply and remove the BiPap facemask and the ability to start the BiPap machine. -A resident's BiPap mask should be in a bag when not in use. -He/she said the comprehensive care plan should show the resident had a a BiPap machine and what was required for the monitoring, care and cleaning of the BiPap machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide ongoing reassessment for behavioral management, to ensure the residents were free from potential inappropriate sexual and physically aggressive behaviors when implementing and re-evaluating interventions, to document the outcomes of preventive measure for effectiveness, and to prevent further occurrences of inappropriate physically aggressive and sexually inappropriate behaviors for two severely cognitively impaired residents, one sampled resident (Resident #26) and one supplemental resident (Resident #34) who were found by facility staff engaged in sexual activity on 10/31/22, 11/12/22 and 1/6/23, and an aggressive or inappropriate behavioral incident on 12/14/22, resulting in Resident #34 hitting Resident #26 on top of head with a bag of change causing Resident #26 to have a painful raised area on his/her head, out 14 sampled residents and nine supplemental residents. The facility census was 41 residents. A policy related to behavior management and dementia care was requested and not received at the time of exit. Record review of the facility undated Resident Self Determination, Capacity and Consent in Sexual Expression policy showed: -Each resident has the right to sexual expression such as but not limited to; hand holding, flirting or teasing, hugs and or kiss, signs of companionship or romantic affection and intercourse. -Consensual sexual expression with another individual requires consent. The resident must have the mental capacity to consent to sexual expression. Capacity is the ability to understand the nature and effects of one's act in a specific moment in time. To determine capacity relate to consent the facility will assess the resident : --The resident able to exhibit an understanding appreciation for the type of sexual expression they wish to engage in. --The resident was able to realize and rationalize the risk and benefits of engaging in sexual expression. --Inform the resident on how to report sexual abuse and their right to refuse sexual expression at any time and the right to voluntary sexual expression without coercion. -The resident must have mental capacity to consent to sexual expression. Capacity is the ability to understand the nature and effects of one's act in a specific moment in time. To determine capacity related to consent the facility will assess the resident. -Capacity to consent to sexual expression will be monitored and re-evaluated over-time as needed on the individual resident's physical, mental and psychosocial needs. -The facility determining capacity for consent to sexual expression should not be determined by a single individual: --Assessing the resident capacity and ability to consent for sexual expression. --The Interdisciplinary Team (IDT) and/or physician to determine the resident's capacity, benefits and potential for harm related to sexual expression. --Consulting the resident family member or guardian to assist with determining capacity and consent relate to sexual expression. -The facility will determining appropriate verses inappropriate sexual expression include: --Any sexual expression involving a resident that has been deemed unable to consent or lacks the capacity to consent would be inappropriate sexual expression. Any expression that was involuntary, non-consensual or coerced is inappropriate sexual expression. -The facility will document in all involved parties health record, how capacity was determined, consent amongst all parties involved was verbalized and understood and that resident rights and sexual abuse was discussed. -The facility will educate and support the resident rights to sexual expression by educating family, legal representative if resident has cognitive impairment and staff on resident rights, protecting the resident from sexual abuse and reporting to management, safety and risk to include but not limited to sexually transmitted infection injury or falls and Identify hyper-sexuality (a human's need to express intimacy but, describes a person's inability to control their sexual behavior), sexual disinhibition (is inappropriate sexual behavior, but persons with dementia may not know how to appropriately meet their needs for closeness and intimacy) and other sexually related physical and cognitive issues resident may have an effect on sexual expression. 1. Record review of Resident #26's Face Sheet showed the resident was admitted to the facility on [DATE], with a diagnosis of: -Stroke (mild). -He/she had a legal guardian. Record review of the resident's nursing note dated 10/31/22 at 1:35 P.M., showed: -His/her guardian and Public Administrator (PA, court appointed guardian) was called and made aware of him/her attempting to be sexually involved with another resident (Resident #34). -It was explained that he/she had been seen kissing on Resident #34, and Resident #34's had his/her hands in inappropriate places on Resident #26's body. -Both residents have been seen attempting to go to each other's rooms with each other and they have been redirected each time with all these behaviors. -The PA did not have any further comments outside of his/her appreciation for us watching them and keeping them safe. -The resident's physicians were aware as well, and had no new orders at that time. Record review of the resident's medical record showed: -Did not have a comprehensive assessment documented to evaluate Resident #26's capacity to consent for consensual sexual expression and finding from the evaluation. Record review of the resident's Behavioral Monitoring Report dated 11/2/22 showed the resident had a check mark by public sexual acts. Record review of the resident's facility care plan initiated on 11/3/22 showed: -Had a history of a brain tumor causing impulsive behaviors. -He/She had a sexual behavior issue on 10/31/22. -He/she would have fewer episodes of sexual behaviors by review date. -The resident's interventions included: --The facility staff were to praise any indication of his/her progress or improvement in decreasing the sexual behaviors and was revised on 11/3/22. --Facility staff were to provide a program of activities that was of interest and accommodated the resident's status and was revised on 11/3/22. --The facility staff were to discuss inappropriate behaviors. Explain and reinforce to the resident why the behavior was inappropriate and/or unacceptable revised on 11/3/22. --The facility staff were to minimize potential for the resident's sexual behaviors by offering tasks that would divert his/her attention such as music, reminiscing. Remove from the situation was initiated on 11/3/22. -No indication or documentation with details on how the resident was sexually acting out. -Did not indicate the resident had the capacity to consent to having a consensual sexual relationship. Record review of the resident's Nursing Behavioral Monitoring and Intervention Report dated 11/12/22 showed documentation of a check mark for no behaviors observed that day. Record review of the resident's medical record showed no documentation related to the incident with Resident #34 on 11/12/22. Record review of the resident's behavioral note dated 11/18/22 at 2:40 p.m. showed: -The resident continued on Paxil (an antidepressant that belongs to group of drugs called selective serotonin reuptake inhibitors), Trazodone (is an antidepressant), Hydroxyzine (is a antihistamine that is used to help control anxiety and tension caused by nervous and emotional conditions) and Risperidone (is an antipsychotic medicine that works by changing the effects of chemicals in the brain) related to the resident's diagnosis of Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) and Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Had no changes in dose or frequency. He/she had no depressive behaviors noted. Resident exhibited anxious and autistic behaviors. He/she responded well to redirection. -He/she had other interventions in place including keeping a consistent schedule, avoiding changes in routine, allowing the resident enough time to process and respond to tasks and requests that were asked of him/her. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/2/22, showed the resident: -Was severely cognitively impaired and his/her Brief Interview Mental Status (BIMS) score was of 6 out of 15. -Was able to understand others and was able to make his/her needs known. -Required limited assistance of one staff member with personal cares and transfers. -Had no behaviors indicated affecting other residents. Record review of the resident's Health Status Note date 12/14/22 at 2:40 A.M. showed: -He/she was at a table in the dining area and was kissing another resident (Resident #34). -The nurse separated the residents. Informed them that they could not be kissing in the dining room. -Resident #26 had followed the nurse to the nursing station and was talking to the nurse. Then Resident #34 walked over to Resident #26 and hit him/her over the head with a baggie of change. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34 had then began to curse at Resident #26. -The nurse had noticed a knot on top of Resident #26's head. Resident #26 was noted to have pain and Tylenol (pain medication) was administered. Record review of the resident's Nursing Behavioral Monitoring and Intervention Report dated 12/14/22 showed a check mark indicating no behaviors were observed that day. Record review of the resident's care plan had no updated documentation related to the incident on 12/14/22. Record review of the resident's Nursing Incident Note dated 1/6/23 at 2:56 P.M. showed: -Resident #26 was found in his/her room with another resident (Resident #34) having sexual intercourse. -One of the residents had accidentally pressed the call light causing Certified Nurses Aide(CNA) C to find Resident #26 and another resident (Resident #34) having sex. -The residents' guardians were notified of the incident. Record review of the resident's Behavioral Monitoring Report dated 1/6/23 showed the resident had no documentation related to the sexual behavior incident with Resident #34. Record review of the resident's medical record showed: -He/she did not have a comprehensive assessment completed to evaluate his/her capacity to consent for consensual sexual expression. -There was nothing to indicate the resident had the capacity to consent to be in a consensual sexual relationship. During an interview on 1/11/23 at 2:24 P.M., the resident's Public Administrator (PA) said; -He/she had been made aware of the resident's sexual behavioral incident on 1/6/23 and the resident had other sexual contact with the same resident in the past. -He/she felt the facility was doing their best in monitoring the resident. -He/she would prefer the resident not be in a sexual relationship with another resident. -The resident had required supervision and assistance by facility care staff due to his/her very short memory. -He/She had been invited to the resident's care plan meeting which included his/her behavioral care plan. -Interventions would include to try keep the residents separated and avoid the potential of sexual contact. -He/she realized the facility may not be able to prevent sexual contact but he/she would hope the sexual relationship would not happen again. -The resident and Resident #34 had the same interactive behaviors toward each other for last few months. 2. Record review of Resident #34's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses of: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety. -Depression. -He/she had a guardian. Record review of the resident's medical record showed there was no comprehensive assessment documented to evaluate his/her capacity to consent for consensual sexual expression and finding from the evaluation. Record review of the resident's Personalized Care Plan dated 11/2/22 showed the resident: -Had a history of dementia and impaired thought processes related to a diagnosis of dementia and had impaired decision making. -Had displayed inappropriate sexual behaviors with staff and peers initiated on 11/2/22. -Goal was to have fewer episodes of sexual behaviors by the next review date. -Interventions revised on 11/2/22 included: --Administer medications as ordered. Monitor/document for side effects and effectiveness --If reasonable, discuss the resident's behavior. Facility staff were to explain and reinforce why the behavior was inappropriate and/or unacceptable for the resident and his/her family. --Facility staff were to intervene as necessary to protect the rights and safety of the resident and others residents. -The facility staff were to approach and speak in a calm manner to the resident. -Facility staff were to try to divert the attention of the resident and remove the resident from the situation and take the resident to an alternate location as needed. -The facility care plan had no indication or documentation with details of how the resident was sexually acting out and with whom. Record review of the resident's Behavioral Note dated 11/12/22 at 9:30 P.M. showed: -He/she and another resident (Resident #26) came to this nurse in the evening and this resident's asked if they could go to bed together. -The nurse responded that they were not allowed to go into each other's rooms and they both had roommates. -This nurse explained that they could sit in the main dining room at the same table and could visit with each other but were not allowed to go into each other's rooms. -Resident #34 became agitated and upset asking which family member said he/she could not have sex and said he/she was a grown adult who could sleep with whomever he/she chose. -The facility staff were able to distract Resident #34 with a snack and being able to sit together in the dining room. -The facility staff were able redirect Resident #26 and he/she had showed no signs and symptoms of agitation or becoming upset. Record review of the resident's Behavioral Note dated 11/12/22 at 9:37 P.M. showed: -The resident was observed by this nurse to be raising his/her shirt in the main dining area and showing other residents his/her body parts. -This nurse quickly intervened and instructed the resident that that behavior was not allowed and if it happened again he/she would have to go to his/her room. -Resident covered himself/herself, stated he/she was sorry and he/she understood. -About five minutes later, he/she again raised his/her shirt and began squeezing his/her breasts towards another resident. -This nurse again stated to the resident that that was inappropriate behavior and he/she would have to leave the dining room. -The resident put his/her top down and walked with this nurse to his/her room. -While walking down the hallway, he/she stated to this nurse that he/she would not have to show his/her body parts if this nurse would only let him/her and his/her friend have sex. -The resident was escorted to his/her room where he/she was assisted with toileting and then went to bed. -The resident did not appear upset or agitated with removal from the main dining area and the resident had returned to the dining room after about 30 minutes later. -No further behaviors noted thus far. Record review of the resident's Nursing Behavioral Monitoring and Intervention Report dated 11/12/22 showed documentation of a check mark indicating no behaviors observed that day. Record review of the resident's Physician Visit Summary Note dated 12/13/22 at 11:48 A.M., showed the resident: -Had a diagnosis of sexual inappropriateness, dementia and hyper-sexuality. -Continued to have difficulties with sexual inappropriateness. -Medication had been initiated to decrease the libido (is the part of their personality that is considered to cause their emotional, especially sexual, desires) and sex drive. -He/she seemed to be inappropriate with a male/female resident at the facility. -He/she was anxious and would wander at times and get upset easily. -The plan was medication adjustment, monitor very closely and family members have to be updated and aware of the resident sexual behaviors. -Nursing staff would notify the physician if any issues or problem occurred. Record review of the resident's Behavioral Note dated 12/14/22 at 2:34 A.M. showed: -The resident was seen being very intimate and physically close to another resident (Resident #26) at the dining area table. -Resident #26 then propelled himself/herself to the nursing station. -Resident #26 was talking with the nurse when all of a sudden Resident #34 took a baggie full of change and proceeded to hit Resident #26 over the head. -Resident #34 had cursed at Resident #26. -The nurse immediately pulled Resident #34 away from Resident #26. -Nurse redirected Resident #34 to his/her room and informed him/her that hitting was not appropriate behavior. -Resident #34 family member was notified of the incident. Record review of the resident's Care Plan dated 12/14/22 showed: -The resident had become and was at risk for further physically aggression of hitting another resident (Resident #26), related to the resident's anger dementia and poor impulse control. -Interventions included administer dementia medication as ordered (family did not agree to antipsychotic mediation). --When he/she became agitated, the facility staff were to intervene before agitation escalated, and were to guide the resident away from the source of distress, engage calmly in conversation. If the resident response was aggressive, staff should walk calmly away and reproach the resident later. --He/she enjoyed coloring, offer color pages as a distraction. Record review of the resident's Behavioral Note dated 12/14/22 at 4:43 P.M. showed: -The resident was seen being very intimate and physically close to another resident (Resident #26). -He/she had recently hit the other resident in the head (on the morning of 12/14/22) for what appeared to be jealousy of Resident #26, who was speaking to another resident. -He/she seemed to not understand due to his/her baseline confusion. -He/she was directed to sit at another table of the same gender and Resident #26 was to sit at a different same gender table. -He/she at first had followed these instructions, but was soon seen again repeating these behaviors with the other resident, who was also confused, and he/she was seen following him/her around the dining hall and stepping in between him/her and any other resident he/she was near. -Anytime Resident #26 would speak to another resident, Resident #34's facial expression would turn to anger and he/she would stare that resident down angrily. -Once Resident #34 had begun those behaviors again with Resident #26 after being told to keep his/her distance, this nurse again explained to Resident #34 that he/she needed to not be around this other resident. -Resident #34 then became aggravated and began to raise his/her voice saying that's my boyfriend/girlfriend, you cannot keep me away and you can't have him/her. -This nurse then walked Resident #34 to his/her room to explain to him/her that he/she had recently hurt Resident #26, and the family and his/her physician had requested he/she stay separated from Resident #26. -This nurse had called Resident #34's family member to reiterate the above. After the phone call, Resident #34 stated he/she understood why staff were asking him/her to stay away from Resident #26 for now. -About 10 minutes later, Resident #34 was seen following Resident #26 back to his/her room and became frustrated again when he/she was redirected and explained he/she could not go to the other resident's room. -This nurse offered to call Resident #34's family member again to explain. -Resident #34 began asking if he/she was a prisoner here because he/she can't do anything. -This nurse said he/she was only being asked to not be around one resident, and that he/she was free to sit wherever else he/she would like. -Resident #34 then sat down and ate his/her dinner, only after Resident #26 went back into his/her room and was out of sight of Resident #34. Record review of the resident's Nursing Behavioral Monitoring and Intervention Report dated 12/14/22 showed: -Documentation of a check mark by hitting, cursing at others, and public sexual acts, -No documentation of what intervention was attempted and what the outcome was. Record review of the resident's Quarterly MDS dated [DATE], showed the resident: -Had a diagnosis of dementia. -Had severe cognitive impairment and he/she had a BIMS of 3 out 15 -Was able to understand others and able to make his/her needs known. -Was independent with ambulation and transfers. -No behaviors indicated affecting other residents. Record review of the resident's Nursing Behavioral Monitoring and Intervention Report dated 1/1/23 to 1/12/23 showed: -On 1/2/23 there was a check mark by accusing, cursing at others, expressed frustration or anger at others. -On 1/6/23 there was a check mark by public sexual acts, entering other resident's rooms or personal space. -On 1/7/23 there was a check mark by cursing at others expressed frustration or anger at others, threatening others, disrobing in public, personal space and public sexual acts. -No documentation of what interventions were attempted and what the outcome was. Record review of the resident's Nursing Incident Note dated 1/6/23 at 2:54 P.M. showed: -The resident was found in Resident #26's room having sexual intercourse. -One of the residents had accidentally pressed the call light which caused CNA C to go answer the call light. -CNA C had found the residents engaging in sexual intercourse. -The resident's family member and guardian had been notified. Record review of the resident's medical record showed: -There was no comprehensive assessment completed to evaluate his/her capacity to consent for consensual sexual expression. -There was nothing to indicate the resident had the capacity to consent to be in a consensual sexual relationship. During an interview on 1/12/23 at 11:14 A.M., Resident #34's guardian said: -He/she was aware of the incident on 1/6/23 of the alleged sexual encounter. -The resident used to sit at the same table with male/female resident for meals and games. -He/she understood an intervention was to place to have the resident sit at the same gender table and other resident at the same gender table. -The facility staff were to watch the resident as he/she was starting to leave the dining room to ensure the resident was not going down the other resident's hallway. -He/she felt the facility staff were trying to keep the resident separated from the other resident as much as possible. -He/she knew this sexual expression may happen while at the facility but preferred the facility to continue to discourage the resident's relationship with another resident. -The resident was very vague related to friend details. -The resident had a diagnosis of dementia that caused memory issues, the resident easily forgets. -The only other final intervention option for the resident would be finding a new facility for dementia care or this facility provided ongoing 1:1 staffing. -He/she felt the resident did not have the capacity to consent for consensual relationship but the resident had the ability's to interact with the resident. -The resident was not able to make good choices and had poor judgement as a part his/her disease process. -The only new behavior since diagnosis of dementia was flashing of body part and swing at a resident. 3. During an interview on 1/11/23 at 10:48 A.M., Housekeeper A said: -He/she was informed to let nursing staff know if he/she found resident's together in bedrooms. -The facility staff were to ensure Resident #26 and Resident #34 did not go onto each other bedrooms. -The facility staff were to redirect the residents from touching each other, such as holding hands. During interview on 1/11/23 at 10:59 A.M., the Care Partner said: -If he/she had noticed or found a resident in sexual interaction with another resident, he/she would report to the charge nurse. -He/she had not seen Resident #26 and Resident #34 in sexual contact. -He/she was instructed to monitor Resident #26 and Resident #34 to make sure they did not go into each other resident's room or hallway. -He/She had seen a change in Resident #26 staying in his/her room more after family member had moved from the facility. During an interview on 1/11/23 at 10:55 AM, the Administrator said: -Resident #34 had been in a relationship with Resident #26 for a while. -Review in the facility policy he/she felt the facility had followed guidelines to review and determine if either of the residents had the capacity to consent to consensual sexual relationship. -The Interdisciplinary Team (IDT, is a professionals plan, coordinate and deliver of resident's personalized health care) resident's physician, family member and/or guardians had been having discussions related to the residents sexual behavior and relationship. -Resident #34 had a history of exposing body parts to the administrator and other staff members. -Resident #34's sexual behavior had been an issue for a while that could have started around November 2022. -The facility had documentation of Resident #34's inappropriate sexual behaviors in his/her nursing notes. -Resident #34 had medication changes by his/her physician but continued ongoing sexual behavior. -The residents' families and Power of Attorney (POA) were aware of Resident #34's and Resident #26's continued relationship and sexual behaviors. -The residents' physician was aware of Resident #34's behavior. -The families and guardian had voiced that it was difficult to stopping the residents relationship. -Resident #26 and Resident #34 have not been reported as having sexual behaviors toward other facility residents. -Resident #34 was the instigator in the two resident's relationship. -The facility had tried to keep Resident #34 and Resident #26 separated as much as possible and to ensure they stay on opposite units. -The facility IDT had met regarding the sexual incident on 1/6/23 between Resident #34 and Resident #26 and was working on a plan to assess and ensure that both residents wanted to continue their relationship and assess the safety of the residents and assess if Resident #26 and Resident #34 had the capacity to consent to consensual relationship. -He/she was not aware if the facility had a formal Capacity to Consent assessment form to complete related to the residents capability to consent to consensual sexual relationship. During an interview on 1/11/23 at 12:26 P.M., CNA B said: -The CNA's had been instructed to try to ensure Resident #34 and Resident #26 did not have personal contact and were to redirect the residents as needed. -He/she would report any sexual contact or behaviors to the charge nurse, and ensure the residents were safe and separated. During interview on 1/11/23 at 2:46 P.M., Licensed Practical Nurse (LPN) C said: -Resident #26 and Resident #34 had been up in dining area for meals and then were separated and instructed by facility care staff to go to their own bedrooms and were directed to their bedrooms. -Resident #26 had headed toward his/her room on a different hallway. -The facility staff had assumed both residents were in their own rooms. -During that time, somehow Resident #34 had made his/her way back to Resident #26's room. -The facility staff were not aware Resident #34 was in Resident #26's room at that time. -CNA C had reported that Resident #34 had his/her legs up in the air while laying on Resident #26's bed. -Resident #26 had his/her pants down around his/her ankles and was in between Resident #34's legs. -The sexual incident happened on Resident #26's bed, which nursing staff should have been able to see on the video monitor located at the nursing station. -CNA C and LPN C had redirected Resident #34 to go to the main dining area. -Facility staff then redirected Resident #34 to his/her own room. -The residents' physician was made aware of the incident and had known about both residents past history of sexual behaviors toward each other. -Resident #34 and Resident #26 had been seen flirting between each other. -The facility staff had been instructed to redirect Resident #26 and Resident #34 from their sexual behaviors and ensure to separate the residents as needed. -Resident #26 was a big flirt and he/she loved the attention of opposite gender. -Resident #34 had taken the flirty behavior too far at times to include trying to touch the resident or take Resident #26 back to his/her room. -Resident #34 was easily upset and could became verbally aggressive when Resident #26 would pay attention to other residents of the opposite gender. -He/she was made aware of another sexual behavioral incident between Resident #34 and Resident #26 in the past, but was unsure of the date. -Resident #26 and Resident #34's care plan interventions were to redirect the residents and to avoid physical contact between the two residents and to discourage their relationship. During an interview on 1/11/23 at 1:06 P.M., CNA C said: -He/she found Resident #34 lying on his/her back on Resident #26's bed. -Resident #34 had his/her pants around one ankle and with his/her legs spread apart and feet up in the air. -Resident # 26 had his/her pants down and was in between Resident #34's legs and was leaning over Resident #34 as he/she was starting to have sexual intercourse with Resident #34. -He/she found the resident's together just in time before they had completed sexual intercourse. -He/she had informed both residents that this was not appropriate behavior and both residents needed to get dressed. -He/She was not aware if Resident #26 and Resident #34 were in a relationship either sexual or as friends. -Resident #34 had a diagnosis of dementia and was confused at times. -Resident #34 had thought he/she was in a relationship with Resident #26 as a married couple at times. -1/6/23 was not the first time Resident #26 and Resident #34 had sexual touching between each other. -He/she had been instructed that the residents could sit by each other in main dining area but were not allowed to touch each other. CNA's and other facility staff were to try and redirect the residents and remove the residents from the situation. During an interview on 1/11/23 at 2:50 P.M., CNA B and Nursing Assistant (NA) A said: -Resident #34 was able to make his/her need known related to activities of daily living. -CNA's would redirect Resident #34 by offering him/her a coloring book, looking out window or remove from area. -CNA's would explain to each resident that was not appropriate behavior and why they needed to separate them. -Resident #26 could make his/her needs k

Based on observation, interview and record review, the facility failed to ensure food containers in the resident use refrigerator, were labeled with the resident 's name and the date it was received and to prevent the storage of staff's food in the resident use refrigerator. This practice potentially affected at least five residents who allowed their food to be stored in the refrigerator. The facility census was 41 residents. Record review of the facility's policy entitled Foods Brought by Family/Visitors, dated 10/2017, showed: - Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable form facility prepared food. - Non-perishable foods will be stored in resealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. - Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator. - Containers will be labeled with the resident's name, the item and the use by date. 1. Observation of the resident use refrigerator on 1/9/23 from 12:24 P.M. through 12:34 P.M., showed: - One gray covered container without a name and date. - One container of citrus punch without a name and date. - One package of microwaveable turnovers generally containing one or more types of cheese, meat, or vegetables, which was not labeled. - Two staff lunch containers with food but not labeled with their names. - A sandwich that had a resident's name but no date. During an interview on 1/9/23 at 12:34 P.M., Licensed practical Nurse (LPN) B said the resident to whom the sandwich belonged, was admitted on the previous weekend. During an interview on 1/9/23 at 12:37 P.M., the Dietary Manager (DM) said the dietary department did not have anything to do with the resident food storage refrigerator. During an interview on 1/10/23 at 12:02 P.M., the Director of Nursing (DON) said he/she expected staff to label and date food, when it was handed to them, to place in that refrigerator and he/she did not expect facility staff to keep their personal food in the resident use fridge.

Based on observation and interview, the facility failed to store dishes in a manner to prevent contamination; to ensure two ceiling vents were free from a buildup of dust; to label four containers with the contents of what was in those containers; to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) one of the reach-in refrigerators; to maintain the blade portion of a spatula in an easily condition; and to maintain the stovetop free of a heavy buildup of food debris and grease. This practice potentially affected all residents. The facility census was 41 residents. 1. Observations on 1/9/23 from 9:22 A.M. through 12:55 P.M., showed: -Two ceiling vents over dishwasher with a heavy buildup of dust inside those vents. -Five pitchers were stored on top of a refrigerator with the container side facing up. -One stainless steel container with contents that had no identifying label, one bottle of a clear liquid with no identifying label and one bottle with a white powdery substance with no identifying label. -One damaged spatula with a burnt section which made the spatula not easily cleanable. -An 8 and 1/4 inch (in.) rip in the gasket of the double door of one of the reach in refrigerator. During an interview on 1/9/23 at 9:53 A.M., the Dietary Manager (DM) said: -There was a salt-free seasoning blend in the stainless steel container and vinegar in the clear bottle, and in the past, he/she had a hard time getting a label to stick to the glass. -He/she would have to contact the manufacturer about the torn gasket and he/she did not notice the tor gasket before that day (1/9/23) during the observation. -He/she checked for outdated items on Mondays or Fridays depending on how busy he/she was. During an interview on 1/9/23 at 12:41 P.M., Dietary Aide (DA) A said if they saw that something that was not labeled, the dietary staff try to get it labeled quickly, because no one wants to guess what the item was. During an interview on 1/9/23 at 1:14 P.M., the DM said the Maintenance Department was notified two weeks ago about cleaning the vents. They cleaned those vents about two weeks ago and he/she has not notified the Maintenance department since then. During an interview on 1/9/23 at 1:18 P.M., the Dietary [NAME] (DC) said he/she cleaned the stove about two weeks ago. During an interview on 1/9/23 at 1:20 P.M., the DM said: -He/she expected facility staff to label containers with their contents and -The pitchers should be stored upside down and normally there were not that many stored on top of the fridge up there because they used those containers for lemonade or other drinks.

2. Record review of the the facility policy titled Handwashing/Hand Hygiene, dated 2001, showed: -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: --Before preparing or handling medications. The facility policy titled Administering Medications, dated April 2019, showed staff should follow established facility infection control procedures (e.g, handwashing, antiseptic technique, gloves, etc.) for the administration of medications, as applicable. A facility policy titled undated Infection Control Guidelines for All Nursing Procedures showed: -In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. -If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: --Before preparing and handling medications. Observation of a medication pass on 1/10/23 at 2:22 P.M., showed Licensed Practical Nurse (LPN) B: -Sanitized his/her hands before starting the medication pass. -Opened a bottle of Acetaminophen 325 mg and poured two tablets into the medication cup. -One pill fell out of the bottle when pouring out the Acetaminophen 325 mg. -He/she then picked up the pill with his/her bare hands and placed the pill back into the bottle of the Acetaminophen 325 mg. -He/she then gave the medication to Resident #240 and sanitized his/her hands. During an interview on 1/10/23 at 2:30 P.M., LPN B said: -He/she would wash/sanitize his/her hands before and after each resident's medication pass. -He/she would wear gloves during the medication pass if the medication indicated glove usage. -If a pill was dropped on the medication cart he/she would use gloves to pick up the medication. -If the medication was an over-the-counter (OTC) medication he/she would just throw the pill away and not put the medication back into the medication bottle. During an interview on 1/13/23 at 11:03 A.M. the Director of Nursing (DON) said: -Dropped medication, even if it is only on the medication cart cannot be put back into the medication bottle. -He/she would expect staff to have gloves on when in physical contact with a medication. Based on observation, interview, and record review, the facility failed to ensure its Water Management Plan outlined plans for implementing testing protocols and plans for corrective actions that the facility would implement as a result of changes in municipal or facility water quality; and to ensure proper hand hygiene was performed during a medication pass. The facility census was 41 residents. 1. Record review of the guidance outlined in the Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated June 2015, showed: -On page three, obtain a written copy of the program policy. -On page five, does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)? -Page 14, is there a standard operating procedure (SOP) for shutting down, isolating, and refilling/flushing for water service areas that have been subjected to repair and/or construction interruptions. Record review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Record review of the facility's Legionella Water Management Plan reviewed on 9/2022 showed the absence of corrective actions that would be taken if there were changes in water quality due to a water main break or construction. During an interview on 1/9/23 at 2:57 P.M. the Administrator said: -The facility had 222 gallons of emergency water in storage located in the Dietary Manager's/Environmental Services Director's office. -Facility personnel including him/her, would contact suppliers that could bring in extra water if needed depending on how long a repair would take. -Contact information for the municipal entities that could repair the water were located in the disaster plan, but not in the Legionella plan. -It was also expected (and outlined in the disaster plan) that the facility staff would test the water for proper chlorination levels, when water service was restored to the facility. Further record review of the facility's disaster plan, reviewed in December 2022, showed the absence of the location and the quantity of emergency water within the facility and the absence of how the facility would test the water for proper chlorination levels. Record review of the facility's Legionella Water Management Plan showed the absence of specific actions which the facility would undertake in response to a Legionella positive water sample. During an interview on 1/9/23 at 3:11 P.M., the Administrator said he/she had looked at the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standards in the past, but did not incorporate those requirements into the facility's Legionella plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record Review of Resident #3's admission Face Sheet showed he/she was readmitted to the facility on [DATE] with the following diagnoses: -Pneumonia (inflammation of one or both lungs with consolidation). -Thrombocytopenia (is low blood counts, which can cause bleeding into the tissues, bruising, and slow blood clotting after injury). -Adult failure to thrive (state of decline in elderly patients that's characterized by weight loss, decreased appetite, poor nutrition, and inactivity). Record review of the resident's Hospice Care Plan reviewed 1/24/20 showed, the resident: -Had chosen to receive hospice care services. -Will experience a peaceful, dignified death. -Will remain comfortable throughout hospice care. -Interventions included: --Assist the resident with setting up hospice services by nursing and social services. --Nursing staff will coordinate resident's care with hospice team, and will call hospice staff for any concerns/questions 24 hours a day seven days a week. --Facility nursing staff will coordinate with the hospice team to assure resident experiences as little pain as possible. --Nursing staff will ensure to provide resident and family with grief and spiritual counseling if desired. --Hospice are to provide the resident with an oxygen concentrator, nebulizer, oral suction machine, briefs, dressing change supplies, disposable pads and personal care items. --Hospice nurse staff are to visit twice weekly and PRN (as needed). --Hospice aid to visit 3 times per week and PRN. --Hospice Social Worker to visit monthly and PRN. --Had a signed DO NOT RESITUATE (DNR) placed in his/her medical chart. --Hospice chaplain are to visit monthly and PRN. --Family was undecided about funeral home, will update as informed. Record review of the resident's Personal Care Plan reviewed 1/24/20 showed, the resident: -Required assistance from staff with grooming and personal hygiene. -Goal was for the resident to continue to be able to groom self with set up help only. -The resident's interventions included --Hospice to provide additional showers through the week, if and when agreeable by the resident. Record review of the resident's Hospice Care Note Book showed the resident: -Had a DNR signed 1/3/20 and was on comfort measure. -Last hospice note assessment was dated 3/10/20. -Last hospice aid visit was on 3/16/20 and the resident had refused a shower, other cares provide by hospice aid to include, assisted the resident with personal cares. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Had a BIMS score of 15 out of 15 and had no cognitive impairment. -Was independent with his/her mobility with wheelchair. -Required supervisor assist by staff with transfer and cares. -Required hospice services while a resident at the facility. -Prognosis was not marked for his/her life expectancy of less than 6 months. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Had a BIMS score of 14 out of 15 and had no cognitive impairment. -Was independent with his/her mobility with wheelchair. -Required supervisor assist by staff with transfer and cares. -Required hospice services while a resident at the facility. -Prognosis had marked his/her life expectancy of less than 6 months. Record review of the resident's Care Plan meeting progress note dated 9/24/2020 at 9:16 A.M. showed his/her care plan held with Inter Disciplinary Team (IDT) members and family member via phone conference. The resident remained a DNR and was on hospice service. Record review of the resident's social service notes dated 9/24/2020 at 4:18 PM, showed: -Had a Care plan meeting was held with IDT members and family member by phone conference. -The resident continued to be a DNR for code status and remained on hospice services. -His/Her child planned on the resident of staying at the facility in the long term and was very happy with the cares the resident had received at the facility. -No social service concerns or questions. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Had a BIMS score of 11 and had moderate cognitive impairment. -Was independent with his/her mobility with wheelchair. -Required supervisor assist by staff with transfer and cares. -Required hospice services while a resident at the facility. -Prognosis had marked his/her life expectancy of less than 6 months. During an interview on 11/09/20 at 9:55 A.M., the resident said he/she had not seen hospice nurse for a while since COVID-19 started. On 11/13/20 at 9:51 A.M. requested any additional hospice notes, no other hospice notes were found. 3. During an interview on 11/10/20 at 11:20 A.M., Licensed Practical Nurse (LPN) B said: -Hospice workers were not allowed to visit. -Hospice called weekly for updates. During an interview on 11/13/20 at 10:30 A.M., Certified Nursing Assistant (CNA) A said he/she had not seen hospice staff in the facility for a while due to COVID-19. During an interview on 11/13/20 at 10:35 A.M., LPN A said: -Hospice staff were not allowed to come into to the facility at that time. -The hospice nursing staff could provide telehealth visit as needed. -The facility nursing staff updated the hospice nurse when there had been a change in condition in the resident. -Normally the resident's hospice nurse would call in for an update on the resident. -The nursing staff do not always document the communication with hospice nursing staff in the resident's progress notes. During an interview on 11/13/20 at 12:37 P.M., the Director of Nursing (DON) and Regional Nurse said: -Hospice had not been allowed in the building since start of COVID-19 around end of March 2020, except for end of life care. -Compassionate care had been allowed as needed. -Hospice policy surrounding COVID-19 in the Infection Control binder was not specific to COVID-19. -Discussions were being done to decide if/when hospice could be allowed in the building. -Hospice had been participating in telehealth and phone consults. -Hospice services visits pre-COVID-19 would be in the hospice binder. -The nursing staff would contact the resident's hospice nursing staff with any change of condition. -The nursing staff may have a brief contact with hospice staff if the resident needed any supplies or other services. -Would expect facility nursing staff to document any hospice conversations in the resident's nurse's notes. -The DON said that Resident #3's hospice staff had called for updates on the resident. -He/she was not aware of documentation of those contacts. -They were not aware of any other documentation or care plan updated of changes with COVID hospice visit decrease and type of care provided. -The facility followed the Center for Disease Control and Prevention (CDC) and Department of Health and Senior Services (DHSS) guidelines for COVID-19 visitation guideline related to essential workers and hospices services for hospice residents. -Was aware of the CMS newest guidelines as of 9/17/20. -Corporate office updates the facility of any COVID-19 CMS/CDC changes. -Currently the facility's county was in the red zone and they were testing employee's two times a week of block testing. -The facility interpretation of the CMS guidelines were the facility was still to restrict visitation of non-essential staff including hospice staff due to the county red zone. -The facility had not had any resident's positive with COVID-19 and only one staff member. During an interview on 11/13/20 at 1:40 P.M., the MDS Coordinator said: -COVID-19 care plan was on a paper care plan. -Hospice staff were contacted by virtual visit and should be documented in the resident's progress notes. -Resident #3 hospice care plan was not updated to reflect the changes of decrease hospice visits and related COVID-19 protocol. During a phone interview on 11/17/20 at 10:28 A.M., Hospice Agency staff said: -The hospice nursing staff had not been making onsite visits for Resident #3. -The facility had not allowed hospice staff to enter the facility. -Hospice nurse had been making contact with the facility nursing staff two times a week for updates on the resident. -Hospice had not been able to update the resident's facility hospice medical record due not being allowed onsite visits. Based on interview and record review, the facility failed to develop a policy regarding hospice (end of life care) visits and to allow hospice visits for two sampled residents (Residents #24 and #3) out of two residents sampled for hospice services. The facility identified four residents on hospice. The facility census was 30 residents. Record review of Centers for Medicare and Medicaid (CMS) Quality Safety & Oversight (QSO)-20-39-NH dated 9/17/20 titled Nursing Home Visitation Coronavirus 2019 (COVID-19 - a new disease caused by a novel (new) coronavirus) showed when core infection control practices are used and testing requirements are met, health care workers who are not employees of the facility but provide direct care to the facility's residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. Record review of a memo dated 9/22/20 from the Director of the Missouri Department of Health and Senior Services provided as the facility's policy showed guidance on how to establish essential caregiver programs and how to allow visitors but it did not address hospice visits under the new 9/17/20 CMS guidance. 1. Record review of Resident #24's care plan for admission date 3/4/20 showed the resident's care would be coordinated with hospice. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/26/20 showed the resident was on hospice and had diagnoses of coronary artery disease (narrowing of the arteries to the heart) and congestive heart failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). Record review of the resident's nurse's note dated 9/29/20 showed the resident continued on hospice services but due to COVID-19, hospice workers were unable to enter the building. Record review of the resident's nurse's note dated 10/6/20, 10/13/20 and 10/20/20 showed the resident continued on hospice services. Record review of the resident's November 2020 Physician's Order Sheet (POS) showed physician's order for hospice. During an interview on 11/9/20 at 2:09 P.M., the resident's responsible party said hospice was not allowed to visit the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to utilize the required format of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (Centers for Medicare and Medicaid Services form (CMS)-10055) and Notice of Medicare Provider Non-Coverage (NOMNC) (form CMS-10123) for two sampled residents (Residents #83 and #84) out of two sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled) services. The facility identified two residents who required beneficiary notices over the past six months. The facility census was 30 residents. No policy was received from the facility. Record review of the form and the instructions for the SNF ABN CMS form 10055 showed: -The SNF ABN form is a CMS-approved model notice and should be replicated as closely as possible when used as a mandatory notice. -Entries in the blanks may be typed or legibly hand-written and should be large enough for easy reading (approximately 12 point font). -Failure to use this notice or significant alterations of the SNF ABN could result in the notice being invalidated and/or the SNF being held liable for the care in question. -It is a one page form. Record review of the instructions for form NOMNC CMS form 10123 showed: -Heading: Contact information: The name, address and telephone number of the provider that delivers the notice must appear above the title of the form. Providers may include their business logo and contact information on the top of the NOMNC. -The NOMNC must remain two pages. The notice can be two sides of one page or one side of two separate pages, but must not be condensed to one page. -Text may not be moved from page one to page two to accommodate large logos, address headers, etc. 1. Record review of Resident #84's SNF ABN notice dated 9/28/20 showed: -The facility did not use the CMS form. -The body text of the form was smaller than 12 point font. -The form was two pages instead of one. Record review of the resident's NOMNC notice dated 9/28/20 showed: -The facility did not use the CMS form. -The resident's NOMNC began on the second page below the bottom of the SNF ABN notice. -Some of the text was moved from one page to another. -The name, address and telephone number of the provider did not appear above the title of the form. 2. Record review of Resident #83's SNF ABN notice dated 8/16/20 showed: -The facility did not use the CMS form. -The body text of the form was smaller than 12 point font. -The form was three pages instead of one. Record review of the resident's NOMNC dated 8/16/20 showed: -The facility did not use the CMS form. -The resident's NOMNC began on the second page below the bottom of the SNF ABN notice. -Some of the text was moved from one page to another. -The name, address and telephone number of the provider did not appear above the title of the form. During an interview on 11/10/20 at 2:15 P.M., the Social Services Manager said: -The facility used a company which provided secure communications tools for long-term care facilities to keep all of their forms in. -He/She completed the forms in using the secure communication system. -He/She didn't know the forms had to be the same as the CMS form. During an interview on 11/10/20 at 2:20 P.M., the facility's corporate licensure, regulation and compliance specialist said they use all of their forms through the secure communication tool system in their computer system and no one had ever said anything about the forms looking different than the CMS forms.

Based on interview and record review, the facility failed to check the Certified Nursing Assistant (CNA) Registry to ensure individuals did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) and check the Employee Disqualification List (EDL) (a marker given to individuals who have committed crimes against residents in long term care settings) for two sampled employees (Employee #4 and #5) out of eight sampled employees hired since the last annual survey. The facility census was 30 residents. Record review of facility undated policy titled, Abuse Prevention Program, showed: -Facility policy requires employee background checks as a part of their abuse prevention program. -Employees are required to have backgriund checks prior to employment. Requested facility policies for criminal background checks and employee disqualification list and these policies were not received at time of exit. 1. Record review of Employee #4's file showed: -He/she was hired on 10/05/20. -There was no record of the Criminal Background Check being completed prior to hire. 2. Record review of Employee #5's file showed: -He/she was hired on 09/21/20. -There was no record of the Employee Disqualification List being checked prior to or upon hire. During an interview on 11/13/20 at 10:05 A.M., the Business Office Administrator said: -Criminal Background Checks were completed as a part of the facility hiring process. -Employee Disqualification List was checked as a step in the facility hiring process. -He/she was unable to find missing documentation in employee files.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #19 admission Record Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). -Acute cystitis (is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen), with hematuria (blood in the urine). -Dysphagia (inability or difficulty swallowing) Following cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they do not get enough blood). -Hypokalemia (a low level of potassium in the blood). Record review of the resident's significant change MDS dated [DATE] showed: -He/She was severely cognitively impaired with a Brief Interview for Mental Status (BIMs) of 1 out of 15. -He/she had a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) in place. - He/She had a diabetic foot ulcer (A full-thickness wound, through the dermis, below the ankle on a weight-bearing or exposed surface in an individual with diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin)) Record review of the resident's November 2020 Physician Oder Sheet (POS) showed: -Order dated 9/22/20 Foley catheter care every shift. -Order dated 10/22/20 to cleanse right coccyx (tailbone) with cleanser of facility choice. Apply skin prep (a topical barrier between skin and adhesives) around open area. Apply small amount of Collagen powder (wound treatment) to wound base. Cover with dry dressing. Change daily and PRN (as needed). - Order dated 11/12/20 to cleanse right buttocks with cleanser of facility choice. Apply skin prep around open area. Cut Collagen pad to size, lightly moisten. Cover with dry dressing. Change daily and PRN. Record review of the resident's Wound assessment dated [DATE] showed: - He/She had a right coccyx stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) acquired 9/22/20 measuring 3.8 centimeters (cm) in length x 1.5 cm in width with small amount of exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) serous (watery, clear, or slightly yellow/tan/pink drainage) drainage. - He/She had a right buttock stage III pressure ulcer 2.1 cm in length x 2.5 cm in width date acquired was 10/1/20 with a small amount of exudate serous drainage. -He/She had a left buttock stage III pressure ulcer acquired 10/1/20 measured 1.1 cm in length x 1.1 cm in width with a small amount of exudate serous drainage. Observation of the resident on 11/12/20 at 8:57 A.M. showed: -A pressure ulcer on the resident's right buttock. -A pressure ulcer on the resident's coccyx. -He/She had a Foley catheter. Record review of the resident's undated Care Plan showed: -The resident was admitted to the facility on [DATE]. -The care plan was last updated on 10/05/2020. -He/She had a diabetic foot ulcer on his/her right foot. -No documentation by the facility staff of the resident's Stage III pressure ulcer on his/her coccyx. -No documentation by the facility staff of the resident's Stage III pressure ulcer on his/her left buttocks. -No documentation by the facility staff of the resident's Stage III pressure ulcer on his/her right buttocks. -No documentation by the facility staff of the resident's Foley catheter or cares. During an interview on 11/13/20 12:11 P.M., Licensed Practical Nurse (LPN) A said: -The Foley catheter should be on the resident's care plan. -He/She could not locate a care plan for the resident's Foley Catheter or his/her pressure ulcers. During an interview on 11/13/20 1:42 P.M., the MDS Coordinator said: -The care plan should have been updated for the Foley catheter. -The care plan should have been updated for each wound the resident had. -A care plan addendum is the tool used to update the care plan, and anyone can fill one out. During an interview on 11/13/20 12:56 P.M., the DON said: -He/She would expect the Foley catheter along with cares to be listed on the care plan. -He/She would expect any new wounds to be listed on the care plan. Based on observation, interview and record review, the facility failed to update the residents' care plans for two sampled residents (Resident #24's and #19) out of 12 sampled residents. The census was 30 residents. The facility did not provide a policy regarding updating care plans. 1. Record review of Resident #24's nurse's note dated 8/26/20 showed: -At approximately 6:20 A.M., the resident spilled hot chocolate on his/her right hand and both thighs. -The resident's right hand was swollen and appeared to have first degree burn (affects only the outer layer of skin and appears red with no blisters). -Both thighs were red. Record review of the resident's care plan for admission date of 3/4/20 showed an update on 8/26/20 that showed the resident spilled hot chocolate on his/her thighs but the update did not include any interventions. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/19/20 showed the resident was severely cognitively impaired and required supervision while eating. Observation on 11/9/20 at 11:53 A.M. showed the resident was eating in the dining room independently and his/her hand holding his/her fork was shaking. Observation on 11/12/20 7:47 A.M. showed the resident was eating in the dining room independently and his/her hand holding his/her fork was shaking. During an interview on 11/12/20 at 11:54 A.M., the Director of Nursing (DON) said: -The intervention included adding ice to the resident's hot chocolate. -The resident had not spilled his/her hot chocolate on himself/herself since then. -The Care Plan Coordinator was responsible for updating the care plan with the new interventions. During an interview on 11/13/20 at 1:40 P.M., the Care Plan Coordinator said he/she updates the care plans.