. Based on observation, policy review and staff interview the facility failed to ensure each resident had a dignified existence. This was a random opportunity for discovery and was true for Resident #37, #65, #40, #57, #330 and #44. Resident identifiers: #37, #65, #40, #57, #330, and #44 . Facility census 82. Findings include: a) Assisting Resident with eating On 04/16/24 at 12:27 PM, Licensed Practical Nurse (LPN) # 35 was standing over Resident #37 while feeding her. LPN #35 was asked if she always feeds residents while standing? LPN #35 said, I just feed, however, I can. LPN #35 went on to say, I do not always feed Residents. The Facility Policy titled, Assistance with Meals Revision date: 03/22, stated, * Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: -Not standing over residents while assisting them with meals. On 04/16/24 at 2:00 PM, the Assistant Director of Nursing (ADON) was informed of the above and no further information was provided. b) Resident #65 Resident #65 was observed on 04/16/24 at 11:55 AM, being lifted from his Geri chair in the Day room by Nurse Aide (NA) #50 and #55. It was noted the residents' pants were not pulled up over his brief and he was exposed to everyone in the Day room. There were 14 residents in the day room and two (2) visitors. The white brief on Resident #65 appeared to be very heavy and was hanging very low, while the resident was hanging in the air being pushed to the bathroom. Resident #65 was transported approximately 10-12 feet into the bathroom via lift. The two (2) NA's used the lift to transport Resident #65 to the bathroom. At 12:02 PM the same two (2) NA's pushed Resident #65 out of the bathroom with the lift back to the chair. A brief interview on 04/16/24 at 12:06 PM, NA #50 was asked about providing privacy for Resident #65. NA #50 stated, she did not know his pants were pulled down. NA #50 stated using the lift to take residents to the bathroom is what they have always done. NA#50 went on to say Resident #65 had a brief on, so he was not really exposed. C) Dining Room At approximately 12:00 PM on 04/17/24, an observation was made in the dining room of the facility during lunch service. Nurse Aide (NA) #55, was observed removing a resident's dishes from a table while Resident #40 was still eating. NA #55 then went to another table and removed another resident's dishes while Resident #57 was still eating at that table. NA #36 then started to remove another resident's dishes from a table while Resident #330 and Resident #44 were still eating at that table. Interviews were conducted with NA #55 and NA #36, in which both stated they were unaware they could not clear tables while residents were still at those tables eating. Assistant Director of Nursing (ADON) notified at approximately 12:45 PM on 04/17/24. ADON stated they were not aware tables could not be cleared if other residents were still at those tables eating.

. Based on observation, record review and resident and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choices in regards to the resident's preference as to how many showers they would like per week. This was true for one (1) of three (3) residents reviewed for self-determination. Resident identifier: Resident #60. Facility Census: 82. Findings Include: a) Resident #60 During an interview on 04/15/24 at 1:23 PM, Resident #60 stated they had asked the staff for three (3) baths per week and was told the facility did not have enough help. The resident reported their shower days are scheduled for Wednesdays and Sundays but they would like to shower on Fridays in addition. The resident reported they have a condition which causes them to itch and believes they may feel better with more frequent showers. On 04/16/24 1:08 PM, a review of the Psychosocial Note dated 02/19/24 stated the resident asked for (their) care plan team to allow (them) to have an additional shower during the week on Fridays. Review of resident's care plan on 04/16/24 3:39 PM, reflects the resident will shower 3 x week in the morning. On 04/16/2024 3:48 PM, a review of Resident #60's bathing tasks reports for February, March and April of 2024 reflect the resident had showered every Sunday and Wednesday morning. On 04/16/2024 at 3:51 PM, a review of the 400 Wing Bath Schedule reflected the resident was scheduled to shower on Wednesday and Sunday. An interview was conducted on 04/16/2024 at 4:02 PM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) who acknowledged the resident's care plan stated resident was to receive showers 3 (three) times per week, the resident had expressed their desire to receive 3 (three) showers per week by adding a shower on Fridays, the resident was listed on the shower schedule for Wednesdays and Sundays and the resident had received 2 (two) showers per week per task reports. The ADON stated the care planned showers must have been overlooked and she would add the additional shower to the shower schedule.

. Based on record review and staff interview the facility failed to develop a personalized centered care plan for a focus of respiratory relating to Chronic Obstructive Pulmonary Disease (COPD). This was true for one (1) of twenty six (26) care plans reviewed during the long term care process. Resident Identifier: #12. Facility Census: 82 Findings Include: a) Resident #12 On 04/15/24 at 12:40 PM and 2:40 PM and on 04/16/24 at 8:24 AM it was observed that Resident #12 had a respiratory nebulizer mask at bedside. On 04/16/24 at 1:30 PM, a record review found Resident #12 had a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). There was also physicians orders as follows: Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. and Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally every 12 hours as needed for COPD. On 04/16/24 at 1:30 PM, a record review found Resident #12 had no personalized care plan in place for a respiratory focus for Chronic Obstructive Pulmonary Disease. The above findings was confirmed with Assistant Director of Nursing #25 on 04/16/24 at 01:32 PM. And no further information was obtained.

. Based on observation and staff interview the facility failed to store respiratory equipment in a clean sanitary manner consistent with professional standards of practice. This was a random opportunity for discovery. Resident Identifiers: #12 and #13. Facility Census: 82 Findings Include: a) Resident #12 On 04/15/24 at 12:40 PM and 2:40 PM and on 04/16/24 at 08:24 AM it was observed that Resident #12's respiratory nebulizer mask was not stored in a clean sanitary manner. It was on the bedside table outside of the plastic storage bag. Resident #12 had a physicians order for: Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. and Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally every 12 hours as needed for COPD. The facility policy for departmental (respiratory Therapy) prevention of infection states Infection control considerations related to medication nebulizer/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses . The above findings was confirmed with Registered Nurse (RN) #71 on 04/16/24 at 08:25 AM. b) Resident #13 On 04/15/24 at 12:35 PM and 2:35 PM and on 04/16/24 at 8:20 AM it was observed that Resident #13's respiratory nebulizer mask was not stored in a clean sanitary manner. It was on the bedside table outside of the plastic storage bag. Resident #13 has a physicians order for: Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 viral inhale orally every 4 hours as needed for shortness of breath (sob) wheezing. The facility policy for departmental (respiratory Therapy) prevention of infection states Infection control considerations related to medication nebulizer/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses . The above findings was confirmed with Registered Nurse (RN) #71 on 04/16/24 at 08:26 AM.

. Based on record review and staff interview, the facility failed to ensure an order for a PRN (as needed) psychotropic medication did not exceed 14 days for Resident #43, and failed to attempt a Gradual Dose Reduction (GDR) for an antidepressant for Resident #7. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications during the long-term care survey process. Resident identifiers: #43,and #7. Facility census: 82. A) Resident #43 At approximately 11:00 AM on 04/15/24, a record review of orders for Resident #43 was conducted. During the review, it was determined the resident had the following order for Ambien: Ambien oral tablet 10 MG (Zolpidem Tartrate) Give 10 mg by mouth as needed at bedtime for insomnia. The hours listed on the order are PRN. The order was written on 12/06/23 and was the current order at the time of this review. Pharmacy recommendations were found for the PRN order of Ambien during a record review, however, appropriate rationales were not given and a specific duration of use was not provided. The following recommendation for the PRN order of Ambien was made on 01/03/24: Please evaluate. If the order is to be continued, please indicate a specific duration of use and provide clinical rationale below. Per review of the eMAR, doses have been requested. The physician supplied the following rationale in response to the recommendation: OK to give. The following recommendation for the PRN order of Ambien was made on 03/06/24: Please evaluate. If the order is to be continued, please indicate a specific duration of use and provide clinical rationale below. Per review of the eMAR, doses have been requested. The physician supplied the following rationale in response to the recommendation: Needs this. At approximately 2:01 PM on 04/16/24, an interview was conducted with the Director of Nursing (DON) regarding the PRN order for Ambien and the rationales given to the pharmacy recommendation. The DON acknowledged there was not a proper clinical rationale given for the PRN order of Ambien and that the order had exceeded 14 days. b) Resident #7 On 04/17/24 at 10:10 AM, a record review of Resident #7's medical diagnosis found the following diagnoses: Unspecified Dementia, moderate with anxiety, unspecified dementia, moderate with mood disturbance, and conduct disorder, unspecified, There is a Physicians order dated 09/09/19 for Fluvoxamine (an anti depressant) 100 milliliter tablet, take one tablet by mouth every night at bedtime for related diagnosis, anxiety disorder, unspecified (indications for use: depression). Record review of Gradual Dose Reductions (GDR) for psychotropic medications shows there has been no GDR attempt for the above anti depressant since 07/06/22. A GDR must be attempted annually, unless clinically contraindicated. There is no documentation that the GDR attempt was made nor was there documentation from the Physician that it is clinically contraindicated to attempt the GDR. The above information was confirmed with the Assistant Director of Nursing, RN #25 on 04/17/24 at 12:41 PM

, Based on observation, policy review, and staff interview the facility failed to ensure establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside at the facility. Facility census 82. Findings include: a) No hand hygiene While monitoring dining in the day room at the end of the 100 halls on 04/16/24 at 11:55 AM. It was noted that Nurse Aide (NA) #55 was opening each tray on a a counter putting cream and sugar in the coffee, butter on the rolls cutting up food etc NA #55 served eight (8) residents and failed to use any hand hygiene between the residents. On 04/16/24 at 12:45 PM, NA #55 was asked if she used hand hygiene between serving residents. NA #55 said no. The facility policy titled, Handwashing/Hand Hygiene, revision date 08/2019. *Use hand hygiene before and after eating or handling food *Before and after assisting a resident with meals. On 04/16/24 at 2:06 PM the Director of Nursing (DON) was informed of the above findings.

. Based on record review and staff interview, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed for Resident #68, #67, and #18 when the residents developed a new mental illness diagnosis during their stay at the facility. This was true for three (3) out of five (5) residents reviewed for care area of PASARR during the long term care survey process. Resident Identifier: #68, #67, and #18. Facility census: 82. Findings include: A) Resident #68 At approximately 2:30 PM on 04/15/24 a record review was conducted for Resident #68. The record noted the resident was admitted to the facility with a PASARR dated 09/01/23. A review of Resident #68's diagnoses noted the resident was diagnosed with Major Depressive Disorder on 10/30/23. Further review indicated the facility had not completed a new PASARR for Resident #68. At approximately 2:01 PM on 04/16/24, the Director of Nursing (DON) acknowledged the facility had not yet completed a new PASARR for Resident #68 after the diagnosis was added. The DON stated they were not aware a new PASARR needed to be completed after a new diagnosis of a major mental illness. B) Resident #67 At approximately 3:00 PM on 04/15/24 a record review was conducted for Resident #67. The record review noted the resident was admitted to the facility with a PASARR dated 11/23/22. A review of Resident #67's diagnoses noted the resident was diagnosed with Major Depressive Disorder on 08/07/23. Further review indicated the facility had not completed a new PASARR for Resident #67. At approximately 2:01 PM on 04/16/24, the Director of Nursing (DON) acknowledged the facility had not yet completed a new PASARR for Resident #67 after the diagnosis. The DON stated they were not aware a new PASARR needed to be completed after a new diagnosis of a major mental illness. c) Resident #18 Review of Resident #18's medical records showed the resident was admitted to the facility in 2017. Further review of Resident #18's medical records showed a PASRR was completed on 05/22/17. The resident was noted to have a diagnosis of major depression. PASRR Level II screening was recommended. However, PASRR Level II desk review determined Resident #18 was not in the Level II screening population and nursing home placement was determined to be appropriate. On 06/05/18, Resident #18 received a diagnosis of bipolar disorder. An updated PASRR was not completed for the resident to determine whether nursing home placement continued to be appropriate for the resident. On 04/16/24 at 3:49 PM, the Director of Nursing confirmed Resident #18's most recent PASRR was performed on 05/22/17 and an updated PASRR was not completed when the resident received a new diagnosis of bipolar disorder in 2018. No further information was provided through the completion of the survey process.

. Based on observation, medical record review and staff interview the facility failed to ensure skin assessments were done at a professional standard of practice and failed to administer Immunizations recommended by the CDC in a timely manner. This failed practice had the potential to affect more than a limited number of residents who currently reside at the facility. Resident Identifier: #52, #19, #18, and #12. Facility census 82. Findings include: a) Skin assessments. On 04/16/24 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked about the facility form called a, SHOWER BODY AUDIT for Residents. The DON said the Nurse Aides do skin assessments when they give showers. If they find a concern, they mark it on the shower body audit sheet and the nurse will go and assess it, then sign the shower body audit. The DON was asked if a Licensed Nurse does routine skin assessments on everyone. The DON said no they go by what the Aides find. Also, at this same time the Licensed Practical Nurse/Treatment Nurse (TN) #120 was present for this interview via phone. TN #120 stated she does not do routine skin assessments. The DON agreed that while it is good practice for the Nurse Aides to report any skin issues they find, a licensed nurse has the training to assess skin issues. During the above interview the DON confirmed routine and/or weekly skin assessments are not being done by a licensed nurse. From the website. NCBI (National Institutes of Health) A complete skin assessment is essential for holistic care and must be completed by nurses and other health professionals on a regular basis. Providing patients and relatives with information on good skin hygiene can improve skin integrity and reduce the risk of pressure damage and skin tears. The assessments need to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In Long term care facilities, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present. b) Facility Immunizations On 04/17/24 at 8:30 AM, a record review found the facility failed to provide information and/or administer the Respiratory Syncytial Virus (RSV), Pneumococcal, the Recombinant Zoster Vaccine (RZV)/Shingrix and the Moderna/Pfizer Fall 2023 immunization per recommendation of the CDC in a timely manner. The Centers for Disease Control and Prevention (CDC) Respiratory Syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available on early August of 2023. In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences. .recommendations specify the use of either PCV20 alone or PCV15 in series with PPSV23 for all adults aged =65 years and for adults aged 19-64 years with certain underlying medical conditions or other risk factors who have not received a PCV or whose vaccination history is unknown. In addition, ACIP recommends use of either a single dose of PCV20 or =1 dose of PPSV23 for adults who have started their pneumococcal vaccine series with PCV13 but have not received all recommended PPSV23 doses. Shared clinical decision-making is recommended regarding use of a supplemental PCV20 dose for adults aged =65 years who have completed their recommended vaccine series with both PCV13 and PPSV23 . Above information was taken from the website: Centers for Disease Control and Prevention (.gov) A random sample of five (5) residents were chosen to review immunizations. Resident #12 had consented to the Pneumococcal (PCV 20), Respiratory Syncytial Virus (RSV), and the Recombinant Zoster Vaccine (RZV)/Shingrix vaccinations on 02/29/24. As of 04/17/24 none of the above vaccines had been administered. Resident #18 had consented to the Pneumococcal (PCV 20), Respiratory Syncytial Virus (RSV), the Recombinant Zoster Vaccine (RZV)/Shingrix and the Pfizer Fall 2023 vaccinations on 04/17/24 (the date of the interview with the Infection Preventionist). As of 04/17/24 none of the above vaccines had been administered. Resident #19 had consented to the Respiratory Syncytial Virus (RSV) and the Recombinant Zoster Vaccine (RZV)/Shingrix vaccinations on 02/16/24. As of 04/17/24 none of the above vaccines had been administered. Resident #52 had consented to the Pneumococcal (PCV 20), Respiratory Syncytial Virus (RSV), and the Recombinant Zoster Vaccine (RZV)/Shingrix vaccinations on 04/10/24. As of 04/17/24 none of the above vaccines had been administered. On 04/17/24 at 11:45 AM during an interview with the Infection Preventionist (IP), she stated she had not given the RSV vaccines yet because she had not received them from the pharmacy. When ask when she ordered them, she responded a few days ago. When asked what the plan was to administer the vaccines that were not complete yet, she stated she planned to administer the RSV when they come in, the COVID 2023 fall vaccination two (2) weeks after the RSV, the Recombinant Zoster Vaccine (RZV)/Shingrix vaccine two (2) weeks after the COVID, and the Pneumococcal vaccines two (2) weeks after the RZV. She plans to have all vaccines up to date in six (6) to eight (8) weeks. She states she has not administered any RSV or RZV vaccinations for the 2023 year. The IP stated she did not know the guidelines for CDC in administering the vaccinations as it pertains to seasons it is to be administered in. On 04/17/24 at 12:30 PM the above information was confirmed with the IP at which time she stated, I agree the vaccines should have already been administered in order to be completed in a timely manner.

. Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free of accident hazards as is possible . These failed practices were random opportunities for discovery and was true for Resident #65 and #26. Resident identifiers: #65 and #26. Facility census 82. Findings include: a) Resident #65 Resident #65 was observed on 04/16/24 at 11:55 AM, being lifted from his Geri chair in the Day room by Nurse Aide (NA) #50 and #55. It was noted the residents' pants were not pulled up over his brief and he was exposed to everyone in the Day room. There were 14 residents in the day room and two (2) visitors. The white brief on Resident #65 appeared to be very heavy and was hanging very low, while the resident was hanging in the air being pushed to the bathroom. Resident #65 was transported approximately 10-12 feet into the bathroom via a mechanical lift. The two (2) NA's used the lift to transport Resident #65 to the bathroom. At 12:02 PM the same two (2) NA's pushed Resident #65 out of the bathroom with the lift back to the chair. A brief interview on 04/16/24 at 12:06 PM, NA #50 was asked about providing privacy for Resident #65. NA #50 stated, she did not know his pants were pulled down. NA #50 stated using the lift to take residents to the bathroom is what they have always done. NA#50 went on to say Resident #65 had a brief on, so he was not really exposed. b) Resident #26 Review of the facility's policy titled Self-Administration of Medications with initiation date 2001 and revision date of February 2021 stated as follows: - The Intradisciplinary Team (IDT) would determine whether residents had the cognitive and physical abilities to safely self-administer medications. - If it was deemed safe and appropriate for a resident to self-administer medications, this would be documented in the medical record and care plan. - Residents who are identified as being able to self-administer medications would be asked if they wished to do so. On 04/17/24 at 7:50 AM, Licensed Practical Nurse (LPN) #104 was observed administering medications to Resident #26. LPN #104 placed the following oral medications into a medication cup: - Amiloride for hypertension - Colace for constipation - Cranberry tablet for history of urinary tract infections - Gabapentin for diabetic neuropathy (Gabapentin is also a controlled substance, kept in a special drawer of the medication cart. Administration of controlled substances is carefully monitored.) - Synthroid for hypothyroidism - Lasix for edema - Lisinopril for hypertension - Prilosec for gastro-esophageal reflux disease - Magnesium for vitamin deficiency - Ferrex for anemia - Famotidine for gastro-esophageal reflux disease - Fiber capsule for constipation - Buspar for anxiety disorder - Metformin for diabetes mellitus - Prozac for major depressive syndrome - Senna for constipation - Multivitamin for vitamin deficiency - Vitamin B12 for deficiency - Vitamin D3 for deficiency - Zyrtec for chronic sinusitis - Trajenta for type II diabetes mellitus Miralax powder for constipation was also placed in a cup. LPN #104 stated Resident #26 liked to mix the Miralax with coffee she already had in her room. LPN #104 entered Resident #26's room with the medications. Resident was lying in bed with the overbed table across the bed. LPN #104 placed Resident #26's oral medications on the overbed table. LPN #104 stated the resident had capacity and would take the medications on her own. LPN #104 then left the resident's room. In the hallway, LPN #104 was questioned about leaving Resident #26's medications in her room for the resident to take independently. LPN #104 stated Resident #26 was care planned to self-administer medications. Review of Resident #26's medical records showed a form titled Self-Administration of Drugs. The form had been signed on 03/13/18 and Resident #26 indicated I do not wish to exercise my right to self-administer my own medications to keep any medications at bedside. Review of Resident #26's comprehensive care plan contained no indication the resident was care planned to self-administer medications. On 04/17/24 at 9:12 AM, the Director of Nursing agreed Resident #26's medications should not have been left at the resident's bedside for the resident to take independently. No further information was provided through the completion of the survey.

. Based on record review, and staff interview, the facility failed to insure the physician documented the actions or rational if no action taken for monthly drug regimen reviews. This was true for three (3) of five (5) reviewed for unnecessary medications. Resident identifier #65, #7 and #43. Facility census: 82. Findings include: a) Resident #65 A medical record review for Resident #65 revealed monthly drug regimen reviews response without actions or rational if no action taken by the physician. --06/07/23 Recommendation to consider reducing Zyprexa 2.5mg and 1.25mg dose by 50%. Physician response -Stable. --03/06/24 Recommendation to consider reducing Zyprexa 2.5mg and 1.25mg dose by 50%. Physician response -Needs this. During an interview on 04/16/24 at 11:02 AM the Director of Nursing verified that the physician did not document the action or rational. b) Resident #7 On 04/17/24 at 10:10 AM a record review of Resident #7's medical diagnosis showed the following: Unspecified Dementia, moderate with anxiety, unspecified dementia, moderate with mood disturbance, and conduct disorder, unspecified. There was a Physicians order dated 04/03/20 for Seroquel Tablet (Quetiapine Fumarate) (an antipsychotic medication) Give 25 milligrams by mouth one time a day for increased behaviors related to severe intellectual disabilities. A review of the Medication Regimen Review (MRR) and Gradual Dose Reductions (GDR) for psychotropic medications shows there was a recommendation from the pharmacy on 01/30/24 for Seroquel 25 mg every day. Recommendation: Please consider a trial reduction to 50% reduction. It is required that the physician document the action taken on the recommendation or if no action is taken, rationale as to why no action was not taken. On 02/07/24 the physician visited the resident and documented on the GDR Note to Attending Physician/Prescriber from the pharmacy with a rationale of needs. This is not sufficient rationale according to the Center for Medicare and Medicaid Services (CMS) guidelines. The above information was confirmed with the Assistant Director of Nursing, RN #25 on 04/17/24 at 12:41 PM. C) Resident #43 At approximately 11:00 AM on 04/15/24, a record review of medication regimen reviews for Resident #43 was conducted. During the review, it was determined there were two recommendations made by the licensed pharmacist pertaining to a PRN (as needed) order Ambien for Resident #43, not accepted by the physician, with no appropriate rationale given. The following recommendation for the PRN order of Ambien was made on 01/03/24: Please evaluate. If the order is to be continued, please indicate a specific duration of use and provide clinical rationale below. Per review of the eMAR, doses have been requested. The physician supplied the following rationale in response to the recommendation: OK to give. The following recommendation for the PRN order of Ambien was made on 03/06/24: Please evaluate. If the order is to be continued, please indicate a specific duration of use and provide clinical rationale below. Per review of the eMAR, doses have been requested. The physician supplied the following rationale in response to the recommendation: Needs this. At approximately 2:01 PM on 04/16/24, an interview was conducted with the Director of Nursing (DON) regarding the PRN order for Ambien and the rationales given to the pharmacy recommendation. The DON acknowledged there was not a proper clinical rationale given for the PRN order of Ambien.

. Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Insulin pens were not dated when opened. Additionally, controlled substances were not properly secured in medication rooms. Also, expired medications were found in the medication room. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #70, #8, #72. Facility census: 82. Findings Include: a) Insulin pens Review of the facility's policy titled Administering Medications, with implementation date 2001 and revision date 2009, stated when a multi-dose container is opened, the opening date should be recorded on the container. On 04/17/24 at 8:16 AM, the 400 hallway medication cart was inspected with Registered Nurse (RN) #18 in attendance. Three (3) multi-dose insulin medications had not been dated when opened. It is important to label multi-dose medications for injection with the opening date because they must be discarded within 28 days of opening unless the manufacturer specifies a different time frame for that medication. This is an infection control measure to decrease the risk of contamination of the medication and bacterial or fungal growth in the vial. These multi-dose insulins were as follows: - Levemir FlexPen Subcutaneous Solution Pen-injector (Insulin Detemir) for Resident #70 - Lantus SoloStar Subcutaneous Solution Pen-injector (Insulin Glargine) for Resident #8 - Humalog Insulin Injection Solution (Insulin Lispro), in a vial, for Resident #72 RN #18 confirmed these insulin medications had not been dated when first opened. No further information was provided through the completion of the survey. b) Facility On 04/17/24 at 8:00 AM, an observation of the 400 Hall Medication Preparation Room found the facility failed to provide separately locked, permanently affixed compartments for storage of controlled Schedule II drugs and other drugs subject to abuse. The refrigerator on the 400 hall had 30 ml of Lorazepam oral concentrate 2 milligrams (mg)/ milliners (ml) in the refrigerator that did not have a lock. There was also no permanently affixed compartment for storage of the controlled medication. This was confirmed with Registered Nurse #18 on 04/17/24 at 8:09 AM and the Administrator and Director of Nursing on 04/17/24 at 8:11 AM. The medication refrigerator in the 100/200 Hall Main Medication Preparation Room did have a lock in place, however, upon entry into the medication room, the refrigerator was unlocked. There was also two (2) permanently affixed compartments for storage of controlled medications. Both of the compartments were unlocked. One affixed compartment contained two (2) vials of Lorazepam 2 mg/ml 1 ml each vial The second affixed compartment contained one (1) vial of Lorazepam 2 mg/ml 1 ml vial This was confirmed with the Director of Nursing on 04/17/24 at 8:47 AM. c) Facility On 04/17/24 at 8:00 AM, an observation of the 400 Hall Medication Preparation Room found the following medications to be expired: One (1) bottle of twenty five (25) tablets of Nitroglycerin that expired 12/28/23 and One (1) bottle of twenty five (25) tablets of Nitroglycerin that expired 01/18/24 This was confirmed with Registered Nurse #18 on 04/17/24 at 8:09 AM. On 04/17/24 at 8:40 AM, an observation of the 100/200 Hall Main Medication Preparation Room found the following medications to be expired: Two (2) bottle of 100 soft gel capsules of Vitamin E 180 mg expired 02/24. This was confirmed with the Director of Nursing on 04/17/24 at 08:45 AM.

. Based on facility record review and staff interview, the facility failed to complete final internal food temperatures and ensure food was held prior to food service at appropriate temperatures. This has the potential to affect all residents that receive their nutrition form the kitchen. Facility census: 82 Findings include: a) Food tempetures On 04/15/24 at12:20 PM during a tour of the kitchen it was discovered the Food temperatures were not completed on: -evening meal 04/01/24 -evening meal 04/02/24 -evening meal 04/03/24 -evening meal 04/04/24 -all meals 04/05/24 -all meals 04/08/24 -evening meal 04/10/24 -all meals 04/11/24 -evening meal 04/12/24 -all meals 04/13/24 -evening meal 04/14/24 During an interview on 04/15/24 at 12:23 PM the Certified Dietary Manager verified the food temperatures were not being completed daily as required.

. Based on observation and staff interview the facility failed to complete labeling and dates in a unit refrigerator and complete refrigerator temperature log unit refrigerator and freezers on the 100, 200 and Sub halls and main dining room in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility Census: 82. Findings Include: a) 100 Hall Unit Refrigerator Observation during the Unit tour on 04/15/24 at 12:44 PM found 3 sodas open, cherry pie, and plastic container in the resident refrigerator with no labeling or dates. During an interview on 04/15/24 at 11:44, the Dietary Manager (DM) verified there was no labeling or dates on the items in the 100-hall resident refrigerator. b) Refrigerator / Freezer Temperature Log On 04/15/24 at 12:58 PM facility record review of the refrigerator temperature log for unit refrigerator and freezers on the 100, 200 and Sub halls and main dining room found the temperatures was not completed on the log at this time on: -04/01/24 -04/06/24 -04/07/24 -04/11/24 -04/14/24 -04/15/24 On 04/15/24 at 12:58 PM during an interview the DM verified that the refrigerator temperatures should have been completed.

. Based on record review and staff interview, the facility failed to implement appropriate interventions for quality deficiencies of which it was aware. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings included: a) Skin assessments. On 04/16/24 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked about the facility form called a, SHOWER BODY AUDIT for Residents. The DON said the Nurse Aides do skin assessments when they give showers. If they find a concern, they mark it on the shower body audit sheet and the nurse will go and assess it, then sign the shower body audit. The DON was asked if a Licensed Nurse does routine skin assessments on everyone. The DON said no they go by what the Aides find. Also, at this same time the Licensed Practical Nurse/Treatment Nurse (TN) #120 was present for this interview via phone. TN #120 stated she does not do routine skin assessments. The DON agreed that while it is good practice for the Nurse Aides to report any skin issues they find, a licensed nurse has the training to assess skin issues. During the above interview the DON confirmed routine and/or weekly skin assessments are not being done by a licensed nurse. From the website. NCBI (National Institutes of Health) A complete skin assessment is essential for holistic care and must be completed by nurses and other health professionals on a regular basis. Providing patients and relatives with information on good skin hygiene can improve skin integrity and reduce the risk of pressure damage and skin tears. The assessments need to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In Long term care facilities, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present. b) Interview On 04/17/24 at 12:49 PM, the Administrator and Corporate Compliance Officer were interviewed. The Administrator and Corporate Compliance Officer stated a Performance Improvement Project (PIP) had been done regarding pressure ulcers. An intervention had been implemented for Nursing Aides (NAs) to perform skin assessments during resident bathing activities. The Administrator and Corporate Compliance Officer confirmed no measures had been implemented for routine skin assessments by licensed nursing staff.

. Based on record review and staff interview, the facility failed to document the attendance of the Medical Director or designee at all quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings include: a) Meeting attendance by medical director On 04/16/24 at 4:21 PM, the Administrator stated Quality Assurance Performance Improvement (QAPI) meetings were held every month. The Administrator stated the facility's Medical Director attended the quarterly meetings held on January, April, July, and October. However, the Administrator was unable to locate the QAPI attendance record for April 2024 to document the Medical Director's attendance at the meeting. No further information was provided through the completion of the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the environment over which it had control was free from accident hazards. The 300 Hall of the facility was being remodeled and there were multiple identified accident hazards readily accessible to residents. The 400 Hall had dangerous chemicals stored on top of an isolation cart. These were random opportunities for discovery. Facility census: 80. a) 300 Hall On 11/14/23 at 1:40 PM, a random opportunity for discovery found the 300 Hall of the facility was under construction and in the process of remodeling resident rooms. The two (2) double doors to the 300 Hall were open. Additionally, the doors to the resident rooms under construction were open. There were no posted room numbers at this time. The following accident hazards were observed: - The sixth room on the left, at the end of the 300 Hall, had a one (1) gallon AC/NA air conditioner coil cleaner. The container read, Danger. Corrosive. Keep out of reach of children. Causes severe skin burn and eye damage. There was also an unidentified one (1) gallon plastic handheld sprayer with a light purple liquid in it. - The third room on the left had an operable [NAME] 20-volt cordless drill with a drill bit attached. Additionally, there was a four inch (4) saw blade lying on the table. -The second room on the left had a six-inch (6) metal retractable utility knife with blade. During an interview, on 11/14/23 at 2:00 PM, the Director of Maintenance confirmed the above-mentioned articles had been left accessible to residents and were potential accident hazards. The Director of Maintenance reported the unidentified light purple liquid in the one (1) gallon plastic handheld sprayer was the AC/NA air conditioner coil cleaner. The Director of Maintenance stated the issues would be immediately addressed. Subsequent review of the Safety Data Sheet for the AC/NA water-based alkali detergent listed the following Acute/Potential Health Effects: -EYES: Causes severe irritation experienced as discomfort or pain, excess blinking, and tear production, with redness and swelling of the conjunctiva (the mucous membrane that covers the front of the eye and lines the inside of the eyelids.) -SKIN: Brief contact may cause slight irritation. Prolonged contact may cause more severe irritation with pain, local redness and swelling and possible tissue destruction. -INHALATION: High vapor concentrations may be irritating to respiratory tract. -INGESTION: May be harmful or fatal if swallowed. Corrosive. Can cause severe burns and complete tissue perforation of mucous membranes, mouth, throat, and stomach. -CHRONIC / LONG TERM EFFECTS: 2-Butoxyethanol has caused red blood cell hemolysis (the rupture or destruction of red blood cells) in lab animals and secondary injury to the liver and kidney. During an interview, on 11/14/23 at 2:20 PM, the Director of Nursing reported despite the fact the facility tries to keep the double doors to the 300 Hall closed that staff sometimes erroneously leave the doors open after transporting residents to the therapy /gym room down the 300 Hall. The Director of Nursing also reported, Some residents also take themselves down to the therapy/gym room and went on to add perhaps those residents were leaving the double doors open. The Director of Nursing also stated the issue had been addressed and all potential accident hazards had been removed from the area. b) 400-Hall The initial tour on 11/14/23 at 12:30 PM, found two (2) disinfectant supplies sitting on the isolation cart in reach of residents. -Two (2) container Lysol Spray Disinfectant with the warning keep out of reach of children, and If not breathing , if breathing is irregular or if respiratory arrest occurs provide artificial respiration or oxygen by trained personnel. -One (1) container Clorox Disinfecting Wipes with the warning Unknown Toxicity 20% of the mixture consists of ingredients of unknown toxicity and in case of skin contact, eye contact, or if swallowed- Call a physician . An interview with Maintenance Assistant #4, on 11/14/23 at 1:33 PM, revealed the disinfectants should not be left out. Maintenance Assistant #4 removed the disinfectants at this time and locked them in a secure location.

. Based on medical record review, facility record review, policy review and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable diseases. The facility did not follow their policy and isolate Covid positive residents in their rooms. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #41 and #67. Facility census: 75. Findings included: a) Covid Policy The facility Covid-19 Prevention and Control Policy last updated 09/28/22, states all residents who test positive will be moved to the designated Covid-19 isolation unit or placed in isolation separate from other residents. b) Covid Outbreak Line List The facility line listing identifies a Covid-19 outbreak on 08/14/23 with five (5) residents and two (2) positive staff. The last positive resident was on 08/25/23 and the last positive staff was on 08/27/23. A total of 24 residents and 23 staff were listed as Covid positive. c) Resident (R) #41 The facility line listing notes Resident (R) #41 tested positive for Covid on 08/16/23 and was placed on isolation until 08/27/23 The occupational therapy note dated 08/22/23 states R#41 was seen in the back day room/family room due to being Covid Positive. d) Resident #67 Resident #67 tested positive for Covid on 08/18/23 and was placed on isolation until 08/29/23 The speech therapy notes dated 08/18/23 and 08/22/23 states R#67 was seen in the 100 Hall day room for speech therapy. e) Staff Interviews On 09/05/23 at 2:00 PM, Physical Therapist (PT) #146 reported the Covid positive residents were not isolated in their room during the outbreak. The Covid positive residents on the 100 hall were placed in the family room with the door closed behind the 100 hall day room. The Covid negative residents were in the 100 hall day room. Covid positive residents were escorted out of the family room, through the day room, past the non infected residents for bathroom breaks. On 09/05/23 at 2:30 PM Nurse Aide (NA) #2 stated the Covid positive residents were placed in the family room behind a closed door connected to the 100 hall day room. Resident assistance to the restroom required donning personal protective equipment, escorting the resident thru the day room among the non-positive residents to their room for the bathroom. During an interview on 09/05/23 at 4:30 PM the Assistant Director of Nursing / Infection Preventionist (IP) confirmed the facility did not follow their Covid-19 policy during the recent outbreak which began on 08/14/23. Covid positive residents were not isolated in their room to prevent the spread of infection. They were placed in the family room behind the 100 hall day room. Covid positive residents passed by non-infected residents to use the restroom. The IP acknowledged this last outbreak contained 24 residents and 23 Covid-19 positive staff.

. Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form and Notice of Medicare Non-Coverage (NOMNC) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed all skilled care residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #370. Facility census: 71. Findings included: a) Resident #370 On 08/09/22 at 2:45 PM, a review was completed regarding the beneficiary protection notification liability notices given to Resident #370 who remained at the facility following the last covered day of Medicare Part A services. - Resident #370 began Medicare Part A skilled services on 05/11/22. The last covered day of Part A service was 06/27/22. There was no evidence that the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms were provided. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary; or - considered custodial. In an interview on 08/09/22 at 1:30 PM, the Minimum Data Set (MDS) Coordinator #99 stated, I was off sick during that time frame. SNF ABN and NOMNC forms were not issued. It was an oversight. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and policy review, the facility failed to ensure Resident #34, who lacked the capacity to consent, was free from sexual abuse. The facility also failed to ensure Resident #23 was free from verbal abuse. This was true for two (2) out of two (2) residents reviewed for the abuse pathway. This failed practice had the potential to affect a limited number of residents in the building. Resident identifiers: #34 and #23. Facility census: 71. Findings included: Review of the facility's policy Reporting Abuse to Facility Management outlined it was the responsibility of all employees to promptly report any incident or suspected incident of neglect or resident abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. a) Resident #34 During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: FIRST SEXUAL ABUSE INCIDENT ON 01/09/22 -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive skills for daily decision making as severely impaired -A Nurses Note, dated 01/09/22 at 1:05 PM, noted Resident #34 moved to [Room Number on new wing of the building] with no distress noted -A Nurses Note, dated 01/09/2022 at 1:53 PM, documented, Resident inappropriately touched by another resident (Resident #320). Residents separated and [Resident #34's First Name] was assessed for visible injury. No injury noted. Social Services notified and made aware, stated they would be coming to facility to contact responsible parties. -An incident report, dated 01/09/22 at 1:46 PM, stated, At approximately 11:30 this nurse was going to obtain a blood sugar when she heard resident yell 'Ouch'. Upon looking towards the yell this nurse saw [male Resident #320] sitting in front of [female Resident #34's First Name] blocking this nurse's view. This nurse immediately walked to where both residents were sitting in the hallway. Upon approaching, [male Resident #320] was noted to have his left hand down the pants of [female Resident #34's First and Last Name]. [Resident #34's first name] had ahold of the wrist of [male Resident #320] and was attempting to push it away. This nurse immediately told resident to let go of [female Resident #34's first name] and separated both residents. [Resident #34's first name] was evaluated and no injuries were noted. -On 01/09/22 at 6:55 PM, Social Worker #95 documented, SW (Social Worker) was made aware at 11:55 AM there was an incident that occurred between resident and a male resident. The nurse stated nursing staff heard resident yell and when they responded they observed resident to be setting beside the male resident. The nurse further reported the male resident was observed to have his hands down the front side of resident's pants. The nurse reported the two residents were separated immediately and staff has been setting with resident since. Nurse stated she was unsure as to how they needed to proceed which prompted her call to SW. SW made contact with DOSS (Director of Social Services) who agreed resident needed to be moved to another hall. DOSS reported both residents physicians needed to be contacted and their MPOAs (Medical Power of Attorneys). SW made contact with the nurse and shared resident needed to be moved to room [new room number]. SW asked the nurse to post on the communication board to the doctors the incident so they would be made aware. The nurse stated she would post to the doctors. SW contacted resident's MPOA to make him aware of an incident that occurred this afternoon with resident. Social Worker #95 also documented, SW let [First Name of MPOA] know the male resident does not go to the other halls other than when he eats lunch. SW let [First Name of MPOA] know at lunch time the male resident eats in the dining room. SW let [First Name of MPOA] know SW would make both activity and dining room staff aware they need to set the two separate from one another. -On 1/10/2022 at 2:50 PM, Social Worker #95 documented that Resident #34's MPOA came in to meet with SW regarding the incident that occurred with resident the day prior. It was documented that Social Worker #95 and the Director of Social Services (DOSS) met with resident's MPOA. The note outlined, DOSS made them aware the male was another resident who was incapacitated. She shared he did not know what he was doing. Social Worker 95 shared she had talked with activities and asked they keep the two separated and if Resident #34 was observed to have a negative reaction with being in the same room as male resident she would not attend the same activities as male resident. Resident #34's MPOA shared when they were made aware of the incident, they came in to meet with resident immediately. While meeting with resident, the resident stated several times, That man, that man, cover, cover. MPOA reported resident appeared to be scared. There was no evidence included in the medical record the sexual abuse was reported to the appropriate state agencies as per facility policy and state guidelines. There was no evidence included in the medical record the sexual abuse incident was reported to law enforcement as a suspicion of a crime against a resident. There was no evidence included in the medical record the sexual abuse was thoroughly investigated and the facility created a written summary (five-day follow-up report) of their plan to protect Resident #34 (and any other resident in the facility) from sexual abuse in the future. SECOND SEXUAL ABUSE INCIDENT ON 05/18/22 -A Nurses Note, dated 05/18/2022 on 7:15 PM, documented, As I was walking past the sub-dining room door nearest activity room, I saw this resident (Resident #34) sitting up next to resident (Resident #320). [Resident #320] had his hand down [Resident #34's] pants. -A Nurses Note, dated 05/18/2022 at 9:15 AM, documented Resident #34's physician was notified of the incident and He was present in facility and assessed resident. No injuries noted. -A review of the facility's reportables revealed this incident was reported to the appropriate state agencies and to law enforcement. In an interview on 08/09/22 at 2:15 PM, the Director of Social Services confirmed the first sexual abuse incident that occurred on 01/09/22 was not reported as sexual abuse to the appropriate state agencies and not reported as a crime to local law enforcement. She stated, It involved two (2) incapacitated residents. I didn't think it required reporting. Additionally, the Director of Social Services recognized the facility had not formulated a written plan (five-day follow-up report) outlining the outcome of an investigation into the sexual abuse and how the facility intended to protect Resident #34 from it reoccurring. The Director of Social Services became tearful and stated, Maybe if we handled things differently in January the second incident wouldn't have occurred. b) Resident #23 During the initial screening process of the Long-Term Care Survey process on 08/08/22 at 3:45 PM, Resident #23 voiced concerns of being treated disrespectful and talked down to by staff in a demeaning way. Resident #23 stated that he prayed to God last night that the state people would come and talk to him soon. Resident #23 stated that about a week ago he rang the bell while him and two (2) other Residents were outside to get help for another Resident that needed to use the bathroom. Resident #23 stated that it took several rings to get someone to come to the door. Once the nurse [licensed practical nurse # 112] showed up she said, I'm a nurse not a dog you don't have to ring eight times for me. The resident further stated that he only has a 5th grade education but that don't give them the right to treat him like any less of a person. Resident #23 stated Resident #29 and Resident #37 were also there and heard the nurse say it just ask them. Resident #23 stated it made him mad and feel like he was being degraded and scolded. Resident #23 stated, [LPN #112's name] acted like I was a nobody just because she is a nurse, she shouldn't treat me that way. Resident #23 also voiced his disgust of his roommate's continued sexual activity and further stated, My roommate [Resident #52's name] plays with himself, for lack of better words, all the time and I am so tired of seeing it and hearing it, being around it. Resident #23 stated that the nurses and aides told him [Resident #52] to stop [masturbating] several times and he told the nurses off and talks dirty to them. He [Resident #52] is just a nasty dirty old man. Resident #23 stated, I shouldn't have to live like that here, this is my home. On 08/09/22 at 12:50 PM the Administrator stated that Resident #23 did tell him about Licensed Practical Nurse (LPN) #112 being a little harsh to him when he rang bell to get assistance for another resident. The Administrator stated that LPN #112 described it to them [Administrator and Assistant Director of Nursing] as they [Residents] were outside and rang doorbell repeatably 6 to 8 times for a Resident to come in and use the bathroom. The Administrator further stated LPN #112 stated to him that the resident paraphrased what happened, and she did not use the word dog but did agree her tone was bad. LPN #112 told the Administrator she could have handled the situation better and that she had already apologized to Resident, and everything was better now between them. The administrator said they verbally warned LPN #112 and did no further investigation. The Administrator further stated that his consideration was that the incident between [LPN #112's name] and Resident #23's name was not verbal abuse, and it didn't need reported. The Administrator stated, Well the Resident didn't want to file a grievance, so I didn't think it was that big of deal. We didn't take it as verbal abuse. I am surprised he is still upset about it. 0n 08/09/22 at 1:17 PM the Director of Nursing (DON) stated that she was on vacation when the incident reported by Resident #23 happened with Licensed Practical Nurse (LPN) #112 and she thought it had been taken care of. The DON asked if she should report it now. The DON stated, I should have looked into it further, no I don't condone that kind of behavior. The Assistant Director of Nursing (ADON) stated she was only there as a witness when the administrator talked to the Resident #23 about the incident, but no investigation was done, and nothing was put in writing. The ADON further stated LPN #112 told her it was misunderstanding that had been clarified. The DON then clarified the Resident #23's roommate was care planned for masturbation and to keep curtain pulled but agreed that Resident #23 should not have to exposed to it day after day. During an interview on 08/09/22 at 1:32 PM Resident #23 stated that last night 08/08/22 when they were putting him to bed his roommate, R #5,2 was playing with his self again. Resident #23 stated he was not trying to get anyone in trouble but enough is enough and you shouldn't have to see that stuff, even staff shouldn't have to see it. Resident #23 also stated he wished he had an administrator that didn't act like he was mad at you when you report stuff. The resident stated he [Administrator] hasn't spoken to him at all for the past 2 days. During an interview in 08/09/22 at 1:30 PM Resident #29 stated, When the nurse (LPN #112) answered the door after he (Resident #23) rang several times she came out the door like a mad wet [NAME] and said 'I am nurse not dog' and kind of scolded us like we were kids. She was hateful. At 3:08 PM on 08/09/22, Licensed Social Worker (LSW) #62 stated that Administrator talked to Resident #23 last week about the problem with his roommates' masturbation and the plan was to have him transferred once we got bed availability. She stated, I am aware, I am working toward a room change for him. During an interview on 08/09/22 at 7:22 PM, Registered Nurse (RN) #113 stated that Resident #52 does masturbate often, and she has seen him do it as recently within the past week. RN #113 stated, I just close the curtain and give him his time. Then he gets mad when we close the curtain because he can't see the tv. RN #113 stated Resident #52 has done it since he has been there at the facility. Resident #52 was admitted on [DATE]. RN #113 stated that Resident #52 was moved today from his normal room where he resided with Resident #23 to the 100-hall due to having Covid-19, and at least Mr. [Resident #23's last name] will get some peace from it [being exposed to Resident #52's sexual activities] for a little while. Record review showed a Physician's Determination of Capacity dated 06/01/22 that stated the Resident does have full capacity. The Residents most recent BIMS score completed in 05/25/22 upon admission was 15. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed implement written abuse and neglect policies and procedures for reporting in order to prevent all types of abuse. The facility failed to report an incident of sexual abuse with Resident #34. The facility failed to report an incident of verbal abuse with resident #23. This practice affected two (2) of three (3) residents reviewed using the abuse pathway in the survey process. Resident identifiers: #34 and #23. Facility census: 71. Findings included: a) Resident #34 Review of the facility's policy Reporting Abuse to Facility Management outlined it was the responsibility of all employees to promptly report any incident or suspected incident of neglect or resident abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy defined mental abuse as humiliation, harassment, threats of punishment, or withholding of treatment or services. Additionally, review of the facility's Abuse Prohibition Policy detailed mental or emotional abuse as any act including verbal assault, humiliation, infantilizing, or any other treatment which may diminish the sense of dignity and self-worth of another. During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive skills for daily decision making as severely impaired -A Nurses Note, dated 01/09/22 at 1:05 PM, noted Resident #34 moved to [Room Number on new wing of the building] with no distress noted -A Nurses Note, dated 01/9/2022 at 1:53 PM, documented, Resident inappropriately touched by another resident (Resident #320). Residents separated and [Resident #34's First Name] was assessed for visible injury. No injury noted. Social Services notified and made aware, stated they would be coming to facility to contact responsible parties. -An incident report, dated 01/09/22 at 1:46 PM, stated, At approximately 11:30 this nurse was going to obtain a blood sugar when she heard resident yell 'Ouch'. Upon looking towards the yell this nurse saw [male Resident #320] sitting in front of [female Resident #34's First Name] blocking this nurse's view. This nurse immediately walked to where both residents were sitting in the hallway. Upon approaching, [male Resident #320] was noted to have his left hand down the pants of [female Resident #34's First and Last Name]. [Resident #34's first name] had ahold of the wrist of [male Resident #320] and was attempting to push it away. This nurse immediately told resident to let go of [female Resident #34's first name] and separated both residents. [Resident #34's first name] was evaluated and no injuries were noted. -On 01/09/22 at 6:55 PM, Social Worker #95 documented, SW (Social Worker) was made aware at 11:55 AM there was an incident that occurred between resident and a male resident. The nurse stated nursing staff heard resident yell and when they responded they observed resident to be setting beside the male resident. The nurse further reported the male resident was observed to have his hands down the front side of resident's pants. The nurse reported the two residents were separated immediately and staff has been setting with resident since. Nurse stated she was unsure as to how they needed to proceed which prompted her call to SW. SW made contact with DOSS (Director of Social Services) who agreed resident needed to be moved to another hall. DOSS reported both residents physicians needed to be contacted and their MPOAs (Medical Power of Attorneys). SW made contact with the nurse and shared resident needed to be moved to room [new room number]. SW asked the nurse to post on the communication board to the doctors the incident so they would be made aware. The nurse stated she would post to the doctors. SW contacted resident's MPOA to make him aware of an incident that occurred this afternoon with resident. Social Worker #95 also documented, SW let [First Name of MPOA] know the male resident does not go to the other halls other than when he eats lunch. SW let [First Name of MPOA] know at lunch time the male resident eats in the dining room. SW let [First Name of MPOA] know SW would make both activity and dining room staff aware they need to set the two separate from one another. -On 1/10/2022 at 2:50 PM, Social Worker #95 documented that Resident #34's MPOA came in to meet with SW regarding the incident that occurred with resident the day prior. It was documented that Social Worker #95 and the Director of Social Services (DOSS) met with resident's MPOA. The note outlined, DOSS made them aware the male was another resident who was incapacitated. She shared he did not know what he was doing. Social Worker 95 shared she had talked with activities and asked they keep the two separated and if Resident #34 was observed to have a negative reaction with being in the same room as male resident she would not attend the same activities as male resident. Resident #34's MPOA shared when they were made aware of the incident, they came in to meet with resident immediately. While meeting with resident, the resident stated several times, That man, that man, cover, cover. MPOA reported resident appeared to be scared. -There was no evidence included in the medical record the sexual abuse incident on 01/09/22 was reported to the appropriate state agencies as per facility policy and state guidelines. -There was no evidence included in the medical record the sexual abuse incident on 01/09/22 was reported to law enforcement as a suspicion of a crime against a resident. -There was no evidence included in the medical record the sexual abuse incident on 01/09/22 was thoroughly investigated and the facility created a written summary (five day follow-up report) of their plan to protect Resident #34 (and any other resident in the facility) from sexual abuse in the future. In an interview on 08/09/22 at 2:15 PM, the Director of Social Services confirmed the incident that occurred on 01/09/22 was not reported as sexual abuse to the appropriate state agencies and not reported as a crime to local law enforcement. She stated, It involved two (2) incapacitated residents. I didn't think it required reporting. b) Resident #23 During the initial screening process of the Long-Term Care Survey process on 08/08/22 at 3:45 PM, Resident #23 voiced concerns of being treated disrespectful and talked down to by staff in a demeaning way. Resident #23 stated that he prayed to God last night that the state people would come and talk to him soon. Resident #23 stated that about a week ago he rang the bell while him and two (2) other Residents were outside to get help for another Resident that needed to use the bathroom. Resident #23 stated that it took several rings to get someone to come to the door. Once the nurse [licensed practical nurse # 112] showed up she said, I'm a nurse not a dog you don't have to ring eight times for me. The resident further stated that he only has a 5th grade education but that don't give them the right to treat him like any less of a person. Resident #23 stated Resident #29 and Resident #37 were also there and heard the nurse say it just ask them. Resident #23 stated it made him mad and feel like he was being degraded and scolded. Resident #23 stated, [LPN #112's name] acted like I was a nobody just because she is a nurse, she shouldn't treat me that way. Resident #23 also voiced his disgust of his roommate's continued sexual activity and further stated, My roommate [Resident #52's name] plays with himself, for lack of better words, all the time and I am so tired of seeing it and hearing it, being around it. Resident #23 stated that the nurses and aides told him [Resident #52] to stop [masturbating] several times and he told the nurses off and talks dirty to them. He [Resident #52] is just a nasty dirty old man. Resident #23 stated, I shouldn't have to live like that here, this is my home. On 08/09/22 at 12:50 PM the Administrator stated that Resident #23 did tell him about Licensed Practical Nurse (LPN) #112 being a little harsh to him when he rang bell to get assistance for another resident. The Administrator stated that LPN #112 described it to them [Administrator and Assistant Director of Nursing] as they [Residents] were outside and rang doorbell repeatably 6 to 8 times for a Resident to come in and use the bathroom. The Administrator further stated LPN #112 stated to him that the resident paraphrased what happened, and she did not use the word dog but did agree her tone was bad. LPN #112 told the Administrator she could have handled the situation better and that she had already apologized to Resident, and everything was better now between them. The administrator said they verbally warned LPN #112 and did no further investigation. The Administrator further stated that his consideration was that the incident between [LPN #112's name] and Resident #23's name was not verbal abuse, and it didn't need reported. The Administrator stated, Well the Resident didn't want to file a grievance, so I didn't think it was that big of deal. We didn't take it as verbal abuse. I am surprised he is still upset about it. 0n 08/09/22 at 1:17 PM the Director of Nursing (DON) stated that she was on vacation when the incident reported by Resident #23 happened with Licensed Practical Nurse (LPN) #112 and she thought it had been taken care of. The DON asked if she should report it now. The DON stated, I should have looked into it further, no I don't condone that kind of behavior. The Assistant Director of Nursing (ADON) stated she was only there as a witness when the administrator talked to the Resident #23 about the incident, but no investigation was done, and nothing was put in writing. The ADON further stated LPN #112 told her it was misunderstanding that had been clarified. The DON then clarified the Resident #23's roommate was care planned for masturbation and to keep curtain pulled but agreed that Resident #23 should not have to exposed to it day after day. During an interview on 08/09/22 at 1:32 PM Resident #23 stated that last night 08/08/22 when they were putting him to bed his roommate, R #5,2 was playing with his self again. Resident #23 stated he was not trying to get anyone in trouble but enough is enough and you shouldn't have to see that stuff, even staff shouldn't have to see it. Resident #23 also stated he wished he had an administrator that didn't act like he was mad at you when you report stuff. The resident stated he [Administrator] hasn't spoken to him at all for the past 2 days. During an interview in 08/09/22 at 1:30 PM Resident #29 stated, When the nurse (LPN #112) answered the door after he (Resident #23) rang several times she came out the door like a mad wet [NAME] and said 'I am nurse not dog' and kind of scolded us like we were kids. She was hateful. At 3:08 PM on 08/09/22, Licensed Social Worker (LSW) #62 stated that Administrator talked to Resident #23 last week about the problem with his roommates' masturbation and the plan was to have him transferred once we got bed availability. She stated, I am aware, I am working toward a room change for him. During an interview on 08/09/22 at 7:22 PM, Registered Nurse (RN) #113 stated that Resident #52 does masturbate often, and she has seen him do it as recently within the past week. RN #113 stated, I just close the curtain and give him his time. Then he gets mad when we close the curtain because he can't see the tv. RN #113 stated Resident #52 has done it since he has been there at the facility. Resident #52 was admitted on [DATE]. RN #113 stated that Resident #52 was moved today from his normal room where he resided with Resident #23 to the 100-hall due to having Covid-19, and at least Mr. [Resident #23's last name] will get some peace from it [being exposed to Resident #52's sexual activities] for a little while. Record review showed a Physician's Determination of Capacity dated 06/01/22 that stated the Resident does have full capacity. The Residents most recent BIMS score completed in 05/25/22 upon admission was 15. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on policy review, record review, and staff interview the facility failed to ensure employees reported a suspicion of a crime against another resident to law enforcement. This was true for one (1) of three (3) residents reviewed under the Abuse Pathway. This failed practice had the potential to affecta limited number of residents. Resident Identifier #34. Facility Census: 71. Findings included: a) Resident #34 Reivew of the facility's Abuse Prohibition Policy, with a revision date of 06/22/22, revealed the facility, and all employees, have an obligation to notify local law enforcement of actions that may be considered criminal in nature. During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive skills for daily decision making as severely impaired -A Nurses Note, dated 01/09/22 at 1:05 PM, noted Resident #34 moved to [Room Number on new wing of the building] with no distress noted -A Nurses Note, dated 01/9/2022 at 1:53 PM, documented, Resident inappropriately touched by another resident (Resident #320). Residents separated and [Resident #34's First Name] was assessed for visible injury. No injury noted. Social Services notified and made aware, stated they would be coming to facility to contact responsible parties. -An incident report, dated 01/09/22 at 1:46 PM, stated, At approximately 11:30 this nurse was going to obtain a blood sugar when she heard resident yell 'Ouch'. Upon looking towards the yell this nurse saw [male Resident #320] sitting in front of [female Resident #34's First Name] blocking this nurse's view. This nurse immediately walked to where both residents were sitting in the hallway. Upon approaching, [male Resident #320] was noted to have his left hand down the pants of [female Resident #34's First and Last Name]. [Resident #34's first name] had ahold of the wrist of [male Resident #320] and was attempting to push it away. This nurse immediately told resident to let go of [female Resident #34's first name] and separated both residents. [Resident #34's first name] was evaluated and no injuries were noted. -On 01/09/22 at 6:55 PM, Social Worker #95 documented, SW (Social Worker) was made aware at 11:55 AM there was an incident that occurred between resident and a male resident. The nurse stated nursing staff heard resident yell and when they responded they observed resident to be setting beside the male resident. The nurse further reported the male resident was observed to have his hands down the front side of resident's pants. The nurse reported the two residents were separated immediately and staff has been setting with resident since. Nurse stated she was unsure as to how they needed to proceed which prompted her call to SW. SW made contact with DOSS (Director of Social Services) who agreed resident needed to be moved to another hall. DOSS reported both residents physicians needed to be contacted and their MPOAs (Medical Power of Attorneys). SW made contact with the nurse and shared resident needed to be moved to room [new room number]. SW asked the nurse to post on the communication board to the doctors the incident so they would be made aware. The nurse stated she would post to the doctors. SW contacted resident's MPOA to make him aware of an incident that occurred this afternoon with resident. Social Worker #95 also documented, SW let [First Name of MPOA] know the male resident does not go to the other halls other than when he eats lunch. SW let [First Name of MPOA] know at lunch time the male resident eats in the dining room. SW let [First Name of MPOA] know SW would make both activity and dining room staff aware they need to set the two separate from one another. -On 1/10/2022 at 2:50 PM, Social Worker #95 documented that Resident #34's MPOA came in to meet with SW regarding the incident that occurred with resident the day prior. It was documented that Social Worker #95 and the Director of Social Services (DOSS) met with resident's MPOA. The note outlined, DOSS made them aware the male was another resident who was incapacitated. She shared he did not know what he was doing. Social Worker 95 shared she had talked with activities and asked they keep the two separated and if Resident #34 was observed to have a negative reaction with being in the same room as male resident she would not attend the same activities as male resident. Resident #34's MPOA shared when they were made aware of the incident, they came in to meet with resident immediately. While meeting with resident, the resident stated several times, That man, that man, cover, cover. MPOA reported resident appeared to be scared. There was no evidence included in the medical record the sexual abuse incident was reported to law enforcement as a suspicion of a crime against a resident. In an interview on 08/09/22 at 2:15 PM, the Director of Social Services confirmed the first sexual abuse incident that occurred on 01/09/22 was not reported as a suspicion of crime against a resident to local law enforcement. She stated, It involved two (2) incapacitated residents. I didn't think it required reporting. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and policy review, the facility failed to ensure that an allegation of sexual abuse and an allegation of verbal abuse were reported immediately, but not later than 2 hours after the allegations were made, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility did not report a witnessed sexual abuse incident for Resident #34. The facility did not report within a two-hour timeframe a second witnessed sexual abuse incident for Resident #34. The facility did not report an allegation of verbal abuse made by Resident #23. This practice affected two (2) of three (3) residents reviewed using the abuse pathway in the survey process. Resident identifiers: #34 and #23. Facility census: 71. Findings included: Review of the facility's policy Reporting Abuse to Facility Management outlined it was the responsibility of all employees to promptly report any incident or suspected incident of neglect or resident abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy defined mental abuse as humiliation, harassment, threats of punishment, or withholding of treatment or services. Additionally, review of the facility's Abuse Prohibition Policy detailed mental or emotional abuse as any act including verbal assault, humiliation, infantilizing, or any other treatment which may diminish the sense of dignity and self-worth of another. a) Resident #34 During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: FIRST SEXUAL ABUSE INCIDENT ON 01/09/22 -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive skills for daily decision making as severely impaired -A Nurses Note, dated 01/09/22 at 1:05 PM, noted Resident #34 moved to [Room Number on new wing of the building] with no distress noted -A Nurses Note, dated 01/9/2022 at 1:53 PM, documented, Resident inappropriately touched by another resident (Resident #320). Residents separated and [Resident #34's First Name] was assessed for visible injury. No injury noted. Social Services notified and made aware, stated they would be coming to facility to contact responsible parties. -An incident report, dated 01/09/22 at 1:46 PM, stated, At approximately 11:30 this nurse was going to obtain a blood sugar when she heard resident yell 'Ouch'. Upon looking towards the yell this nurse saw [male Resident #320] sitting in front of [female Resident #34's First Name] blocking this nurse's view. This nurse immediately walked to where both residents were sitting in the hallway. Upon approaching, [male Resident #320] was noted to have his left hand down the pants of [female Resident #34's First and Last Name]. [Resident #34's first name] had ahold of the wrist of [male Resident #320] and was attempting to push it away. This nurse immediately told resident to let go of [female Resident #34's first name] and separated both residents. [Resident #34's first name] was evaluated and no injuries were noted. -On 01/09/22 at 6:55 PM, Social Worker #95 documented, SW (Social Worker) was made aware at 11:55 AM there was an incident that occurred between resident and a male resident. The nurse stated nursing staff heard resident yell and when they responded they observed resident to be setting beside the male resident. The nurse further reported the male resident was observed to have his hands down the front side of resident's pants. The nurse reported the two residents were separated immediately and staff has been setting with resident since. Nurse stated she was unsure as to how they needed to proceed which prompted her call to SW. SW made contact with DOSS (Director of Social Services) who agreed resident needed to be moved to another hall. DOSS reported both residents physicians needed to be contacted and their MPOAs (Medical Power of Attorneys). SW made contact with the nurse and shared resident needed to be moved to room [new room number]. SW asked the nurse to post on the communication board to the doctors the incident so they would be made aware. The nurse stated she would post to the doctors. SW contacted resident's MPOA to make him aware of an incident that occurred this afternoon with resident. Social Worker #95 also documented, SW let [First Name of MPOA] know the male resident does not go to the other halls other than when he eats lunch. SW let [First Name of MPOA] know at lunch time the male resident eats in the dining room. SW let [First Name of MPOA] know SW would make both activity and dining room staff aware they need to set the two separate from one another. -On 1/10/2022 at 2:50 PM, Social Worker #95 documented that Resident #34's MPOA came in to meet with SW regarding the incident that occurred with resident the day prior. It was documented that Social Worker #95 and the Director of Social Services (DOSS) met with resident's MPOA. The note outlined, DOSS made them aware the male was another resident who was incapacitated. She shared he did not know what he was doing. Social Worker 95 shared she had talked with activities and asked they keep the two separated and if Resident #34 was observed to have a negative reaction with being in the same room as male resident she would not attend the same activities as male resident. Resident #34's MPOA shared when they were made aware of the incident, they came in to meet with resident immediately. While meeting with resident, the resident stated several times, That man, that man, cover, cover. MPOA reported resident appeared to be scared. There was no evidence included in the medical record the sexual abuse was reported to the appropriate state agencies as per facility policy and state guidelines. SECOND SEXUAL ABUSE INCIDENT ON 05/18/22 -A Nurses Note, dated 05/18/2022 on 7:15 PM, documented, As I was walking past the sub-dining room door nearest activity room, I saw this resident (Resident #34) sitting up next to resident (Resident #320). [Resident #320] had his hand down [Resident #34's] pants. -A Nurses Note, dated 05/18/2022 at 9:15 AM, documented Resident #34's physician was notified of the incident and He was present in facility and assessed resident. No injuries noted. -A review of the facility's reportables revealed this incident was reported to the appropriate state agencies and to law enforcement on 05/18/22 at 11:58 AM which did not meet the expectation for a facility to report within two (2) hours of having knowledge of the abuse. In an interview on 08/09/22 at 2:15 PM, the Director of Social Services confirmed the first sexual abuse incident that occurred on 01/09/22 was not reported as sexual abuse to the appropriate state agencies and not reported as a crime to local law enforcement. She stated, It involved two (2) incapacitated residents. I didn't think it required reporting. When discussing the second sexual abuse incident on 05/18/22, the Director of Social Services recognized the facility had not met the requirement to report within two (2) hours. b) Resident #23 During the initial screening process of the Long-Term Care Survey process on 08/08/22 at 3:45 PM, Resident #23 voiced concerns of being treated disrespectful and talked down to by staff in a demeaning way. Resident #23 stated that he prayed to God last night that the state people would come and talk to him soon. Resident #23 stated that about a week ago he rang the bell while him and two (2) other Residents were outside to get help for another Resident that needed to use the bathroom. Resident #23 stated that it took several rings to get someone to come to the door. Once the nurse [licensed practical nurse # 112] showed up she said, I'm a nurse not a dog you don't have to ring eight times for me. The resident further stated that he only has a 5th grade education but that don't give them the right to treat him like any less of a person. Resident #23 stated Resident #29 and Resident #37 were also there and heard the nurse say it just ask them. Resident #23 stated it made him mad and feel like he was being degraded and scolded. Resident #23 stated, [LPN #112's name] acted like I was a nobody just because she is a nurse, she shouldn't treat me that way. Resident #23 also voiced his disgust of his roommate's continued sexual activity and further stated, My roommate [Resident #52's name] plays with himself, for lack of better words, all the time and I am so tired of seeing it and hearing it, being around it. Resident #23 stated that the nurses and aides told him [Resident #52] to stop [masturbating] several times and he told the nurses off and talks dirty to them. He [Resident #52] is just a nasty dirty old man. Resident #23 stated, I shouldn't have to live like that here, this is my home. On 08/09/22 at 12:50 PM the Administrator stated that Resident #23 did tell him about Licensed Practical Nurse (LPN) #112 being a little harsh to him when he rang bell to get assistance for another resident. The Administrator stated that LPN #112 described it to them [Administrator and Assistant Director of Nursing] as they [Residents] were outside and rang doorbell repeatably 6 to 8 times for a Resident to come in and use the bathroom. The Administrator further stated LPN #112 stated to him that the resident paraphrased what happened, and she did not use the word dog but did agree her tone was bad. LPN #112 told the Administrator she could have handled the situation better and that she had already apologized to Resident, and everything was better now between them. The administrator said they verbally warned LPN #112 and did no further investigation. The Administrator further stated that his consideration was that the incident between [LPN #112's name] and Resident #23's name was not verbal abuse, and it didn't need reported. The Administrator stated, Well the Resident didn't want to file a grievance, so I didn't think it was that big of deal. We didn't take it as verbal abuse. I am surprised he is still upset about it. 0n 08/09/22 at 1:17 PM the Director of Nursing (DON) stated that she was on vacation when the incident reported by Resident #23 happened with Licensed Practical Nurse (LPN) #112 and she thought it had been taken care of. The DON asked if she should report it now. The DON stated, I should have looked into it further, no I don't condone that kind of behavior. The Assistant Director of Nursing (ADON) stated she was only there as a witness when the administrator talked to the Resident #23 about the incident, but no investigation was done, and nothing was put in writing. The ADON further stated LPN #112 told her it was misunderstanding that had been clarified. The DON then clarified the Resident #23's roommate was care planned for masturbation and to keep curtain pulled but agreed that Resident #23 should not have to exposed to it day after day. During an interview on 08/09/22 at 1:32 PM Resident #23 stated that last night 08/08/22 when they were putting him to bed his roommate, R #5,2 was playing with his self again. Resident #23 stated he was not trying to get anyone in trouble but enough is enough and you shouldn't have to see that stuff, even staff shouldn't have to see it. Resident #23 also stated he wished he had an administrator that didn't act like he was mad at you when you report stuff. The resident stated he [Administrator] hasn't spoken to him at all for the past 2 days. During an interview in 08/09/22 at 1:30 PM Resident #29 stated, When the nurse (LPN #112) answered the door after he (Resident #23) rang several times she came out the door like a mad wet [NAME] and said 'I am nurse not dog' and kind of scolded us like we were kids. She was hateful. At 3:08 PM on 08/09/22, Licensed Social Worker (LSW) #62 stated that Administrator talked to Resident #23 last week about the problem with his roommates' masturbation and the plan was to have him transferred once we got bed availability. She stated, I am aware, I am working toward a room change for him. During an interview on 08/09/22 at 7:22 PM, Registered Nurse (RN) #113 stated that Resident #52 does masturbate often, and she has seen him do it as recently within the past week. RN #113 stated, I just close the curtain and give him his time. Then he gets mad when we close the curtain because he can't see the tv. RN #113 stated Resident #52 has done it since he has been there at the facility. Resident #52 was admitted on [DATE]. RN #113 stated that Resident #52 was moved today from his normal room where he resided with Resident #23 to the 100-hall due to having Covid-19, and at least Mr. [Resident #23's last name] will get some peace from it [being exposed to Resident #52's sexual activities] for a little while. Record review showed a Physician's Determination of Capacity dated 06/01/22 that stated the Resident does have full capacity. The Residents most recent BIMS score completed in 05/25/22 upon admission was 15. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure that an incidents involving sexual abuse and verbal abuse were thoroughly investigated. The facility did not investigate a witnessed sexual abuse incident for Resident #34. The facility did not investigate an instance of verbal abuse for Resident #23. This practice affected two (2) of the three (3) residents reviewed using the abuse pathway in the survey process. Resident identifiers: #34 and #23. Facility census: 71. a) Resident #34 During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: FIRST SEXUAL ABUSE INCIDENT ON 01/09/22 -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive skills for daily decision making as severely impaired -A Nurses Note, dated 01/09/22 at 1:05 PM, noted Resident #34 moved to [Room Number on new wing of the building] with no distress noted -A Nurses Note, dated 01/9/2022 at 1:53 PM, documented, Resident inappropriately touched by another resident (Resident #320). Residents separated and [Resident #34's First Name] was assessed for visible injury. No injury noted. Social Services notified and made aware, stated they would be coming to facility to contact responsible parties. -An incident report, dated 01/09/22 at 1:46 PM, stated, At approximately 11:30 this nurse was going to obtain a blood sugar when she heard resident yell 'Ouch'. Upon looking towards the yell this nurse saw [male Resident #320] sitting in front of [female Resident #34's First Name] blocking this nurse's view. This nurse immediately walked to where both residents were sitting in the hallway. Upon approaching, [male Resident #320] was noted to have his left hand down the pants of [female Resident #34's First and Last Name]. [Resident #34's first name] had ahold of the wrist of [male Resident #320] and was attempting to push it away. This nurse immediately told resident to let go of [female Resident #34's first name] and separated both residents. [Resident #34's first name] was evaluated and no injuries were noted. -On 01/09/22 at 6:55 PM, Social Worker #95 documented, SW (Social Worker) was made aware at 11:55 AM there was an incident that occurred between resident and a male resident. The nurse stated nursing staff heard resident yell and when they responded they observed resident to be setting beside the male resident. The nurse further reported the male resident was observed to have his hands down the front side of resident's pants. The nurse reported the two residents were separated immediately and staff has been setting with resident since. Nurse stated she was unsure as to how they needed to proceed which prompted her call to SW. SW made contact with DOSS (Director of Social Services) who agreed resident needed to be moved to another hall. DOSS reported both residents physicians needed to be contacted and their MPOAs (Medical Power of Attorneys). SW made contact with the nurse and shared resident needed to be moved to room [new room number]. SW asked the nurse to post on the communication board to the doctors the incident so they would be made aware. The nurse stated she would post to the doctors. SW contacted resident's MPOA to make him aware of an incident that occurred this afternoon with resident. Social Worker #95 also documented, SW let [First Name of MPOA] know the male resident does not go to the other halls other than when he eats lunch. SW let [First Name of MPOA] know at lunch time the male resident eats in the dining room. SW let [First Name of MPOA] know SW would make both activity and dining room staff aware they need to set the two separate from one another. -On 1/10/2022 at 2:50 PM, Social Worker #95 documented that Resident #34's MPOA came in to meet with SW regarding the incident that occurred with resident the day prior. It was documented that Social Worker #95 and the Director of Social Services (DOSS) met with resident's MPOA. The note outlined, DOSS made them aware the male was another resident who was incapacitated. She shared he did not know what he was doing. Social Worker 95 shared she had talked with activities and asked they keep the two separated and if Resident #34 was observed to have a negative reaction with being in the same room as male resident she would not attend the same activities as male resident. Resident #34's MPOA shared when they were made aware of the incident, they came in to meet with resident immediately. While meeting with resident, the resident stated several times, That man, that man, cover, cover. MPOA reported resident appeared to be scared. There was no evidence included in the medical record the sexual abuse was reported to the appropriate state agencies as per facility policy and state guidelines. As a result of the incident not being reported, the facility had no evidence that a meaningful investgation (five-day follow-up report) was completed in an effort to prevent the incident from happening again. SECOND SEXUAL ABUSE INCIDENT ON 05/18/22 -A Nurses Note, dated 05/18/2022 on 7:15 PM, documented, As I was walking past the sub-dining room door nearest activity room, I saw this resident (Resident #34) sitting up next to resident (Resident #320). [Resident #320] had his hand down [Resident #34's] pants. -A Nurses Note, dated 05/18/2022 at 9:15 AM, documented Resident #34's physician was notified of the incident and He was present in facility and assessed resident. No injuries noted. -A review of the facility's reportables revealed this incident was reported to the appropriate state agencies and to law enforcement on 05/18/22 at 11:58 AM which did not meet the expectation for a facility to report within two (2) hours of having knowledge of the abuse. In an interview on 08/09/22 at 2:15 PM, the Director of Social Services confirmed the first sexual abuse incident that occurred on 01/09/22 was not reported as sexual abuse to the appropriate state agencies and not reported as a crime to local law enforcement. She stated, It involved two (2) incapacitated residents. I didn't think it required reporting. Additionally, the Director of Social Services recognized the facility had not formulated a written plan (five-day follow-up report) outlining the outcome of an investigation into the sexual abuse and how the facility intended to protect Resident #34 from it reoccurring. The Director of Social Services became tearful and stated, Maybe if we handled things differently in January the second incident wouldn't have occurred. b) Resident #23 During the initial screening process of the Long-Term Care Survey process on 08/08/22 at 3:45 PM, Resident #23 voiced concerns of being treated disrespectful and talked down to by staff in a demeaning way. Resident #23 stated that he prayed to God last night that the state people would come and talk to him soon. Resident #23 stated that about a week ago he rang the bell while him and two (2) other Residents were outside to get help for another Resident that needed to use the bathroom. Resident #23 stated that it took several rings to get someone to come to the door. Once the nurse [licensed practical nurse # 112] showed up she said, I'm a nurse not a dog you don't have to ring eight times for me. The resident further stated that he only has a 5th grade education but that don't give them the right to treat him like any less of a person. Resident #23 stated Resident #29 and Resident #37 were also there and heard the nurse say it just ask them. Resident #23 stated it made him mad and feel like he was being degraded and scolded. Resident #23 stated, [LPN #112's name] acted like I was a nobody just because she is a nurse, she shouldn't treat me that way. Resident #23 also voiced his disgust of his roommate's continued sexual activity and further stated, My roommate [Resident #52's name] plays with himself, for lack of better words, all the time and I am so tired of seeing it and hearing it, being around it. Resident #23 stated that the nurses and aides told him [Resident #52] to stop [masturbating] several times and he told the nurses off and talks dirty to them. He [Resident #52] is just a nasty dirty old man. Resident #23 stated, I shouldn't have to live like that here, this is my home. On 08/09/22 at 12:50 PM the Administrator stated that Resident #23 did tell him about Licensed Practical Nurse (LPN) #112 being a little harsh to him when he rang bell to get assistance for another resident. The Administrator stated that LPN #112 described it to them [Administrator and Assistant Director of Nursing] as they [Residents] were outside and rang doorbell repeatably 6 to 8 times for a Resident to come in and use the bathroom. The Administrator further stated LPN #112 stated to him that the resident paraphrased what happened, and she did not use the word dog but did agree her tone was bad. LPN #112 told the Administrator she could have handled the situation better and that she had already apologized to Resident, and everything was better now between them. The administrator said they verbally warned LPN #112 and did no further investigation. The Administrator further stated that his consideration was that the incident between [LPN #112's name] and Resident #23's name was not verbal abuse, and it didn't need reported. The Administrator stated, Well the Resident didn't want to file a grievance, so I didn't think it was that big of deal. We didn't take it as verbal abuse. I am surprised he is still upset about it. 0n 08/09/22 at 1:17 PM the Director of Nursing (DON) stated that she was on vacation when the incident reported by Resident #23 happened with Licensed Practical Nurse (LPN) #112 and she thought it had been taken care of. The DON asked if she should report it now. The DON stated, I should have looked into it further, no I don't condone that kind of behavior. The Assistant Director of Nursing (ADON) stated she was only there as a witness when the administrator talked to the Resident #23 about the incident, but no investigation was done, and nothing was put in writing. The ADON further stated LPN #112 told her it was misunderstanding that had been clarified. The DON then clarified the Resident #23's roommate was care planned for masturbation and to keep curtain pulled but agreed that Resident #23 should not have to exposed to it day after day. During an interview on 08/09/22 at 1:32 PM Resident #23 stated that last night 08/08/22 when they were putting him to bed his roommate, R #5,2 was playing with his self again. Resident #23 stated he was not trying to get anyone in trouble but enough is enough and you shouldn't have to see that stuff, even staff shouldn't have to see it. Resident #23 also stated he wished he had an administrator that didn't act like he was mad at you when you report stuff. The resident stated he [Administrator] hasn't spoken to him at all for the past 2 days. During an interview in 08/09/22 at 1:30 PM Resident #29 stated, When the nurse (LPN #112) answered the door after he (Resident #23) rang several times she came out the door like a mad wet [NAME] and said 'I am nurse not dog' and kind of scolded us like we were kids. She was hateful. At 3:08 PM on 08/09/22, Licensed Social Worker (LSW) #62 stated that Administrator talked to Resident #23 last week about the problem with his roommates' masturbation and the plan was to have him transferred once we got bed availability. She stated, I am aware, I am working toward a room change for him. During an interview on 08/09/22 at 7:22 PM, Registered Nurse (RN) #113 stated that Resident #52 does masturbate often, and she has seen him do it as recently within the past week. RN #113 stated, I just close the curtain and give him his time. Then he gets mad when we close the curtain because he can't see the tv. RN #113 stated Resident #52 has done it since he has been there at the facility. Resident #52 was admitted on [DATE]. RN #113 stated that Resident #52 was moved today from his normal room where he resided with Resident #23 to the 100-hall due to having Covid-19, and at least Mr. [Resident #23's last name] will get some peace from it [being exposed to Resident #52's sexual activities] for a little while. Record review showed a Physician's Determination of Capacity dated 06/01/22 that stated the Resident does have full capacity. The Residents most recent BIMS score completed in 05/25/22 upon admission was 15. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility inaccurately assessed a non-insulin medication as an insulin on the minimal data set (MDS). This was true for one (1) of two (2) Residents reviewed for insulin. Resident identifier: #64. Facility census: 71. Findings included: a) Resident #64 A review of Resident #64's medical record showed a diagnosis of Type (two) 2 Diabetes Mellitus with hyperglycemia. The physician orders showed prescribed diabetic medications to include Jardiance Tab 10 milligrams (MG) give one (1) tablet by mouth one (1) time a day , Metformin Tablet 500 MG give one (1) tablet by mouth two (2) times a day and Ozempic Solution Pen-injector two (2) MG inject 0.5 MG subcutaneously in the morning every Monday. The care plan showed a focus that stated, Diabetes Mellitus, takes oral diabetic medications and Ozempic. Further review of Resident #64's medical record showed a Quarterly minimal data set (MDS) dated [DATE] that stated Resident #64 received insulin for one (1) day. During an interview on 08/09/22 at 12:25 PM, Minimum Data Set (MDS) Coordinator #99 stated that Resident # 64 had received Ozempic one time during the Quarterly 07/26/22 MDS look back but marking Ozempic as an insulin was wrong as it is not insulin. MDS Coordinator #99 stated that Resident #64 never received insulin and insulin should not have been marked on the MDS. .

. Based on record review and staff interview, the facility failed to revise the comprehensive care plan for one (1) of 26 residents reviewed during the long-term care survey process. Resident Identifier: #34. Facility census: 71. Findings included: a) Resident #34 Review of Resident #34's comprehensive care plan showed the following focus, [Resident #34's First Name] may express fear, crying, be easily startled, and/or display emotional numbness related to a male resident and inappropriate contact. The focus was initiated on 06/14/2022. One of the interventions listed was Remain with the resident at all times when levels of anxiety are high; reassure client of her safety and security. During an interview on, 08/10/22 at 11:44 AM, the Director of Social Services acknowledged Resident #34's care plan was not updated / revised following the first instance of inappropriate sexual contact on 01/09/22 but that it had been updated / revised following the second instance of inappropriate sexual contact on 05/18/22. The Director of Social Services stated, That was an oversight. The care plan should have been updated sooner. .

. Based on observation, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not stored safely or properly for residents reviewed during the Long-Term Care Survey Process (LTCSP). This was a random opportunity for discovery. Resident identifier #268. Facility census: #71. Findings include: a) Resident #268 An observation on 08/08/22 at 3:05 PM found, Resident #268's nebulizer machine mask and tubing were laying on the bed side stand without being placed in a protective bag. During an interview on 08/08/22 at 3:05 PM, Resident #268 stated that they never put it in a bag. An interview on 08/08/22 at 3:16 PM with Licensed Practical Nurse (LPN) #104 confirmed that Resident #268's nebulizer mask should be placed in a protective bag when not in use. LPN #104 stated that she would have to go to supplies for a protective bag. .

. Based on observation, staff interview and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of residents. Facility census: 71. Findings included: a) Test Tray Temperature An observation on 08/09/22 at 8:10 AM showed an open-air food tray cart located on 200-hall with breakfast trays waiting to be served to Residents. During an interview on 08/09/22 at 8:10 AM, Nurse Aide (NA) #107 stated that the food tray cart arrived at 200-hall at 7:30 AM. A test tray temperature was taken on 08/09/22 at 8:25 AM of the last food tray on the 200-hall food cart. The test tray temperatures showed the following temperatures: French Toast Sticks- 93 degrees Sausage Patty- 95.2 degrees Milk- 57.3 degrees Orange Juice- 58.2 degrees During an interview on 08/09/22 at 8:25 AM, Director of Food Services (DFS) stated the food on the test tray was not within appropriate temperatures. .

. c) Resident #66 On 08/10/22 at 10:25 AM, after reviewing the treatment administration record (TAR) found resident #66 to have 12 blank holes for month of June for treatments for wounds, (apply Silver alginate to wound bed on sacrum with each dressing change after cleaning and prior to applying mepilex dressing until further notice. every shift). Four (4) blank holes for July for treatments,(apply Silver alginate to wound bed on sacrum with each dressing change after cleaning and prior to applying mepilex dressing until further notice. every shift). These treatment to wound were to be done by midnight shift as well. On 8/10/22 at 10: 40 AM, Interview with assistant director of nursing (ADON) after observing TAR showed 12 blank holes for June and four (4) blank holes for July of where treatment and observations were to be done on night shift. ADON stated, yes they are blank holes and treatments were not done by night shift nurse. Based on observation, staff interview and record review the facility failed to provide care as stated within the physician's orders. Medications for Resident #5 and Resident #36 were not admininstered as ordered. Wound care treatments and observations of wound dressings for Resident #66 were not completed. These findings were a random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifiers: #5, #36, #66. Facility census: 71 Findings included: a) Resident #5 During medication pass observation on 08/09/22 at 8:03 AM, Registered Nurse (RN) #36 failed to have Resident #5 rinse her mouth after administration of the first puff of the Symbicort inhaler. At 8:08 AM, RN #36 did not prompt the Resident to rinse her mouth after administration of the second puff of the Symbicort inhaler. Record review indicated an order for Symbicort 80/4.5 mcg inhaler, 2 puffs twice daily for chronic obstructive pulmonary disease. Additional Directions: rinse mouth with water past use. On 08/09/22 at 1:20 PM, the Director of Nursing verified the order stated to rinse mouth after use and agreed Resident #5 should have been prompted to rinse her mouth and she would do some education with the nursing staff regarding inhalers. b) Resident #36 During medication pass observation on 08/09/22 at 8:11 AM, Registered Nurse (RN) #36 failed to have Resident #36 rinse her mouth after administration of the Advair diskus inhaler. Record review indicated an order for Advair Diskus Aerosol Powder Breath Activated 250-50 mcg. Inhale one (1) puff orally two times a day related to chronic obstructive pulmonary disease. Rinse mouth with water and spit out after each use . On 08/09/22 at 1:21 PM, the Director of Nursing verified the order stated to rinse mouth after use and spit out and stated Resident #36 should have been reminded to rinse her mouth after the 'puff'. The DON further stated she needed to do some education with the nursing staff regarding the issue. .

. Based on facility documentation review, staff interview and policy review the facility failed to obtain current and active food handler cards for all dietary staff. This was true for four (4) of 13 dietary staff reviewed. The failed practice had the potential to affect more than a limited number of Residents. Staff identifiers: #55, #56, #59 and #137. Facility census 71. Finding included: Record review of the facility's policy titled, Preventing Foodborne Illness: Employee Hygiene and Sanitary Practices, dated 10/2017, stated, New hire employees will obtain a food handler's card within thirty (30) days of being hired. a) Food Handler Cards Record review of the facility's food handler cards showed that two (2) food handler cards were expired and two (2) dietary staff did not have food handler cards available. 1) Dietary Staff (DS) #55 A review of Dietary Staff (DS) #55's food handler card showed no available food handler card on record. During an interview on 08/08/22 at 12:20 PM, Director of Food Services (DFS) stated that DS #55's food handler card was thrown away as it expired in July 2022. DFS stated that DS #55 would be unable to take the food handler certification this date due to being out of the facility. 2) Dietary Staff (DS) #56 A review of Dietary Staff (DS) #56's food handler card showed no available food handler card on record. During an interview on 08/08/22 at 12:20 PM, DFS stated that DS #56's food handlers' card was never obtained after being newly hired on 06/22/22 which did not meet the facility's policy for obtaining the food handler card within 30 days of being hired. 3) Dietary Staff (DS) #59 A review of Dietary Staff (DS) #59's food handler card showed no available food handler card on record. During an interview on 08/08/22 at 12:20 PM, DFS stated that DS #59's food handlers' card was never obtained after being hired on 12/01/21 which did not meet the facility's policy for obtaining the food handler card within 30 days of being hired. 4.) Dietary Staff (DS) #137 A review of Dietary Staff (DS) #137's food handler card showed a date of 05/06/21 and expired one (1) year later. During an interview on 08/08/22 at 12:20 PM, DFS stated that DS #137's food handlers' card was expired. DFS stated that DS #137 would ensure the food handler card was updated today. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview, and policy review, the facility failed to ensure that an allegation of neglect was reported immediately, but not later than 2 hours after the allegations were made, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility did not report an unwitnessed fall with injury for Resident #85, which was caused by the neglect of the facility staff. This practice affected two (1) of seven (7) residents reviewed for reportable incidents during the Long Term Care Survey Process (LTCSP). Facility census: 102. Findings included: a) Resident #85 An observation of the Resident, on 08/12/19 at 1:45 PM, revealed the Resident had her right arm in a sling. An interview with the Resident, on 08/12/19 at 1:47 PM, revealed she had fallen in the bathroom a few weeks ago when I was left alone on the toilet. The Resident stated I broke my arm when I fell. A review of the Resident's Care Plan, on 08/12/19 at 1:55 PM, revealed the Focus-Resident is at high risk for falls with injury related to gait and balance problems, incontinence, psychoactive drug use, and attempting to transfer alone with the intervention Assistance of 1-2 to bathroom and do not leave alone on the commode with an initiation date of 07/26/19. A review of the Resident's admission Minimum Data Set (MDS) Resident Assessment and Care Screening, on 08/12/19 at 2:10 PM, revealed the MDS Assessment was completed on 07/19/19. The functional status in Section G concerning toilet use assessed the Resident as extensive assistance with two plus person assistance the the resident uses the toilet. A review of the Resident's Progress Notes, on 08/12/19 at 2:30 PM, revealed the Resident was admitted to the facility on [DATE]. A Progress Note stated the Resident was sent to an acute care hospital on [DATE]. The note further stated the Resident returned from the hospital with an immobililzer to the right arm. A progress note dated 08/04/19 stated the emergency room discharge instructions included the Resident being diagnosed with a fracture of shaft of Humerus in the right arm. The progress notes did not include why the Resident was sent to the hospital or any falls at that time. Further review of the medical record, on 08/12/19 at 3:00 PM, revealed an X-Ray Report dated 08/03/19 that was taken at the acute care hospital. The report stated the an acute comminuted fracture of the right proximal humerus. An interview with the Director of Nursing (DON), on 08/13/19 at 1:00 PM, revealed the Resident had fallen on 08/03/19 and broke her arm. The DON stated there are no Progress Notes concerning the fall. The DON stated the only place the fall is documented is on the Incident Report. The DON stated this fall as well as all other falls should be documented in the Progress Notes. A review of the Incident Report, on 08/13/19 at 1:15 PM, revealed an unwitnessed fall occurred for the Resident on 08/03/19. The incident description stated the Certified Nursing Assistant was in bathroom with the Resident and needed a brief so she ran down the hall to get one. The Resident fell onto the floor and was found on her right side with her right arm under her. A further interview with the DON, on 08/13/19 at 1:30 PM, revealed the Nurse Aide taking care of the Resident should have never left her alone to get supplies. The DON confirmed the Resident's Care Plan stated to not leave the Resident alone in the bathroom and that the Resident was assessed on the MDS as requiring extensive assistance involving two staff members. The DON did confirm the Resident sustained a fracture due to the fall. An interview with the Administrator, on 08/13/19 at 2:30 PM, revealed the Resident's fall was considered neglect on the part of the nurse aide involved. The Administrator stated the incident should have been reported immediately but was not done. The Administrator verified the incident had never been reported to the State Survey Agency or Adult Protective Services. A review of the (undated) facility policy titled Reporting Abuse, on 08/13/19 at 3:15 PM, revealed the policy stated When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident: -The State Licensing/Certification Agency -The Ombudsman -Adult Protective Services. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, record review, and policy review, the facility failed to ensure that an incidents involving neglect and falls with injury were thoroughly investigated. The facility did not investigate an unwitnessed fall with injury for Resident #85, which was caused by the neglect of the facility staff. The facility also failed to investigate an unwitnessed fall with injury for Resident #97. This practice affected two (2) of seven (7) residents reviewed for falls during the Long Term Care Survey Process (LTCSP). Facility census: 102. Findings included: a) Resident #85 An observation of the Resident, on 08/12/19 at 1:45 PM, revealed the Resident had her right arm in a sling. An interview with the Resident, on 08/12/19 at 1:47 PM, revealed she had fallen in the bathroom a few weeks ago when I was left alone on the toilet. The Resident stated I broke my arm when I fell. A review of the Resident's Care Plan, on 08/12/19 at 1:55 PM, revealed the Focus-Resident is at high risk for falls with injury related to gait and balance problems, incontinence, psychoactive drug use, and attempting to transfer alone with the intervention Assistance of 1-2 to bathroom and do not leave alone on the commode with an initiation date of 07/26/19. A review of the Resident's admission Minimum Data Set (MDS) Resident Assessment and Care Screening, on 08/12/19 at 2:10 PM, revealed the MDS Assessment was completed on 07/19/19. The functional status in Section G concerning toilet use assessed the Resident as extensive assistance with two plus person assistance the the resident uses the toilet. A review of the Resident's Progress Notes, on 08/12/19 at 2:30 PM, revealed the Resident was admitted to the facility on [DATE]. A Progress Note stated the Resident was sent to an acute care hospital on [DATE]. The note further stated the Resident returned from the hospital with an immobililzer to the right arm. A progress note dated 08/04/19 stated the emergency room discharge instructions included the Resident being diagnosed with a fracture of shaft of Humerus in the right arm. The progress notes did not include why the Resident was sent to the hospital or any falls at that time. Further review of the medical record, on 08/12/19 at 3:00 PM, revealed an X-Ray Report dated 08/03/19 that was taken at the acute care hospital. The report stated the an acute comminuted fracture of the right proximal humerus. An interview with the Director of Nursing (DON), on 08/13/19 at 1:00 PM, revealed the Resident had fallen on 08/03/19 and broke her arm. The DON stated there are no Progress Notes concerning the fall. The DON stated the only place the fall is documented is on the Incident Report. The DON stated this fall as well as all other falls should be documented in the Progress Notes. A review of the Incident Report, on 08/13/19 at 1:15 PM, revealed an unwitnessed fall occurred for the Resident on 08/03/19. The incident description stated the Certified Nursing Assistant was in bathroom with the Resident and needed a brief so she ran down the hall to get one. The Resident fell onto the floor and was found on her right side with her right arm under her. A further interview with the DON, on 08/13/19 at 1:30 PM, revealed the Nurse Aide taking care of the Resident should have never left her alone to get supplies. The DON confirmed the Resident's Care Plan stated to not leave the Resident alone in the bathroom and that the Resident was assessed on the MDS as requiring extensive assistance involving two staff members with toileting. The DON did confirm the Resident sustained a fracture due to the fall. The DON stated this incident would be considered neglect on the part of the nurse aide caring for the Resident at the time of the fall. The DON stated the incident was not reported or investigated as it should have been. The DON stated she did not obtain witness statements or document anything other than what it is on the Incident Report. An interview with the Administrator, on 08/13/19 at 2:30 PM, revealed the Resident's fall was considered neglect on the part of the nurse aide involved. The Administrator stated the incident should have been reported immediately but was not done. The Administrator verified the incident had never been reported to the State Survey Agency or Adult Protective Services. The Administrator verified an investigation was not conducted thoroughly concerning the incident. A review of the (undated) facility policy titled Abuse Investigations, on 08/13/19 at 3:30 PM, revealed the policy stated All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to accurately reflect a resident status related to wearing a wander/elopement alarm for a annual and a quarterly Minimum Data Set (MDS). This affected one (1) of 24 resident reviewed during the facility's annual survey. Resident identifier #11. Facility Census 102. Findings included: a) Resident #11. A review of Resident #11's physician order finds an order for Resident #11 to wear a secure care bracelet. This order has been in effect since 03/20/17. Resident #11's has a care plan dated 03/20/17. The care plan focus states, Resident's name (Resident #11) is at risk for mood/behavior problem related to Dementia. The resident is currently on Seroquel related to roaming, potential elopement. The intervention in Resident #11 care plan are for the resident to wear a secure care bracelet. In an interview with Nurse Aide (NA) #155 on 08/13/19 at 11:18 AM, she was asked whether Resident #11 wear a secure care bracelet on her ankle. NA #155 agreed that Resident #11 has always wore a secure care bracelet due to Resident #11 has the potential to walk out of the front door. In an interview with Licensed Practical Nurse (LPN ) #78, on 08/13/19 at 1:18 PM, the LPN was asked whether Resident #11 has a secure care bracelet and the nurse stated, Yes. LPN #78 revealed that a secure care bracelet was placed on the resident since she came to the facility. Resident #11 was admitted on [DATE]. On 08/13/19 at 1:27 PM, the Clinical Reimbursement Coordinator (CRC) #103 was asked to review Resident #11's annual and quarterly MDS with the Assessment Reference Date (ARD) of 02/05/19 and 05/07/19. CRC (103) was asked whether the MDS accurately reflected Resident #11's wore a wander/elopement alarm. The CRC stated that, Resident #11 did wear a secure care bracelet since she had came here and the annual and the quarterly MDS was inaccurate. The CRC #103 stated that she will have to fix the MDS to reflect Resident #11 does wear an wander/elopement alarm. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review, and staff interview, the facility failed to implement the comprehensive person-centered care plan for a resident with fall interventions. Resident #85, assessed as a high fall risk, was left unattended while on the toilet resulting in a fall with a fracture. This failed practice had the potential to affected one (1) of six (6) residents reviewed for falls during the Long Term Care Survey Process (LTCSP). Resident identifier: #85. Facility census: 102. Findings included: a) Resident #85 An observation of the Resident, on 08/12/19 at 1:45 PM, revealed the Resident had her right arm in a sling. An interview with the Resident, on 08/12/19 at 1:47 PM, revealed she had fallen in the bathroom a few weeks ago when I was left alone on the toilet. The Resident stated I broke my arm when I fell. A review of the Resident's Care Plan, on 08/12/19 at 1:55 PM, revealed the following focus area: --The resident is athigh risk for falls with injury related to gait and balance problems, incontinence, psychoactive drug use, and attempting to transfer alone without the intervention. --Intervention was noted as the assistance of 1 to 2 staff to transfer to the bathroom --Further intervention was noted as the staff were to not leave the resident alone on the commode This care plan had an initiation date of 07/26/19. A review of the Resident's admission Minimum Data Set (MDS) Resident Assessment and Care Screening, on 08/12/19 at 2:10 PM, revealed the MDS Assessment was completed on 07/19/19. The functional status in Section G concerning toilet use assessed the Resident as extensive assistance with two plus person assistance the the resident uses the toilet. A review of the Resident's Progress Notes, on 08/12/19 at 2:30 PM, revealed the Resident was admitted to the facility on [DATE]. A Progress Note stated the Resident was sent to an acute care hospital on [DATE]. The note further stated the Resident returned from the hospital with an immobililzer to the right arm. A progress note dated 08/04/19 stated the emergency room discharge instructions included the Resident being diagnosed with a fracture of shaft of Humerus in the right arm. The progress notes did not include why the Resident was sent to the hospital or any falls at that time. Further review of the medical record, on 08/12/19 at 3:00 PM, revealed an X-Ray Report dated 08/03/19 that was taken at the acute care hospital. The report stated the an acute comminuted fracture of the right proximal humerus. An interview with the Director of Nursing (DON), on 08/13/19 at 1:00 PM, revealed the Resident had fallen on 08/03/19 and broke her arm. A review of the Incident Report, on 08/13/19 at 1:15 PM, revealed an unwitnessed fall occurred for the Resident on 08/03/19. The incident description stated the Certified Nursing Assistant was in bathroom with the Resident and needed a brief so she ran down the hall to get one. The Resident fell onto the floor and was found on her right side with her right arm under her. A further interview with the DON, on 08/13/19 at 1:30 PM, revealed the Nurse Aide taking care of the Resident should have never left her alone to get supplies. The DON confirmed the Resident's Care Plan stated to not leave the Resident alone in the bathroom and that the Resident was assessed on the MDS as requiring extensive assistance involving two staff members with toileting. The DON did confirm the Resident sustained a fracture due to the fall. The DON stated this incident would be considered neglect on the part of the nurse aide caring for the Resident at the time of the fall. .

. Based on record review and staff interview the facility failed to revise a Residents comprehensive care plan to include behavior monitoring interventions that were implemented. This was true for one (1) of twenty-three residents care plans reviewed. Resident identifier: #4. Facility census: 102. Findings included: a) Resident #4 During record review on 08/13/19 at 09:00 a.m., Resident was noted to have behavioral monitoring implemented and in progress. The order was initiated on 03/05/19 within the Task list and specified for staff to monitor Resident and check every half hour for inappropriate behavior and report if inappropriate behavior was observed. On 08/13/19 at 9:05 a.m., Residents care plan was reviewed for behavioral focus area. No interventions were included for behavioral monitoring. During an interview with the Administrator at 9:10 a.m., she stated she will look into the care plan and check for any interventions that may apply. On 08/13/19 at 11:59 a.m., after surveyor intervention the Residents Care plan now includes the following focus area with interventions with date initiated 08/13/19: --The resident has a behavior problem of inappropriate (sexual) verbalizations and/or personal contact towards staff during care, and towards other residents at times. The Resident will not exhibit any inappropriate behaviors, either verbally or physically, towards staff providing his care, nor towards other residents through review period. Document and report any unacceptable behaviors to charge nurse. Intervene as necessary to protect the rights and safety of other residents. At 2:42 p.m. on 08/13/19 during an interview the Administrator stated, The behavioral monitoring is now care planned for (Resident's first name), it was added today. The Administrator agreed the care plan should have been revised to include the behavioral monitoring when it was initiated on 03/05/19. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review, and staff interview, the facility failed to maintain medical records on each resident that are complete and accurate. Resident #85, assessed as a high fall risk, was left unattended while on the toilet resulting in a fall with a fracture. The Resident's Progress Notes do not include anything about the actual fall. This practice affected (1) of twenty (24) resident records reviewed during the Long Term Care Survey Process (LTCSP). Facility census: 102. Findings include: a) Resident #85 An observation of the Resident, on 08/12/19 at 1:45 PM, revealed the Resident had her right arm in a sling. An interview with the Resident, on 08/12/19 at 1:47 PM, revealed she had fallen in the bathroom a few weeks ago when I was left alone on the toilet. The Resident stated I broke my arm when I fell. A review of the Resident's Care Plan, on 08/12/19 at 1:55 PM, revealed the following focus area: --The resident is athigh risk for falls with injury related to gait and balance problems, incontinence, psychoactive drug use, and attempting to transfer alone without the intervention. --Intervention was noted as the assistance of 1 to 2 staff to transfer to the bathroom. --Further intervention was noted as the staff were to not leave the resident alone on the commode. This care plan had an initiation date of 07/26/19. A review of the Resident's admission Minimum Data Set (MDS) Resident Assessment and Care Screening, on 08/12/19 at 2:10 PM, revealed the MDS Assessment was completed on 07/19/19. The functional status in Section G concerning toilet use assessed the Resident as extensive assistance with two plus person assistance the the resident uses the toilet. A review of the Resident's Progress Notes, on 08/12/19 at 2:30 PM, revealed the Resident was admitted to the facility on [DATE]. A Progress Note stated the Resident was sent to an acute care hospital on [DATE]. The note further stated the Resident returned from the hospital with an immobililzer to the right arm. A progress note dated 08/04/19 stated the emergency room discharge instructions included the Resident being diagnosed with a fracture of shaft of Humerus in the right arm. The progress notes did not include why the Resident was sent to the hospital or any falls at that time. Further review of the medical record, on 08/12/19 at 3:00 PM, revealed an X-Ray Report dated 08/03/19 that was taken at the acute care hospital. The report stated the an acute comminuted fracture of the right proximal humerus. An interview with the Director of Nursing (DON), on 08/13/19 at 1:00 PM, revealed the Resident had fallen on 08/03/19 and broke her arm. The DON stated there are no Progress Notes concerning the fall. The DON stated the only place the fall is documented is on the Incident Report. The DON stated this fall as well as all other falls should be documented in the Progress Notes. .

. Based on staff interview and observation, the facility failed to ensure Report Sheets were secured in a manner that protected personal, medical, and health information. Personal identifiers including the resident's names, room numbers, appointments, orders, blood pressure readings, medications, medical interventions, and diagnoses, were listed on the 300 and 400 Hall Report Sheets. This practice affected more than a limited number of residents. Facility census: 102. Findings included: a) 300 Hall An observation of the 300 Hall, on 08/12/19 at 11:35 AM, revealed a Report Sheet was lying face up on a stand beside the Shower Room in the hallway. The information on the sheet was visible for anyone in the hallway to see. The Report Sheet was for eighteen (18) residents and contained the following resident information: -Resident names -Resident room numbers -Bowel movement information -Alarm information -Appointment time and date -Shower information An interview with LPN #54, on 08/12/19 at 11:40 AM, revealed the report sheet should not have been left in the hallway. The LPN stated she would take the Report Sheet and give it to the nurse aide it belongs to. b) 400 Hall An observation of the 400 Hall, on 08/12/19 at 12:15 PM, revealed a Report Sheet hanging on the wall beside the Shower Room. The information on the sheet was visible for anyone in the hallway to see. The Report Sheet was for twenty-eight (28) residents and contained the following resident information: -Resident names -Resident room numbers -Alarm information -Blood pressure readings An interview with Nurse Aide (NA) #122, on 08/12/19 at 12:17 PM, revealed the Report Sheets are posted on the wall to share the information with all the nurse aides on the hall. .

. Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple opened medications stored in the 400 Hall Medication Room and 300 Hall Medication Cart were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 102. Findings include: a) 400 Hall Medication Room An observation of the 400 Hall Medication Room, on 08/13/19 at 9:45 AM, revealed the following medications were opened but not labeled or dated as to when: --One (1) Novolog Flex-Pen --One (1) container of Diphenhydramine 12.5 mg solution An interview with Registered Nurse (RN) #171, on 08/13/19 at 10:00 AM, revealed all opened medications should be dated with the date they were opened and who opened them. b) 300 Hall Medication Cart An observation of the 300 Hall Medication Cart, on 08/13/19 at 10:10 AM, revealed the following medication was opened but not labeled or dated as to when: --One (1) bottle of Lactulose An interview with Licensed Practical Nurse (LPN) #54, on 08/13/19 at 10:12 AM, revealed the LPN stated everything is to be labeled and dated when opened but we can't catch everything. .

. Based on observation and staff interview the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items in the kitchen and sub dining room areas. The failed practice had the potential to affect more than unlimited number of residents. Facility census: 102. Findings included: a) Kitchen During the initial tour with the Director of Food Nutrition Services (DFNS) #141, on 08/12/19 at 10:45 AM, items were found not to be stored in the original box and not labeled or dated. The items included: --Five (5) bags of frozen hoagie buns laid on a shelf of the freezer. The bags were taken out of the original dated box and not labeled or dated. --A plastic container filled with 30 individually wrapped salad wafer crackers were taken out of the original dated box and container was not labeled or dated. --A plastic container filled with 32 individually wrapped Monarch Saltines were take out of the original dated box and container was not labeled or dated. --An interview with DFNS #141, on 08/12/19 at 11:00 AM, confirmed items were not dated or labeled and stated, I'll get that taken care of. b) Sub Dining Room An observation in the Sub Dining Room, on 08/13/19 at 10:20 AM, revealed three (3) white plastic containers of items not dated or labeled and an unidentifiable orange substance in the refrigerator not labeled or dated. The items included: --A plastic container filled with 11 individually wrapped soft chewy chocolate chip cookies were taken out of the original dated box and container was not dated. --A plastic container filled with 28 individually wrapped Monarch Saltines taken out of the original dated box and container was not labeled or dated. --A plastic container filled with 18 individually wrapped Vanilla Wafers taken out of the original dated box and container was not labeled or dated. --A styrofoam cup filled with an unidentifiable orange substance was found in in the sub dining room refrigerator was not labeled or dated. An interview with DFNS #141, on 08/13/19 at 12:20 PM, confirmed plastic containers should have been dated and labeled. DFNS # 141 stated, I will get that taken care of and immediately pulled the Styrofoam cup filled with the unidentifiable orange substance from the refrigerator. .

. Based on observation, staff interview, and policy review, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. Multiple hairbrushes and combs were not labeled on the 300 and 400 Halls and a nurse failed to wash her hands during medication administration. These practices affected more than a limited number of residents. Facility census: 102. Findings include: a) Hairbrushes and combs An observation of the 300 and 400 Hall Shower Rooms, on 08/12/19 at 11:30 AM, revealed both rooms contained multiple unlabeled hairbrushes and combs containing hair in each of them. An interview with LPN #54, on 08/12/19 at 11:45 AM, revealed she stated I have no idea who the combs and hairbrushes belong to. The LPN stated she would ensure they were discarded. b) Observation of hand hygiene during medication administration Observation of the Medication Administration pass on 08/14/19 at 8:45 AM, revealed Licensed Practical nurse (LPN) #63 did no perform hand hygiene when she administered Resident #68 and #7's medications. LPN #63 obtained Resident #68's medication from the medication cart, picked up her pen wrote on the medication packets, tore open the packets, picked up a medication cup, placed the medication into the cup, poured some water in a cup from a pitcher that was sitting on her medication cart went and administered Resident #68's medication without performing any type of hand hygiene prior to or following administrating Resident #68 medications. After LPN #63 administered Resident #68's medication, she went back to her medication cart and removed Resident #7's medication from the medication cart. LPN #63 picked up her pen and wrote on some of her medication packets, then torn open the medication packets, reached over and picked up a medication cup and placed the medication in the cup. The LPN then reached over and picked up one (1) cup and poured some water in the cup from a pitcher that was sitting on her medication cart, touched the computer screen, placed pudding in a medication cup, donned a pair of gloves, picked up two (2)tissues, reached up and readjusted her eye glasses, picked up the cup of water, and Resident #7's by mouth, oral and nasal inhaler. LPN #63 went to where Resident #7 was sitting in her wheelchair in her room and administered Resident #7's oral medication with the pudding, removed the cap off of the nasal inhaler (Flonase), administered the nasal medication one (1) spray into each nostril, replaced the cap, removed the oral inhaler cap (Symbocort)administered Resident #7 two (2) puffs by mouth. LPN #68 asked Resident #7 to rinse and spit into the plastic cup. LPN removed her gloves and washed her hands. An interview was conducted on 08/14/19 at 8:56 AM with LPN #63. The surveyor reviewed with LPN #63 the observation of her not performing hand hygiene prior to obtaining medication for Resident #68 and #7's medication, in between different types of medication from oral (by mouth) to a nasal inhaler(by nose) to an oral inhalers (inhalation medication by mouth)for Resident #7, and following the administration of Resident #68's medication. LPN #68 acknowledged that she should have performed some kind of hand hygiene when she administered Resident #68 and #7's medication. The facility's policy states to provide hand hygiene before preparing or handling medication. .