**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not formulate an advance directive for the resident. Resident (R) 185 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 13 residents surveyed (R185). Findings include: The facility policy, entitled Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR) Orders, dated [DATE], states: 1. Upon Admission, the licensed nurse of social worker will discuss the options, CPR or DNR and any other advanced directives with the resident and/or legal representative and received the corresponding physician orders. The Physician Order Summery (POS) is the designated place in the medical record for staff to record/find the CPR/DNR designation for each resident. R185 was admitted on [DATE] to the facility and is able to be understood by peers and understands. On [DATE], record review of R185's hard charts and electronic record could not produce an order for a Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR). Surveyor could not find a Provider Orders for Scope of Treatment form on file for R185. On [DATE] at 10:26 AM, Surveyor interviewed Registered Nurse (RN) C regarding the process for determining if a person was designated a CPR or DNR. RN C said they would look at the resident's most recent signed orders in the hard charts that were located at the nurse's station. They look at the orders because they are the most up to date source of information regarding the resident's designation for care. On [DATE] at 10:49 AM, Surveyor reviewed the hard charts again and did not find any doctor orders regarding CPR or DNR designations. Surveyor did not find the POST in the hard charts. On [DATE] at 2:19 PM, Surveyor interviewed Quality Consultant (QC) D, regarding the process and missing orders for R185. QC D said the normal process if someone were to need CPR or DNR services would be for staff to look at the hard chart physician orders. If the orders were not signed yet they would have something printed out and on file that looks like the signed orders. QC D and other staff members looked for the orders in the hard charts and in the electronic medical record and could not locate the orders for a DNR. There were orders from the hospital that indicated the resident was a DNR, but these were not accessible to staff who would need them. QC D agreed the orders for the DNR were not accessible, and they would not expect staff to look at the hospital transfer paperwork that was in a different area in the hard charts for a DNR designation. QC D would expect the order sheet be placed in the binder so that staff know where to look in the case of an emergency. QC D, after conversation with Surveyor, contacted the hospital that R185 transferred from and asked for signed orders for the DNR to be placed as soon as possible in the hard charts.

Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This affected 1 of 4 residents (R17) observed for medication administration. R17 received two insulin injections by using injectable pens that a safety check was not completed on to ensure the injectable pens were dispensing insulin before administration. Findings include: Manufacturer's instructions for Basaglar Kwikpen (insulin glargine) state in part.Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps . On 07/02/24 at 8:13 AM, Surveyor observed Registered Nurse (RN) C take two insulin pens out of the medication cart and attach needles to the end of each pen. RN C verified the pens with the orders on the Medication Administration Record (MAR) for R17. One pen was Insulin Glargine 100 units/milliliter (ml) with orders to administer 9 units by subcutaneous (sub-Q) injection daily. The other pen was Insulin Aspart 100 units/ml with orders to administer 3 units sub-Q twice per day. Surveyor observed RN C turn the dose knob to 9 on the Insulin Glargine pen. Surveyor observed RN C turn the dose knob to 3 on the Insulin Aspart pen. RN C did not prime either pen prior to selecting the prescribed dose. RN C carried both pens to R17's room and administered both injections into R17's abdomen per procedure. Immediately following the procedure, Surveyor interviewed RN C and asked if they primed the needles on the insulin pens prior to setting the pens to the prescribed dose. RN C stated they had never been taught that and didn't know they were supposed to do that prior to administering insulin with a pen injector. On 07/02/24 at 8:28 AM, Surveyor interviewed Director of Nursing (DON) B about the policy and procedure for use of insulin pens. DON B was not sure they had a specific policy and procedure for insulin pens and was not sure if insulin pens required priming of the needle prior to administering the dose. DON B stated they follow the manufacturer's instructions for insulin pens. DON B stated they would provide the manufacturer's instructions and facility policy, if they had one, for Surveyor to review. On 07/02/24 at 8:46 AM, DON B provided the manufacturer's information for the insulin pens and stated RN C did not follow the proper procedure for priming the insulin pens prior to administering insulin to R17. DON B stated they would provide education about the proper procedure to RN C and all nursing staff.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure that potentially hazardous foods were served at temperatures that would reduce the chance of illness for residents. The facility did not cover food while transporting room trays past resident rooms and in hallways. This has the potential to affect 2 residents (R) (R1, R12) on a pureed diet and 3 of 8 residents (R6, R17, R5) receiving room trays. Findings include: The facility policy entitled, Food Temperatures, dated January 2024, states in part, 4. Take temperatures a. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking . 5. The food service manager will a. review logs daily to ensure that appropriate temperatures are recorded and corrective actions are being taken. b. take corrective action as necessary. The facility policy entitled, Food Temperature Log, dated May 2024, states in part, HOT HOLDING: Typical serving temperature standards . All hot foods should be held at 140 degrees Fahrenheit or above On 07/02/24 at 8:09 AM, Surveyor observed a tray of food delivered to R6. On the tray was a bowl of cereal that had no covering and was exposed. Licensed Practical Nurse (LPN) E delivered the tray walking approximately 100 ft past three other resident rooms with the uncovered food. On 07/02/24 at 8:11 AM, Surveyor observed a tray of food delivered to R17. On the tray was a bowl of cereal, juice, and coffee that had no coverings and was exposed. LPN E delivered the tray walking approximately 50 ft past activity room where residents frequently are and shower room. On 07/02/24 at 8:15 AM, Surveyor observed a tray of food delivered to R5. On the tray was a bowl of oatmeal, juice, and milk that had no covering and was exposed. LPN E delivered the tray walking approximately 80 ft past one other resident room and offices with the uncovered food. On 07/02/24 at 11:50 AM, Surveyor observed food being served for service in the kitchen. During observation Dietary Aide (DA) G was taking temperatures of all foods on the steam table. One item, the pureed lasagna, was checked and the temperature read 128 degrees Fahrenheit. DA G reported that temperature to Dietary Manager (DM) F who recorded the temperature in their logbook and service continued. The pureed lasagna was not reheated and stayed in the steam table. The first pureed diet to be dished was for R12, and when they were making the tray, they did not recheck the temperature and they dished the pureed meal for the resident. The meal was then put into the enclosed metal cart to be delivered. The meal for R12 was then pushed out of the kitchen and was in route for delivery to the resident room. Surveyor asked DM F who would have been served the puree today, and DM F said R12 and R1 were the only two who received the pureed diet that day. These 2 residents had the potential to be affected by the unsafe food temperature. Surveyor then asked DM F and DA G what temperature they would expect food to be held at prior to service. DM F said at least 130 degrees Fahrenheit, they believed. Survey asked what the temperature of the puree had been when they took temperature at the beginning of service, and DA G said it was at 128 degrees Fahrenheit. Surveyor then asked DM F what they would have expected to have been done if any food temperature was found to be below the normal food holding limit. DM F said they should have caught that and heated the puree dishes back up to an appropriate temperature prior to serving. There was no intention of reheating the puree dishes which were to be served to two residents residing in the facility. Before the food could be delivered to R12 it was taken back to the kitchen and reheated. It was noted the signage posted next to the bulletin board in the kitchen read the food should be held at least 135 degrees at the lowest. On 07/03/24 at 8:39 AM, Surveyor interviewed DM F regarding their expectations for the concerns noticed during survey. When asked about covering the food when traveling down the halls, DM F said they would expect food to be covered, and if they were to send an individual tray, they would cover all items on the tray not just the main course. DM F said they would want the food covered if being walked down the hall out of the holding cart. When asked about expectations for holding temperatures for food, DM F said they would expect the food be held at 135 degrees Fahrenheit or above, unfortunately it was missed and won't happen again.

Based on observation, interview and record review, the facility did not assist 1 of 13 sampled and supplemental residents (R19) with eating in a dignified manner by scooping food from her lip and chin with a spoon and feeding it to her. This is evidenced by: Surveyor requested and received the facility policy titled Meal Service Standards which is dated as last revised on 12/18. The policy in part reads: Purpose: The following meal service standards will ensure our residents have a safe, pleasant and enjoyable dining service. Protocol: 1. Dignity: h. All residents are served in a dignified and courteous manner. Surveyor reviewed R19's record and noted the following: The most recent quarterly Minimum Data Set (MDS) completed 12/28/24 notes R19 is dependent on staff to eat. On 3/26/24 at 12:49 PM, Surveyor observed Certified Nursing Assistant (CNA) E sitting at dining room table between R19 and another resident. R19 was faced away from the table in the wheelchair and CNA E was seated at table with her lunch tray. CNA E alternated bites of food that was pureed and drinks of beverages using a glass with a straw. CNA E wiped food from R19's lower lip and upper chin with spoon that she was using to feed resident. CNA E fed R19 the food from her lip and chin. Surveyor observed CNA repeat the swiping food from R19's lower lip and chin with her spoon several times and feeding R19 the food. On 3/27/24 at 8:04 AM, Surveyor observed breakfast in the dining room. CNA E placed R19 at the same table in the same manner as observed for lunch on 3/26/24. CNA E sat at table at R19's side. CNA E was brought R19's breakfast tray of eggs, hot cereal and beverages. CNA E applied a cloth napkin under R19's chin and began feeding her the scrambled eggs and cereal. CNA E alternated feeding R19 and another resident at the table. Surveyor observed CNA E wipe food that was dripping from R19's lip and chin with a spoon and feeding it to her 11 times while assisting her to eat. CNA E did not use the cloth napkin that was placed under R19's chin to wipe the food from R19's lower lip or chin. On 03/27/24 at 2:01 PM, Surveyor spoke with CNA E about the observation. CNA E indicated she works 3 days a week and assists R19 with her meal each day CNA E works. CNA E expressed CNA E has never been told not to use a spoon to wipe food from resident faces and refeed it to them. CNA E further expressed not being aware it is not dignified to do so and frequently clears food from R19's face as Surveyor observed. On 3/27/24 at 3:00 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B explained it is not appropriate for staff to wipe residents' chins or lips with a spoon and re-feed them due to dignity and infection control reasons. DON B indicated staff reeducation will be initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility did not ensure that 1 of 3 sampled and supplemental residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition (assistance with meals). (R9) Findings include: R9 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia with anxiety, irritability and anger, depression, chronic diarrhea, peripheral vascular disease, osteoarthritis, and hypertension. R9's Minimum Data Set (MDS) assessment, completed on 01/12/24, confirmed R9 scored 01 during a Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R9 had weight loss and requires set-up assistance with eating. R9 requires substantial maximal assistance from staff for dressing and is dependent on staff for bathing, toileting, and transfers. R9's care plan was initiated on 10/14/23, and included the following: R9 is at nutritional risk due to dementia, forgets to drink with cup and needs reminders. Interventions include remind to drink out of cup at meals, set-up and assist resident as needed, and offer substitutes if more than 50% of food is left uneaten. Speech therapy recommendations dated 10/30/23, notes Provide verbal cues and physical assist during meals to continue eating and for safety, provide feeding assist if not initiating or discontinues on her own. Surveyor reviewed weights and noted: R9 lost 19.8 pounds which is a 9.17% loss in 5 months while residing at the facility. Observations were continuous from 03/26/24 at 12:25 PM to 03/26/24 at 1:09 PM. On 03/26/24 at 12:25 PM, R9 received the lunch tray which consisted of 4oz juice, 8oz milk, bread, ham, scalloped potatoes, peas, and cake. R9 wheeled up to the table, picked up the spoon, licked it, then picked up ham with fingers and ate it. R9 then took juice and poured it over the meal. Registered Nurse (RN) G offered to help and R9 said no, then RN G left. R9 then fed self peas and ate bread soaked with juice. R9 placed the spoon in the cup of milk and tried to drink it like a straw. R9 ate a huge bite of cake and then placed the fork in the milk. Unsuccessfully, R9 tipped up small bowl with a few cake crumbs in it and tried to eat it. At 1:01 PM, RN G stated quietly, Oh we are going to eat with juice today, then assisted R9 back to the table, cued her to eat, handed R9 a fork with potatoes on it, then walked away. R9 did not eat the potatoes but drank 2 oz of juice independently and no milk. At 1:09 PM, R9's tray was picked up and placed on the cart. R9 did not drink milk and ate the cake, 3 bites of ham, and one spoon of peas of which most fell off the spoon and landed on the floor. Surveyor reviewed R9's meal ticket that noted: Special instructions: Finger foods. Dislikes oatmeal. Lunch drinks 8oz milk and 4oz juice. Staff did not offer fluids, did not replace food soaked in juice, did not offer finger foods or alternative foods, and only one attempt at physical assistance to eat was made in the 44 minutes R9 had her lunch tray. Only 2 staff were in the dining room, and they were assisting 6 residents. Observations were continuous from 03/27/24 at 7:51 AM to 03/27/24 at 9:10 AM. On 03/27/24 at 8:03 AM, R9 was brought to dining room via wheelchair by Certified Nursing Assistant (CNA) H and was provided with breakfast. Breakfast included: Scrambled eggs, toast, cheerios, 8oz milk 4 oz juice. R9 was falling asleep at the table. At 8:10, R9 scooted away from table/breakfast. At 8:22 AM, CNA H checked on another resident at same table as R9 but did not offer or assist R9. R9 remained sitting approximately 5 feet away from the table/meal. At 8:30 AM (27 minutes after receiving her meal), CNA H approached R9 and verbally cued R9 to move to the table to eat. R9 scooted self to the table and was scraping toast with a spoon, then took spoon and moved food around on the tray but did not take any bites. R9 then put the spoon back on the tray. At 8:33 AM, R9 picked up the spoon and stirred the cereal. At 8:36 AM, CNA H applied glasses to R9 and walked away without cueing or assisting with the meal. At 8:40 AM, CNA H offered and provided R9 with coffee, setting it on the table, then tried to move R9 back to the table. R9 put feet down to avoid being brought to the table. A few minutes later, R9 moved to the table and looked at the meal. At 8:42 AM, CNA H cued R9 to eat as she walked past R9 and told Licensed Practical Nurse (LPN) I that R9 is more sleepy in the mornings lately and R9 likes jelly on her toast. At 8:44 AM (41 minutes after receiving meal), LPN I put jelly on R9's toast, handed it to R9 who ate the 1/2 piece. R9 then took a bite of cereal on her own then stopped feeding self. On 03/27/24 at 8:54 AM, Surveyor interviewed LPN I what the approaches were for R9 during meals. LPN I stated that R9 will eat when she wants and it depends on her mood. LPN I said, I tried to feed her yesterday and she slapped me. Surveyor asked what R9 would do if handed drinks, which LPN I said R9 will set it back down or throw it at us. At 8:57 AM (almost an hour after receiving her tray), LPN I handed her the other half of jelly toast and R9 ate it. At 8:59 AM, Surveyor noted the limited assistance for R9 and asked LPN I to hand R9 the milk to see how R9 responds. LPN I handed the milk to R9 who took it in her hand and guzzled the whole 8 ounces at one time. No other foods or drinks were offered. Tray was removed at 9:10 AM. R9 was not assisted timely on 03/27/24 with the breakfast meal or to the extent required. The meal was not reheated. Additional fluids or finger foods were not offered for a resident with severe cognitive impairment and weight loss. On 03/27/24 at 9:50 AM, Surveyor interviewed Certified Dietary Manager (CDM) C who stated, I am aware of the weight loss for R9. We monitor weights, provide finger foods, and send double breakfasts since she likes breakfast. R9 likes jelly toast and sweets. We send both finger foods and regular meals because R9 sometimes will eat regular food. Surveyor informed CDM C of observations, and CDM C stated she was not aware and will provide cups with lids and straws for R9. Surveyor reviewed Registered Dietitian notes dated 10/14/23 and noted that R9 needs direction and drinks 240-360cc/day and estimated needs are 1650-1980cc/day. Assessed again on 11/14/23 and noted decreased intake and poor appetite resulting in a 7.8% weight loss in 90 days and has no chewing or swallowing concerns. On 03/27/24 at 10:10 AM, Surveyor interviewed Speech Therapist (ST) J. ST J stated she treated R9 from 10/30/23 to 11/06/23 and there were no concerns with swallowing or chewing and worked mostly with R9's attention span. On 03/27/24 at 1:36 PM, Surveyor interviewed DON B and RN K. Surveyor asked what would be expected from staff when a resident with dementia continues to move away from the table and stops eating. RN K stated it would be expected to encourage the resident to eat, try finger foods and other snacks later. Surveyor explained the concern with R9 noted above. DON B stated they will educate right away and get right on that. RN K stated she will provide any education and interventions they are able to complete by tomorrow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not comprehensively assess 1 of 2 residents (R31) for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. This is evidenced by: Surveyor requested and received the facility policy titled Providing Culturally Competent and Trauma-Informed Care dated as most recently revised on 8/22. The policy in part reads: Purpose: Residents who are trauma survivors will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Protocol: 1. Assessment: a. A multi-faceted approach to identifying resident history of trauma as well as his or her cultural preferences will be utilized. This includes asking the resident about triggers that may be stressors or may prompt recall of previous traumatic event; as well as screening and assessment tools such as the Resident Assessment Instrument, admission Assessment, history and physical, the social history/assessment, and other assessment such as the PTSD-Civilian Screening Checklist and Life Events Checklist in ECS. 2. Recognizing and Assessing Trauma: a. Residents may be trauma survivors such as military veterans . b. Residents with a history of trauma may have diagnosis such as anxiety, depression or may have substance abuse issues such as alcoholism .Evidence of physical and/or psychological trauma can be reveled during a comprehensive .assessment 3. Recognizing and Assessing Triggers: a. The facility will attempt to identify triggers which may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts stimulus that prompts recall of a previous traumatic event, trauma .For many trauma survivors, the transition to living in an institutional setting and associated loss of independence can trigger profound re-traumatization . 4. Care Planning to Address Past Trauma: a. The facility will collaborate with resident trauma survivors .to develop and implement individualized interventions . e. Trauma-specific interventions should also recognize the interrelation between trauma and symptoms of trauma such as substance abuse .depression .anxiety. On 03/26/24 at 10:25 AM, Surveyor spoke with R31 about mood and past trauma. R31 was calm and able to hold conversation. R31 reported no concerns with his mood at this time as R31 has plans to discharge home soon. R31 indicated issues with his mood in the past with alcohol dependence and sleep issues. R31 expressed he is a military veteran of the Vietnam war. Surveyor asked R31 if anyone from the facility has spoken with him about his history and anything that may cause him stress and how to avoid any re-traumatization. R31 indicated he could not recall anyone from the facility speaking with him about his history and things that may cause him stress. Surveyor reviewed R31's record and noted he was admitted [DATE] from Veteran's Association hospital. R31's diagnoses include post-traumatic stress disorder, alcohol dependence in remission, bipolar disorder, current episode depressed, mild or moderate severity, unspecified, adjustment disorder with depressed mood, primary insomnia, dysthymic disorder (persistent depressive disorder). Surveyor reviewed R31's Significant Change In Status Minimum Data Set (MDS) dated [DATE] which notes he understands, is understood and is cognitively intact. R31 has depressed mood indicators and no behavioral concerns. Surveyor reviewed R31's record and no trauma informed assessment was located. Surveyor reviewed R31's care plan and noted no trauma informed approaches to mitigate any retriggering of R31's past trauma. On 3/27/24 at 2:55 PM, Surveyor spoke with Assistant Nursing Home Administrator (ANHA) F, who took over social services responsibilities in February 2024 on an interim basis. ANHA F explained the facility process is to conduct a comprehensive trauma informed assessment when residents are admitted with diagnosis of PTSD or past trauma such as serving in a war. The assessment would determine if a care plan should be developed to address any triggers such as loud noises or bright lights that may cause stress to individuals. ANHA F indicated a comprehensive assessment was not completed with R31 thus no care plan was developed. ANHA F further expressed ANHA F had a conversation with R31 at some point about the diagnosis and any potential triggers. ANHA F could not recall when the conversation took place but recalled R31 indicated R31 was a veteran of the Vietnam war and did not indicate any triggers during the conversation; however, a comprehensive assessment was not completed. Surveyor requested a copy of the note of her conversation with R31 to determine what was discussed with R31 as Surveyor could not locate a note of the discussion in R31's record.

Based on observations and interviews, the facility did not provide pharmaceutical services to meet the needs of 1 of 1 resident reviewed for insulin administration (R31). This is evidenced by: The Bureau of Quality Assurance issued a memo dated 9/23/2003 (Memo number 03-014) which states that insulin is classified into five categories: Rapid-acting, Short-acting, Intermediate-acting, Long-acting, and Combination products. The memo points out that Rapid-acting, Short-acting, and Combination products start working within a short time frame and are meant to control blood sugar levels at meals. The memo states that it is important that the meal and administration of the insulin are properly timed to optimize blood sugar control. The memo also states that rapid-acting insulins (Novolog and Humalog) should be administered 0-15 minutes before meals or immediately following a meal. Drugs.com states in relation to meal service with Insulin Aspart: .Insulin Aspart (Novolog): Administer subcutaneously within 5 to 10 minutes before a meal . On 3/27/24 at 6:57 AM, Surveyor observed Registered Nurse (RN) G measure R31's blood sugar, which recorded as 113. At 6:59 AM, RN G administered 10 units of Insulin Aspart (Humalog) to R31's right arm. R31 was observed by Surveyor until 7:57 AM, when he began to eat his meal. There were no offers until this time for juice, milk or any snack. This was 58 minutes after the insulin was given. On 3/27/24 at 3:00 PM, Surveyor interviewed RN G regarding her knowledge of administration of rapid-acting insulin. RN G stated, Well, it's a short-acting. I thought the meal was going to be around 7:30. Generally I would have given it closer to the meal. He was low (blood sugars). But, yes, I should have made sure it was closer to the meal. Surveyor then explained that because R31's blood sugars were low, diligence in regard to meal service and insulin administration should have been practiced. On 3/27/24 at 4:02 PM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation of nurses administering rapid-acting insulin. DON B stated that her expectation is that The nurse should administer it within 5-10 minutes of a meal or right after. Surveyor then explained the observation made above. DON B stated, I will get right on this with education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) of 5 sampled residents (R4) was offered a COVID-19 vaccine as indicated. This is evidenced by: R4 was admitted to the facility on [DATE] and had a diagnosis of depression. R4 was tested COVID positive on the evening of 11/27/23. R4 received the following vaccinations: COVID shot (Moderna) on 2/5/21 and 3/4/21. COVID boosters on 11/19/21, 4/21/22 and 10/5/22. On 11/29/23 at 11:45 AM, Surveyor interviewed Director of Nursing (DON) B and asked if R4 received the most recent COVID booster and flu shot. DON B indicated no, that hospice did not want to give R4 the current COVID booster and that the facility had the flu vaccination and R4 got that. Surveyor asked DON B if the power of attorney (POA) wanted R4 to have the COVID booster. DON B indicated the POA agreed to R4 having the COVID booster. At 12:28 PM, Surveyor asked DON B if there was any documentation from hospice indicating not to give R4 the booster. DON B indicated there was no documentation of a conversation with hospice as to why they were not going to give resident the booster. Surveyor was not able to locate any further follow up that the facility had offered to provide R4 the Covid booster. R4 previously was up to date on COVID vaccinations and did not receive the COVID booster that was given to the other residents in October. R4 tested COVID positive on the evening of 11/27/23. R4 had the right to receive the COVID booster, but the facility did not administer it to her per the POA's request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 On 11/28/23 at about 7:56 AM, Surveyor noticed that staff that had been wearing a surgical mask had now switched to an N95 mask. Surveyor asked DON B if there was something the survey team needed to know. DON B indicated they had staff and 2 residents (R1 and R4) test positive for COVID last night and they were recommending that their staff wear an N95. Surveyor observed on the 200 hall a bin outside of R1's room with PPE in and a sign on the door that indicated R1 was on contact precautions. Surveyor went to the 100 hall to R4's room and observed a bin outside the room with PPE in it and a sign on the door that indicated R4 was on contact precautions. The 200 hall has a total of 18 residents residing, 100 hall has 7 residents residing, and the 300 hall has 11 residents residing. On 11/29/23 at about 10:00 AM, Surveyor interviewed DON B and RN G and asked if contact precautions were the appropriate precautions for a resident that is positive for COVID. RN G indicated it should be airborne precautions. Example 3 R1 was admitted to the facility on [DATE], and had diagnoses that include: paranoid schizophrenia, bipolar disorder, schizoaffective disorder and anxiety. On the evening of 11/27/23, R1 tested positive for COVID and was placed on contact precautions. On 11/28/23 at 9:03 AM, Surveyor observed Certified Nursing Assistant (CNA) L going into R1's room putting on full PPE (gown, gloves, N95 mask and goggles or face shield) prior to entering R1's room. At 9:05 AM, CNA L came back out of R1's room, took off PPE just inside R1's room, sanitized hands, kept on same N95 mask and did not change contaminated N95 mask or disinfect goggles. CNA L was observed to continue to work the other areas of the facility with the same contaminated N95 mask including providing cares to other residents who were not COVID positive, relieve other CNAs for break throughout the facility, and assisting other residents in the dining room. On 11/28/23 at 9:51 AM, Surveyor observed CNA L, with the same contaminated N95 mask, go into R1's room. They put on gown, gloves, and goggles prior to entering the room. At 9:53 AM, Surveyor observed CNA L come out of R1's room with N95 mask and goggles on carrying R1's breakfast tray inside a garbage bag bringing it to the cart. CNA L did not replace contaminated N95 mask or sanitize their goggles after being in R1's room. CDC recommendations state the use of an N95 mask used during the care of residents with COVID infection should be removed and discarded after the resident care encounter and a new one should be donned. [https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html] On 11/28/23 at 1:26 PM, Surveyor observed CNA J go into R1's room with a blue surgical mask, gloves and gown, no goggles, no N95 mask. CNA H also went in and put on a gown, used hand sanitizer then put on gloves, had a N95 mask on, but no goggles. Both CNA J and H were observed providing cares to other residents that were not COVID positive. Staff did not wear the appropriate PPE (N95 mask and goggles) when caring for a COVID positive resident. Example 4 Facility's policy entitled Handling Resident Meal Trays from Isolation/Transmission-Based Precautions Rooms with a date revised of 3/23 reads in part When residents have finished their meal trays, the tray is covered with a clear plastic bag and tied off, placed on the cart and then taken back to the dirty area of the dish room for stripping/sanitizing. On 11/28/23 at 1:31 PM, Surveyor observed CNA J wearing PPE of a blue surgical mask when coming out of R1's COVID positive room with R1's lunch tray uncovered. CNA J took the uncovered tray through resident hallways and down to the kitchen. CNA H came out of R1's room with N95 mask on, Surveyor did not observe CNA H change into a new N95 mask. COVID positive residents require staff to wear the appropriate PPE (N95 mask). The tray needed to be covered with a clear plastic bag to prevent the spread of COVID to other residents, staff, and visitors. Staff N95 masks needed to be changed into a new one once leaving a COVID positive room. On 11/28/23 at 2:28 PM, Surveyor observed Housekeeper I go into R1's room, put on a gown and gloves along with an N95 mask, went into R1's room and brought out some garbage in the hallway, then shut R1's door, and stood in the hallway with same gown and gloves on. Surveyor asked Housekeeper I if the resident was busy; they indicated R1 was in the bathroom. Housekeeper I went back in and out of R1's COVID positive room a few times then came out in the hallway with the same gown and gloves on. DON B walked by and asked Housekeeper I if they had a face shield. Housekeeper I indicated no, but I have goggles on my cart and asked if they needed to wear both. DON B indicated that they should wear a face shield. Housekeeper I walked down the hallway with their contaminated gown, gloves and N95 mask on to meet another staff member. Housekeeper I had the same gown and gloves on that they had on in the COVID positive room. Housekeeper I had been in and out of R1's room two times again going back and forth to their cart wearing the same contaminated gown and gloves that was worn to clean R1's room. At 2:36 PM, R1's call light was on. CNA K was observed by Surveyor putting on a gown, hand sanitizing, putting on gloves and wearing a blue surgical mask to enter R1's room not wearing eye protection. At 2:52 PM, CNA K came out of R1's room wearing a surgical mask and no eye protection. CNA K removed their gloves and left on the same surgical mask that was worn in a COVID positive room. CNA K had just started their shift and was observed providing cares to other residents that were not COVID positive with a contaminated blue surgical mask. COVID positive residents require staff to wear the appropriate PPE (goggles and N95 mask). Staff also need to take off the contaminated PPE properly before leaving the room. Walking down the hallway with the PPE worn inside a COVID positive room can cause COVID to spread to others who are in the hallway. Surveyor interviewed NHA A and asked how the facility staffs the floor. NHA A indicated there are 3 CNAs for 100 and 200 halls and that 1 of the CNAs is considered a floater that helps throughout the facility and the CNAs relieve each other for breaks, including the memory care unit that is staffed with only 1 CNA. On 11/29/23 at 9:34 AM, Surveyor interviewed DON B and Registered Nurse (RN) G and asked what PPE staff should be wearing when in a COVID positive room. DON B indicated an N95 mask, goggles or face shield, gown, and gloves. Surveyor asked when staff come out of the room what should staff do. DON B indicated they should be removing all the PPE. RN G indicated that they have plenty of N95 masks and should be putting on a new N95 mask. Example 5 R2 was admitted to the facility on [DATE] and had a diagnosis of neuromuscular dysfunction of bladder and has a indwelling catheter. R2 had a sign on the door indicating that they were on enhanced barrier precautions. On 11/28/23 at 1:40 PM, Surveyor observed CNA J empty R2's catheter. CNA J put down a barrier, wiped port and emptied urine from the catheter into graduate. CNA J emptied the urine from the graduate into the toilet and put soap in the graduate. Surveyor could hear CNA J pouring water into the graduate. CNA J then swished the soap and water around in the graduate and dumped it in the toilet. Surveyor asked CNA J if they put the graduate under the faucet in the bathroom sink to put water in it. CNA J indicated that she tried to and it would not fit under the faucet so they used a cup to put water in the graduate. Surveyor asked CNA J what cup they used. CNA J indicated that blue cup; the only blue cup by the sink was R2's denture cup. Use of the resident's denture cup to pour water into the graduate that was used to remove urine from the resident's catheter is inappropriate due to the cross contamination of urine being splashed into the resident's denture cup. On 11/28/23 at 4:24 PM, Surveyor interviewed DON B and told her about the above observation and asked if CNA J did it properly. DON B indicated no that's not appropriate, and I will go and remove the denture cup. Based on observations, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when covid precautions of appropriate Personal Protective Equipment (PPE) were not followed, incorrect signs were placed on rooms, improper cleaning of urine graduate, surveillance of infections and employee testing for covid were incomplete. This has the potential to affect all 36 residents residing in the facility at the time of survey. This is evidenced by: Example 1 Centers for Disease Control and Preventions (CDC) for interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic date September 2023, document in part: A single new case of SARS-CoV-2 infection in any Health Care Personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. When testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test . Surveyor reviewed facility's respiratory outbreak starting 10/13/23 with positive COVID-19. On 10/30/23, the infection control log for employees listed Activities Aide (AA) O had start of symptoms at 2:00 p.m. of cough and nasal congestion with a negative COVID-19 test. The log section COVID Vaccine Up-to-date? (Y/N) was not completed. AA O had a well date of 10/31/23 with no documented time and a return to work on 11/03/23 at 3:00 p.m. The log documented a physician diagnosis is not applicable with determining if another diagnosis other than COVID was the reason for symptoms. AA O did not have a second COVID antigen test taken 48 hours after the first negative test before returning to work. AA O was not listed on the facility's respiratory outbreak line list of residents and employees to track and trend the respiratory illness. On 10/31/23, the infection control log for employees listed Registered Nurse (RN) P had onset of symptoms of nasal congestion and a negative COVID-19 test. RN P had a well date of 11/03/23 with no time documented and a return to work date of 11/04/23 at 6:00 a.m. The log documented a physician diagnosis is not applicable with determining if another diagnosis other than COVID was the reason for symptoms. RN P did not have a second COVID antigen test taken 48 hours after the first negative test before returning to work. RN P was not listed on the facility's respiratory outbreak line list of residents and employees to track and trend the respiratory illness. Surveyor reviewed facility's Respiratory Outbreak Line List of Residents and Employees dated Oct. 2023. The line list was not completed with First Case Date, Last Case Date, Total Number of Residents at Time of Outbreak, Total Number of Staff at Time of Outbreak. The October respiratory outbreak line list of residents and employees documented on the second line an employee's first name and no last name. The sections in Vaccination Status for influenza, pneumococcal, and COVID was not completed. The section for Date/Time last Symptom was completed with a date of 10/21/23 with no time listed, with a return to work date of 10/24/23 at 10:00 p.m. The logs did not identify if staff had contact with residents for contact tracing. The third line listed Resident (R)338 with a date of illness onset of 10/20/23 of a runny nose. Documenting a positive COVID-19 test with no date to when tested positive. The date documented for the start of precautions was 10/23/23, this was three days after the start of symptoms. The line list was not completed with Date/Time Last symptom and Well Date. Surveyor reviewed facility's email communication to the public health nurse. The email from Director of Nursing (DON) B was sent on 11/01/23 noting the COVID positive patient is in the hospital and will continue to be in outbreak status until 11/09. On 11/29/23 at 3:14 PM, Surveyor interviewed DON B and Corporate RN G asking about the email communication to public health on 11/01/23 with a COVID positive resident in the hospital. DON B stated R338 was positive for covid and sent to the hospital for confusion; this was not listed on the line list. Surveyor reviewed with DON B the respiratory outbreak line list did not document R338 was hospitalized , when symptoms resolved, well date, or when returned to the facility. Surveyor reviewed R338's hospital Discharge summary dated [DATE]. R338 was referred to hospital for observation for repeated falls after COVID-19 infection while in the nursing home. The discharge diagnoses were vascular dementia with progressive decline, recent COVID-19 with post infection weakness and repeated falls. Surveyor reviewed the facility's November GI outbreak line list of residents and employees for the first case date of 11/05/23. This GI line list did not have listed the last case date. Listed were three staff with illness and did not list a well date and time and a return to work date and time. The facility would not be able to determine if the staff returned with no risk to infect other residents. On 11/29/23 at 3:14 PM, Surveyor interviewed DON B and RN G asking about the October GI outbreak line list. DON B and RN G indicated the residents were listed on the surveillance infection report. Surveyor reviewed with DON B and RN G the line list did not match with that reported to public health on 10/25/23. DON B stated the infection report was not accurate with R13. R13 had GI symptoms prior to being on the list on 10/30/23. R13 had symptoms about 4-5 days prior had only symptoms for one day then and symptom returned on 10/30. Surveyor reviewed the facility's surveillance infection report and R13 was not listed with symptoms prior to 10/30/23. Surveyor reviewed the facility's November respiratory outbreak line list of residents and employees with the first case date of 11/27/23. Listed first were three staff with symptoms and positive COVID-19 tests on 11/27/23. The outbreak line list did not document when employees last worked and if staff had contact with residents. The facility indicated they use contact tracing as the method to determine testing. Without knowledge of who staff had contact with, the facility is unable to complete accurate contact trace testing. The fourth and fifth listed are residents and did not document room number. On 11/29/23 at 3:14 PM, Surveyor interviewed DON B and RN G asking about line list of last day working in the facility and where the staff worked to conduct contact tracing. DON B indicated DON B will interview the staff and ask who they had contact with and test that resident. DON B would not write down when and where they last worked. Surveyor reviewed with DON B the line lists that were not completed. Surveyor requested all information the facility has completed for the outbreaks including timelines, testing logs and contact tracing and any additional information. No further information was given to Surveyor while on survey to show evidence of contact tracing and resident testing. On 11/29/23 at 3:14 PM, Surveyor interviewed DON B about the incomplete data on the respiratory and GI line lists. Surveyor asked how a complete infection control investigation could be completed to determine the onset of the outbreak with missing data. Surveyor asked if symptomatic staff or residents are negative for COVID if they are tested for influenza. DON B and RN G indicated no they have not tested for influenza. Surveyor reviewed with DON B and RN G current CDC guidance for acute respiratory illness symptoms suggests testing for both COVID and influenza.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were reported to other officials in accordance with State law through established procedures for 1 of 3 residents reviewed for abuse (R3). R3 was touched on her breast by another resident and the incident was not reported to the Legal Guardian, nor to other officials. This is evidenced by: The Facility Policy, titled, Resident Safety Abuse Policy, with a revision date of 2/2022, includes, in part: Purpose: It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property. Providing a safe environment is one of the most basic and essential duties of the facility .Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals .SEXUAL ABUSE is non-consensual sexual contact of any type with a resident. Determination of the resident's ability to consent must be determined. The facility Policy titled, Change in Residents Condition/Status: Resident, Physician and Family/Legal Representative Notification/Consultation, with a revision date of 8/2021, includes, in part: Purpose: The facility will promptly notify (and consult with, when appropriate) the resident, the resident's attending physician and the resident's legal representative or interested family member of changes in the resident's condition and/or status .5. Unless otherwise instructed by the competent resident, the Licensed Nurse will notify the resident's family or legal representative when .b. There is suspected or alleged abuse . R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's disease, unspecified dementia, restlessness and agitation, major depressive disorder, vascular dementia, and need for continuous Supervision. R3's most recent Minimum Data Set (MDS) with a target date of 11/18/22, documents a Brief Interview for Mental Status (BIMS) score of 2, which indicates, severe cognitive impairment. Review of the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, with a Report Submitted Date of 12/1/22, indicates, .Brief Summary of Incident: Resident A (R1) reached out toward Resident B (R3) and touched them on the arm and also touched their breast. Resident A (R1) has a tendency toward physical contact (rubbing shoulders/arms, patting backs) and their hand has slipped. Review of the Misconduct Incident Report, with a Report Submitted Date of 12/8/22, documents, .5. Law Enforcement Involvement: Was law enforcement contacted or involved? No . On 12/20/22 at 11:05 AM Surveyor interviewed ANHA C (Assistant Nursing Home Administrator) and asked if a staff member reports a resident touched another resident's breast, should that allegation be investigated as an allegation of sexual abuse. ANHA C indicated, yes. Surveyor asked ANHA C if an allegation of sexual abuse should be reported to police. ANHA C indicated, yes. Surveyor asked ANHA C if the POA (Powers of Attorney) for R1 should have been notified of the incident. ANHA C indicated, yes. Surveyor asked ANHA C if she has any evidence that they were notified. ANHA C indicated she would have to look. No further evidence regarding notification of the POA or Law Enforcement was provided to the surveyor by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to conduct a thorough investigation regarding the incidents that occurred on 12/2/22 and 12/10/22 between R1 and R2. The facility failed to complete a physical assessment and monitor R2 after both incidents to ensure R2 was not experiencing psychosocial affects. The facility failed to complete body checks for residents who are unable to verbally communicate to ensure they did not experience abuse or unwanted touch. The facility failed to interview all staff that were involved in the incident. R2 was admitted to the facility on [DATE] with a diagnoses including Dementia, major depressive disorder, anxiety disorder, acute stress reaction, and age-related cognitive decline. R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/23/22, indicated R2's cognition was severely impaired with a BIMS (Brief Interview for Mental Status) score of 01 out of 15. R2's CNA (Certified Nursing Assistant) Assignment Sheet, dated 12/19/22, indicates, R2 needs assist of 1 for showering and personal cares. Ensure to alert nurse of any exit attempts immediately. Benefits from social stimulation during the day and into evening hours. If she becomes upset with others provide her a safe quiet place to allow her to vent. Encourage her to lay down for rest periods throughout the day, especially after lunch or when anxious, STOP sign on door as she gets agitated when others wander into her room, maintain social distancing when in common areas to reduce risk of altered interpersonal response to others .Encourage erect posture and rest in the afternoon to aid in reduction of agitation, Maintain social distancing when in common areas to reduce risk of altered interpersonal response to others. Redirect from easily agitated residents to avoid negative behavior from others. DO NOT allow resident to hold hands, hug, kiss or otherwise be generally affectionate with opposite sex. Should always be supervised in a common area. Redirect as needed. R2's Comprehensive Care Plan includes, in part, 12/13/22 PROBLEM: Resident seeking opposite sex attention with or without intent. RELATED TO: urge to companionship with male resident(s), low BIMS. 12/16/22 MANIFESTED BY: actively seeking male resident encouraging male resident to hold her hands, hugging male resident, displaying jealousy, kissing, and joined exit seeking. Nurses- redirect, engage and encourage activity participation, provide independent activities, utilize daily itinerary, monitor exit seeking, social distance from male resident, document anxiety and tearful moments, report inappropriate/concerning behaviors to DON/Administrator immediately. Ensure 1:1 at all time with male resident that she may be seeing to provide well being and dignity for all involved, intervene as needed. Nurse Aide- redirect, engage and encourage activity participation, provide independent activities, utilize daily itinerary, monitor exit seeking, social distance from male resident, document anxiety and tearful moments report inappropriate/concerning behaviors to charge nurse, and DON/Administrator immediately. Ensure 1:1 at all time with male resident that she may be seeking to provide well being and dignity for all involved, intervene as needed. 12/13/22 Maintain appropriate display of affection in social setting, maintain personal dignity, continue with quality of life, no episodes of inappropriate sexual behaviors. Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 12/02/2022, states, in part, Time occurred: 07:00PM Brief Summary of Incident: Staff was walking with Resident A (R1), Resident A (R1) leaned over and kissed Resident B (R2) on the cheek. Resident A (R1) returned to their room with direct observation. Son in attendance. MD notified for clinical work up. Resident B (R2) and family with no concerns. DESCRIBE THE EFFECT: Resident B (R2) has no recollection of event and has no concerns. No Change in mood nor affect. EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Resident interviews- no concerns, staff interviews- no concerns, both resident care plans updated. Line of sight to continue. Family and staff providing 1:1 during the afternoon/evening hours when resident tends to wander more. Education for effective redirection. Referral made to MD for assessment and new orders. Follow up referral to MD with additional medication management. It is important to note, after the first incident on 12/02/2022, there was no monitoring completed to ensure R2 did not experience any psychosocial affects from the incident. There were no assessments to consent to sexual activity completed for either R2 or R3. The facility failed to identify three residents that were interviewed were unable to verbally answer, there were no body checks completed to ensure these residents did not experience abuse or unwanted touch. There was no education provided to staff after the first incident. The facility did not provide education to staff until 12/8/22 and 12/9/22: Redirection of residents Education provided to staff: Effective redirection for MCU (Memory Care Unit) residents (focus on R1 and R2) Staff sign off sheet dated 12/08/22 and 12/09/22. Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 12/10/2022, states, in part, Time: 01:10 PM Brief Summary of Incident: Resident A (R1) observed in Resident B's (R2) room with Resident B's (R2) pants lowered. Nurse observed Resident A (R1) on opposite side of unit just prior to staff observing residents together. Residents families aware and just recently agreed to the two having a relationship as both have been seeking each other out for companionship. Briefly Describe the incident- Resident A (R1) observed in Resident B's (R2) room with Resident B's (R2) pants lowered, when Med Tech arrived Resident B (R2) said oops, pulled up their under garments and went over to their bed. Resident A (R1) was escorted out of the room. Families in agreement for residents to have a relationship with each other. BIMS score of Resident A (R1)- 2 BIMS score of Resident B (R2)- 1. Time frame of 3.5-4 minutes. DESCRIBE THE EFFECT that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident: Resident B (R2) has no ill effects. Resident B (R2) behaviors for seeking out Resident A (R1) have decreased and remains easily redirectable. EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Residents separated immediately. Ensured safety of all residents DON and Administrator notified immediately. Resident A (R1) put on direct observation. Police notified. Resident A (R1) left facility for the weekend. Families notified. Interviewed staff- no new events, no concerns. Physician contacted for further review. Resident returned to facility Monday 12/12 at 10:30am and new intervention put into place of 1:1. One-to One Education provided to staff: One to one with R1 expectations, when assigned and leaving, must find another staff member to relieve the duty. Staff member is within arms reach at all times while awake, and during sleeping hours must be able to visualize exit of room. Staff sign off sheet dated 12/12/22, 12/13/22, and 12/14/22. It is important to note, after the second incident on 12/10/2022, there was no monitoring completed to ensure R2 did not experience any psychosocial affects from the incident. There were no assessments to consent to sexual activity completed for either R2 or R1. The facility failed to identify three residents that were interviewed were unable to verbally answer, there were no body checks completed to ensure these residents did not experience abuse or unwanted touch. The Police Report and the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report do not match, in the Police Report and through interviews it was identified that both residents had their pants down and R1 had his hands on both of R2's breasts. On 12/19/22 at 10:50 AM, RN (Registered Nurse) F indicated staff just recently received training on abuse and the different types of abuse. RN F indicated they received education on the importance of reporting and on-going 1:1 supports and ensuring visual sight of residents. RN F indicated that R1 is now 1:1 and this means that he must be within arm's reach of a staff member that is assigned to him. RN F indicated for all resident-to-resident altercations staff must separate the residents, ensure a safe environment, and immediately report the incident. RN F indicated management discusses interventions and then will relay what the interventions are to staff. RN F indicated nursing staff are not involved in deciding appropriate interventions. RN F indicated they will assign extra staff to ensure safety for residents. RN F indicated she was the staff that was with R1 on 12/10/22. RN F indicated she was watching and keeping R1 in line of sight on 12/10/22 from around 6:45AM to 11:40AM. RN F indicated the DON (Director of Nursing) called and had her leave the Memory Care Unit because she needed to do something in regard to another resident testing positive for influenza. RN F indicated she didn't ask any other staff to keep R1 in line of sight when she left the area. RN F indicated there was a CNA, Med Tech, Housekeeper, and an LPN (Licensed Practical Nurse) from Corporate. RN F indicated she saw the Corporate LPN walk past her (RN F) at the main nurses station. RN F indicated that she questioned the LPN leaving and felt it wasn't the best moment to leave the Memory Care Unit since she (RN F) was not back there. LPN indicated she had to check in to her hotel and left. RN F indicated the incident between R1 and R2 occurred a little after 1PM shortly after lunch time. RN F indicated that Housekeeper R heard a noise that sounded off and went to R2's bedroom. Housekeeper R yelled for Med Tech S. RN F indicated that no one interviewed her regarding this incident. RN F indicated she felt they should have since she was the nurse in charge that day. RN F indicated R1 will touch staff when they are assisting him with personal cares. RN F indicated they asked R1 a few hours later if he remembered R2 and what her name is. RN F indicated R1 didn't remember the incident or R2's name. Surveyor asked RN F what was put in place to support R2 after this incident. RN F indicated we didn't do anything to support R2 after the incident. She wanted to go back and be with him. Surveyor asked if R2's POA (Power of Attorney) was notified. RN F indicated she was sure that management did that. Surveyor asked RN F what the facility process was for the victim in any abuse situation. RN F indicated they will chart, keep watch and monitor that resident. RN F indicated they may send the person to the hospital for an exam as well. RN F indicated they would keep doing the extra monitoring and charting for a month and this would be in the resident's progress notes. RN F indicated this was not done for R2 because they felt she wanted it. Surveyor asked RN F in there was a sexual consent assessment completed with R2. RN F was unsure if this was completed but didn't believe so. On 12/19/22 at 12:30 PM, LPN (Licensed Practical Nurse) G indicated she was the staff that was assisting R1 during the first investigation with R2. LPN G indicated she was walking with R1, R1 bent down and kissed R2 on the cheek. LPN G indicated she immediately stepped in between the two residents and redirected. R1 became mad and started yelling and swearing at LPN G. R2 was giggling. LPN G indicated that R1 and R2 will look for each other and seek each other out. LPN G indicated the incident happened so quickly. LPN G indicated R1's POA will come and sit with him. There is always one CNA and one nurse back in the Memory Care Unit, more recently there is now a 1:1 with R1 as well. LPN G indicated after the incident she ensured both residents were safe. LPN G indicated she ensured that R2 still felt safe, and she was doing different activities after incident. LPN G is unaware if a sexual consent assessment was completed for both residents. On 12/19/22 at 1:30 PM, Housekeeper R indicated she was the staff person that first witnessed the 12/10/22 incident with R1 and R2. Housekeeper R indicated there was a strange noise, walked in to R2's bedroom, and saw the two residents. Housekeeper R indicated she saw R2 standing in front of R1, his hands on her breasts, R1 had his pants down, and it looked like R2 was pulling up her pants. Housekeeper R indicated she was so shocked she said, Holy shit. Housekeeper R indicated she did not leave the room and yelled for assistance. Housekeeper R indicated that the Med Tech came and assisted with the situation. Housekeeper R indicated R2 went and laid down in her bed, R2 looked like she was embarrassed, and asked if she was in trouble. Housekeeper R indicated there were two staff in the Memory Care Unit at that time. Housekeeper R indicated there was a Med Tech and a CNA. The Med Tech was in another room charting and the CNA was assisting another resident. Housekeeper R indicated she feels the 1:1 with R1 is helping the situation and that R1 does try to get close to some of the female residents. Housekeeper R indicated she has known R1 to stand a little too close to some of the residents and irritate them but that the other two female residents R1 seems interested in will either glare at him or tell him to get away from them. Housekeeper R indicated R2 does get upset and will cry and call staff names because she thinks that the staff and R1 are a couple. Housekeeper R indicated R2 has called her names before because she thought R1 and Housekeeper R are dating. On 12/19/22 at 5:45PM, Surveyor visited with R2. R2 was dressed appropriately, smiling, and talking about how she owns a food truck. R2 shared with Surveyor all the different foods she prepares in her food truck and how busy it gets. R2 gave Surveyor a tour of her bedroom. Bedroom was clean and personalized. R2 indicated she gets along with all of her housemates and didn't elaborate any further. On 12/19/22 at 10:15 AM, Surveyor asked ANHA (Assistant Nursing Home Administrator) C if the facility had any assessments for R2 regarding sexual consent. ANHA stated, No, we don't. On 12/20/22 at 9:30AM, Med Tech S indicated she was one of the first staff to witness the 12/10/22 incident between R1 and R2. At 1:09PM she was completing charting in the charting/med room. She heard someone yell nurse, nurse, nurse. Med Tech S indicated she went to R2's bedroom, R1 was walking away and zipping his pants, R2 appeared to be pulling up her pants. Med Tech S indicated she said, Are we being a little inappropriate in here? R1 stated he was trying to pick up his hat and he attempted to go by R2. Housekeeper R stayed by R2. Med Tech S stated both residents looked like two high school students that got caught Med Tech S notified RN F. Surveyor asked who was assigned to keep R1 in line of sight? Med Tech S indicated all staff are responsible for keeping track of residents. Med Tech S indicated R1 and R2 had just finished lunch. Med Tech S indicated RN F told her to contact DON immediately. ANHA (Assistant Nursing Home Administrator) C called Med Tech S and told her to do the following: Keep residents away from each other, ANHA asked Med Tech S if R2 was wearing any underwear at the time, and asked Med Tech S to keep phone by her for further calls. Surveyor asked Med Tech S what residents were doing after the incident. Med Tech S indicated R1 and R2 were sitting across from each other at a table, holding hands, and smiling at each other. Med Tech S indicated staff were keeping an eye on them. On 12/20/22 at 12:15PM, SW (Social Worker) I indicated she had a conversation with R2's POA (Power of Attorney) regarding R2 and R1. SW I indicated POA approved of holding hands and sitting next to each other. On 12/9/22 R2's Comprehensive Care Plan was updated: Special Care Remarks: May allow resident to hold hands, hug, kiss or otherwise be generally affectionate with R1 per POA, this should always be supervised in a common area. This is only allowed with R1, no sexual activity would be allowed. SW I indicated after incident on 12/10/22 R2's Comprehensive Care Plan was updated. On 12/20/22 at 12:30 PM, Surveyor spoke with the Police Officer that was called to the facility on [DATE] at 4:00PM. Officer indicated he was called to the facility due to (R1) having (R2) up against a wall with his hands on her breasts. Staff reported to Officer that both residents had their pants down. Officer indicated he did not interview or have any contact with either of the two residents. Through discussion it was agreed upon that the facility would talk with POA to see if (R1) could go with him for the weekend. Officer shared his discussion with APS (Adult Protective Services) and Northwest Connections. Officer commented that if this continues being an on-going issue with him (R1), we may be referring charges because he might know what's going on. Officer indicated he is aware that the facility said they were going to be reaching out to R1's Medical Doctor for recommendations. Note in packet of investigation from 12/10/22, no name of who wrote document and no date: At 4:00 PM, Officer ([NAME]) from (BRF PD) arrived. Officer ([NAME]) asked Is this our same friend (R1)? The situation that occurred was explained to the officer. He exited the room returning 10 minutes later to explain that APS had been contacted to seek direction. Officer explained that APS is not available, unable to assist on the weekend, only CPS. He added that he also contacted Northwest Connections as his senior officer had directed him to do so. Officer ([NAME]) explained that the current situation with (R1) does not meet criteria to chapter 51. The reason of ch 51 is more for mental instability, being a danger to self or others. No assault had taken place, being that both parties were mutual members and that (R2) was not trying to remove him or herself from the situation. (R2) was actively participating while he was touching her breast. Officer ([NAME]) was lawfully unable to remove (R1) from the facility. Officer ([NAME]) suggested that POA be contacted, requesting that (R1) spend the night or weekend with POA. The other suggestion given by Officer ([NAME]) was that if aggression were to be displayed from (R1) for any reason, that he could be transported to the local hospital to further consider ch 51. Officer ([NAME]) suggested contacting APS Monday morning and possibly seek an all-male placement, less restrictive environment that has less vulnerable residents present. On 12/20/22 at 11:15 AM, Surveyor asked ANHA C to walk through the investigation process for the two incidents with R1 and R2. ANHA C indicated on 12/2/22 around 7:00 PM ANHA C received a call regarding the incident with R1 and R2. ANHA C interviewed LPN G. ANHA C indicated LPN G reported she was walking with R1, he bent down and kissed R2. It was reported R1 began to show aggression towards the nurse, but she was able to redirect him. The CNA that was working was assisting someone else during this time. ANHA C interviewed all residents, and they had no concerns. ANHA C interviewed staff and they had no concerns with R1. Surveyor asked for the residents who are unable to verbally communicate, was there body checks or anything in addition completed? ANHA C indicated, No. Surveyor asked if R2's Comprehensive Care Plan was updated after this incident and if there were any new interventions put in place? ANHA C indicated she would have to check and see what was put in place after the first incident. Of note, no further information or documentation regarding interventions for R2 were provided to Surveyor. ANHA C indicated on 12/10/22 at 1:10 PM a Housekeeper walked in to R2's bedroom to find R1 in her bedroom. R2's pants were lowered and R1 was touching her breasts. Housekeeping separated the two residents and yelled for assistance. Med Tech came into room and escorted R1 out of R2's bedroom. ANHA C indicated the police were called, residents and staff were interviewed. Surveyor asked if the facility completed body checks for the three residents identified who were unable to verbally communicate, ANHA C stated, No. ANHA C indicated the Police Officer had suggested contacting R1's POA to see if R1 could spend the weekend with him. Surveyor asked what the facility's practice is for monitoring the victim in a resident-to-resident altercation? ANHA C indicated the facility will interview the resident and generally complete behavior monitoring. ANHA C indicated this was not completed for R2 because she was actively seeking out R1. Surveyor asked if the facility completed assessments to consent to sexual activity for R1 and R2? ANHA C indicated they had not completed the assessments. Surveyor asked ANHA C what document is correct, the self-report to the state or the Police Report and interviews? Surveyor asked ANHA C does it indicate on the self-report that R1 was touching R2's breasts and had her up against her wall? ANHA C stated, No. Based on interview and record review, the facility failed to thoroughly investigate incidents of sexual abuse and take steps to prevent further abuse for 2 of 3 abuse violations reviewed (involving R1, R2, and R3) of a total sample of 3 residents. On 12/1/2022, the facility became aware of a sexual abuse allegation involving R1 and R3 and a thorough investigation was not completed. This is evidenced by: The Facility Policy, titled, Resident Safety Abuse Policy, with a revision date of 2/2022, includes, in part, .PROCEDURE FOR INVESTIGATION: a. All alleged violations, will be thoroughly investigated and all investigations are conducted by or coordinated through facility administration. b. When appropriate, the Quality Assurance Performance Improvement (QAPI) Leader and/or the supervisor on duty will assess the resident ., and properly document the date, time, and location of the reported or suspected incident. There may be circumstances, such as sexual abuse, when a specifically-trained professional should be utilized if available . d. The supervisor will ensure that the resident(s) is/are protected from further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress . f. The residents' attending physician, facility medical director, corporate management and family will be notified as soon as possible . i. All witnesses or involved parties will be interviewed giving their own description of the incident and will be recorded by the QAPI Leader and/or supervisor on duty. These records will become part of the permanent investigation file. i. The QAPI Leader and/or supervisor on duty will interview the residents as well as any nursing, housekeeping, laundry, dietary, activity, or social service staff, any visitors or others who may have knowledge of the occurrence or who may have been in the vicinity at the time the incident happened . l. The Administrator will be the custodian of all documents generated during the course of the investigation. m. The facility must have evidence that all alleged violations are thoroughly investigated . Findings Include: R1 was admitted to the facility on [DATE] with diagnoses including: cognitive impairment of uncertain etiology, age related cognitive behaviors, bilateral hearing loss. On 12/5/22, R1 was diagnosed with dementia with associated psychotic-agitated behavior. R1 has an APOA (Activated Power of Attorney) for health care. Of note, concerns had been identified when R1 had inappropriate contact with other residents on 11/16/22 and wandering behaviors into other resident rooms between 11/18/22 and 11/21/22, with citations issued on 11/21/22. R1 was moved to the Memory Care Unit on 11/18/22. On 11/15/22, R1's admission Minimum Data Set (MDS) assessment notes a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Section E of the MDS notes R1 wandering behaviors occurred daily. Section G notes R1 is independent in transfers, ambulation, and locomotion on the unit. R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's disease; Unspecified Dementia; Restlessness and agitation; Major Depressive Disorder; Vascular dementia; and Need for Continuous Supervision . R3's most recent MDS with a target date of 11/18/22, documents a BIMS score of 2, which indicates, severe cognitive impairment. Review of the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, with a Report Submitted Date of 12/1/22, indicates the following: .Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation Brief Summary of Incident: Resident A (R1) reached out toward Resident B (R3) and touched them on the arm and also touched their breast. Resident A (R1) has a tendency toward physical contact (rubbing shoulders/arms, patting backs) and their hand has slipped. Of note, the original Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, with DRAFT noted across the document, and no Report Submitted Date, that was originally provided to surveyors indicated the above information, as well as, an additional sentence: Resident frequently touches others. Review of the Misconduct Incident Report, with a Report Submitted Date of 12/8/22, documents the following: .2. Summary of Incident: Is date and time when occurred known? No Of note, Date occurred, Time Occurred, and Is occurred date and time estimated are blank. Date discovered: 12/1/22. Briefly describe the incident .Resident A (R1) reached out toward Resident B (R3) and touched them in the arm and inadvertently touched the side of their breast with the back of their hand. Resident A (R1) has a tendency toward physical contact which may include rubbing shoulders, arms, and patting backs of others. Describe the effect . Resident B (R3) has no recollection of event nor change in mood or affect. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct .Interviews of residents - no concerns. Interviews of staff - no concerns. Both residents care plans updated. Line of sight to continue. Family and staff providing 1:1 during the afternoon/evening hours when resident tends to wander more. Education for effective redirection. Referral made to MD for assessment and new orders. Specific location where the incident happened is blank. 3. Affected Person Information: R3 is listed. Of note, the area for R3's Guardian information is blank. On 12/19/22, Surveyor interviewed LPN D, LPN E, RN F, LPN G, CNA J, and CNA K, and all indicated they were not aware of an incident between R3 and R1. On 12/19/22 at 3:23PM, ANHA C provided surveyor with a three-page, typed document that notes, Interviews conducted on 12/2/22, at the top. ANHA C indicated, the document is staff interviews. The document contains ten names with times after the names and the following three questions under each name: Have you seen R1 touch any other residents inappropriately?; Has he touched you on the buttocks, groin, or chest?; What would you do if that happened? There is no information on the document of who the listed names are; signatures from the interviewees indicating they provided this information; or information on who the other resident was that was involved in the incident with R1. Surveyor asked ANHA C what self-report these are in relation too. ANHA C indicted they were from the incident with R3 and R1. Surveyor asked ANHA C how this would be known as R3's name nor the incident date was included on the document. ANHA C indicated, from the date and pointed to the 12/2/22 date at the top of the document. ANHA C also provided a diagram that was drawn on notebook paper and states it is showing the path of the CNA (Certified Nursing Assistant) walking with R1 and where R3 was sitting. ANHA C indicates, the CNA was CNA H and that as R1 was walking by that is when the incident happened. On 12/20/22 at 8:04AM Surveyor interviewed LPN D. Surveyor showed LPN D the document dated 12/2/22 with his interview questions. Surveyor asked LPN D, when you were asked the questions on 12/2/22 about R1 touching another resident inappropriately, who did you believe was the original resident that was being referred to. LPN D indicated, R2, when you brought up R3 before, I was like what? On 12/20/22 at 8:07AM Surveyor interviewed LPN G. Surveyor showed LPN G the document dated 12/2/22 with her interview questions. Surveyor asked LPN G, when you were asked the questions on 12/2/22 about R1 touching another resident inappropriately, who did you believe was the original resident that was being referred to. LPN G indicated, I didn't know who they were referring to. I've never seen him touch anyone inappropriately. It doesn't mean it didn't happen, but I've never seen it. On 12/19/22 at 3:35PM, Surveyor interviewed CNA H and asked what she did to ensure R3's safety after the incident with R1 on 12/1/22. CNA H indicated, I went and asked her how she was and she said she was fine but that she didn't trust him. Surveyor asked CNA H what was done to ensure R1 didn't go back by R3 again. CNA H indicated, he didn't go back by her, she would snap, we would have known, she told him, don't come by me again. Surveyor asked CNA H how she ensured R3 and other resident's safety. CNA H indicated, we watched him. Surveyor asked CNA H, how did you watch him. CNA H indicated, I was out here. Surveyor asked CNA H, you never went into a resident room that night. CNA H indicated, well, the nurse was here too. Surveyor asked CNA H if she was with R3 or R1 one hundred percent of the time after the incident to know he didn't reapproach. CNA H indicated she wasn't with either of them one hundred percent of the time after it happened. Surveyor asked CNA H how then she knew he did not reapproach. CNA H indicated, we would have known, she would have yelled. On 12/20/22 at 9:20AM Surveyor interviewed DON B and asked what would constitute a thorough investigation. DON B indicated, witness statements; other staff and resident interviews; look at pieces of information. Surveyor asked if staff write their own witness statements. DON B indicated, no, our corporate philosophy is to have us talk to the staff and transcribe their statement. Surveyor asked DON B if those should be in the investigation. DON B indicated, yes, exactly. Surveyor asked DON B if it should be a statement and not just questions they ask the staff. DON B indicated, typically that's not me. If it's the person that witnessed it, I would expect a statement. Surveyor asked DON B what her role is in these incidents. DON B indicated, assist in reporting; doing assessments if they need to be done; sometimes it could be helping with staff interviews; care plan changes if needed. Really, it's ANHA C, NHA A, and VPO L (Vice President of Operations) gets called on all self-reports. Surveyor asked DON B if witness statements should have been obtained. DON B indicated, yes. Surveyor asked DON B how resident safety was ensured after the incident with R1 and R3. DON B indicated she would have to check. Surveyor offered a copy of the self-report for review to DON B. DON B indicated, this is the full report you were given. Surveyor indicated, yes. Surveyor asked DON B if there was more that wasn't provided. DON B indicated, I don't know. DON B indicated, staff and family were providing 1:1 with R1 that evening. Surveyor asked DON B if she was aware of what was done for R3. DON B indicated, I don't. DON B added, I do know ANHA C said R3 didn't remember the incident the next day and I haven't seen any changes, she's been at baseline. Surveyor asked DON B if there is documenta[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3: R2 was admitted to the facility on [DATE] with a diagnoses including dementia, major depressive disorder, anxiety disorder, acute stress reaction, and age-related cognitive decline. On 12/2/22, the facility submitted a self-report to the State Agency regarding a resident kissing R2. On 12/10/22, the facility submitted a self-report to the State Agency regarding a resident going into R2's room and inappropriately touching R2. Record review shows no documentation of these events, no assessments for R2, and no mention of immediate interventions in R2's medical records. Based on interview and record review, the facility did not maintain Medical Records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices for 3 residents (R1, R2, and R3) of a total sample of 3 residents. R2 and R3 had an inapporpriate encounters with R1. Staff did not document these incidents in the residents' medical records. Evidenced by: The Facility Policy titled, Nurse Charting Guidelines, with a revision date of 7/19, includes in part: Purpose: To ensure an accurate and comprehensive resident medical record, the facility licensed nurses will document on all residents per the following protocol. Protocol: .4. Nurse charting general documentation guidelines: .f. Incident investigation Reports: Never document the existence of an incident investigation report in your nurse's notes. The incident investigation report is an internal document intended to facilitate improvement of processes and systems at the facility. If a nurse records a note mentioning that an incident investigation report was done, the internal form could now be subject to discovery by external attorneys if litigation arises in the future . Example 1: R3 was admitted to the facility on [DATE] with diagnoses that include, Alzheimer's disease, unspecified dementia, restlessness and agitation, vascular dementia, and need for continuous supervision Review of the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, with a Report Submitted Date of 12/1/22, indicates, .Brief Summary of Incident: Resident A (R1) reached out toward Resident B (R3) and touched them on the arm and also touched their breast. Resident A (R1) has a tendency toward physical contact (rubbing shoulders/arms, patting backs) and their hand has slipped. There is no specific documentation in R3's Nurses Notes regarding the facility submitted self-report to the State Agency regarding R1 inappropriately touching R3's arm and breast. On 12/20/22 at 8:20AM Surveyor interviewed DON B and showed DON B the nursing notes in the facility's electronic health record. Surveyor asked DON B if this was all the charting for R1 or if there is documentation elsewhere, as there were no actual assessments, documentation of the incident, notes about the resident, just the vitals and pain ratings. DON B indicated, No, that is what's there, what you're seeing is what there is. On 12/20/22 at 9:20AM Surveyor interviewed DON B and asked if this incident should be documented in either R1's or R3's chart or both. DON B indicated, it's going to depend on what it is. Surveyor asked DON B if she could elaborate. DON B indicated, typically what we enter into ECS (Facility's electronic health record) is what is pertaining to the resident's health. So if there is something that is needed like an assessment, behavior tracking/monitoring, you would see that but otherwise the incident itself would be on paper in a file. Surveyors requested documentation of items not found in record review, however, no further evidence was provided. Example 2: -The facility submitted a self-report to the State Agency regarding R1 inappropriately touching R3's arm and breast which occurred on 12/1/22. -The facility submitted a self-report to the State Agency regarding R1 going into R2's room on 12/10/22, unsupervised by staff, and staff found R1 having inappropriate contact with R2. R1's record review shows no documentation of these incidents involving R1, no assessment of R1, no immediate interventions or corrective actions in R1's record related specifically to these incidents. R1's record notes the facility was monitoring and reporting behaviors to the physician, and R1's adjusting medications. R1's record notes R1 was sent on LOA (leave of absence) with his son on 12/10/22, and R1's care plan was updated on 12/13/22 to include one to one supervision to R1. However, R1's record does not reflect any specific incident for these changes. On 12/20/22 at 10:10 AM, Surveyor interviewed DON B (Director of Nursing) regarding the lack of documentation and new interventions to protect R1 from other residents in R1's record for self-reports of incidents involving R1 on 12/1/22 with R3, the incidents self reported involving R1 and R2 on 12/2/22 and 12/10/22. DON B indicated that the corporate office has directed facility staff, that unless the incident affects residents' health status it is not documented in the resident record.

Based on interview and record review, the facility is not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well-being of each resident. This deficient practice has the potential to affect all 45 residents residing at the facility at the time of the survey. The facility has had repeated incidents for allegations of resident abuse and resident safety since 06/30/22, with repeat citations issued. NHA A (Nursing Home Administrator) has allowed ANHA C (Assistant Nursing Home Administrator) to receive resident abuse/safety incident reports, submit reports to the State Agency, and complete abuse investigations since May of 2022 without proof of oversight by NHA A, resulting in repeated concerns regarding resident abuse/safety. ANHA C is not licensed as a Nursing Home Administrator. (Cross reference F609 & F610.) The facility did not ensure all residents were free from abuse incidents. (Cross Reference F600.) The facility has also been cited 3 times at F689 related to resident safety for accidents and supervision (9/15/22 at immediate jeopardy, 11/21/22 potential for harm, and 12/20/22 immediate jeopardy.) Additionally, staff and family members identify ANHA C as the NHA for the facility. This is evidenced by: The facility's Administrator Job Description includes in part: Responsible for directing the administration of healthcare facility within the authority of the management company . Develops or expands programs and services for medical and psycho/social rehabilitation and community health and welfare promotion for the aged at the specific facility . Develops and maintains written policies and procedures that govern the operation of the facility . Ensures continued compliance with current regulations on all levels including safety regulations . Responsible for 24-hour operation of facility . Reviews incident/accident reports and establishes effective accident prevention program . Complies with federal, state, local and Facility regulation and procedures . Certificates, Licenses, Registrations: Nursing Home Administrator license required . The facility's Assistant Administrator Job Description includes in part: Assists in the direction of administration of health care facility with the authority of the management company . Assists in the maintenance of written policies and procedures that govern the operation of the facility .Certificates, Licenses, Registrations: Nursing Home Administrators license. The facility's Resident Safety Abuse Policy revised 2/22, states in part: . 8. Reporting Suspected Violations . a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source . to the facility administrator. The Administrator will notify the DON and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility to the State Agency and one or more law enforcement entities . 9. Procedure for Investigation: .The Administrator will be the custodian of all documents generated during the investigation. 10. Other administrative duties: . e. If an alleged violation is verified, the administrator will ensure appropriate corrective action is taken. Findings: On 12/19/22 at 2:45PM, Surveyor interviewed ANHA C (Assistant Nursing Home Administrator) asking about the facility process for completion of self-reports including allegations of abuse. ANHA C stated, if something occurs, staff contact the DON (Director of Nursing) then ANHA C. Surveyor asked if ANHA C is available 24/7? ANHA C reported she is available and that she is contacted by staff at home if needed. ANHA C reported she lets NHA A (Nursing Home Administrator) know immediately of concerns. ANHA C stated if it's something that needs to be investigated immediately, ANHA C would give direction to staff over the phone and then generally call NHA A on her 45-minute drive to the facility. ANHA C indicated, with any self-report for potential abuse, resident to resident, anything that could fall under abuse, the facility has a flow chart to use which determines if the abuse is willful or not. Surveyor asked ANHA C if she used the flowchart with the 3 self-report investigations the survey team was reviewing? ANHA C stated, I believe we did with R3, I will have to look before I can give an answer. Surveyor requested ANHA C to provide the flow charts used for the investigations. On 12/19/22 at 3:30PM, ANHA C notified Surveyor that no flowsheets were completed for the resident-to-resident incidents/self-reports involving R1, R2, and R3, dated 12/1/22, 12/2/22, or 12/10/22. On 12/20/22 at 8:40 AM, Surveyor interviewed CNA M (Certified Nursing Assistant) about abuse reporting. CNA M stated he would report abuse to his nurse on the unit, the DON (Director of Nursing,) and the Administrator. Surveyor asked CNA M who was the administrator, CNA M stated the administrator is (name) ANHA C. On 12/20/22 at 8:45 AM, Surveyor interviewed LPN D (Licensed Practical Nurse) about reporting behaviors or abuse. LPN D stated ANHA C is notified if something happens, and on the weekends, LPN D will notify ANHA C and DON B (Director of Nursing.) Surveyor asked LPN D about LPN D's documentation in R1's record on 12/14/22 at 1:23 PM noting R1's behaviors which states in part: .The administrator was in the room also and resident wanted to sit in her lap . Surveyor asked LPN D who the documentation referred to, LPN D stated (name) ANHA C. On 12/20/22 at 9:10 AM, Surveyor interviewed FM T (Family Member) about who he communicates with regarding concerns for R1. FM T stated he talks to the administrator (name - ANHA C), (name) DON B and (name) SW I (Social Worker). On 12/20/22 at 8:28, Surveyor interviewed CNA M and asked who she identifies as the nursing home administrator for the facility. CNA M indicated ANHA C. On 12/20/22 at 8:33AM, Surveyor interviewed CNA N and asked who she identifies as the nursing home administrator for the facility. CNA N indicated ANHA C. On 12/20/22 at 8:36AM, Surveyor interviewed Housekeeping O and asked who she identifies as the nursing home administrator for the facility? Housekeeping O indicated ANHA C. On 12/20/22 at 10:30 AM, Surveyor interviewed NHA A about who conducts investigations for allegations of abuse at the facility. NHA A stated ANHA C and SW I (Social Worker) have been completing investigations since 5/22, with one person taking resident interviews and one taking staff. Surveyor asked what qualifies ANHA C to take on the role of conducting investigations of allegations of abuse. NHA A stated she and ANHA C had completed training for abuse investigations. NHA A stated she oversees the facility's investigations to ensure they are done timely and touches all areas. Surveyor asked NHA A who was responsible to make sure abuse investigations were complete, and that the facility was in compliance; NHA A stated she was. Surveyors shared concerns to NHA A that investigation files the facility provided for Surveyors to review for self-reports involving R1 and R2 on 12/1/22 and 12/10/22, and R3 on 12/2/22 were incomplete, for example: draft documents in file rather than originals, missing interviews, missing education documentation, care plan updates. NHA A indicated she would provide the documents for Surveyors. On 12/20/22, NHA A provided copies of education for Investigating and Reporting Allegation of Misconduct provided to SW I on 11/1/22, NHA A and ANHA C on 3/24/22. NHA A also provided copy of education on Preventing and Investigating Abuse/Neglect and Mistreatment dated 7/6/22, for NHA A, ANHA C, and SW I. Surveyor asked for documentation that NHA A completed a review of investigations involving R1, R2, and R3, no further information was provided. The facility has received multiple citations for accidents and supervision. The facility has failed to ensure resident safety and maintain resident safety. Most recently the facility was cited at F689 for failure to ensure resident supervision after R1 was noted to have inappropriate sexual interaction with female residents R2 and R3. (Cross Reference F600 and F689.) The facility has had repeated citations for abuse reporting, investigating, and accidents and supervision. Management staff should be aware of regulatory requirements for reporting and completing a thorough abuse investigation. NHA A has delegated the duties of abuse reporting and investigating to ANHA C and SW I and should be completing oversight of this delegated task to ensure abuse reporting and investigation is completed per regulatory language. Furthermore, ANHA C is not a licensed NHA, and staff indicate they report to ANHA C, and she is the functioning NHA. NHA A is the NHA on record. The facility has failed to ensure it is effectively and efficiently using resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on interview and record review, the facility's Quality Assurance Committee failed to systematically identify, report, track, and take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. The Quality Assurance Committee did not identify and correct quality of care deficiencies regarding the investigation and reporting of suspect abuse, neglect, and exploitation and did not ensure the facility sustained corrective actions once an action plan was created for R1. The facility failed to ensure their action plan of adequate supervision was maintained. This deficient practice has the potential to affect all 45 residents at the facility. Since the facility's recertification survey on 6/30/22, the facility has been cited at F609 2 times (11/1/22 and 12/20/22) for deficiencies related to the reporting of abuse. The facility was cited at F610 3 times (6/30/22, 11/1/22, and 12/20/22) for deficiencies related to the investigation and prevention of abuse. The facility was also cited 3 times at F689 related to resident safety for accidents and supervision (9/15/22 at immediate jeopardy, 11/21/22 potential for harm, and 12/20/22 immediate jeopardy.) Cross reference F609, F610, F689. The facility's Resident Safety Abuse Policy, updated on 2/22 includes in part: . 9. Procedure for Investigation: . m. The facility must have evidence that all alleged violations are thoroughly investigated. n. These documents will be identified as QAPI documents and will be reviewed by the QAPI (Quality Assurance Process Improvement) Committee for re-evaluation of the policies and procedures and for revision to the same policies and procedures if warranted to prevent re-occurrence. The facility's QAPI Plan dated as revised on 2017 and reviewed 2021, states in part: .Our QAPI plan include the policies and procedures use to: .Identify and prioritize problems and opportunities for improvement, systematically analyze underlying causes of systemic problems and adverse events. Develop corrective action or performance improvement activities . Findings: R1 had known behaviors of wandering into other resident rooms and touching other residents inappropriately on 12/1/22, 12/2/22, and 12/10/22. R1 also had daily aggressive and inappropriate behaviors toward staff documented in R1's record since 11/21/22. On 12/20/22 at 12:10 PM, Surveyor interviewed NHA A (Nursing Home Administrator) asking if the facility had brought concerns of abuse, abuse reporting, abuse investigations, and R1's behaviors to the QAPI Committee. NHA A stated no, that the facility had a scheduled QAPI meeting for 12/22/22 and provided a copy of the QAPI Agenda to discuss many items including Deficient areas of F689 (Resident Safety and Supervision), F609 (Abuse Reporting) and F610 (Abuse Investigations). Surveyor asked for any QAPI information regarding the facility's corrective actions related to R1 abuse allegations and resident safety. NHA A stated she would have to contact corporate office for the information. Surveyor asked NHA A if the facility had an ad hoc (for immediate correction) QAPI meeting regarding abuse and the incidents involving R1? NHA A stated no, but the team met and developed a plan which included having R1 go home with his son for the weekend of 12/10/22 and returning on 12/12/22 with 1:1 supervision and education provided to all staff. On 12/20/22 at 1:10 PM, NHA A provided a document to Surveyor entitled QAPI Written Summary Template to Prove Past Noncompliance dated 12/12/22, which specifically addresses a quality issue of R1 was not within line of sight for approximately 4 minutes, identified on 12/10/22. This document indicates on check list: directed audit to be completed, identified the root cause through root cause analysis activities, Implemented 1:1 with (R1.) This document also notes a comprehensive performance improvement plan was developed on 12/12/22. Implemented on 12/12/22 . The performance improvement plan was successful and corrected the quality issue on 12/2/22 . Ongoing monitoring involving 1:1 with (R1) expectations when assigned and leaving, must find another staff member to relieve the duty. Staff member is always within arm's reach while awake, and during sleeping hours must be able to visualize exit of room, will be conducted by assigned employee 3 times weekly for the next 3 months and 1 time weekly for 3 additional months. It should be noted the facility was initially cited at immediate jeopardy at past non-compliance for F689 albeit the facility failed to ensure R1 received adequate supervision and was found to be in current noncompliance on 1/4/23 when the State Agency completed the partial extended survey. As part of the removal plan, the facility stated R1 would receive supervision to include 1 to 1 supervision within arm's length. The facility failed to ensure it sustained corrective actions to include R1 is receiving adequate supervision as evidenced by observation during the partial extended survey. (Cross Reference F689.) Upon request, the facility did not provide any additional QAPI documentation related to Abuse, Abuse Reporting and Investigation, or Resident Supervision. The facility failed to systematically identify, report, track, and ensure that improvements are realized and sustained. The Quality Assurance Committee did not identify and correct quality of care deficiencies regarding the investigation and reporting of suspect abuse, neglect, and exploitation and did not ensure the facility sustained corrective actions once an action plan was created for R1. The facility failed to ensure their action plan of adequate supervision was maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. R5 was known to wander into other resident rooms the facility did not implement care planned interventions or ensure adequated supervision of R5. R5 entered 5 (R2, R4, R6, R7 and R8's) of 46 resident rooms uninvited this lead to the potential for resident to resident altercations. R5 was a known wanderer R5 wandered into multiple resident rooms and the facility did not put a plan in place to ensure R5 had adequate supervision. Findings include R5 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's. R5's care plan states, 11/11/2022 Problem: Alteration in thought process, Related to: loss of memory, cognitive impairment .manifested by: difficulty with decision making, Alzheimer's/dementia, restlessness, disorientation, short term memory problem, unable to recall after 5 minutes long term memory problem, unable to recall long past, paranoid statements. R5's care plan also states the following, 11/10/22 Problem: need for appropriate sexual expression/display of affection .Related to: touching peers and staff in affectionate manner ex, cues to have hand held, habit of placing his hand on others back, placing hand on shoulder of others .Manifested by: grief, recent loss of wife, confusion and altered mental state, fear of placement at skilled nursing facility .Approach: be mindful of personal space, redirect as needed, monitor personal boundaries and document/report redirecting as needed and any inappropriate behaviors, involve family, encourage group activities. Additionally, R5's care plan states, Problem: Potential for elopement (intended or unintended) .Related to: decreased cognition, new environment .Manifested by: statements of wanting to leave nursing home, exit seeking, frustration with nursing home placement .Approach: reorient, praise positives, 1:1, monitor for exit seeking, monitor for frustration with nursing home placement, respond immediately to all door alarms, enjoys watching sports/hunting shows, store winter jacket out of residents room. R4 was admitted to the facility on [DATE] and has diagnoses that include bipolar and Alzheimer's dementia. Her most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 6, indicating R4 is severely cognitively impaired. R2 was admitted on [DATE]. Her most recent MDS, dated [DATE], shows a BIMS score of 15, indicating she is cognitively intact. R6 was admitted to the facility on [DATE]. His most recent MDS, dated [DATE], shows a BIMS score of 8, indicating he is moderately cognitively impaired. R6's care plan states the following, Problem: aggressive behavior with fellow resident .can be aggressive towards staff and residents at times .Manifested by: Striking out at staff or other residents when agitated or feels provoked. R7 was admitted to the facility on [DATE] and has diagnoses that include dementia. Her most recent MDS, dated [DATE], shows a BIMS score of 7, indicating she is severely cognitively impaired. R8 was admitted to the facility on [DATE]. Her most recent MDS, dated [DATE], shows a BIMS score of 15, indicating she is cognitively intact. On 11/16/22, the facility submitted a report to the state agency which stated that R5 entered R4's room next door and approached R4 thinking she (R4) was his (R5's) wife. R5 then touched the thigh, arm, and shoulder which were under a fleece blanket. R4 asked R5 to leave, which R5 complied. R5 came back later to the doorway and R4 asked him to leave again and R5 left her entry way. On 11/21/22, while at the facility, Surveyors requested all investigation pieces of the self-report. The facility's report included handwritten notes by SW C (Social Worker), which indicated CNA D (Certified Nursing Assistant) had reported around 8:50 AM that R4 stated to her that R5 had come into her room with his zipper down and touched her privates. At 12:24 PM, Surveyors interviewed SW C, who stated that after it had been reported that R5 touched R4, she went down to speak with R4, but R4 was finishing eating and was to leave for an appointment in a few minutes. SW C stated that she waited for R4 to return from her appointment at approximately 11:20 AM and then asked her about the incident with R5. At that time, R4 stated that the touching done by R5 was the arms and legs, but R4 did not indicate her private areas were touched. SW C stated that R4 told her It was the man next door. He was asking where his wife was. Additionally, SW C gathered interviews from other residents for the self-report and it was revealed that R5 had entered 2 other residents' rooms, R2 and R8. According to SW C, R2 had stated this to her on 11/16/22. SW C stated R8 had raised a concern on 11/18/22. Additionally, SW C stated the facility had not put any measures on the care plan related to R5 wandering into other resident rooms, but that the facility moved R5 to the memory care unit on 11/18/22 after additional reports of wandering into others' rooms. When asked what the facility was doing to prevent further room intrusions between the event of 11/16/22 until R5 was moved on 11/18/22, SW C stated that staff were made aware to be mindful about his whereabouts. The facility's 24 hour sheet, dated 11/17/22, states that during the night shift R5 was up following a female staff and groping, attempting to kiss staff. It should be noted that R5 was moved from his room to the memory care unit on 11/18/22. Until that time, he was next door to R4, two doors down from R2, and three doors down from R8, all of whom resided on the same wing. Additionally, R6 and R7 resided on the same wing as R5. As of 11/21/22, the memory care unit consisted of 11 women and 5 men, including R5. Surveyors conducted the following staff interviews on 11/21/22: *At 1:35 PM, CNA E stated that she had heard R5 had went into R4's room and had been told by R8 that R5 had went into her room. CNA E stated R8 told her that she tells R5 to leave and he does right away. CNA E also stated that she had seen R5 in R6's room rummaging through his dresser. According to CNA E, R6 was not in his room at that time. CNA E stated the staff generally knew that R5 wandered up and down the halls and went into resident rooms but he was always immediately compliant with redirection. Additionally, CNA E stated she had not been given any information or additionally direction after R5 had went into R4's room on 11/16. *At 2:01 PM, CNA F (while on the memory care unit) stated that R5 frequently asked about his wife or was looking for her. CNA F stated that R5 had tried to exit the building a few days earlier (no specific date was given) but was intercepted near the front door. Additionally, CNA F stated that, according to R5's son, R5 really liked cribbage but he (CNA F) didn't think that anybody had played with him. CNA F stated that R5 is easily redirectable but seems to forget quickly after being redirected and continues to wander. CNA F, along with RN H (Registered Nurse), stated that they were not aware of any direction as to how to manage R5 around women or wandering into any other resident rooms. *At 2:06 PM, CNA G stated to Surveyors that R5 would frequently wander up and down the halls and she observed R5 in R6's room on one occasion looking through his (R6's) dresser. R6 was not in the room at the time. CNA G also stated that she had recently (exact date unknown) responded to R7's room (who also lived on the same hall as R5 prior to his relocation on 11/18/22) as she was yelling at R5 to get away from her room. Additionally, CNA G stated that R5 responded well to redirection, and he liked to read magazines and newspapers. CNA G stated she was not aware of any changes or expectations in regards to R5 after the even of 11/16/22. CNA G stated, From what I heard, he (R5) had issue with R4. Surveyors interviewed R2, R4, and R8 on 11/21/22, none of which had any concerns or fears inside the facility. R4 did not recall the events of 11/16/22 and did not have any concerns with other residents in the facility. At 1:52 PM, R8 stated to Surveyors that R5 had entered her room at around 2:00 AM in the morning. Although she could not remember the exact day, it was right before R5 was moved. R8 stated that when R5 entered her room, he was asking for his wife, to which R8 asked him to leave. Upon the request, R5 left the room. R8 stated that R5 came back a few other times that morning, but she continued to ask him to leave, which was successful. R8 stated that she was not afraid of R5 and she understood that he did not know where he was and that he must be scared. The facility was aware R5 was a risk to elope, wandered the halls frequently, and made inappropriate sexual expressions and touched peers. On 11/16/22, R4 stated that R5 had wandered into her room and touched her. As part of the investigation, it was discovered that R5 had also wandered into R2's room. Between 11/16 and 11/18, no interventions were put into place to prevent additional wandering and on 11/18, R5 wandered into R8's room, at which time, he was moved to the memory care unit. Staff interviews revealed R5 had also wandered into the rooms of R6 and R7. The facility did not put measures in place to ensure the safety of other residents and did not monitor R5 to prevent further wandering and potential altercation. R6 had been observed yelling at R5, and R7 is known to strike out at staff and other residents when agitated or provoked.

Based on interview and record review the facility did not report alleged violations of abuse to the State Agency for 2 of 7 sampled residents (R7 and R6). CNA C was aware of (2) allegations of abuse. CNA C failed to immediately report the allegations of abuse to the Nursing Home Administrator (NHA). CNA C (Certified Nursing Assistant) CNA C failed to immediately report these allegations of of abuse to the facility. The facility failed to report and thoroughly investigate CNA C's allegations of abuse once they were made aware. This is evidenced by: The facility policy and procedure entitled Resident Safety Abuse Policy, revised 2/2022, indicates the following: Policy: 8. Reporting Suspected Violations: c. The administrator shall report immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. e. All facility staff members shall ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made The facility received an allegation (different) of abuse on 9/17/22 at 12:15 PM. Brief Summary of Incident: Staff member took a resident into an unoccupied area of the building for an unknown amount of time. Administrator, Assistant Administrator, and DON B (Director of Nursing) notified immediately. Staff member removed from the building immediately and suspended while investigation is completed. Investigation began immediately The facility conducted staff interviews in follow up to this allegation of abuse. While conducting interviews, a staff member reported the following allegations of abuse on her written statement: CNA C (Certified Nursing Assistant) indicated: About 4 weeks ago CNA D got yelled at by R7. R7 kept yelling, Not so rough. CNA C indicated: About 3 weeks ago CNA D brought R6 into the shower, R6 started yelling about pinching him your [sic] being to [sic] rough. A second staff member came over, took over giving R6's shower. CNA D and R6 were yelling at each other. CNA C failed to immediately report these allegations of abuse at the time they occurred. Subsequently, NHA A (Nursing Home Administrator) failed to report these allegations of abuse to the State Agency. Of note, CNA C ended her employment with the facility. On 11/1/22 at approximately 4:30 PM and 5:00 PM, Surveyor spoke with SS F (Social Services) and ANHA E (Assistant Nursing Home Administrator). SS F stated she did not follow up on these allegations of abuse. ANHA E stated she did not follow up on these allegations of abuse. ANHA E stated she does not believe these allegations should have been reported or investigated. The facility failed to report and investigate allegations of abuse.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 2 of 7 residents (R6 and R7) reviewed for abuse. CNA C reported two (2) allegations of abuse. The facility failed to investigation CNA C's allegations of abuse. Evidenced by: The facility policy and procedure entitled Resident Safety Abuse Policy, revised 2/2022, states in part, as follows: Policy: 8. Reporting Suspected Violations: c. The administrator shall report immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. e. All facility staff members shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made 8. Reporting Suspected Violations: a. The Supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. The Administrator will notify the DON (Director of Nursing) and/or others as appropriate. CNA C (Certified Nursing Assistant) indicated: About 4 weeks ago CNA D (Certified Nursing Assistant) got yelled at by R7. R7 kept yelling, Not so rough. CNA C indicated: About 3 weeks ago CNA D brought R6 in to the shower, R6 started yelling about pinching him your [sic] being to [sic] rough. A second staff member came over, took over giving R6 the shower. CNA D and R6 were yelling at each other. CNA C failed to immediately report these allegations of abuse at the time they occurred. The facility failed to report these allegations to the State Agency and to thoroughly investigate CNA C's allegations of abuse once they were made aware. Of note, CNA C ended her employment with the facility On 11/1/22 at approximately 4:30 PM and 5:00 PM, Surveyor spoke with SS F (Social Services) and ANHA E (Assistant Nursing Home Administrator). SS F stated she did not follow up on these allegations of abuse. ANHA E stated she did not follow up on these allegations of abuse. ANHA E stated she does not believe these allegations should have been reported or investigated. Surveyor reviewed an discussed the facility's Abuse Policy and that all allegations of rough treatment and pinching, etc. needs to be reported to the State Agency and the facility needs to thoroughly investigation the allegations of abuse.