Gallatin Manor

Based on interview and record review the facility failed to provide notification in advance of discharge for one (R1) of 4 residents reviewed for notification of discharge in a sample of 4. Findings include:R1's admission record documents an admission date of 01/13/23 with diagnoses including: disorder of urea cycle metabolism, cirrhosis of the liver, disorder of urea cycle metabolism, fatigue, dysphagia, muscle weakness, lack of coordination, history of falling, long term drug therapy, hypotension, personal history of traumatic brain injury, cognitive communication deficit, anxiety disorder, seizures, vitamin B12 deficiency, anemia, estrapyramidal and movement disorder, insomnia, schizoaffective disorder, accidental poisoning by amphetamines, vitamin D deficiency, dependence on wheelchair, abnormal posture, and muscle wasting and atrophy. R1's admission record documents V5 (Family) as R1's responsible party. R1's MDS (Minimum Data Set) dated 11/10/25 documents R1 has a brief interview of mental status (BIMS) of 01 indicating severe cognition impairment. R1's Admission/Discharge to/from report dated 11/24/25, documents R1 was discharged from the facility on 11/10/25.On 11/24/25 at 10:20 AM, V1 (Administrator) stated he believes R1's brief interview of mental status was one or two indicating she was severely cognitively impaired. V1 stated, R1 had a POA (power of attorney) that made her decisions for her. V1 stated, V5 (Family) wanted R1 closer to her to visit if her care needs could be met. V1 stated, they did not document in R1's electronic health record when referrals were sent for R1. V1 stated they did not document in R1's health record when they attempted to contact V5. On 11/24/25 at 1:40 PM, V2 (Regional Administrator) stated he has been looking for placement for R1 for approximately a year and a half. V2 stated, the discussion started when V5 wanted R1 closer, but then we discussed what services she wanted for R1 so we expanded the search to include other facilities that were not necessarily closer but had the services she wanted due to R1's younger age and diagnoses. V2 stated, after sending referrals to several facilities and either being denied or that facility was full, R1 was finally accepted at a facility they felt she would fit well at and it was closer to V5. V2 stated, they accepted the referral and transferred R1.On 11/24/25 at 2:50 PM, V6 (Ombudsman) stated she did not receive a notice of discharge for R1 prior to her discharge. V6 stated, she spoke with V5 and V5 told her she did not know R1 was being transferred before she was transferred and wanted to know if she knew anything about that.On 11/24/25 at 5:18 PM, V5 (Family) stated she did not know they were transferring R1 to (new facility name). V5 stated, she was unaware R1 was accepted at a new facility until V4 (receiving facility Social Services Director) called her to tell her she needed to sign some paperwork because R1 would be arriving at the facility in approximately 30 minutes. V5 stated, it had been at least a month and a half ago since the facility had discussed with her about transferring R1 to a new facility.On 11/25/25 at 10:42 AM, V3 (Social Services Director) stated, when she does a referral she sends the resident's information to the potential facility then she contacts the facility to make sure they have received the information. V3 stated, she did not get into contact with V5 (Family) or send her the information. V3 stated, she did talk to V5 on 11/07/25 and they did not discuss the discharge to the new facility. V3 stated, she did not document any phone calls to V5 or document anything about the upcoming transfer in R1's progress notes. V3 stated, she failed to do the documentation that she would typically do. On 11/25/25 at 3:30 PM, V4 (receiving facility Social Services Director) stated V5 told her she did not know R1 was coming to (facility name) until she (V4) called her to discuss V5 coming to discuss signing the admission paperwork. R1's medical record did not include evidence that a 30-day written notice of transfer was provided to V5 or V6. The facility policy dated 2025 documents: Notice before transfer: before the facility transfers or discharges a resident, the facility shall; notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, send a copy of the notice to a representative of the office of the state long term care ombudsman. The facility shall maintain evidence that the notice was sent to the ombudsman, record the reasons for the transfer or discharge in the resident's medical record in accordance with this policy and procedure. The contents of the notice; the written notice shall include the following, the reason for transfer or discharge, the effective date of transfer or discharge, the specific location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including the name of the entity which receives such requests and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address and telephone number of the office of the state long-term care ombudsman. Timing of the notice: except as specified in section IV (C)(b) below and except in cases of facility closure, the notice of transfer or discharge required shall be made by the facility as least 30 days before the resident is to be transferred or discharged . Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation shall be discussed with the resident or resident's representative. Discharge summary; when the facility anticipates discharging a resident, the resident shall have a discharge summary that includes, but is not limited to the following: a post discharge plan of care that is developed with the participation of the resident and , with the resident's consent, the resident representative, which will assist the resident to adjust to his or her new living environment. The post discharge plan of care shall indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up and care and any post-discharge medical and non-medical services.

Based on observation, interview and record review the facility failed to ensure dishes and utensils were properly washed/sanitized and food/drinks were covered /dated to prevent cross contamination. This failure has the potential to affect all 37 residents residing in the facility. Findings Include: On 9/16/25, during the initial walk through of the kitchen that occurred between 9:30 AM and 10:00 AM two cups of frozen ice cream were left uncovered and not labeled in the freezer. At this same time a tray full of beverages were found in the reach in refrigerator not covered nor dated/timed. During this same initial tour the dish machine was found to have no sanitizer registering on the chlorine test strip. V3 (Dietary) stated at this time that she had not been able to get any sanitizer to register on her test strip this morning either and couldn't figure out what to do. V3 went on to state that they have been having issues with the dish machine for over a week now and it has been worked on in attempt to get the sanitizer to dispense properly. V3 stated that they have been using the dish machine this morning even though no sanitizer was in registering on the test strip. On 9/16/25 at 10:45 AM during a follow up visit to the kitchen the staff were using the three-compartment sink to wash, rinse and sanitize the dishes. At this time V4 (Dietary) was asked to check the sanitizer level in the sink. V4 provided surveyor with quat (Quaternary Ammonium) strips, and two strips were checked, and no sanitizer was registering. V4 then made new sanitizer water and the level and check and checked it to ensure that it was within recommended range. V4 stated at this time while making the new sanitizing solution how the measurements of water and sanitizer are mixed. V4 stated that the machine does the mixing of the solution into the water ran into the sink. V4 stated that there is no water fill line, you just fill the sink to where they think it should be and then use the strip to check the level. On 9/17/25 at 10:30 AM, V5 (Dietary Manager) stated that all items should be covered and labeled with what it is and dated in the refrigerator and freezer. V5 also stated that when the dish machine does not work/sanitize they should be using the three-compartment sink. A policy for Pot and Pan Washing with a revision date of 12/30/24 documents Policy Interpretation and Implementation 3. The third sink will be filled to the designated line with warm water (not less that 75 degrees) and two pumps (two fluid ounces) of sanitizer from the dispenser over the sink. A solution of sanitizer at the rate of 200 PPM (Parts Per Million) is necessary. Pots should remain in the solution for not less than one minute. A policy and procedure titled Food Storage area with a revision date of 12/30/24 documents 5. prepared food stored in the refrigerator until service shall be dated. Such foods will be tightly sealed with plastic wrap, foil or a lid. The Long-Term Care Facility Application for Medicare and Medicaid form dated 9/16/25, documents that there are 37 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure the safety of 1 (R20) of 2 residents reviewed for smoking in a sample of 25.Findings include:R20's admission Record documented an admission date of 4/12/22 with diagnoses including: cerebral infarction, expressive language disorder, dysphagia following cerebral infarction. R20's 7/10/25 Minimum Data Set (MDS) documented .Should a Brief Interview for Mental Status (BIMS) be Conducted? with the code .0. No (resident is rarely/ never understood).R20's Electronic Medical Record (EMR) documented no Smoking Evaluation Assessment since the 7/8/24 Smoking Evaluation Assessment documenting .E. Has resident had any safety issue in the past related to smoking (current of pervious setting)? b. No. G. Resident is able to safely handle lit smoking materials? . a. Yes. I. Does resident have clothing with burn holes? b. No. K. Does resident wear a smoking apron? b. No. If resident does not wear a smoking apron, is one needed? b. No. Care plan reviewed and revised for appropriate supervision and smoking directions to include: b. General Supervision.R20's Care Plan Report documented a created 6/2/22 Focus of .(R20) is a smoker. with the only Intervention/ Tasks created 6/2/22 . (R20) was given a schedule with facility scheduled smoke times.On 9/16/25 at 10:08 AM, R20's jacket was hanging on the bathroom door in his room and was observed to have multiple burn holes in it.On 9/18/25 at 1:08 PM, R20 wheeled himself outside to smoke wearing the jacket with multiple burn holes and a pair of pajama pants with multiple burn holes. R20 was giving 2 cigarettes by a staff member. R20 held the cigarette between his thumb and index finger with the ignited end closest to the palm of his hand. When R20 lowered the cigarette the ignited end of the cigarette was positioned toward his body and clothing. R20 was observed to have his cigarette almost touching his pants and bumping the plastic cushion of R20's wheelchair.On 9/18/25 at 1:20 PM, V7 (Regional Director of Operations) said the Interdisciplinary Team (IDT) should complete a smoking assessment quarterly and R20 should have interventions in place for safe smoking. V7 said he was not sure why R20 would not have interventions in place due to all the burn holes in R20's clothing.The facility's 2025 Resident Smoking Policy and Procedure documented in part . A. Each resident should be individually assessed to determine whether or not he/she can safely smoke without supervision. The facility shall conduct an assessment to determine whether the resident requires a smoking apron and shall document this in the resident's care plan. Reassessments should be conducted, as necessary. The determination should be noted in the resident's care plan and in a smoking log to be kept on each residential floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer narcotic pain medication as ordered for 1 (R1) of 5 residents reviewed for pain control in a sample of 5.
Findings include:
R1's admission Record documented an admission date of 1/13/23 with diagnoses including: Parkinson's disease, low back pain, Crohn's disease, dysarthria, systemic inflammatory response syndrome, and chronic pain syndrome.
R1's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section J documents under Pain Management that R1 has received a PRN (as needed) pain medication or was offered and declined in the last 5 days from the assessment date.
R1's Care Plan documented a focus area initiated on 1/13/23 I currently have an alteration d/t (due to) chronic pain r/t (related to) SIRS (Systemic Inflammatory Response Syndrome). Documented interventions include Administer medication & treatments ordered by MD (Medical Doctor) and monitor for side effects and effectiveness to current medication regimens with an initiation date of 1/13/23.
On 5/1/25 at 1:40 PM, R1 was observed in her room in her wheelchair. R1 was non-interviewable related to confusion.
R1's Order Summary Report documented the following orders: 4/10/25 fentanyl patch 12 mcg (microgram)/ HR (hour) apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/16/25 fentanyl patch 25 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/21/25 fentanyl patch 12 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/25/25 fentanyl patch 25 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 5/1/25 fentanyl patch 50 mcg/ HR apply 1 patch transdermally every 72 hours with an order status of active, 1/3/18 hydrocodone- acetaminophen 5-325 mg (milligram) 1 tablet by mouth every 6 hours as needed with an order status of discontinued, and 3/24/25 hydrocodone- acetaminophen 5-325 mg 1 tablet by mouth every 6 hours as needed with an order status of active.
R1's 4/1/25 through 4/30/25 Electronic Medication Administration Record (eMAR) documented a fentanyl patch 12 mcg/hr was administered on 4/13/25 and removed on 4/16/25. R1's eMAR documented on 4/17/25, 4/20/25, and 4/21/25 a code of 9 for the fentanyl patch 25 mcg/ hr. The Chart Code on the eMAR documents 9 indicates Other-See Progress Notes. R1's eMAR documented on 4/21/25 a fentanyl patch 12 mcg/ hr was administered.
On 5/1/25 at 10:20 AM, V3 (Director of Nursing/ DON) said on 4/17/25 R1's fentanyl patch order was changed from 12 mcg/ hr to 25 mcg/hr but the pharmacy had not delivered the fentanyl 25 mcg/ hr patches to the facility yet, so the order was changed back to fentanyl 12 mcg/hr on 4/21/25 (5 days later). V3 said she would expect staff to call a medical provider if a medication was not available.
On 5/1/25 at 10:30 AM, V16 (Registered Nurse/ RN) said when R1's 4/16/25 order for fentanyl 25 mcg/hr every 72 hours was put into the electronic medical record the administration dates for every 72 hours were wrong and that is how she found R1 had not had a fentanyl patch administered from 4/17/25 through 4/21/25. V16 said she called to get an order to change R1's fentanyl patch back to 12 mcg/hr on 4/21/25 due to the facility having 1 fentanyl patch 12 mcg/hr left and the fentanyl patch 25 mcg/hr had not been delivered to the facility. V16 said R1 did not complain of increased pain during that time.
The facility's revised 10/15/23 Administering Medications policy documented in part .3. Medications shall be administered according to physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards .

Based on interview and record review the facility failed to maintain records of controlled substances for accurate reconciliation and administer controlled substances as ordered for 4 (R1, R2, R3, and R5) of 5 residents reviewed for narcotic medication administration in a sample of 5.
Findings include:
1. R1's admission Record documented an admission date of 1/13/23 with diagnoses including: Parkinson's disease, low back pain, Crohn's disease, dysarthria, systemic inflammatory response syndrome, and chronic pain syndrome.
R1's Order Summary Report documented the following orders: 4/10/25 fentanyl patch 12 mcg (microgram)/ HR (hour) apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/16/25 fentanyl patch 25 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/21/25 fentanyl patch 12 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/25/25 fentanyl patch 25 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 5/1/25 fentanyl patch 50 mcg/ HR apply 1 patch transdermally every 72 hours with an order status of active, and 1/3/18 hydrocodone- acetaminophen 5-325 mg (milligram) 1 tablet by mouth every 6 hours as needed with an order status of discontinued, and 3/24/25 hydrocodone- acetaminophen 5-325 mg (milligram) 1 tablet by mouth every 6 hours as needed with an order status of active.
R1's 4/1/25 through 4/30/25 Electronic Medication Administration Record (eMAR) documented a fentanyl patch 12 mcg/hr was administered on 4/13/25 and removed on 4/16/25. R1's eMAR documented on 4/17/25, 4/20/25, and 4/21/25 a code of 9 for the fentanyl patch 25 mcg/ hr. The Chart Code on the eMAR documents 9 indicates Other-See Progress Notes. R1's eMAR documented on 4/21/25 a fentanyl patch 12 mcg/ hr was administered.
On 5/1/25 at 10:20 AM, V3 (Director of Nursing/ DON) said on 4/17/25 R1's fentanyl patch order was changed from 12 mcg/ hr to 25 mcg/hr but the pharmacy had not delivered the fentanyl 25 mcg/ hr patches to the facility yet, so the order was changed back to fentanyl 12 mcg/hr on 4/21/25 (5 days later). V3 said she would expect staff to call a medical provider if a medication was not available.
On 5/1/25 at 10:30 AM, V16 (Registered Nurse/ RN) said when R1's 4/16/25 order for fentanyl 25 mcg/hr every 72 hours was put into the electronic medical record the administration dates for every 72 hours were wrong and that is how she found R1 had not had a fentanyl patch administered from 4/17/25 through 4/21/25 . V16 said she called to get an order to change R1's fentanyl patch back to 12 mcg/hr on 4/21/25 due to the facility having 1 fentanyl patch 12 mcg/hr left and the fentanyl patch 25 mcg/hr had not been delivered to the facility.
On 5/1/25 at 10:40 AM, V1 (Regional Director of Operations) provided a facility undated and untitled spreadsheet of narcotic medication Controlled Substance Proof of Use forms that could not be found. This spreadsheet documented R1's Controlled Substance Proof of Use forms for hydrocodone- acetaminophen 5-325 mg for the 30 tablets delivered on 3/24/25 as missing.
R1's Electronic Medication Administration Record (eMAR) dated 3/1/25 through 3/31/25 documented 5 hydrocodone- acetaminophen 5-325 mg tablets were administered.
R1's 4/1/25 through 4/30/25 eMAR documented 8 hydrocodone- acetaminophen 5-325 mg tablets were administered.
R1's Controlled Substance Proof of Use form documented 30 hydrocodone-acetaminophen 5-325 mg tablets were delivered to the facility on 4/10/25 and tablets were administered as follows: 4/12/25 3 tablets, 4/13/25 2 tablets, 4/14/25 2 tablets, 4/15/25 3 tablets, 4/16/25 2 tablets, 4/18/25 1 tablet, 4/19/25 2 tablets, 4/20/25 2 tablets, 4/21/25 2 tablets, 4/22/25 4 tablets, 4/23/25 2 tablets for a total of 25 tablets administered.
On 4/24/25 at 11:40 AM, V13 (Assistant Director of Nursing/ ADON) said it was the responsibility of V3 to ensure medications were being correctly documented on the Controlled Substance Proof of Use forms and on the resident's eMAR. V13 said she was not sure if that was being completed due to V3 only working in the facility 2 days a week as the interim DON.
On 5/2/25 at 10:31 AM, V9 (Licensed Practical Nurse/ LPN) said she tried to but did not always document on the eMAR when an as needed (PRN) medication was administered. V9 said PRN medications were always documented on the Controlled Substance Proof of Use form because that was the form used when nurses counted the narcotic medications at shift change. V9 said the Controlled Substance Proof of Use form would be the most accurate documentation on when a resident received medications.
On 5/2/25 at 10:58 AM, V7 (Registered Nurse/ RN) said V7 forgets to document on the eMAR due to medication administration time being chaotic but would always document on the Controlled Substance Proof of Use form. V7 said when controlled substance card was empty the Controlled Substance Proof of Use form would be put in a folder on the Business Office door to be filed.
On 5/2/25 at 10:25 AM, V10 (Medical Records) said the Controlled Substance Proof of Use forms were stored in the business office until V10 could scan them into the resident's electronic medical record. V10 said she would scan them monthly so she knew all of them had been scanned. V10 said she had not yet scanned any Controlled Substance Proof of Use forms into any resident chart in 2025.
2. R2's admission Record documented an admission date of 5/4/22 with diagnoses including: pain in left hip, muscle spasm, low back pain, and sleep related leg cramps.
R2's Order Summary Report printed 5/2/25 documented a 12/4/24 order for oxycodone -acetaminophen 5-325 mg 1 tablet by mouth every 8 hours as needed for pain.
On 5/1/25 at 10:40 AM, V1 (Regional Director of Operations) provided a facility undated and untitled spreadsheet of narcotic medication Controlled Substance Proof of Use forms that could not be found. This spreadsheet documented on 1/1/25, 1/19/25, 2/12/25, 2/27/25, and 3/11/25 R2's oxycodone- acetaminophen 5-325 mg 30 tablets were delivered to the facility and the Controlled Substance Proof of Use forms were missing.
R2's 1/1/25 through 1/31/25 eMAR documented 13 oxycodone-acetaminophen 5-325 mg tablets were administered.
R2's oxycodone- acetaminophen 5-325 mg Controlled Substance Proof of Use form documented a delivery date of 2/3/25 and 27 tablets were administered from 2/3/25 through 2/16/25.
R2's 2/1/25 through 2/28/25 eMAR documented 15 oxycodone-acetaminophen 5-325 mg tablets were administered.
R2's 3/1/25 through 3/31/25 eMAR documented 8 oxycodone-acetaminophen 5-325 mg tablets were administered.
R2's oxycodone- acetaminophen 5-325 mg Controlled Substance Proof of Use form documented a delivery date of 3/31/25 and 30 tablets were administered from 3/31/25 through 4/23/25.
R2's oxycodone- acetaminophen 5-325 mg Controlled Substance Proof of Use form documented a delivery date of 4/16/25 and 9 tablets were administered from 4/24/25 through 4/30/25.
R2's 4/1/25 through 4/30/25 eMAR documented 14 oxycodone-acetaminophen 5-325 mg tablets were administered.
3. R3's admission Record documented an admission date of 1/4/24 with diagnoses including: dementia, history of falling, schizoaffective disorder, and polyneuropathy.
R3's Order Summary Report with a print date of 5/2/25 documents the following orders: 12/1/24 Morphine Sulfate (Concentrate) Solution 20 mg/mL give 10 mg by mouth every 4 hours as needed and 3/15/25 Morphine Sulfate Oral Tablet 30 mg Give 30 mg by mouth every 4 hours as needed for pain.
On 5/1/25 at 10:40 AM, V1 (Regional Director of Operations) provided a facility undated and untitled spreadsheet of narcotic medication Controlled Substance Proof of Use forms that could not be found. This spreadsheet documented on 2/18/25 15 doses of morphine 100mg/ 5ml, 3/17/25 18 morphine 30 mg tablets, and 3/24/25 15 doses of morphine 100mg/5ml were delivered to the facility and the Controlled Substance Proof of Use forms were missing.
R3's 2/1/25 through 2/28/25 eMAR documented 6 doses of morphine were administered.
R3's 3/1/25 through 3/31/25 eMAR documented 4 doses of morphine were administered.
R3's 4/1/25 through 4/30/25 eMAR documented 4 doses of morphine were administered.
R3's morphine 30 mg tablet Controlled Substance Proof of Use form documented 30 tablets were delivered on 4/24/25 and 9 tablets were administered from 4/28/25 through 4/30/25.
4. R5's admission Record documented an admission date of 5/24/22 with diagnoses including: cerebral palsy, unspecified abdominal pain, peptic ulcer, Huntington's disease, and epilepsy.
R5's Order Summary Report with a print date of 5/25/25 documents the following orders: 11/12/24 Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain, 3/18/25 Hydrocodone-Acetaminophen Oral Tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain, and 3/24/25 Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain.
On 5/1/25 at 10:40 AM, V1 (Regional Director of Operations) provided a facility undated and untitled spreadsheet of narcotic medication Controlled Substance Proof of Use forms that could not be found. This spreadsheet documented on 1/7/25 26 hydrocodone-acetaminophen 7.5-325 mg tablets, 1/20/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 2/2/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 2/7/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 2/17/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 3/6/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 3/11/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 3/24/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, 3/30/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets, and 4/2/25 30 hydrocodone-acetaminophen 7.5-325 mg tablets were delivered to the facility for R5 and the Controlled Substance Proof of Use forms were documented as missing.
R5's 1/1/25 through 1/31/25 eMAR documented 10 hydrocodone-acetaminophen 7.5-325 mg tablets were administered.
R5's hydrocodone-acetaminophen 7.5-325 mg Controlled Substance Proof of Use form documented 30 tablets were delivered to the facility on 2/25/25 and 30 tablets were administered from 2/26/25 through 3/9/25.
R5's hydrocodone-acetaminophen 7.5-325 mg Controlled Substance Proof of Use form documented 30 tablets were delivered to the facility on 3/22/25 and 6 tablets were administered from 3/22/25 through 3/23/25.
R5's 2/1/25 through 2/28/25 eMAR documented 10 hydrocodone-acetaminophen 7.5-325 mg tablets were administered.
R5's 3/1/25 through 3/31/25 eMAR documented 24 hydrocodone-acetaminophen 7.5-325 mg tablets were administered.
R5's 4/1/25 through 4/30/25 eMAR documented 18 hydrocodone-acetaminophen 7.5-325 mg tablets were administered.
The facility's revised 10/15/23 Administering Medications policy documented in part . 2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered according to physician's written/ verbal orders . 8. The individual administering the medication shall sign off on the Electronic Medication Administration Record (eMAR) date for that specific day before administering the medication . 10. If it is discovered the person administrating [sic] medications has forgot to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/ treatment has been administered/ performed. 1. If the response indicates the medication/ treatment was administered the staff member shall return to the facility, sign off on the Electronic Medication Administration Record (eMAR)/ Electronic Treatment Record (eTAR) [sic] to indicate a late entry. 2. A late entry note will be documented indicating the administration of the medication .
The facility's undated Controlled Substances policy documented in part . Policy . II. Drugs listed in the Schedule II, II [sic], IV and V of the Federal Comprehensive Drug Abuse Program and Control Acro 1970 shall not be accessible to any personnel other than licensed nursing, pharmacy and medical personnel designated by the facility. III. The Director of Nurses is designated by the facility to be responsible for the control of such drugs . 2. Ordering of Controlled Substances-Schedule 11-V a) All scheduled medications require a written prescription from the physician. b) Pharmacy will accept an original written prescription order by the physician or a facsimile of said order followed by the actual original prescription. c) If a written prescription is not available, the pharmacy can accept verbal authorization directly from the physician to dispense a one time, 5 day emergency supply of a Scheduled medication, and an original prescription must be sent to the pharmacy within 7 based on applicable state law . 4. Accountability of Controlled Substances . a) A declining inventory form will be provided with each Controlled Substance (CS) prescription dispensed by the pharmacy . b) When the nurse receives a CS medication from the pharmacy, he/ she will verify the contents with the label and will note the date received and quantity on the declining inventory form. c) When a CS medication is administered, in addition to following proper procedure for charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/ her initials. d) An inventory count of all CS medications stored on each nursing unit shall be performed at each change of shift. Both the incoming and outgoing nurse on each unit that is responsible for handling controlled substances will sign the inventory count .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate treatment and services to follow up on an abnormal urinalysis for 1 (R7) of 1 resident reviewed for urinary tract infections in a sample of 24.
Findings include:
R7's Face Sheet documented an admission date of 04/29/2019 and included a diagnosis of chronic kidney disease.
R7's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 00 out of 15 total, which indicates a severe impairment. R7's MDS further documents in section h-bowel and bladder, that R7 is always incontinent of bladder.
A Physician's Note dated 03/01/2024, found in the miscellaneous tab of R7's medical record, documents that R7 was having an increase in behaviors and insomnia. This same physician's note documents an order for a CBC (complete blood count), BMP (basic metabolic panel), and a UA (urinalysis) and C&S (culture and sensitivity).
R7's Progress Notes document on 03/03/2024 Resident straight cathed (sic) via sterile technique with immediate return of cloudy dark yellow urine. UA (Urinalysis) specimen collected and taken to (local) hospital lab. There is no other documentation in the progress notes related to this lab.
A urinalysis for R7, dated 03/03/2024 at 07:32pm documents the following abnormal findings; positive for nitrates, slightly cloudy, [NAME] Blood cell count of 11-20 (normal range is less than 5), and many bacteria. The culture and sensitivity for the same above date lists sensitivities to 20 different antibiotics that could possibly treat the bacteria in R7's urine.
On 09/12/2024 at 12:49 PM, V1 (Administrator) stated, if a urinalysis is done, it would not go on the infection tracking log unless it was treated. V1 stated, if there was no follow-up or orders received from the doctor on a pending urinalysis, someone should follow-up and it would be the infection prevention nurse. V1 stated he would still expect to see documentation in the resident's medical record that the doctor addressed an abnormal lab, even if there were no new orders.
09/11/2024 at 12:28 PMm, V2 (Director of Nursing/DON) stated that the Director of Nursing is the infection prevention nurse. V2 stated she was not employed here on 03/03/2024, but that she would try her best to locate the follow-up documentation to the UA results from 03/03/2024. She stated, she would expect to see some follow-up and/or antibiotics ordered on a lab like that.
On 09/11/2024 at 02:30 PM, V2 (DON) stated she was still having issues locating any follow-up documentation from 03/03/2024.
On 09/12/2024 at 10:36 AM, V8 (Licensed Practical Nurse/LPN) stated, when they received lab results, it comes over as a fax, they are then supposed to send the fax to the doctor to review and write orders if they need to.
On 09/12/2024 at 10:55 AM, V2 stated, she had contacted the primary Physician yesterday and they could see where they had received the lab results from 03/03/2024, but there was no documentation of follow-up, or any orders given. V2 stated, the physician's office was unsure why it had not been addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop an individualized plan of care for the treatment of PTSD (Post traumatic Stress Disorder) for 1 of 1 (R13) residents reviewed for mental health services in a sample of 24.
Findings included:
On 9/9/2024 at 10:30 AM, R13 stated he was a war veteran and had PTSD (Post Traumatic Stress Disorder). R13 said that due to his PTSD, he suffers from flash backs. R13 said when he reports having issues with flash backs the staff does not really do anything to help him.
R13's Face Sheet documented R13 was admitted to this facility on 10/31/2018 with diagnoses of PTSD, schizophrenia, anxiety and dementia among others. R13's Minimum Data Set (MDS) dated [DATE] documented R13's has a Brief Interview for Mental Status (BIMS) score of 10, which indicated R13 had moderate cognitive impairment.
A form in R13's Electronic Health Record (EHR) titled Initial Social History and dated 11/2/2018, documents R13 was admitted to this facility with the diagnosis of PTSD among others.
A form in R13's EHR titled Psychiatric Evaluation and Consultation dated 8/22/2024 documents that during this evaluation, R13 reported not sleeping well at night due to getting flashbacks and getting nightmares every other day and R13 does not want to talk about the memories of his PTSD.
R13's Physician Order Sheet (POS) dated 8/26/2024 documents R13 was prescribed Prazosin 6mg (milligrams) by mouth every day to treat PTSD.
A review of R13's EHR and Care Pan revealed no plan of care for R13's PTSD. There were no individualized non-pharmacological interventions listed for the diagnosis of PTSD, nor any plan for tracking/monitoring of symptoms or the effectiveness of the medication prescribed for R13's PTSD.
On 9/10/2024 at 11:00 AM, V6 (Licensed Practical Nurse/LPN) stated that R13 has reported to her having flashbacks, but she just encourages him to try to think positively and not to let it get him upset. V6 said as far as she knows, the staff do not track when R13 has PTSD symptoms.
On 9/11/2024 at 9:15 AM, V10 (Certified Nursing Assistant/CNA) said she was not aware of any tracking of PTSD symptoms for R13.
On 9/12/2024 at 9:50 AM, V2 (Director of Nursing/DON) said she was aware of R13's diagnosis of PTSD. V2 said R13's IDT (Interdisciplinary Team) should have developed a plan of care for R13's PTSD but they had not. V2 said the facility has not been monitoring or tracking R13's PTSD symptoms.
On 9/12/2024 at 12:30 PM, V9 (Social Service Director/SSD) stated the staff are not tracking/monitoring R13 for PTSD symptoms, but were tracking other behavioral issues not related to PTSD.
On 9/11/2024 at 12:00 PM, V1 (Administrator) stated the facility did not have a policy regarding PTSD care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pneumonia vaccinations were offered in accordance with Centers for Disease Control and Prevention (CDC) recommendations for five (R4, R8, R12, R25, R26) of five residents reviewed for immunizations in a sample of 24.
Findings Include:
1. R25's Face Sheet documents an admission date of 3/15/2022 and documents R25 is [AGE] years old. R25's Diagnosis Information listed on the Face Sheet included type 2 diabetes mellitus and malignant neoplasm of unspecified site of unspecified female breast.
R25's facility document titled Clinical-Immunizations documents PCV13 (pneumococcal 13-valent conjugate vaccine) was administered on 9/29/2014. The facility did not have documentation to show R25 was offered another pneumococcal vaccine after receiving the PCV13 on 09/29/14 nor any documentation of refusal.
R25's Physician Order Sheet (POS) documents an order of: may administer immunizations per facility policy with an order date of 03/16/2022.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Adults greater than or equal to [AGE] years old, Complete pneumococcal vaccine schedules: If PCV13 was the only vaccine administered at any age, Option A documents to administer PCV20 (pneumococcal 20-valent conjugate vaccine) or PCV21 (pneumococcal 21-valent conjugate vaccine) greater than or equal to a year after; or Option B documents to administer PPSV23 (pneumococcal polysaccharide vaccine) greater than or equal to a year after. This job aid also documents consider minimum interval (8 weeks) for adults with immunocompromising condition .
2. R12's Face Sheet documents an admission date of 7/01/2022 and documents R12 is [AGE] years old. R12's Diagnosis Information listed on the Face Sheet included Type 2 Diabetes Mellitus.
R12's facility document titled Clinical-Immunizations documents PPSV23 was administered on 02/12/2015.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Adults 19-[AGE] years old with chronic health conditions (which includes Diabetes mellitus), Complete pneumococcal vaccine schedules: If PPSV23 was the only prior vaccine administered, Option A documents to administer PCV20 or PCV21 greater than or equal to a year after; or Option B documents to administer PCV15 (pneumococcal 15-valent conjugate vaccine) greater than or equal to a year after.
R12's POS documents an order of: may administer immunizations per facility policy with an order date of 07/01/22.
The facility did not have documentation to show R12 was offered another pneumococcal vaccine after receiving the PPSV23 on 02/12/15 nor any documentation of refusal.
3. R26's Face Sheet documents an admission date of 7/28/2022 and documents R26 is [AGE] years old. R26's Diagnosis Information listed on the Face Sheet included unspecified bacterial pneumonia, chronic obstructive pulmonary disease, unspecified, hypoxemia, type 2 diabetes mellitus, other viral pneumonia, acute cough, acute upper respiratory infection, and cannabis use.
R26's Immunization Report does not document administration of any pneumonia vaccinations.
R26's POS documents an order of: may administer immunizations per facility policy with an order date of 07/29/2022.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Adults 19-[AGE] years old with chronic health conditions (which includes Diabetes mellitus and chronic obstructive pulmonary disease), Complete pneumococcal vaccine schedules: If no prior pneumococcal vaccines have been administered, Option A documents to administer PCV20 or PCV21; or Option B documents if PCV15 is used, then follow with one dose of PPSV23 greater than or equal to one year later.
The facility did not have documentation to show R26 was offered a pneumococcal vaccine nor any documentation of refusal.
4. R4's Face Sheet documents an admission date of 11/20/2015 and documents R4 is [AGE] years old. R4's Diagnosis Information listed on the Face Sheet included pneumonia, unspecified organism, and heart failure, unspecified.
R4's facility document titled Clinical-Immunizations documents Pneumovax Dose 1 (Manuacturer's Name: Prevnar 13) was administered on 5/1/2016 and Pneumovax Dose 1 (Manufacturer's Name: Pneumovax 23) was administered on 5/26/2017.
R4's POS documents an order of: may administer immunizations per facility policy with an order date of 11/19/2019.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Shared Clinical decision-making for those who already completed the series with PCV13 and PPSV23: Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults (greater than or equal to) [AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.
The facility did not have documentation to show whether R4 was offered another pneumococcal vaccine or if R4's vaccine provider recommended consideration for the PCV20 or PCV21 vaccine for R4.
5. R8's Face Sheet documents an admission date of 10/31/2023 and documents R8 is [AGE] years old. R8's Diagnosis Information listed on the Face Sheet included chronic obstructive pulmonary disease with (acute) exacerbation, other specified viral diseases, and prediabetes.
R8's facility document titled Clinical-Immunizations in the electronic health record (EHR) documents Pneumonia, unspecified on 05/31/2017 and 12/06/2018. R8's State of Illinois Certificate of Child Health Examination document provided by the facility documents Pneumococcal Conjugate Dose 1 was administered on 05/31/2017 and Dose 2 was administered on 12/06/2018.
The facility did not have documentation to show what types of pneumonia vaccines were administered to R8 or any attempts to determine which pneumonia vaccines were administered.
R8's POS documents an order of: may administer immunizations per facility policy with an order date of 01/05/2024.
On 9/10/24 at 9:54 AM, V2 (Director of Nursing/DON) stated, no pneumonia vaccines have been given since V2 took over the role a few months ago. V2 stated the pneumonia vaccines should be given per the CDC and the facility's policy.
The facility document titled, Pneumococcal Vaccination Policy and Procedure dated 10/16/2023 documents under Procedure: The pneumococcal vaccine is ordered upon admission by the attending physician. If the vaccine is not ordered, the physician/nurse must document as to reason why not .and documentation in (the facility's EHR) Immunization tab regarding the administration, type, time, lot, expiration and location of the pneumonia vaccine administration must be input into the Medication Administration Record, 24 hour Resident Condition Report and Progress Notes. This policy further documents the CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors, including (but not limited to) diabetes mellitus, chronic lung disease, including chronic obstructive pulmonary disease, generalized malignancy, and cigarette smoking. For those who have not previously received any pneumococcal vaccine the CDC recommends to give one dose of PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or PCV20. For those who have only received the PPSV23, PCV15 vaccination or PCV20 vaccination should be administered at least one year after the most recent PPSV23 vaccination. For Adults 65 years or older who have only received PPSV23 vaccination the PCV15 vaccination or PCV20 vaccination should be administered at least one year after the most recent PPSV23 vaccination. For adults who have received the PCV13, then give the PPSV23 vaccination. If the PCV15 vaccination is used this should be followed by PPSV23 vaccination one year later.
The facilty's Pneumococcal Vaccination Policy and Procedure does not include any updated information regarding the PCV21 vaccine that is documented as an option in the current CDC's Pneumococcal Vaccine Timing for Adults job aid.

Based on interview and record review, the facility failed to obtain a Level II PASRR (Preadmission screening and Resident Review) screening for 1 of 10 residents (R4) reviewed for PASSR screenings in the sample of 22.
The findings include:
R4's face sheet document that R2's initial admission date was 11/18/2015. The same face sheet includes diagnoses as Epilepsy, unspecified, intractable, without status epilepticus, schizophrenia, unspecified, generalized anxiety disorder.
R4's PAS (Preadmission Screening)/MH (Mental Health) Level 1 Determination dated 11/18/16 documents in part, Determination: Doesn't meet Severe Mental Illness Criteria Level 1 Narrative Summary Medical is primary, therefore referred to (Name of Provider) for certification.:\
The Facility's for Policy and Procedure Pre-admission Process dated 8/19/2020 notes under Procedures vii, PASRR level I for all referrals and Level II when appropriate.
On 8/10/23 at 9:00am, V1 said he had called the agency that performs the screenings to request a copy of R4's Level II screening. On 8/11/23 at 10:00am, V1 said the agency could not find where a Level II screening was done for R4. V1 said that he requested that a Level II screening be performed.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an alleged allegation of abuse to the State Survey Agency within 24 hours for one of ome residents (R22) reviewed for abuse in a sample of 22.
The Findings Include:
On 8/8/23 at 9:30 AM, V11 (Ombudsman) stated that she had reported an allegation of staff to resident abuse brought to her by a resident in regards to an event that occurred on 6/9/23. V11 stated that she reported the abuse to V1 (Administrator) on 7/31/23 around 4:30 PM and that she has not heard any follow up the allegations.
On 8/10/23 at 10:00 AM, V1 (Administrator) stated that he had not officially reported the incident but started his investigation. V1 stated that he would immediately report to the Illinois Department of Public Health. V1 acknowledged that this was beyond the 24 hour window of reporting the alleged incident to the state agency. V1 stated that he had contacted the staff members that were mentioned in the abuse allegation and would thoroughly investigate the allegation.
V1 provided the long term care facility report of serious injury incident report. This document contains the information provided from V11 regarding the alleged abuse that was reported to her from another resident. This had a report date listed as 8/10/23 and the incident date listed as 6/9/23. V1 confirmed that he was first notified of the allegation on 7/31/23 from V11. In the incident report it states that V11 (Certified Nurse Assistant)(CNA) and V12 (CNA) were verbally abusive to R22 when transporting her to her room and in the dining room.
R22's admission record documents an admission date of 1/13/23. Diagnosis information on this same document include the following: toxic effect of other organic solvents, anxiety disorder, cognitive communication deficit, personal history of traumatic brain injury, and schizoaffective disorder.
R22's Quarterly Minimum Data Set (MDS) dated [DATE] Section G documents that R22 has a Brief Interview of Mental Status score of 3, indicating a severe cognitive impairment.
The facilities Resident Right To Freedom From Abuse, Neglect, and Exploitation Policy and Procedure dated 2022 documents in part IV When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. the facility will increase enforcement action, including, but not limited to B. Reporting the alleged violation and investigation within required timeframes pursuant to the Federal and State statues and regulations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to document resident behaviors, and failed to update and implement resident centered care plans following a new diagnosis and introduction of new medication for 3 of 8 residents (R12, R14, R21) reviewed for behaviors in a sample of 22.
The Findings Include:
1. R12's admitting Diagnoses Sheet dated 10/31/18 includes Schizophrenia, anxiety, bipolar, mood disorder, delusional disorder, Parkinson's, dementia, and major depressive. R12 was given a new diagnosis of other sexual dysfunction not due to a substance or known physiological condition on 05/12/23. R12's Face Sheet indicates he is his own representative.
R12's August 2023 Physician's Order Sheet (POS) includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml (milligram/milliliter) (Medroxyprogesterone Acetate (Contraceptive) dated 05/12/23 - Inject 1 milliliter intramuscularly one time a day every 90 day(s) related to other sexual dysfunction not due to a substance or known physiological condition.
R12s May 2023 Medication Administration Record (MAR) documents he received an injection of Depo-Provera on 05/15/23.
R12's Care Plan includes a focus area: (R12) demonstrates behaviors that include story fabrication, argumentative with staff, soliciting staff for money and gifts, and inappropriate interactions and comments to staff. Goal: (R12) episodes of inappropriate behavior will decrease through review date. Interventions: Make (R12) aware when behaviors are inappropriate. Monitor and report behaviors to nurse. Report abusive or aggressive behaviors to the appropriate supervisor. Date Initiated: 02/22/2019. Revision on: 04/25/2022. There is no documentation on R12's care plan indicating sexually inappropriate behavior towards other residents in the facility or the introduction of Depo-Provera for this behavior.
R12's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicates he is moderately cognitively impaired with a brief interview for mental status (BIMS) score of 9. R12 requires extensive one person assistance for bed mobility and transfers, requiring supervision and set up only for locomotion in his room or corridor. R12 is assessed to exhibit no physical, verbal, or behavioral manifestations of hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds.
R12's behavior tracking from July 2022 to present was reviewed. Problem: Inappropriate Sexual Behavior. Interventions: 1. Remove R12 from the situation to protect R12's safety and the rights of others. 2. Make R12 aware of behavior by educating him on appropriate behavior. 3. Distract and redirect R12 from inappropriate behavior. 4. Report behavior to Administrator, immediately. R12 is documented to have 15 documented episodes of inappropriate sexual behavior with no follow-up documentation describing the incident or who else was involved. R12's behavior notes are not specific to the behavior manifested or against whom.
On 08/10/23 at 2:49 PM, R12 was sitting in the dining room at a table by himself drinking juice. R12 was asked if he had given consent to receive an injection of Depo-Provera and had no response. When asked if he had been getting a new shot, he stated, Yes, and he wasn't going to talk about that. R12 then stated, I love you and I would marry you if you weren't married. R12 did not possess the mental capacity to comprehend what was being asked of him. R12 was observed daily from 08/08/23 to 08/11/23 self-propelling in his wheelchair or walking with his walker about the facility.
2. R14 admitted to this facility on 05/25/23 with diagnoses to include Alzheimer's disease, dementia, diffuse large b-cell lymphoma, extra [NAME] and solid organ sites, and an additional diagnosis dated 05/30/23 of unspecified sexual dysfunction not due to a substance or known physiological condition.
R14's August 2023 POS includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml (Medroxyprogesterone Acetate (Contraceptive) dated 05/30/23 - Inject 1 milliliter intramuscularly one time a day every 90 day(s) related to other sexual dysfunction not due to a substance or known physiological condition.
R14's May 2023 MAR documents he received an injection of Depo-Provera on 05/31/23.
R14's care plan included a focus: I currently have an alteration in my behavior status at times sexually inappropriate with staff. Date initiated 6/8/23. Goal: I will be compliant with labs and diagnostics if ordered by my doctor through the review date. This medication has a Black Box Warning resident will have no complications through review date. I will have fewer episodes of being sexually inappropriate to less than daily by review date. Intervention: 2 staff with care PRN (as needed). My behaviors will be monitored every shift and documented. I will be monitored for a change in condition and the MD (Medical Doctor) will be notified. Administer medication and treatments ordered by MD and monitor for side effects to current medication regimens. Explain all procedures to the (SPECIFY) before starting and allow the resident (X minutes) to adjust to changes. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. All interventions included an initiated date of 6/8/23.
R14's most recent quarterly MDS dated [DATE] indicates he is severely cognitively impaired with a BIMS score of 6. R14 requires extensive two-person assistance for bed mobility and transfers, and extensive one person assist for ambulating in his room or corridor. R14 is assessed to exhibit no physical, verbal, or behavioral manifestations of hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds.
The facility was only able to provide R14's behavior tracking sheet dated 07/11/23 through 07/25/23 which indicated R14 displayed one sexually inappropriate physical behavior on 07/23/23 at 4:26 PM. R14's record did not document what this behavior was or with whom.
On 08/11/23 at 11:00 AM, R14 stated he has not received any type of shot or injection related to inappropriate sexual behavior, and stated he was doing just fine.
3. R21's face sheet notes R11 was admitted to the facility on [DATE]. The same face sheet lists some of R21's diagnoses as: unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety, other sexual dysfunction not due to a substance or known physiological condition, schizophrenia, unspecified.
R21's MDS dated [DATE] notes that R21 has a BIMS of 02 which indicates that R21 has severe cognitive impairment. R21 is unable to be interviewed.
R21's Physician orders dated 8/1/23 - 8/31/23 note an order for Depo-Provera Suspension 150mg/ml Inject 1 ml intramuscularly one time a day every 90 days, with a start date of 10/13/19 according to the consent signed by V20 (Guardian).
R21's MAR documents the following dates he received a Depo-Provera infection - 09/29/22, 12/28/22, 03/28/23, and 06/26/23.
R21's care plan notes R21 has behavior symptoms associated with sexually inappropriate behavior with staff, resident, visitors. On 4/30/21 R21 grabbed a staff members breast. Some interventions listed are R21 will be redirected by staff when inappropriate touching is initiated, Redirect R21 away from risky situations, speak with R21 to see what he is needing/wanting, redirect R21 to room or quiet area to calm. There is no documentation of R21's care plan including a focus area for the injection of Depo-Provera.
Facility Document labeled Behavior Summary Report for the week ending through 8/13/22 through the week ending 8/12/23 indicate R21 had 8 documents occurrences of sexually inappropriate behavior with distraction and redirection provided.
On 08/10/23 at 12:34 PM, when asked if V1 (Administrator) had any documentation regarding R12, R14, or R21's sexually inappropriate behavior for each date marked on the tracking sheets, he stated there was nothing really documented to describe what happened, just the code that it happened and the code for the intervention used. V1 stated he did recall the incident on 07/23/23 stating R14 asked the nurse to get in bed with him when she was passing his medication on that day. V1 stated that nurse no longer works here, but did report this to him so that he could be aware of the comment made. When asked if he had any documentation of that interaction, V1 stated he did not. V1 stated there had been no reporting of inappropriate sexual behavior towards residents that he recalled, just mainly with staff.
On 08/10/23 at 1:00 PM, V15 (Certified Nursing Assistant/CNA) stated R12, R14, or R21 have never had sexual inappropriate behavior towards her or any residents that she is aware of.
On 08/11/23 at 8:10 AM, CNAs V17, V18, and V19 stated they had not witnessed any inappropriate sexual behavior from R12, R14, or R21 towards other residents lately.
On 08/10/23 at 3:19 PM, V4 (Social Services) stated that the CNAs document resident behaviors on their tracking sheet, report to the nurse, and the nurse lets her know and she makes a note in the record. When asked if there were any notes that would explain what the behavior of R12, R14, or R21 was besides sexually inappropriate behavior and who it involved other than staff, V4 stated they did not document specifics, but would definitely make that addition of some type of incident write up in the future. V4 stated their behaviors were towards staff. There was no other documentation provided to explain what these three residents' behaviors were specifically, or to whom they were against.
On 08/11/23 at 2:42 PM, V23 (Licensed Practical Nurse) states she is aware of incidents when R12, R14, R21 have inappropriately touched staff while CNAs are providing care. She stated what normally happens is the CNAs chart, tell the nurse, and the nurse reports this to social services so they can address the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to allow an independent smoker the right to choose when to smoke for 1 of 3 residents (R29) reviewed for smoking in a sample of 22.
Findings include:
1. R29's face sheet documented an admission date of 9/27/21 and diagnoses including: generalized arthritis, pneumonia, acute sinusitis, refractory anemia, osteomyelitis, hyperlipidemia. R29's 7/31/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R29 was cognitively intact. R29's 7/21/23 Wandering/ Elopement Risk Assessment documented R29 was a low wandering or elopement risk.
R29's Smoking Evaluation assessment dated [DATE] documented a score of 7-16 requires supervision.
On 8/10/23 at 11:47 AM, V4 (Social Services Director) said she completed R29's 7/14/23 Smoking Evaluation Assessment. V4 said she selected 2) Moderate problem to the questions General awareness and orientation, including ability to understand the facility safe smoking policy and Ability to follow smoking policy because R29 would ask to go out to smoke at times that were not designated smoking times. V4 said if R29 was to sleep through a designated smoking time R29 would come to the nurse's station and ask several times to go out to smoke and would have to be reeducated on the facility smoking policy and told R29 would have to wait until the next designated smoking time. V4 said all residents had to be supervised during smoking per the facility policy.
On 8/9/23 at 1:07 PM, R29 was observed independently ambulating herself in her wheelchair out to the designated smoking area. R29 was observed to safely smoke a cigarette and extinguish it. R29 said she was able to independently wheel herself outside, light her cigarette, smoke her cigarette, and extinguish it. R29 said the facility would not let any residents go outside to smoke if it was not during the designated smoking times. R29 said if she wakes up in the middle of the night and wants go smoke facility staff will tell her no.
On 8/9/23 at 1:00 PM residents were lined up in the 100-hallway leading to the door of the designated smoking area. V6 (Activities Assistant) was handing residents cigarettes out of a box containing all the resident's cigarettes. V5 (Activities Director) was lighting resident's cigarettes for them on the designated smoking area patio. V5 said she was lighting all the resident's cigarettes because the facility smoking policy documented no residents were allowed to handle lighters. V5 said no residents were allowed to smoke without staff supervision. When V5 was asked why a resident had to be supervised while smoking if they were alert and oriented, able to independently smoke, and was not an elopement risk V5 said that was the facility policy. V6 said residents are given one cigarette at six of the designated smoking times and two cigarettes at the 1:00 PM - 1:15 PM and 8:30 PM - 8:45 PM designated smoking times. V5 said residents were given two cigarettes at the 8:30 PM - 8:45 PM designated smoking time because no residents would be allowed to smoke again until the 6:30 AM - 6:45 AM designated smoke time. V5 said if a resident requested to go outside to smoke at a time other than the designated smoking times they would be told no they had to wait until the next designated smoking time. V5 said in the past independent smokers were allow to go outside to smoke whenever they wanted to and that started to cause problems with the unsafe smokers getting upset they could not go outside to smoke whenever they wanted to so the facility changed the policy to all residents could only go outside at designated smoking times.
The facility's 10/7/21 Smoking, Tobacco, & Nicotine Products Safety- Resident policy documented in part . 5. All residents, visitors and staff shall smoke in designated area and at designated times only . 6. The facility shall establish reasonable designated times to provide smoking opportunities to residents requiring assistance and/ or supervision. These times are subject to change according to staffing and census . 7 A facility staff member must be available to assist and ensure the safety of all residents during the smoking activities per plan of care, unless an approved guest/ volunteer is present while the resident is smoking . 12. Supervised smoking will be 15 minutes for each smoking session .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an adequate indication for the use and sufficient monitoring of male residents prescribed an oral contraceptive (Depo Provera) for 3 of 8 residents (R12, R14, R21) reviewed for unnecessary medications in a sample of 22.
The Findings Include:
1. R12's admitting Diagnoses Sheet dated 10/31/18 includes Schizophrenia, anxiety, bipolar, mood disorder, delusional disorder, Parkinson's, dementia, and major depressive. R12 was given a new diagnosis of other sexual dysfunction not due to a substance or known physiological condition on 05/12/23. R12's Face Sheet indicates he is his own representative.
R12's August 2023 Physician's Order Sheet (POS) includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml (milligram/milliliter) (Medroxyprogesterone Acetate (Contraceptive) dated 05/12/23, Inject 1 milliliter intramuscularly one time a day every 90 day(s) related to other sexual dysfunction not due to a substance or known physiological condition.
R12s May 2023 Medication Administration Record (MAR) documents he received an injection of Depo-Provera on 05/15/23.
R12's Care Plan includes a focus area: (R12) demonstrates behaviors that include story fabrication, argumentative with staff, soliciting staff for money and gifts, and inappropriate interactions and comments to staff. Goal: (R12) episodes of inappropriate behavior will decrease through review date. Interventions: Make (R12) aware when behaviors are inappropriate. Monitor and report behaviors to nurse. Report abusive or aggressive behaviors to the appropriate supervisor. Date Initiated: 2/22/2019. Revision on: 04/25/2022. There is no documentation on R12's care plan indicating sexually inappropriate behavior towards other residents in the facility.
R12's most recent quarterly minimum data set (MDS) dated [DATE] indicates he is moderately cognitively impaired with a brief interview for mental status (BIMS) score of 9. R12 requires extensive one person assistance for bed mobility and transfers, requiring supervision and set up only for locomotion in his room or corridor. R12 is assessed to exhibit no physical, verbal, or behavioral manifestations of hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds.
R12's behavior tracking from July 2022 to present was reviewed - Problem: Inappropriate Sexual Behavior. Interventions: 1. Remove R12 from the situation to protect R12's safety and the rights of others. 2. Make R12 aware of behavior by educating him on appropriate behavior. 3. Distract and redirect R12 from inappropriate behavior. 4. Report behavior to Administrator, immediately. R12 is documented to have 15 documented episodes of inappropriate sexual behavior with no follow-up documentation describing the incident or who else was involved.
On 08/10/23 at 2:49 PM, R12 was sitting in the dining room at a table by himself drinking juice. R12 was asked if he had given consent to receive an injection of Depo-Provera and had no response. When asked if he had been getting a new shot, he stated, Yes, and he wasn't going to talk about that R12 then stated, I love you and I would marry you if you weren't married. R12 did not possess the mental capacity to comprehend what was being asked of him. R12 has been observed daily during this survey from 08/08/23 to 08/11/23 self-propelling in his wheelchair or walking with his walker about the facility. There were no observations of inappropriate behavior between R12 and other residents.
2. R14 admitted to this facility on 05/25/23 with diagnoses to include Alzheimer's disease, dementia, diffuse large b-cell lymphoma, extra [NAME] and solid organ sites, and an additional diagnosis dated 05/30/23 of unspecified sexual dysfunction not due to a substance or known physiological condition.
R14's August 2023 POS includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml (Medroxyprogesterone Acetate (Contraceptive) dated 05/30/23, Inject 1 milliliter intramuscularly one time a day every 90 day(s) related to other sexual dysfunction not due to a substance or known physiological condition.
R14's May 2023 MAR documents he received an injection of Depo-Provera on 05/31/23.
R14's care plan included a focus: I currently have an alteration in my behavior status at times sexually inappropriate with staff. Goal: I will be compliant with labs and diagnostics if ordered by my doctor through the review date. This medication has a Black Box Warning resident will have no complications through review date. I will have fewer episodes of being sexually inappropriate to less than daily by review date. Intervention: 2 staff with care PRN (as needed). My behaviors will be monitored every shift and documented. I will be monitored for a change in condition and the MD (Medical Doctor) will be notified. Administer medication and treatments ordered by MD and monitor for side effects to current medication regimens. Explain all procedures to the (SPECIFY) before starting and allow the resident (X minutes) to adjust to changes. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 06/08/23.
R14's most recent quarterly MDS dated [DATE] indicates he is severely cognitively impaired with a BIMS score of 6. R14 requires extensive two person assistance for bed mobility and transfers, and extensive one person assist for ambulating in his room or corridor. R14 is assessed to exhibit no physical, verbal, or behavioral manifestations of hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds.
The facility was only able to provide R14's behavior tracking sheet dated 07/11/23 through 07/25/23 which indicated R14 displayed one sexually inappropriate physical behavior on 07/23/23 at 4:26 PM. R14's record did not document what this behavior was or with whom.
On 08/11/23 at 11:00 AM, R14 stated he was not receiving any type of shot or injection related to inappropriate sexual behavior, and stated he was doing just fine.
3. R21's face sheet notes R11 was admitted to the facility on [DATE]. The same face sheet lists some of R21's diagnoses as: unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety, other sexual dysfunction not due to a substance or known physiological condition, schizophrenia, unspecified.
R21's MDS dated [DATE] notes that R21 has a BIMS of 02 which indicates that R21 has severe cognitive impairment.
R21's Physician orders dated 8/1/23 - 8/31/23 note an order for Depo-Provera Suspension 150mg/ml Inject 1 ml intramuscularly one time a day every 90 days, with a start date of 10/13/19 according to the consent signed by V20 (Guardian).
R21's MAR documents the following dates he received a Depo-Provera injection - 09/29/22, 12/28/22, 03/28/23, and 06/26/23.
R21's care plan notes R21 has behavior symptoms associated with sexually inappropriate behavior with staff, resident, visitors. On 4/30/21 R21 grabbed a staff members breast. Some interventions listed are R21 will be redirected by staff when inappropriate touching is initiated, redirect R21 away from risky situations, speak with R21 to see what he is needing/wanting, redirect R21 to room or quiet area to calm. There is no documentation of R21's care plan including a focus area for the injection of Depo-Provera.
On 08/10/23 at 12:34 PM, when asked if V1 (Administrator) had any documentation regarding R12, R14, or R21's sexually inappropriate behavior for each date marked on the tracking sheets, he stated there was nothing really documented to describe what happened, just the code that it happened and the code for the intervention used. V1 stated he did recall the incident on 07/23/23 stating R14 asked the nurse to get in bed with him when she was passing his medication on that day. V1 stated that nurse no longer works here, but did report this to him so that he could be aware of the comment made. When asked if he had any documentation of that interaction, V1 stated he did not. V1 stated there had been no reporting of inappropriate sexual behavior towards residents that he recalled, just mainly with staff.
On 08/10/23 at 1:00 PM, V15 (Certified Nursing Assistant/CNA) stated R12, R14, or R21 have never had sexual inappropriate behavior towards her or any residents that she is aware of.
On 08/11/23 at 8:10 AM, CNA's V17, V18, and V19 stated they had not witnessed any inappropriate sexual behavior from R12, R14, or R21 towards other residents lately.
On 08/10/23 at 2:12 PM, V20 (Guardian) was asked if she had given consent for R21 to receive injections of Depo-Provera. V20 stated she vaguely remembered the facility calling in 2019 explaining it was the physician's recommendation R21 be placed on this drug. V20 stated if her memory served her correctly, R21 was reported to have gone into a female resident's room but does not remember exact details. She stated she did give verbal approval for this drug to be started due to being the physician's recommendation and was not going to question that recommendation.
On 08/10/23 at 1:34 PM, an attempt to contact V21 (Family Member/POA of R14 - Power of Attorney) was made with no success.
On 08/10/23 01:41 PM, V2 (Director of Nursing - DON) stated the physician had not ordered testosterone levels to be drawn on R12, R14, or R21. When asked about consents for the Depo-Provera injections V2 stated R12 was his own person, R14's admission packet and any consents sent to his POA (Power of Attorney) for signature had not been returned. R21's guardian had given consent in 2019.
On 08/11/23 at 9:52 AM, V22 (Primary Care Physician - PCP) was asked about R12, R14, and R21's reported behaviors that prompted his decision to initiate treatment with the Depo-Provera injections. V22 stated R21 was at another facility prior to coming to this facility in 2019. V22 stated R21 had problems with the nurses and when they came to check on him he would do basically say sexually inappropriate comments to them that escalated to touching. V22 stated as far as he was told it was just towards staff. V22 stated R12 had similar incidents reported by staff. V22 stated R14 also came from a different facility and had issues there, but from what V22 was told R14 had not really exhibited sexually inappropriate behavior since being in this facility. V22 stated he believed R14 may have had inappropriate behaviors towards other residents there and staff were complaining so it was decided to place him on the depo injections here. When asked the criteria to introduce the Depo injection to the male population, V22 stated it would be related to sexually inappropriate behaviors that don't stop with staff interventions. V22 said it was just the male behavior, and the fact that the frontal lobe is basically gone, they act without thinking, and most likely would continue. V21 stated R12, R14, and R21 cannot mentally understand or retain redirection so it just happens over and over. When asked if the resident had to be physically/sexually aggressive, violent, or have behaviors that rise to the level of rape, he stated they did not. When asked about monitoring testosterone levels, V22 stated that was not necessary because testosterone was not the issue, the issue was their mental capacity and the inability to be redirected. V22 stated these residents could be on the drug indefinitely without causing adverse issues, but he could certainly trial a discontinuation of the Depo-Provera injections and see how it goes.
The Food and Drug Administration (FDA) Highlights for Prescribing Medication (per https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020246s036lbl.pdf) documents under Indications and Usage that Depo Provera is a progestin injectable contraceptive indicated only for the prevention of pregnancy. A black box warning documents that Women who use Depo-Provera Contraceptive Injection may lose significant bone mineral density. Bone loss is greater with increasing duration of use and may not be completely reversible and Depo-Provera Contraceptive Injection should not be used as a long term birth control method (i.e., longer than 2 years) unless other birth control methods are considered inadequate.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so the facility is free of flies. This has the potential to affect all 34 residents residing in the facility.
Findings include:
On 8/8/23 at 9:45 AM during the lunch preparation observation flies were observed to be flying over the stove, the steam table, dish washing room and landing on the countertops. At that time, V8 (Dietary Supervisor) stated that she wishes that they could rid of the flies.
On 08/08/23 at 10:00 AM, R14 was lying in bed with his eyes closed, with food that had spilled onto his sweat shirt, and four flies sitting on his sweat shirt around the food.
On 8/8/23 at 10:45, V9 (Dietary Aide) stated that the flies are horrible. V9 thinks that part of the problem is that the door that leads to the outside where staff take breaks lets the flies in. They try to keep the door closed to that hallway, but the flies still make their way in.
On 8/8/23 at 1:30AM, R7 who was alert to person, place and time stated that flies are bad and she needs her own fly swatter.
On 8/8/23 at 2:00 PM, R27 who was alert to person, place and time complained about the flies and asked surveyor to hand her the fly swatter on her chair.
On 08/10/23 at 2:31 PM, R11 who was alert to person, place and time was sitting in his room attempting to wave three flies from around his face. Two were observed having landed on his face, and one sitting on his left arm. R11 was asked if this was normal, and he stated, (expletive) yeah, it's all the time.
On 8/10/23 at 3:00 PM, V1 (Administrator) stated that flies are bad this time of year. V1 went on to state that the pest control company comes once a month, V1 stated that they have fly lights in the facility in various places, but with the residents going in and out to the front porch that is where the flies come in.
On 08/11/23 at 2:40 PM, R14 who was alert to person and place was sitting in the hall in his wheelchair with flies observed buzzing around his head. When asked, R14 stated this did bother him.
The Pest Control Policy documents dated 9/19/19 6. Maintian routine pest control services .
The resident census and conditions of residents dated 8/10/23 document that 34 residents reside in the facility.