Andrew Residence

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to immediately respond, investigate timely, and implement resident protections for 4 of 4 residents (R1, R2, R3, R4) after an allegation of sexual abuse of R1 by R2 was reported, which resulted in subsequent sexual abuse for R3 and R4. The immediate jeopardy began on 11/7/25 at 1:30 p.m., when R1's family member (FM)-A reported unwanted sexual touching, by R2 to R1 while the residents were in R1's room, to the Social Worker (SW)-A and the facility failed to timely report the incident to the State Agency, begin an investigation, and place resident protections to ensure other vulnerable residents at risk of sexual abuse were safe. The director of clinical services (DCS)-A and director of nursing (DON) were notified of the immediate jeopardy at 5:02 p.m. on 11/20/25. The immediate jeopardy was removed on 11/21/25, but noncompliance remained at the lower scope and severity level D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses that included bipolar disorder, (a mental health condition characterized by extreme shifts in mood, energy and activity levels), anxiety, post-traumatic stress disorder and depression, and borderline personality disorder (a mental health condition characterized by long-term patterns of unstable emotions, relationships, and self-image, leading to impulsive and self-destructive behavior.)R1's care plan dated 10/3/24 indicated R1 was at risk for and/or had a history of sexual victimization and dated 5/27/25 indicated R1 exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her. R1's Interpersonal Skills Assessment (IPS) assessment dated [DATE], indicated a history of sexual trauma and victimization related to being sexually trafficked. R1's progress notes dated 11/13/25 at 1:35 p.m., entered as a late entry for 11/7/25 at 1:30 p.m., revealed R1's family member called the facility, spoke to SW-A, and reported someone had gone in R1's room and made sexual advances towards R1.R2 R2's annual MDS dated [DATE] indicated intact cognition and diagnoses that included paranoid schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a break from reality that may include symptoms of paranoia, false beliefs, seeing or hearing things that are not there, disorganized thinking and speech, and lack of normal emotional expression.) R2's care plan dated 11/13/25, indicated R2 displayed sexually exploitive behavior with interventions that included restriction from visiting all other residential floors, and consider precaution checks as needed. On 11/17/25, the care plan was adjusted to restrict R2 from other residential floors, female rooms, and the short hall of R2's residential floor and for staff to remind R2 weekly and as needed of behavioral expectations related to not exposing himself or asking other residents to engage in any sexual activity.R2's IPS assessment dated [DATE] indicated when R2 was symptomatic, misperceived communication from others resulting in interpersonal conflict. R2 had a history of participating in unwanted physical contact and violating no-contact orders. R2 understood others must have the capacity to consent to sexual activity before and throughout the activity and demonstrated knowledge of consent. The Assessment indicated no care plan in place for sexual exploitation or other vulnerability related to sexual health at the time of assessment. The assessment lacked indication of a care plan to address behaviors when symptomatic, despite a history of unwanted physical contact and violations of no-contact orders.R2's progress notes indicated the following:-11/12/25 at 10:58 p.m., indicated a resident [R4] reported unwanted advancements from R2. Staff spoke to R2, who stated he was getting mixed signals from the other resident but agreed to respect others' boundaries. Staff restricted R2 from visiting R4's floor (3rd).-11/13/25 at 6:56 a.m., R2 was noted to be on the 3rd floor, found in R4's room having consensual sex with her roommate. Progress note did not indicate any immediate action or supervision to ensure R2's stayed off 3rd floor.-11/13/25 at 3:15 p.m., indicated R2 was placed on 1-hour location checks and shift checks due to multiple incidents of inappropriate interaction with numerous residents.-11/17/25 at 11:00 p.m., indicated staff met with R2 after R2 exposed himself to another resident (R3). R2 was prohibited from entering other residential floors, female rooms, and the other hall of his own floor. Staff included police in the discussion with R2.-11/18/25 at 6:44 a.m., indicated R2 remained on 1-hour location checks and shift checks due to multiple incidents on 11/12/25, 11/13/25, and 11/17/25 and post SA reports on 11/13/25 and 11/17/25 related to R2's poor sexual boundaries.-11/19/25 at 10:49 p.m., indicated interventions were added to R2's care plan - R2 was restricted from visiting other residential floors, female rooms, and the short hall of his own residential floor.During an interview on 11/20/25 at 10:59 a.m., FM-A stated on 11/7/25, R1 reported a male resident came into her room and made sexual advances towards her, would back off, and then would try again. R1 did not want FM-A to report the incident to the facility but FM-A called the facility on 11/7/25 and reported the incident to the SW-A so it would not happen to anyone else. During an interview on 11/20/25 at 1:03 p.m., SW-A stated she became aware of an incident between R1, and R2 after FM-A called on 11/7/25, and reported unwanted touch by R2 to R1. SW-A stated she attempted to call R1 several times after the report to inquire about the details of the incident but was unable to reach her as she was already on leave from the facility. SW-A stated she reported the incident to an evening staff, but didn't recall who, and acknowledged she had not documented the report from FM-A, the report to the evening staff, or the attempted phone calls to R1. SW-A further stated she did not tell administrative staff about FM-A's report because without talking to R1 first about the details of the incident, there was not enough information at the time to make a report to the State. SW-A stated she told the program director (PD)-A about the incident in passing on her way out of the building, after her shift but had not documented that either. SW-A acknowledged if a resident reported unwanted touch by another resident, the event would be reportable within two hours of the incident or within two hours of staff knowing about the incident, but thought she would need to obtain full details of the incident before making the report. SW-A was then off work for four days and started to follow up on the report when she returned to work on 11/12/25.During an interview on 11/21/25 at 11:01 a.m., R1 stated she reported the incident to her parents because authority figures at the facility freak me out. [R2] went further than he should have. R1 informed her parents she was harassed, and had to yell at R2 and threaten to pull the alert cord to get staff's help because R2 would not leave her room. R1 stated she went to R2's room to look at something he wanted to sell and then left his room and went back to her own room. About 5 minutes later, R2 came to R1's room with a scarf he thought R1 would like, and R1 stated she wanted the scarf. R1 showed R2 old pictures from her high school yearbook, and thought maybe R2 liked her because she showed him pretty pictures of herself. R1 stated she allowed R2 to lay on her bed with her but stated she did not want anything sexual to happen, did not want to kiss, and kept saying no. R1 told R2 she never wanted to have sex with him and R2 was shocked and asked, Never? R1 said no, she was gay and was not interested in any man. R1 told R2 she didn't like any penis, and R2 kept saying R1 might like to see it, and then R2 exposed himself and told R1 she had never tried sex with him, and she might like it. R2 reached across R1, who was lying on her bed and, He used that opportunity to kind of grind on me. R1 yelled at R2 and threatened to use the pull cord to summon staff, and R2 left the room. R1 stated she had a long, extensive history of sexual trauma. During an interview on 11/20/25 at 11:59 a.m., R2 stated R1 invited him to lay on her bed with her, showed him her stomach, and allowed R2 to touch it. R2 asked if R1 had ever been with a boyfriend, and R1 stated she had but it never ended well. R2 stated he didn't know what to do because he was confused after R1 let R2 touch her stomach, so he pulled his pants down, and reached across both R1 and the bed to look for something. R2 stated R1 told him to leave or R1 was going to pull the call light to get staff assistance. R2 stated he took that seriously and left the room. R3R3's annual MDS dated [DATE] indicated intact cognition and diagnoses that included anxiety, borderline personality disorder, and depression.R3's care plan dated 1/23/17 indicated a risk and/or history of sexual victimization with an update on 11/17/25 to notify staff of distressing interactions, use her pull cord to get help from staff as needed, and to discuss safety planning weekly and as needed.R3's IPS assessment dated [DATE], indicated R3 struggled to set appropriate boundaries and had a history of sexual abuse.R3's progress notes dated 11/17/25, indicated R3 reported R2 walked across her room naked to close the door when he was visiting R3's roommate, and then later, she was left alone with R2, and R2 engaged in inappropriate sexual conversation with R3 and he exposed himself, which made R3 very uncomfortable. R4R4's quarterly MDS dated [DATE] indicated moderate cognitive impairment and diagnoses that included depression, anxiety, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-a thought disorder such as delusions and hallucinations with symptoms of a mood disorder like bipolar disorder or depression.)R4's care plan dated 6/11/25, indicated risk and/or history of sexual victimization. On 8/15/25, the care plan indicated staff would monitor for interactions in common spaces between R4 and R2 and intervene to assist R4 in setting boundaries, and on 11/12/25, the care plan was updated with an intervention to restrict R2 from R4's residential floor.R4's IPS assessment dated [DATE], indicated a history of physical and sexual abuse and R4 as a victim of sexual exploitation. R4's progress notes indicated the following:-11/12/25 at 10:37 p.m., indicated R2 embraced R4 in R4's room doorway and staff intervened due to R2's history of poor boundaries. R4 reported R2 kissed R4 on the cheek and it was unwanted, and the same behavior occurred a few times in the previous week. Staff discussed boundary-setting with R4, and R4 acknowledged difficulty setting boundaries. Prior to this incident, R4 was observed to be spending time with R2, and reported that the relationship was consensual and that she had the ability to place boundaries. When asked about her safety, R4 confirmed feeling safe and did not express any concerns related to this. She expressed general annoyance and frustration with R2's clinginess.-11/13/25 at 6:53 a.m., indicated R4 was on shift checks due to an uncomfortable interaction with her peer.-11/13/25 at 2:40 p.m., indicated R4 requested a meeting with staff and indicated she was unable to maintain boundaries with R2 and asked for staff assistance to maintain distance from R2. An intervention was added to R2's care plan to restrict R2 from R4's residential floor. A state agency reported five-day report from the facility dated 11/18/25 at 2:18 p.m., indicated R3 (via a confidant) reported on 11/17/25 that on 11/16/25, R2 exposed himself to her after he had consensual sex with R3's roommate and her roommate had left the room. R3 reported R2 additionally exposed himself to her several days earlier. The report also stated R2 was involved in an incident on 11/12/25 where he kissed R4 without permission. Additionally, the report indicated on 11/12/25 R2 kissed R4 without permission. During staff follow-up discussions with R2, R2 displayed limited insight into the impact and distress caused by exposing himself to another resident and acknowledged exposing himself after R1 explicitly told him she did not want to engage in sexual relations with him. During an interview on 11/19/25 at 2:50 p.m., R4 stated R2 tried to kiss her on two different occasions. The first was when R2 asked R4 to come to his room to show R4 his TV but then R2 wouldn't stop touching or kissing R4. After that incident, R2 was banned from R4's residential floor (3rd floor) (progress notes indicate this occurred 11/12/25). R4 stated the second incident was when R2 kissed her in the hallway outside her room, R4 said no, R2 kissed her again, and staff intervened. R4 stated R2 was supposed to be banned from her floor but was there anyway (progress notes indicate this occurred 11/13/25). During an interview on 11/20/25 at 11:59 a.m., R2 stated he kissed R4 on the cheek, R4 said no and R2 kissed R4 again. R2 confirmed he was already restricted from being on R4's residential floor from a different incident but had forgotten about the restriction and went there anyway. R2 stated he was not allowed to have sexual relations with women in the facility, and stated, They [staff] are acting like it was all my fault, like I am a hungry, thirsty, sex fiend just looking to f**k. They [the female residents] wanted to be friends and invited me over. During an interview on 11/19/25 at 4:55 p.m., R3 stated R2 exposed himself to her twice, but could not recall the dates (second incident 11/16/25 via report from confidant, other date unknown). R3 stated she was in the room when R2 and her roommate, were together, R2 walked across the room with his penis exposed, and didn't say anything to R3 at the time. The second incident was after R2 and R3's roommate had sex with R3 in the room. Afterwards her roommate left the room, and R2 exposed himself to her (R3). R3 stated she was uncomfortable with the incident, she didn't want to see R2's penis, was afraid of R2 and that he, Would try something with me. R3 stated R2 asked her personal questions, asked if she wanted to touch it or suck it (penis), and she told R2 she did not want to. R3 then stated R2 put his penis away, but stayed in the room, sat on her bed, and continued to make her feel uncomfortable so she thought R2 still wanted something from her.During an interview on 11/20/25 at 11:59 a.m., R2 stated he had been having sexual encounters with R3's roommate, and afterwards she left the room he was alone with R3. R2 asked to sit on R3's bed, asked R3 if she ever had sex with someone and if she thought about having sex, and offered to show R3 his penis. He indicated she said no, but he still thought maybe she wanted to see it, so he took his penis partially out of his pants and R3 looked. R2 then asked her if she wanted to see the rest of it, and since R3 didn't say no, he took his penis fully out of his pants. R2 stated it was his duty to ask if R3 was uncomfortable but hadn't and thought R3 looked confused and uncomfortable. R2 put his penis back in his pants and left the room.During an interview on 11/21/25 at 9:11 a.m., program manager (PM)-A stated she was informed of the incident involving R1 from SW-B but was unsure of the date. The PM-A stated if someone made sexual advances towards a resident, staff should interview the resident, inquire if they needed additional support, perform an investigation, and make a State Agency report. Adding If it were her, she would report advances right away. When in doubt, report and then look into it right away. We would want immediate action. During an interview on 11/21/25 at 9:39 a.m., SW-B stated she was informed R2 forced himself into R1's room and tried to force himself on her on 11/14/25. SW-B stated staff should have interviewed R1 on 11/7/25, when they knew of the incident and should have contacted her mental health providers on 11/7/25 as well. SW-B stated it sounded like a traumatizing experience, but especially so with R1's history. SW-B indicated R1 may not have the capacity to consent for sexual contact and may not be able to consent well due to impulsivity and making decisions to distract from her own feelings.During an interview on 11/20/25 at 1:34 p.m., the PD-A stated she became aware of the incident involving R1 on 11/13/25, when SW-A informed her about the report from FM-A received on 11/7/25. The PD-A stated the primary focus and direction around the event was R1 had asked the person to leave, and they did, but the facility needed to know more about the unwanted touch before it was reportable to the SA. The PD-A stated the expectation was for SW-A to get clarification with R1's treatment team immediately about who would follow up. The PD-A acknowledged no one followed up, the incident was not relayed to other staff, the incident should have been investigated sooner. The PD-A stated she was not sure a full-on investigation was needed, but the facility needed more details, and if the follow-up had occurred on 11/7/25, interventions could have been implemented to protect R1 and other residents. PD-A stated after the facility had more information the State report was filed on 11/13/25. PD-A acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved from 11/7/25 to 11/13/25. During an interview on 11/20/25 at 12:49 p.m., the mental health worker (MHW)-A stated staff was doing hourly checks on R2 due to multiple incidents with other residents and demonstrated compliance with the hourly checks with the staff signature sheets for the checks, except one missed check on 11/19/25 at 3:00 p.m.The Vulnerability Adult Reporting Policy and Procedure dated 9/28/22, indicated when there are occurrences of resident - to - resident abuse, the facility shall take immediate action to protect the resident(s) involved.The policy stipulates abuse included sexual abuse, and is willful, meaning the individual acted deliberately, and is any non-consensual contact of any type with a resident.Any facility associate who has knowledge of the maltreatment of a resident, or has a reasonable cause to believe that a resident has been maltreated, shall immediately make a verbal report to the supervisor or person in charge and complete an incident report. The person in charge shall inform the administrator. Allegations of abuse shall be reported immediately, but not later than 2 hours after the allegation is made or after forming the suspicion to the State Agency. Reporting is a two-step process, initially reporting and then submitting an investigative report, within 5 working days of the incident.After an internal report of maltreatment is made, the Director of Clinical Services shall investigate the incident. The immediate jeopardy that began on 11/7/25 was removed on 11/21/25, when it was verified, the facility completed the following actions:-Reviewed and revised policies and procedures related to reporting and investigating allegations of abuse and neglect.-Educated all staff and leadership on the above policies and procedures with competency before next shift worked.-Interviewed all residents R2 had access to, including residents on other floors. -Identified a plan to assess and monitor female residents with impaired cognition for possible abuse.-Identified a care plan intervention for medication non-compliance to ensure adequate safeguards are in place related to sexual defiance/deviation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report an allegation of alleged sexual abuse immediately (within two hours) to the State Agency (SA) for 3 of 4 residents (R1, R2) when R2 was alleged to make unwanted sexual advances towards R1 and R4. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses that included bipolar disorder, (a mental health condition characterized by extreme shifts in mood, energy and activity levels), anxiety, post-traumatic stress disorder, and depression, and borderline personality disorder (a mental health condition characterized by long-term patterns of unstable emotions, relationships, and self-image, leading to impulsive and self-destructive behavior). The State Agency report dated 11/13/25, indicated R1's family member (FM)-A reported on 11/7/25 an incident of romantic overtures by R2 in R1's room to social worker (SW)-A. R2 exposed himself to R1 and R2 and pushed his pelvis against R1's hip. Per the SA report, the facility began the investigation on 11/12/25, and no report for alleged abuse was filed for R1 until 11/13/25. R1's care plan dated 10/3/24 indicated R1 was at risk for and/or had a history of sexual victimization and also indicated R1 exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her, dated 5/27/25.R1's Interpersonal Skills Assessment (IPS) assessment dated [DATE], indicated diagnoses that included post-traumatic stress disorder and further indicated a history of sexual trauma and victimization related to being sexually trafficked. R1's progress notes dated 11/13/25 at 1:35 p.m., entered as a late entry for 11/7/25 at 1:30 p.m., indicated R1's family member called the facility, spoke to SW-A, and reported another resident went into R1's room and made sexual advances towards R1. During an interview on 11/20/25 at 10:59 a.m., FM-A stated on 11/7/25 R1 reported a male resident came into her room and made sexual advances towards her, would back off, and then would try again. R1 did not want FM-A to report the incident to the facility but FM-A called the facility on 11/7/25 and reported the incident to SW-A so it would not happen to anyone else. During an interview on 11/20/25 at 1:03 p.m., SW-A stated she became aware of an incident between R1 and R2 after FM-A called on 11/7/25 and reported unwanted touch by R2 to R1. SW-A stated she attempted to call R1 several times after the report to inquire about the details of the incident but was unable to reach her as she was already on leave from the facility. SW-A stated she reported the incident to an evening staff, but didn't recall who, and acknowledged she had not documented the report from FM-A, the report to the evening staff, or the attempted phone calls to R1. SW-A further stated she did not tell administrative staff about FM-A's report because without talking to R1 first about the details of the incident, there was not enough information at the time to make a report to the State. SW-A stated she told the program director (PD)-A about the incident in passing on her way out of the building, after her shift but had not documented that either. SW-A acknowledged if a resident reported unwanted touch by another resident, the event would be reportable within two hours of the incident or within two hours of staff knowing about the incident but thought she would need to obtain full details of the incident before making the report. SW-A was then off work for four days and started to follow up on the report when she returned to work on 11/12/25. During an interview on 11/20/25 at 1:34 p.m., the PD-A stated she became aware of the incident between R1 and R2 on 11/13/25, when SW-A informed her about the phone call from FM-A on 11/7/25. SW-A tried to reach R1 on 11/7/25, and the primary focus and direction around the event was R1 had asked the person to leave, and they did, but the facility needed to know more about the unwanted touch before it was reportable. The PD-A stated the expectation was for SW-A to get clarification with R1's treatment team about who would follow up. The PD-A stated no one followed up, and it was not relayed to other staff, but acknowledged it should have been investigated sooner. The PD-A stated she was not sure a full-on investigation was needed, but the facility needed more details, and if the follow-up had occurred on 11/7/25, interventions could have been implemented to protect R1 and other residents. PD-A stated after the facility had more information the State report was filed on 11/13/25. PD-A acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved from 11/7/25 to 11/13/25. During an interview on 11/21/25 at 9:11 a.m., program manager (PM)-A stated she was informed of the incident between R1 and R2 from SW-B but was unsure of the date. The PM-A stated if someone made sexual advances towards a resident, staff should interview the resident, inquire if they needed additional support, perform an investigation, and make a State Agency report of abuse. During an interview on 11/21/25 at 9:39 a.m., SW-B stated staff informed her of the incident between R1 and R2 on 11/14/25 and was told a resident forced himself into R1's room and tried to force himself on her. SW-B stated staff should have interviewed R1 on 11/7/25 when they knew of the incident. SW-B stated it sounded like a traumatizing experience, but especially so with a sexual trauma history and unwanted sexual contact would be difficult for any resident. During an interview on 11/21/25 at 11:01 a.m., R1 stated she reported the incident to her parents because authority figures at the facility freak me out. [R2] went further than he should have. R1 informed her parents she was harassed and had to yell at R2 and threaten to pull the alert cord to get staff's help because R2 would not leave her room. R4's quarterly MDS dated [DATE] indicated moderate cognitive impairment and diagnoses that included depression, anxiety, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-a thought disorder such as delusions and hallucinations with symptoms of a mood disorder like bipolar disorder or depression). R4's care plan dated 6/11/25, indicated risk and/or history of sexual victimization. On 8/15/25, the care plan indicated staff would monitor for interactions in common spaces between R4 and R2 and intervene to assist R4 in setting boundaries, and on 11/12/25, the care plan was updated with an intervention to restrict R2 from R4's residential floor. R4's IPS assessment dated [DATE], indicated a history of physical and sexual abuse and R4 as a victim of sexual exploitation. R4's progress notes indicated the following:-11/12/25 at 10:37 p.m., indicated R2 embraced R4 in R4's room doorway and staff intervened due to R2's history of poor boundaries. R4 reported R2 kissed R4 on the cheek and it was unwanted, and the same behavior occurred a few times in the previous week. Staff discussed boundary-setting with R4, and R4 acknowledged difficulty setting boundaries.-11/13/25 at 6:53 a.m., indicated R4 was on shift checks due to an uncomfortable interaction with her peer.-11/13/25 at 2:40 p.m., indicated R4 requested a meeting with staff and indicated she was unable to maintain boundaries with R2 and asked for staff assistance to maintain distance from R2. An intervention was added to R2's care plan to restrict R2 from R4's residential floor. During an interview on 11/19/25 at 2:50 p.m., R4 stated R2 tried to kiss her on two different occasions. The first was when R2 asked R4 to come to his room to show R4 his TV but then R2 wouldn't stop touching or kissing R4. After that incident, R2 was banned from R4's residential floor. R4 stated the second incident was when R2 kissed her in the hallway outside her room, R4 said no, R2 kissed her again, and staff intervened. R4 stated R2 was supposed to be banned from her floor but was there anyway. During an interview on 11/20/25 at 11:59 a.m., R2 stated he kissed R4 on the cheek, R4 said no and R2 kissed R4 again. R2 stated he was already restricted from being on R4's residential floor from a different incident, but had forgotten about the restriction and went there anyway. R2 stated he was not allowed to have sexual relations with women in the facility, and stated, They [staff] are acting like it was all my fault, like I am a hungry, thirsty, sex fiend just looking to f**k. They [the other residents he had approached for sex] wanted to be friends and invited me over. During an interview on 11/20/25 at 3:57 p.m., the director of clinical services (DCS)-A stated R1 was not always a strong self-advocate. R1 talked to the program manager about the incident on the 11/12/25, but didn't fully disclose the details until 11/13/25, when the incident was reported. The DCS-A stated the facility staff should have asked R1 about the incident sooner if the SW knew about the incident on 11/7/25. The DCS-A further stated the facility didn't report the incident to the SA until 11/13/25 because the facility didn't have the full details to report. The DCS-A stated the facility did not have to ask R1 about the details again after R1 declined to give the details on 11/12/25, but the facility did ask again, which was good on their part. The DCS-A stated potentially R1 could have disclosed the details sooner if she had been asked about it sooner. Additionally, when asked about the abuse staff observed between R2 and R4, DCS-A stated, [R4] and [R2] just kissed and staff intervened immediately. That was not reportable. The Vulnerability Adult Reporting Policy and Procedure dated 9/28/22, indicated when there are occurrences of resident - to - resident abuse, the facility shall take immediate action to protect the resident(s) involved. The policy stipulates abuse included sexual abuse, and is willful, meaning the individual acted deliberately, and is any non-consensual contact of any type with a resident. Any facility associates who has knowledge of the maltreatment of a resident or has a reasonable cause to believe that a resident has been maltreated shall immediately make a verbal report to the supervisor or person in charge and complete an incident report. The person in charge shall inform the administrator. Allegations of abuse shall be reported immediately, but not later than 2 hours after the allegation is made or after forming the suspicion to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review the facility failed to ensure 4 of 4 residents (R1, R2, R3, R4) reviewed for abuse were free of sexual abuse when R1, R3 and R4 were subjected to unwanted sexual touch by R2.Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses that included bipolar disorder, (a mental health condition characterized by extreme shifts in mood, energy and activity levels), anxiety, post-traumatic stress disorder, and depression, and borderline personality disorder (a mental health condition characterized by long-term patterns of unstable emotions, relationships, and self-image, leading to impulsive and self-destructive behavior). R1's care plan dated 10/3/24 indicated R1 was at risk for and/or had a history of sexual victimization and dated 5/27/25 indicated R1 exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her. R1's Interpersonal Skills Assessment (IPS) assessment dated [DATE], indicated a history of sexual trauma and victimization related to being sexually trafficked. R1's progress notes dated 11/13/25 at 1:35 p.m., entered as a late entry for 11/7/25 at 1:30 p.m., revealed R1's family member called the facility, spoke to SW-A, and reported someone had gone in R1's room and made sexual advances towards R1. R2's annual MDS dated [DATE] indicated intact cognition and diagnoses that included paranoid schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a break from reality that may include symptoms of paranoia, false beliefs, seeing or hearing things that are not there, disorganized thinking and speech, and lack of normal emotional expression). R2's care plan dated 11/13/25, indicated R2 displayed sexually exploitive behavior with interventions that included restriction from visiting all other residential floors, and consider precaution checks as needed. On 11/17/25, the care plan was adjusted to restrict R2 from other residential floors, female rooms, and the short hall of R2's residential floor and for staff to remind R2 weekly and as needed of behavioral expectations related to not exposing himself or asking other residents to engage in any sexual activity. The care plan lacked interventions to protect other residents from unwanted advances after being informed of the behavior on 11/7/25. R2's IPS assessment dated [DATE] indicated when R2 was symptomatic misperceived communication from others resulting in interpersonal conflict. R2 had a history of participating in unwanted physical contact and violating no-contact orders. R2 understood others must have the capacity to consent to sexual activity before and throughout the activity and demonstrated knowledge of consent. The Assessment indicated no care plan in place for sexual exploitation or other vulnerability related to sexual health at the time of assessment. The assessment lacked indication of a care plan to address behaviors when symptomatic, despite a history of unwanted physical contact and violations of no-contact orders. Further, the assessment lacked indication of an update after R2's behaviors changed. R2's progress notes indicated the following:-11/12/25 at 10:58 p.m., indicated a resident [R4] reported unwanted advancements from R2. Staff spoke to R2, who stated he was getting mixed signals from the other resident but agreed to respect others' boundaries. Staff restricted R2 from visiting R4's floor. -11/13/25 at 3:15 p.m., indicated R2 was placed on 1-hour location checks and shift checks due to multiple incidents of inappropriate interaction with numerous residents.-11/17/25 at 11:00 p.m., indicated staff met with R2 after R2 exposed himself to another resident [R3]. R2 was prohibited from entering other residential floors, female rooms, and the other hall of his own floor. Staff included police in the discussion with R2. -11/18/25 at 6:44 a.m., indicated R2 remained on 1-hour location checks and shift checks due to multiple incidents on 11/12/25, 11/13/25, and 11/17/25 and post SA reports on 11/13/25 and 11/17/25 related to R2's poor sexual boundaries. -11/19/25 at 10:49 p.m., indicated interventions were added to R2's care plan - R2 was restricted from visiting other residential floors, female rooms, and the short hall of his own residential floor. During an observation on 11/20/25 at 11:54 a.m., R1 was in his room asleep. Staff awakened R2 while performing a schedule check on him. R3's annual MDS dated [DATE] indicated intact cognition and diagnoses that included anxiety, borderline personality disorder, and depression. R3's care plan dated 1/23/17 indicated a risk and/or history of sexual victimization with an update on 11/17/25 to notify staff of distressing interactions, use her pull cord to get help from staff as needed, and to discuss safety planning weekly and as needed. R3's IPS assessment dated [DATE], indicated R3 struggled to set appropriate boundaries and had a history of sexual abuse.R3's progress notes dated 11/17/25, indicated R3 reported R2 walked across her room naked to close the door when he was visiting R3's roommate, and then later, she was left alone with R2, and R2 engaged in inappropriate sexual conversation with R3 and exposed himself, which made R3 very uncomfortable. The subsequent SA 5-Day report dated 11/18/25 at 2:18 p.m., indicated R2 exposed himself to R3, R2 had sexual relations with R2's roommate, and boundary concerns were expressed about R2 on 11/12/25 involving R2 kissing R4. The report also revealed a separate incident in which R2 exposed himself days earlier but was not reported at the time. During staff follow-up discussions with R2, R2 displayed limited insight into the impact and distress caused by exposing himself to another resident and acknowledged exposing himself after R1 explicitly told him she did not want to engage in sexual relations with him. R4's quarterly MDS dated [DATE] indicated moderate cognitive impairment and diagnoses that included depression, anxiety, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-a thought disorder such as delusions and hallucinations with symptoms of a mood disorder like bipolar disorder or depression). R4's care plan dated 6/11/25, indicated risk and/or history of sexual victimization. On 8/15/25, the care plan indicated staff would monitor for interactions in common spaces between R4 and R2 and intervene to assist R4 in setting boundaries, and on 11/12/25, the care plan was updated with an intervention to restrict R2 from R4's residential floor. R4's IPS assessment dated [DATE], indicated a history of physical and sexual abuse and R4 as a victim of sexual exploitation. R4's progress notes indicated the following: -11/12/25 at 10:37 p.m., indicated R2 embraced R4 in R4's room doorway and staff intervened due to R2's history of poor boundaries. R4 reported R2 kissed R4 on the cheek and it was unwanted, and the same behavior occurred a few times in the previous week. Staff discussed boundary-setting with R4, and R4 acknowledged difficulty setting boundaries. -11/13/25 at 6:53 a.m., indicated R4 was on shift checks due to an uncomfortable interaction with her peer. -11/13/25 at 2:40 p.m., indicated R4 requested a meeting with staff and indicated she was unable to maintain boundaries with R2 and asked for staff assistance to maintain distance from R2. An intervention was added to R2's care plan to restrict R2 from R4's residential floor. During an interview on 11/19/25 at 2:50 p.m., R4 stated R2 tried to kiss her on two different occasions. The first was when R2 asked R4 to come to his room to show R4 his TV but then R2 wouldn't stop touching or kissing R4. After that incident, R2 was banned from R4's residential floor. R4 stated the second incident was when R2 kissed her in the hallway outside her room, R4 said no, R2 kissed her again, and staff intervened. R4 stated R2 was supposed to be banned from her floor but was there anyway. During an interview on 11/20/25 at 11:59 a.m., R2 stated he kissed R4 on the cheek, R4 said no and R2 kissed R4 again. R2 stated he was already restricted from being on R4's residential floor from a different incident, but had forgotten about the restriction and went there anyway. R2 stated he was not allowed to have sexual relations with women in the facility, and stated, They [staff] are acting like it was all my fault, like I am a hungry, thirsty, sex fiend just looking to f**k. They [the other residents he had approached for sex] wanted to be friends and invited me over. During an interview on 11/20/25 at 10:59 a.m., FM-A stated on 11/7/25, R1 reported a male resident came into her room and made sexual advances towards her, would back off, and then would try again. R1 did not want FM-A to report the incident to the facility but FM-A called the facility on 11/7/25 and reported the incident to the SW-A so it would not happen to anyone else. During an interview on 11/20/25 at 1:03 p.m., SW-A stated she became aware of an incident between R1 and R2 after FM-A called on 11/7/25, and reported unwanted touch by R2 to R1. SW-A stated she attempted to reach the R1 for more information but was unsuccessful, did inform other staff on shift and told the Program Director (PD)-A in passing but had not documented any of that information. SW-A confirmed no investigation or protections were started or considered until she returned to work on 11/12/25. During an interview on 11/21/25 at 11:01 a.m., R1 stated she reported the incident to her parents because authority figures at the facility freak me out. [R2] went further than he should have. R1 informed her parents she was harassed, and had to yell at R2 and threaten to pull the alert cord to get staff's help because R2 would not leave her room. R1 stated she went to R2's room to look at something he wanted to sell and then left his room and went back to her own room. About 5 minutes later, R2 came to R1's room with a scarf he thought R1would like, and R1 stated she wanted the scarf. R1 showed R2 old pictures from her high school yearbook, and thought maybe R2 liked her because she showed him pretty pictures of herself. R1 stated she allowed R2 to lay on her bed with her but stated she did not want anything sexual to happen, did not want to kiss, and kept saying no. R1 told R2 she never wanted to have sex with him and R2 was shocked and asked, Never? R1 said no, she was gay and was not interested in any man. R1 told R2 she didn't like any penis, and R2 kept saying R1 might like to see it, and then R2 exposed himself and told R1 she had never tried sex with him, and she might like it. R2 reached across R1, who was lying on her bed and, He used that opportunity to kind of grind on me. R1 yelled at R2 and threatened to use the pull cord to summon staff, and R2 left the room. R1 stated she had a long, extensive history of sexual trauma. During an interview on 11/20/25 at 11:59 a.m., R2 stated he had been asleep in his room all morning while wearing headphones and had not left his room. R2 stated R1 invited him to lay on her bed with her, showed him her stomach, and allowed R2 to touch it. R2 asked if R1 had ever been with a boyfriend, and R1 stated she had but it never ended well. R2 stated he didn't know what to do because he was confused after R1 let R2 touch her stomach, so he pulled his pants down, and reached across both R1 and the bed to look for something. R2 stated R1 told him to leave or R1 was going to pull the call light to get staff assistance. R2 stated he took that seriously and left the room. During an interview on 11/19/25 at 4:55 p.m., R3 stated R2 exposed himself to her twice, but could not recall the dates. R3 stated she was in the room when R2 and her roommate, were together, R2 walked across the room with his penis exposed, and didn't say anything to R3 at the time. The second incident was after R2, and her roommate had sex with her in the room. Afterwards her roommate left the room, and R2 exposed himself to her. R3 stated she was uncomfortable with the incident, she didn't want to see R2's penis, was afraid of R2 and that he, Would try something with me. R3 stated R2 asked her personal questions, asked if she wanted to touch it or suck it (penis), and she told R2 she did not want to. R3 then stated R2 put his penis away, but stayed in the room, sat on her bed, and continued to make her feel uncomfortable so she thought R2 still wanted something from her. During an interview on 1120/25 at 11:59 a.m., R2 stated he had been having a sexual encounters with R3's roommate, and afterwards she left the room he was alone with R3. R2 asked to sit on R3's bed, asked R3 if she ever had sex with someone and if she thought about having sex, and offered to show R3 his penis. He indicated she said no, but he still thought maybe she wanted to see it, so he took his penis partially out of his pants and R3 looked. R2 then asked her if she wanted to see the rest of it, and since R3 didn't say no, he took his penis fully out of his pants. R2 stated it was his duty to ask if R3 was uncomfortable but hadn't and thought R3 looked confused and uncomfortable. R2 put his penis back in his pants and left the room. During an interview on 11/20/25 at 1:34 p.m., the PD-A stated she became aware of the incident on 11/13/25, when SW-A informed her about the report from FM-A received on 11/7/25. The PD-A acknowledged no one followed up, the incident was not relayed to other staff, the incident should have been investigated sooner. The PD-A stated she was not sure a full-on investigation was needed, but the facility needed more details, and if the follow-up had occurred on 11/7/25, interventions could have been implemented to protect R1 and other residents. PD-A stated after the facility had more information the State report was filed on 11/13/25. PD-A acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved from 11/7/25 to 11/13/25. The Vulnerability Adult Reporting Policy and Procedure dated 9/28/22, indicated when there are occurrences of resident - to - resident abuse, the facility shall take immediate action to protect the resident(s) involved. The policy stipulates abuse included sexual abuse, and is willful, meaning the individual acted deliberately, and is any non-consensual contact of any type with a resident. Any facility associate who has knowledge of the maltreatment of a resident, or has a reasonable cause to believe that a resident has been maltreated, shall immediately make a verbal report to the supervisor or person in charge and complete an incident report. The person in charge shall inform the administrator. Allegations of abuse shall be reported immediately, but not later than 2 hours after the allegation is made or after forming the suspicion to the State Agency. Reporting is a two-step process, initially reporting and then submitting an investigative report, within 5 working days of the incident.After an internal report of maltreatment is made, the Director of Clinical Services shall investigate the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to identify baseline SpO2 (blood oxygen levels), and parameters for use based on resident specific risk factors for 1 of 1 resident (R176) reviewed for O2 therapy.Findings include:R176's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no staff assistance was needed for activities of daily living. Diagnoses included non-traumatic brain dysfunction and chronic obstructive pulmonary disease (COPD) which is an ongoing lung condition caused by damage to the lungs. No oxygen use was identified on the MDS.R176's care plan dated 9/11/25, identified problems of COPD and chronic bronchitis, goal of no SOB (shortness of breath) as evidenced by respirations of 14 - 20 per minute. Interventions included monitor vital signs and SpO2 monthly and more frequently as needed, and effective 6/12/25; O2 concentrator as needed per physician order 4 liters per minute (L/min) via nasal cannula. The care plan lacked parameters for when to use or discontinue and lacked baseline SpO2.R176's Physician Orders dated 8/20/25 through 9/11/25, identified Oxygen Concentrator 4L/min and lacked parameters for when to use or discontinue, and lacked baseline SpO2.R176's Treatment Administration Record (TAR) dated 8/1/25 through 9/11/25, identified SpO2 levels ranging from 91% to 99% but lacked identification if supplemental O2 was in use. During an interview and observation on 9/8/25 at 5:14 p.m., R176 pointed to his O2 concentrator and stated it was new. R176 stated he used it a few times when he had shortness of breath related to COPD. During an observation on 9/10/25 at 11:46 a.m., R176 was in bed with his eyes closed, O2 was on at 4 L/min with the use of a nasal cannula. During an interview on 9/10/25 at 1:00 p.m., registered nurse (RN)-A reviewed R176's O2 orders and agreed there were no parameters for use or baseline SpO2 levels in place. RN-A stated over-oxygenation could be a risk for COPD without parameters in place.During an interview on 9/11/25 at 1:08 p.m., the director of nursing (DON) stated she would expect a flow rate, parameters for use, when to initiate and discontinue along with baseline Sp02 levels to be included on O2 orders. The DON stated with a diagnosis of COPD over-oxygenation and reduced O2 drive could be risk factors when supplemental O2 was in use. The DON stated their O2 policy was currently under revision. The facility's Oxygen Concentrator policy dated 11/8/99, identified continuous O2 therapy was not provided, and the nurse would assess the resident as compliant with O2 treatment. The policy lacked method to identify baseline SpO2 (blood oxygen levels), and parameters for use based on resident specific risk factors.

Based on observation, interview, and document review, the facility failed to ensure its system for medication reconciliation was adequate to ensure timely identification of loss or diversion of non-narcotic, controlled medications for 8 of 8 medication carts. Findings include: During an observation and interview with mental health worker (MHW)-A and MHW-B on 9/9/25 at 3:18 p.m., the two fifth-floor medication carts were reviewed. The non-narcotic, controlled medications were observed in a permanently affixed lock box in each locked medication cart. A count of the non-narcotic, controlled medications was observed to be completed with no discrepancies noted. MHW-B stated staff reconciled the non-narcotic, controlled medications every shift and demonstrated this in an observed controlled medication three-ring binder containing loose three-hole punched paper. MHW-B stated that if facility staff had a concern regarding a drug count, they would reference the medication administration record to verify medication administration. During an observation and interview with MHW-C and MHW-D on 9/10/25 at 7:20 a.m., the two fourth-floor medication carts were reviewed. The non-narcotic, controlled medications were observed in a permanently affixed lock box in each locked medication cart. A count of the non-narcotic, controlled medications was observed to be completed with no discrepancies noted. MHW-C confirmed staff reconciled the non-narcotic controlled medications every shift in an observed controlled medication three-ring binder containing loose three-hole punched paper. During an interview on 9/10/25 at 2:33 p.m., the director of nursing (DON) confirmed the current practice for non-narcotic, controlled medication reconciliation and tracking involved using a three-ring binder with loose paper and did not have a current plan in place to change this practice. On a follow-up interview on 9/11/25 at 11:11 a.m., the DON confirmed the facility had been working on updating its controlled medication storage and reconciliation practices after recent concerns for possible drug diversion. The DON stated that after the surveyor helped raise concern yesterday about the use of a three-ring binder to reconcile and track controlled medication, she was going to order bound books to track both the narcotic and non-narcotic medications and acknowledged the limitations in the timely identification of the diversion of controlled medications when using a three-ring binder.During an interview on 9/10/25 at 2:45 p.m., MHW-E confirmed that she assisted with completing the reconciliation of non-narcotic, controlled medications at shift change. MHW-E stated that when she reconciled non-narcotic, controlled medications, she would reference the controlled drug three-ring drug binder and the count of the medication itself. MHW-E stated she was unsure how staff would know if someone took a sheet out of the controlled medication three-ring binder with the corresponding medication, as you could not tell when the sheet was removed. MHW-E then stated she hoped that the staff completing the medication reconciliation were familiar enough with what medications were supposed to be in the locked non-narcotic controlled medication box to realize a medication had gone missing, based on memory of counting the medications in the past.During an interview and observation on 9/11/25 at 7:40 a.m., two medication carts with corresponding controlled medication three-ring binders were observed on the third floor. MHW-F confirmed that he assisted with completing the reconciliation of non-narcotic controlled medications at shift change, and the three-ring binders were used to accomplish this. MHW-F stated that staff would compare the counts of non-narcotic medications in the locked box to the count of the correlating sheet in the three-ring controlled medication binder, and if a discrepancy was noticed, staff would reference the medication administration record. MHW-F stated he was unsure how staff would notice if a non-narcotic controlled medication sheet and the correlating medication card were removed and referred further questions to registered nurse (RN)-B. At 7:45 a.m., RN-B demonstrated how staff marked a date and time next to every medication bubble that was emptied for the non-narcotic controlled medication administration and that could be checked against the medication administration record and controlled drug three-ring binder. RN-B stated that if a medication card and the controlled medication sheet were taken out of the three-ring binder for an as-needed medication, it would not be noticed until the next time the medication was administered, and the medication was no longer found in the locked box. During an interview and observation on 9/11/25 at 7:55 a.m., two medication carts with corresponding controlled medication three-ring binders were observed on the second floor. RN-C confirmed these binders were used for the tracking and reconciliation of non-narcotic, controlled medications. The facility's Controlled Medications- Schedule C policy dated 1/20/23, indicated a count of the quantity of the controlled medication on hand would be completed at the change of shift and documented on the controlled drug record and the C-drug Count Acknowledgement Form. The policy did not indicate whether this record or form would be kept in a three-ring binder with loose paper or a bound book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate Minimum Data Set assessments (MDS) were completed for 2 of 3 residents (R2, R7) reviewed for accuracy of assessments. Findings include:
R2’s quarterly MDS dated [DATE], indicated R2 was cognitively intact and had diagnoses of diabetes. Furthermore, R2’s MDS indicated R2 had seven days of insulin injections.
R2’s medication administration record (MAR) dated 7/2025, lacked indication R2 received insulin injections.
When interviewed on 9/11/25 at 10:08 a.m., registered nurse (RN)-D stated information was gathered from the observation period, staff, the residents medical record and the resident when completing their MDS assessment. RN-D verified R2 had a diagnosis of diabetes and was on Metformin (an oral medication to help lower blood glucose) and Victoza (non-insulin injectable medication) for diabetes. RN-D looked up Victoza and verified it was not an insulin and should not have been included in the insulin injections of the MDS.
When interviewed on 9/11/25 at 11:03 p.m., the Director of Nursing (DON) verified Victoza should be classified as a hypoglycemic medication and should not be included for an insulin injection.
R7's quarterly MDS dated [DATE], indicated in Section I: Active Diagnoses that R7 was diagnosed with non-Alzheimer's dementia (e.g., Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases).
R7's medical record was reviewed, and documentation indicating R7 had a diagnosis of non-Alzheimer's dementia was not found.
During an interview on 9/11/25 at 11:07 a.m., the DON confirmed she had reviewed R7's medical record and was not able to find that R7 had a diagnosis of dementia. The DON further stated it was an error, referring to R7’s MDS coding of a dementia diagnosis, and the MDS would need to be corrected.

Based on observation, interview, and record review, the facility failed to ensure equipment was in proper working order for 1 of 2 washing machines on the 5th floor. Furthermore, the facility failed to provide a sanitary environment in laundry room. Findings include: During interview on 9/8/25 at 12:47 p.m., R4 stated concern the facility washing machines were frequently broken. R4 stated they had been intermittently working for the last few months, however, this time it had been over 2 weeks. The staff had been updated about the broken machine. R4's MDS indicated cognitively intact, independent with activities of daily living. During interview on 9/8/25 at 3:42 p.m., R141 stated the washing machine on the 5th floor had been broken, it was intermittently repaired for the last 3 months or so. However, it had been about 2 weeks since they reported the broken machine with standing water in it. R141 stated it was unacceptable 5th floor residents only had an intermittent functioning washing machine. It was difficult doing laundry due to the lack of supervision and accountability for usage. R141's MDS indicated cognitively intact, independent with activities of daily living. During interview on 9/10/25 at 8:28 a.m., maintenance-A stated the process for repairs was residents notified staff, staff fill out a TELS ticket, explained what, where and the situation for repairs. The TELS report were reviewed every morning and organized most to least important. During interview on 9/11/25 at 8:47 a.m., mental health worker (MHW-G) stated they were aware the washing machine had been broken for a few weeks, however, did not know there was standing water in the machine. She filed 3 TELS reports on the washing machine in the past 3 months. During interview on 9/11/25 at 9:35 a.m., MHW-H stated washer and dryer combo was approximately 2 yrs old, the machines got used continually. Staff checked to see what the issues were then filed a TELS report. It had been a few weeks of issues. However, MHW-H was unaware there was standing water in it. During interview on 9/11/25 at 11:05 am, MHW-E stated, the washing machine had been in and out of order all summer, waiting for parts, then repaired, worked 1 to 2 days then broke again. MHW-E stated they were unaware of standing water in the washing machine. On 9/9/25, she filed a TELS request. The facility was looking into purchasing new combo machines. However, the area for the combo units were small for the new units. It was their understanding, a mother board for the washer was the issue and needed repair. Due to the fact that the issue was ongoing, there was a breakdown of communication from residents, to staff, to TELS report, and repair. During observation on 9/8/25 at 4:40 p.m., the laundry room on the 5th floor had 2 sets of stackable washer and dryers. The washing machine labeled B had an OUT OF ORDER sign on it. Inside the lid was standing dark grey water with white floating chunks in the water and film layer coated the top of the water. Housekeeping-A confirmed findings. During observation on 9/9/25 at 11:20 a.m., two maintenance employees (unknown) were in the 5th floor laundry room. After they left, inside the lid of washing machine B, still had dark grey standing water with white particles floating in it. During observation on 9/10/25 at 7:58 a.m., washing machine B on 5th floor still had dark grey standing water with white floating particles in it. An OUT OF ORDER sign was not visible. Housekeeping-A stated the washing machine looked like it was broken, no OUT OF ORDER sign, she stated the water inside of machine was dark, cloudy with fuzzy stuff floating around. Usually if item was broken, there was a sign, and maintenance came right away. However, it had been a while that the machine had been broken. During observation on 9/10/25 at 8:29 a.m., maintenance-A was attempting to repair washing machine B, he asked for an OUT OF ORDER sign at desk, placed linen in machine, and attempted to run the washing machine. He stated he was unaware of how long the washing machine had been broken. During observation on 9/11/25 at 9:39 a.m., washing machine B on 5th floor was dry, no standing water in machine, an OUT OF ORDER sign was visible, housekeeping A verified observation. During record review, the TELS report received had one documented report on 7/26/25 for the 5th floor washing machine, report closed on 7/28/25. Requested a complete TELS report, did not receive. Maintenance-B provided an email that stated the timeline for work order regarding washing machine B on the 5th floor was on 9/9/25 at 10:08 a.m., work order created, on 9/10/25 at 6:09 a.m., work order assigned to maintenance-A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to revise the care plan to include a smoking-related safety intervention for 1 of 3 residents (R1) reviewed for safety.
Findings include:
R1's facesheet dated 5/7/25, indicated he had diagnoses including schizoaffective disorder (chronic illness causing changes in thoughts, moods, and behaviors) and tobacco use.
R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1 was independent with activities of daily living (ADLs) and mobility, had behavioral symptoms not directed towards others, and currently used tobacco.
R1's physician orders included an order dated 10/25/24, to observe forearms for self-inflicted burns or picking two times per day and to notify nurse if present.
R1's physician note from psychiatrist dated 4/15/25, indicated R1 had a history of schizoaffective disorder and baseline included some ongoing paranoia and anxiety. Further, he has preservative focus on his hair and skin, resulting in picking and [NAME] [sick, burning] hair in the past. R1 denied recent issues with hair/removal and substance use included pipe tobacco.
R1's Vulnerability Assessment and Abuse Prevention Plan dated 4/23/25, identified he was unable to recognize unsafe smoking behavior with status of vulnerable. The summary noted R1 had a history of sustaining burns to skin and clothing due to unsafe smoking and to prevent burns he was provided with flameless lighters which were kept behind the staff desk. The assessment also identified R1 had severe psychiatric symptoms or cognitive deficits that significantly impair judgment and functioning with status of vulnerable. The summary noted on 7/27/21 R1 was observed to burn his arm hair with a lit cigarette, on 4/23/22 R1 burned his arm with a flameless lighter, and on 6/9/22 staff observed micro burns to his arms from flameless lighter and staff to begin assisting with hair removal twice monthly.
R1's Tobacco and Electronic Delivery Device Use Screening dated 4/24/25, identified R1 was vulnerable for unsafe smoking behaviors and had a history of intentionally burning himself with cigarettes in an attempt to remove body hair. The assessment included, as outlined in [R1's] treatment plan, he is discouraged to utilize cigarettes . instead encouraged to use his pipe and loose tobacco. He may request his flameless lighter at program times. Before providing his flameless lighter, staff ask [R1] if he endorses urges to burn his hair or engage in other unsafe smoking behaviors. Smoking and vaping materials used by the resident on assessment included pipe and filtered cigarettes. Visual observation of tobacco use identified no concerns though it is important to note that he refused to follow through with his care plan and utilized a cigarette rather than a pipe.
R1's progress note dated 5/1/25, noted at 8:45 p.m. staff conducted a routine skin check after administering bedtime medications and observed a number of wounds down R1's forearms. R1 reported he had used a lit cigarette to attempt to remove the hair on his forearms. Nursing staff assess R1, provided wound care, and made notifications. R1 was to be placed on one hour precaution checks, smoking patio restrictions, and shift checks.
Facility Incident Report dated 5/1/25, indicated staff completed a routine skin check on R1 and observed a significant number of wounds on his forearms. R1 reported that he had used a lit cigarette to attempt to remove the hair on his forearms. Identified antecedents or triggers to the incident included R1 reporting to his program manager (PM) on 4/19/25 that his pipe was broken and he had thrown it away, stated he did not know what his plan was for smoking since he did not have another pipe, and when asked directly he described no plan to smoke until he purchased a pipe. The incident's outcome and follow-up (to include interventions/corrective action implemented) noted R1 reported having two boxes of cigarettes, did not want them discarded, and gave them to his unit's program director (PD). R1 and the PD developed a plan to store the cigarettes behind the staff desk, request one cigarette and flameless lighter at program times, and then be escorted outdoors by staff for 1:1 [one-to-one] observation to ensure safety. R1 reported he received personal funds that day and was open to purchasing a new pipe and tobacco and re-engaging with his previous smoking plan which had been effective in preventing burns with last burns from a cigarette in 2022. The report's interventions implemented section included a list of possible interventions. Selected interventions included 1:1 staff support.
R1's care plan problem dated 5/29/18, identified he was unable to recognize unsafe smoking behavior. Interventions included:
- Staff will notify/consult with psychiatric provider, primary health care provider, and/or other community professionals as needed, dated 5/29/18.
- Staff will provide education on smoking risks and encourage smoking cessation, dated 5/29/18.
- Provide and encourage use of smoking cessation aides, dated 5/29/18.
- Staff will discourage R1 from obtaining cigarettes from others and smoking cigarette butts, dated 5/29/18.
- Staff will encourage R1 to refrain from spending time in smoking areas, dated 5/29/18.
- Provide R1 with options for positive replacement activities as an alterative to smoking, dated 5/29/18.
- Staff will provide and encourage use of adaptive smoking/lighting equipment, dated 5/29/18.
- Staff will encourage R1 to allow staff to assist in hair removal as needed, dated 5/1/25.
Staff will encourage R1 to have his pipe and loose tobacco with him before going downstairs to smoke, dated 5/2/25.
Staff will encourage R1 to seek out staff available on the first floor if in need of immediate assistance/support in order to address concerns without having to return to the floor, dated 5/2/25.
R1's care plan problem dated 12/10/18, identified he had severe psychiatric symptoms or cognitive deficits that significantly impair judgment and functioning. Interventions included:
- Staff will visualize R1's arms for new burns twice a day. If new burns are present, staff will notify the charge nurse and person in charge immediately, dated 6/9/22.
Staff will request that R1 checks out/in a flameless lighter immediately before/after he smokes. Lighters will be kept behind the staff desk. Before providing a lighter, staff will ask R1 if he has any urge/intention to use lighter/cigarette to remove hair, ask to show staff his pipe and loose tobacco, remind to refrain from obtaining cigarettes from others and remind to turn in his lighter within 20 minutes. After receiving a lighter, staff will ask R1 if he used lighter/cigarette to remove hair, dated 5/4/23.
- PM will meet with R1 to discuss hair removal needs and assist with removing hair weekly. If R1 declines, PM will provide education about history of hair removal incidents and strongly encourage his agreement to shave in the moment, dated 5/2/25.
- Staff will encourage R1 to utilize as needed (PRN) medication when endorsing increased anxiety, impulses related to unwanted hair, and as needed, dated 5/2/25.
- Staff will encourage R1 to notify staff as soon as possible when feeling urges to remove unwanted hair from his body, dated 5/2/25.
R1's care plan did not identify or include the implemented intervention of staff escorting him outside for one-to-one observation when smoking cigarettes.
Coffee/Cigarettes & Programs signage, undated, posted behind the staff desk identified the daily program times for smoking. Additional undated signage titled Smoking Plan for [R1], identified R1 could check e-lighters in/out at the desk. The plan noted before checking a lighter out, staff were to ask if R1 had any urge/intention to use lighter/cigarettes to remove hair, ask to show staff R1's pipe and loose tobacco, remind to refrain from obtaining cigarettes from others, and remind to turn in his lighter within 20 minutes. After checking a lighter in, staff were to ask if he used lighter/cigarette to remove hair.
During an interview on 5/5/25 at 2:04 p.m., mental health worker (MHW)-B stated if someone was deemed unsafe to smoke a vulnerability care plan was created. Staff knew which specific interventions or assistance a resident needed based on the care plan and smoking safety assessment. MHW-B stated the care plan was always updated to fit individual resident needs. MHW-B stated R1 had a smoking program where he checked lighters in/out from staff and staff asked him safety questions. MHW-B noted R1's pipe broke recently and he had been smoking cigarettes instead until obtaining a new pipe.
During an interview on 5/5/25 at 2:36 p.m., registered nurse (RN)-B stated she looked at care plans to see what interventions or assistance residents needed for smoking. RN-B stated if R1 didn't have a flameless lighter or pipe he would be at an increased risk of being unsafe with smoking.
During an interview on 5/5/25 at 3:56 p.m., MHW-C stated she was working when R1's recent burns happened, she noted the burns when completing his evening skin check, and he had reported burning himself with a cigarette. MHW-C stated R1 usually smoked a pipe and that's part of his care plan as well because he didn't burn himself with a pipe. MHW-C noted after R1's pipe broke the plan was to get him a new pipe. While smoking cigarettes, MHW-C stated staff were helping him more frequently with hair removal. MHW-C identified additional interventions for R1's smoking safety while using cigarettes included checking in with him more frequently. MHW-C stated R1 was now back to smoking a pipe.
During an observation on 5/5/25 at 4:39 p.m., R1 approached the staff desk to request smoking materials. Program director (PD)-A asked if he wanted a cigarette or his pipe and R1 stated he wanted a cigarette. PD-A asked R1 safety questions and confirmed no intent or urges to burn. PD-A retrieved two cigarettes from storage behind the staff desk and a flameless lighter, and escorted R1 off the floor to smoke.
During an interview on 5/5/25 at 4:42 p.m., therapeutic recreation intervention specialist (TRIS)-A was seated at the staff desk and present when R1 retrieved cigarettes from PD-A. TRIS-A noted R1 usually only smoke a pipe and hadn't always had cigarettes stored behind the desk but must right now. TRIS-A noted if R1 asked for a cigarette, staff would have to make sure someone was available to go outside with him.
During an interview on 5/7/25 at 9:07 a.m., MHW-A stated she was R1's program manager (PM). MHW-A stated R1 had been smoking cigarettes after his pipe broke and she had completed a safety assessment and observed him smoke a cigarette. MHW-A noted staff need to be hyper vigilant when he [R1[ is using cigarettes because that is not part of his care plan. Regarding interventions for R1 when smoking cigarettes, MHW-A stated, let me check the care plan, I don't know if anything new was added specifically for that, but what I would do personally is observe him and escort him.
During an interview on 5/7/25 at 9:47 a.m., MHW-D stated R1 was smoking cigarettes and had to be on one-to-one's for cigarettes and had to be supervised because he had used a cigarette to burn himself. R1 did not require supervision if smoking a pipe. MHW-D stated he was positive the one-to-one supervision with cigarettes was an intervention on R1's care plan and it would be on someone's care plan if they required a staff escort for smoking. MHW-D reviewed R1's care plan and did not see where this intervention was located.
During an interview on 5/7/25 at 3:55 p.m., R1 stated he recently got a new pipe but had some cigarettes left, almost two packs that he bought a while ago. R1 stated I always go out with staff if I smoke them, they want me to go out with them. He noted staff checked in with him and asked him how he was doing before smoking when he went to the desk to retrieve a lighter. R1 had a bandage on his left forearm, did not identify the source of the wound, but stated it was doing okay.
During an interview on 5/7/25 at 10:22 a.m., PD-A stated R1 started smoking cigarettes when his pipe broke in mid-April. R1 still had some cigarettes, agreed to keep them behind the desk, had obtained a new pipe, but continued smoking the cigarettes. PD-A stated, any time he is going to smoke a cigarette he is on a one-to-one with staff until the cigarettes are gone. PD-A stated staff were aware of this intervention because it was discussed verbally and was in R1's progress notes and incident report. PD-A stated this documentation identified he needed a one-to-one escort for cigarettes, but it's not in his care plan at this time. Further, PD-A noted, she would expect this to be on the care plan and it would have been a helpful care plan intervention.
During an interview on 5/7/25 at 1:48 p.m., the director of nursing (DON) stated she would expect to see one-to-one staff escorts for smoking identified on a resident's smoking vulnerability care plan. The DON noted if this was not on the care plan staff would know R1 needed a one-to-one escort because it would be included in the staff communication log and on a resident's individual program sheet for smoking. The DON was not aware R1's individual Smoking Plan sheet at the staff desk lacked this information. The DON stated the director of clinical services (DCS) had been more involved in R1's recent burn incident and knew more.
During an interview on 5/7/25 at 3:04 p.m., the DCS stated since R1's recent burn incident he had been on a one-to-one with staff if smoking cigarettes. The DCS stated she would expect to see the intervention of a one-to-one staff escort on the care plan. The DCS noted staff had been effective in providing one-to-one supervision for R1 with cigarettes and it one hundred percent makes sense for it to be care planned, for the continuity and consistency. The DCS confirmed she did not see this intervention on R1's care plan.
Facility policy titled Smoking and Vaping Policy and Procedure dated 2/25/25, indicated residents were assessed on admission and quarterly for unsafe smoking and vaping behavior in the Vulnerability Assessment and Abuse Prevention Plan. If assess to be vulnerable in this area, would have a vulnerability plan outlined in the Vulnerability Assessment and Abuse Prevention Plan and interventions may be documented in the resident's treatment plan.
Facility policy title Tobacco and Electronic Delivery Device Use Screening Procedure dated 2/25/25, indicated this screening was to screen for a resident's ability to safely smoke and utilize an electronic delivery device. The information gathered from the screening would be shared with the treatment team in order to determine whether the resident is able to use tobacco without intervention due to a low burn risk or requires intervention to reduce burn risk and/or use an electronic delivery device safely. If determined to require intervention due to burn risk, the treatment team would make recommendations as to how to best ensure resident safety and a subsequent Vulnerability Care Plan will be created. The Vulnerability Care Plan would be reviewed quarterly and as needed to ensure [NAME] practices were being followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure professional standards of practice for documentation were followed during transcription and administration of a standing order medication for 2 of 2 residents reviewed (R1, R2) with wounds requiring antibiotic ointment.
Findings include:
Facility policy titled Standing Medication and Treatment Orders dated 5/18/22, included a copy of the facility standing orders list. Non-oral/topical routine treatments included: bacitracin zinc (antibiotic used to treat minor skin injuries such as cuts/scrapes/burns) ointment, apply topically to affected areas up to three times daily PRN, with a seven-day time limit.
R1
R1's annual Minimum Data Set, dated [DATE], indicated R1 admitted to the facility on [DATE] with primary diagnosis of schizoaffective disorder (chronic illness causing changes in thoughts, moods, and behaviors) and did not have any ulcers, wounds, or skin problems.
R1's care plan included a problem dated 5/1/25, of burns to bilateral arms. Interventions included administer analgesics as ordered.
R1's care plan included a problem dated 5/6/25, of scratch to right fourth finger. Interventions included provide skin care as indicated. R1's care plan included a problem dated 5/7/25, of abrasion to left hand. Interventions included apply sterile bandage as needed.
Physician orders in R1's electronic health record (EHR) included order dated 11/27/1998, for medications noting [facility] PRN [as needed] list OK.
R1's progress note dated 5/1/25 at 10:16 p.m., indicated R1 sustained self-inflicted burns to both forearms totaling 82 burns. Both forearms were cleaned with dermal wound cleanser and thin coating of bacitracin to all burns of both arms. R1 declined application of dressings.
R1's progress note dated 5/2/25 at 2:13 p.m., indicated two open areas on left forearm and the site was cleansed using a BZK (benzalkonium chloride) wipe but R1 would not allow application of a bandage. It did not indicate if bacitracin was applied or refused.
R1's progress note dated 5/2/25 at 8:52 p.m., indicated the burns on left forearm were cleansed with an antiseptic wipe and transparent dressings applied to all blisters on left forearm. It did not indicate if bacitracin was applied or refused.
R1's progress note dated 5/3/25 at 9:14 a.m., indicated two open areas on left forearm were cleansed with wound cleanser spray, and bacitracin and 2x2 island dressing [gauze bandage] placed on top of both open areas.
R1's progress note dated 5/3/25 at 8:27 p.m., indicated affected areas were cleansed with wound cleansing spray, bacitracin applied, and covered with two 2x2 island dressings.
R1's progress note dated 5/4/25 at 9:14 a.m., indicated three open areas on left forearm were cleansed with BZK, and bacitracin and 2x2 island dressing placed over top of all three wounds. Areas were healing without concern with plan to decrease physical health checks from twice to once daily for monitoring and daily dressing changes.
R1's progress note dated 5/5/25 at 9:58 a.m., indicated one of the three open areas had scabbed over and they were cleansed with BZK and bacitracin and 2x2 island dressing placed over top of all three wounds.
R1's progress note dated 5/6/25 at 10:36 a.m., indicated three open areas on left forearm were cleansed with a BZK wipe, thin layer of bacitracin ointment applied, and all three areas covered with island dressings.
R1's progress note dated 5/6/25 at 12:58 p.m., indicated R1 sustained a scratch on his right fourth finger. The area was cleansed with a BZK wipe, a thin layer of bacitracin applied, and covered with a Band-aid. Plan to place on once daily physical health checks to monitor healing.
R1's progress note dated 5/7/25 at 1:44 p.m., indicated the scratch on R1's right fourth finger was cleansed with BZK wipe with bacitracin and Band-aid placed over top.
R1's progress note dated 5/7/25 at 1:45 p.m., indicated three wounds on left forearm were cleansed with BZK wipes with bacitracin and an island dressing placed over top.
R1's progress note dated 5/7/25 at 2:00 p.m., indicated R1 presented with a bleeding superficial abrasion on left hand that occurred while staff assisted with shaving. Wound was cleansed with BZK with bacitracin and Band-aid placed over top.
R1's paper medication and treatment administration records (MAR/TAR) dated month of May 2025, included an order noting facility PRN list okay with note FYI (for your information). The MAR/TAR did not include an order for bacitracin zinc ointment to be applied topically to affected areas up to three times daily PRN with a seven-day time limit, as identified in the referenced standing orders list. The MAR/TAR lacked identification of the medication's prescribing practitioner's name, full medication name, dosage, route of administration, frequency, duration, specific indication for use, or date of medication order for the administrations of bacitracin documented in progress notes as follows:
-5/1/25 once to both arms
-5/3/25 twice to left arm
-5/4/25 once to left arm
-5/5/25 once to left arm
-5/6/25 once to left arm and right finger
-5/7/25 once to left arm, right finger, and left hand
Physician orders in R1's EHR did not include transcription of the specific standing order for bacitracin including the prescribing practitioner's name, medication name, dosage, route of administration, frequency, duration, indication for use, or date of medication order.
During an interview on 5/5/25 at 2:36 p.m., registered nurse (RN)-B stated she had been providing wound care for R1's forearm burns. The wound care was cleaning it with an antiseptic wipe, putting a little bacitracin ointment on, and then a small bandage.
During an observation on 5/7/25 at 8:45 a.m., R1 had a new small bleeding cut on the back of his left hand and presented to the nursing station. RN-A cleansed the area with a BZK wipe, applied bacitracin, and placed a Band-aid on top.
During an interview on 5/7/25 at 8:53 a.m., RN-A stated she believed bacitracin was a medication and it was once of the facility's standing orders. RN-A stated staff documented in a resident's MAR if they had active wound care and we would write down the specifics of like cleanings, bacitracin, and then would sign for it in the MAR. We would write in the standing order for the bacitracin and sign for it there. RN-A stated she had applied bacitracin to R1's forearm wounds over the previous weekend and documented this in progress notes but not in his MAR. She confirmed the bacitracin standing order should have been transcribed into R1's MAR. She noted the process for standing orders was to have a nurse assess the need for it and, if indicated, write it into the paper MAR, date it, sign it, then administer and document it.
On 5/7/25 at 10:03 a.m., RN-A stated if nursing staff enter an order on the paper MAR, you also put it into the physician orders in [EHR]. RN-A reviewed R1's paper MAR and the physician orders in R1's EHR and confirmed she did not see an order for bacitracin in either location.
R2
R2's quarterly MDS dated [DATE], indicated R2 admitted to the facility on [DATE] with no ulcers, wounds, or skin problems.
R2's care plan included a problem dated 5/2/25, of burn to right middle finger. Interventions included administer analgesics as ordered.
Physician orders in R2's electronic health record (EHR) included order dated 12/8/24, for medications noting [facility] PRN list OK - Has different melatonin and nicotine lozenge order prescribed by [provider name].
R2's progress note dated 5/2/25 at 8:54 a.m., indicated R2 sustained a burn on his right middle finger. The area was cleansed with an antiseptic wipe and aloe vera and a Band-aid applied.
R2's progress note dated 5/3/25 at 12:31 p.m., indicated bacitracin and a bandage were applied to the finger.
R2's progress note dated 5/3/25 at 8:41 p.m., indicated bacitracin and a bandage were applied to the finger.
R2's progress note dated 5/4/25 at 9:19 am, indicated bacitracin and a bandage were applied. Physical health checks were decreased from twice daily to daily to monitor healing and continue daily dressing changes.
R2's progress note dated 5/5/25 at 8:34 a.m., indicated the burn was cleansed and bandage applied. Further noted will put a daily wound care/Band-aid change in his MAR and reduce physical health checks to Monday, Wednesday, Friday.
R2's progress note dated 5/7/25 at 9:22 a.m., indicated the burn was cleansed and bandage applied. Daily wound care and bandage changes in the MAR were ongoing.
R2's paper MAR/TAR dated month of May 2025, included an order noting facility PRN list okay with note has different melatonin and nicotine lozenge order. The MAR/TAR also included an order for daily wound care (cleanse with BZK wipe, apply bacitracin ointment) and Band-aid change to right third finger until healed scheduled for a.m. (morning) with start date 5/5/25. Administrations were documented on 5/5/25 and 5/7/25. The application of bacitracin identified in progress notes twice on 5/3/25 and once on 5/4/25 was not documented, as they were prior to the wound care order start date of 5/5/25. Wound care documentation, including application of bacitracin, dated 5/6/25 was blank. Further, while the wound care order identified the use of the bacitracin, the MAR lacked transcription of the specific order for the bacitracin including the prescribing practitioner's name, full medication name, dosage, route of administration, frequency, duration, specific indication for use, or date of medication order for the administrations of bacitracin documented in progress notes and wound care order. In addition, the wound care order did not identify the parameters included in the standing order for bacitracin limiting its use to seven days.
Physician orders in R2's EHR did not include transcription of the specific standing order for bacitracin including the prescribing practitioner's name, medication name, dosage, route of administration, frequency, duration, indication for use, or date of medication order.
On 5/7/25 at 10:10 a.m., R2 stated he accidentally burnt his middle finger four or five days ago. R2 stated staff looked at it that morning and they put some bacitracin and the Band-aid on it. The middle finger on R2's right hand had a Band-aid present.
During an interview on 5/7/25 at 12:56 p.m., RN-C stated if a resident had a minor wound, it would be treated per nursing judgement with treatment orders written on the MAR for type of treatment and frequency. This would include identifying use of bacitracin and the type of dressing used. RN-C stated resident MARs typically included a physician order noting the facility's standing orders were okay to administer and would note exceptions, so she did not transcribe the individual orders into the EHR. If a resident had standing orders and a new medication from the list was administered, she would transcribe it onto the paper MAR.
During an interview on 5/7/25 at 1:48 p.m., the director of nursing (DON) stated the process for using standing orders included staff first checking a resident's MAR to see if it included an order directing it was okay to use facility standing orders. The DON stated wound care based on standing orders included bacitracin as an antibiotic as indicated by the type of concern. She noted this was not expected to be documented on the MAR but would be part of progress notes for wound treatment, including the type of ointment or bandaging and wound care provided. The DON confirmed bacitracin is an ordered medication and medications should be documented on the MAR. The DON was unable to articulate further explanation as to why the specific standing order for bacitracin administration was not transcribed onto the MAR but noted she saw the rationale and opportunity for changing this practice. The DON was not able to articulate how this aligned with professional standards of practice. The DON noted if a resident was transferred to a different facility it wouldn't be abundantly clear if bacitracin was being used on a wound. The DON confirmed the standing order for bacitracin included a seven-day time limit for use. When asked how staff were adhering to this parameter if they were not transcribing the order and documenting the administration she replied, they aren't. The DON noted it had been facility practice to refer to all medications in the standing orders collectively as the facility's standing orders within the physician orders in the EHR rather than transcribing individual orders upon utilization. She further noted in an emergency transfer, individual medications administered from standing orders would not be identified in the EHR physician orders and it was not facility practice to provide a copy of standing orders. The DON then noted for a standing order used for the first time, nurses needed to transcribe the order onto the paper MAR prior to administration.
Facility policy titled Standing Medication and Treatment orders dated 5/18/22, indicated the orders were entered into the electronic medical record system as [Facility] Standing Orders O.K. Any standing medication and treatment order that was administered would be entered on the MAR individually if it was utilized.
Facility policy titled Medication Orders: Communication and Transcription dated 10/13/23, indicated following specific procedures in transcribing medication orders would reduce the potential for medication error, which was the purpose of the policy. A complete medication order was identified to include the following elements: resident name, prescribing practitioner's name, medication name, dosage, route of administration, frequency, duration, indication for use, date of medication order.
Facility policy titled PRN Medication Administration dated 4/13/09, indicated PRN medication orders would be filed in a resident's chart and documented on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to use appropriate personal protective equipment during high-contact cares for 1 of 1 resident (R1) reviewed with enhanced barrier precautions implemented.
Findings include:
Enhanced Barrier Precautions (EBPs): the use of personal protective equipment (PPE) including gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing.
R1's facesheet dated 5/7/25, indicated R1 had diagnoses including bladder disorder, urethral stricture (narrowing of urethra), benign prostatic hyperplasia (BPH, enlarged prostate), bladder neck obstruction, and overactive bladder.
R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had an indwelling catheter.
R1's care plan dated 2/8/24, indicated R1 had altered urinary elimination related to urinary retention, BPH, urethral stricture with outlet obstruction requiring suprapubic catheter, and history of atonic bladder (weak bladder muscles). Interventions included: annual urinary assessment, suprapubic catheter care per medical provider instructions, labs and diagnostics per physician order, encourage limiting fluids and caffeine in the evening, provide incontinence pads as needed, instruct regarding proper disposal of soiled items and assist as needed, provide education about proper technique for emptying catheter bag, assessment by physician as needed, and instruct to notify staff if experiencing hematuria (blood in urine) or pain at catheter site. The care plan did not identify that EBPs were implemented for R1 due to his indwelling catheter.
R1's Activities of Daily Living Documentation Record dated May 2025, instructed staff to shave R1's head and body with full staff assist twice monthly. Documentation noted R1's arms, pubic area, and buttock were shaved on 5/7/25.
EBP signage on R1's door undated, indicated everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toilet use, when caring for or using devices, and when caring for wounds.
During an observation on 5/7/25 at 8:29 a.m., Mental Health Worker (MHW)-A stated she was a nursing assistant (NA) and trained medication aide (TMA). MHW-A stated she assisted R1 with shaving every Wednesday. MHW-A noted the EBP sign on R1's door (a room shared by three residents) was because R1 had a catheter. Outside of R1's door were drawers containing gowns, masks, and glasses but no gloves or hand sanitizer. MHW-A entered R1's room without completing observed hand hygiene or donning (putting on) PPE including gloves or gown, though had gloves with her along with shaving supplies. MHW-A noted there was hand sanitizer present on R1's bedside table at the far end of the room, with R1's bed the farthest from the door. MHW-A put gloves on once inside the room and proceeded to shave R1's inner thigh/pubic, buttock, and arm hair. Upon completion, MHW-A exited the room without completing hand hygiene and carrying soiled shaving supplies in her gloved hands down the hallway.
During an interview on 5/7/25 at 9:07 a.m., MHW-A stated she had completed online training about EBPs and received information about EBPs at orientation. MHW-A stated all staff members should be taking those precautions and anyone providing direct care with a resident should wear gloves. She stated PPE needed for shaving R1 was definitely gloves but staff don't need to gown up or anything like that. MHW-A noted when shaving R1 earlier, she had used hand sanitizer and obtained gloves at the nursing station prior to walking to R1's room. She stated she didn't put on a gown when shaving him, I don't ever do that. When shaving him I clean my hands and use gloves. She stated she had not ever been told to put on a gown for shaving R1.
During an interview on 5/7/25 at 1:48 p.m., the director of nursing (DON) stated the facility had a new infection preventionist starting tomorrow and she was currently assuming those responsibilities. The DON confirmed EBPs were needed for residents with indwelling devices, including suprapubic catheters. She noted staff needed hand hygiene, gloves, and a gown when providing direct care to residents and anyone providing high contact activities needed to adhere to EBPs. The DON confirmed staff needed to perform hand hygiene and wear gloves and a gown when shaving R1. The DON noted the risk of not doing so included MDROs and though R1 did not have an MDRO he was at an enhanced risk for infection due to his indwelling device. The DON stated EBPs should be part of the care plan for an indwelling device, and she would expect to see EBPs on the care plan.
Facility policy titled Enhanced Barrier Precautions Policy dated 8/14/23, indicated EBPs would be implemented during high-contact resident care activities when caring for residents with an increased risk of acquiring an MDRO such as residents with wounds, indwelling medical devices, or residents infected or colonized with an MDRO. EBPs required gown and glove use for residents with indwelling medical devices during specific high-contact resident care activities including bathing/showering, device care or use, and providing hygiene cares. Indwelling medical devices included urinary catheters. In addition, an isolation care with PPE was to be immediately outside the resident room and alcohol-based hand sanitizer both inside and outside the resident room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure resident call light was within reach from the bathroom floor in a multi -resident bathroom for 3 of 3 residents (R135, R193, R39,) reviewed for call light accessibility.
Findings include:
R135
R135's quarterly Minimum Data Set (MDS) dated [DATE], identified R135 had intact cognition and diagnosis which included seizure disorder, anxiety, and schizophrenia. MDS identified R135 was independent with activities of daily living (ADL's) which included transfers, toileting, and showering.
R135's fall risk assessment dated [DATE], identified R135 was a moderate risk for falls related to medication use. Further identified R135 had three falls in the past year, one with an injury from striking her head.
R135's care plan dated 12/10/21, identified R135 was at risk for falls related to medication use and history of falls. Care plan instructed to encourage use of emergency call-light system as needed, for immediate and urgent staff assistance.
During an observation on 7/29/24 at 7:00 p.m., the multi-resident bathroom was noted to have a call light on the wall to the right side of the shower with a cord that that was approximately three feet from the floor and a call light on the wall to the left side of the toilet with a cord that was approximately two feet from the floor.
During an observation on 7/30/24 at 8:22 a.m., the multi- resident bathroom continued to have a call light on the wall to the right side of the shower with a cord that that was approximately three feet from the floor and a call light on the wall to the left side of the toilet with a cord that was approximately two feet from the floor.
During an interview on 7/30/24 at 11:34 a.m., R135 confirmed she used the toilet and shower independently in the multi-resident bathroom. R135 stated she would not be able to reach the emergency call light if she fell on the floor while using the toilet or the shower. R135 stated she had a history of falls and should have access to a call light if she were to fall on the floor while in the bathroom.
R193
R193's quarterly MDS dated [DATE], identified R193 had intact cognition and diagnosis which included post-traumatic stress disorder (PTSD), anxiety, and schizophrenia. MDS identified R193 was independent with activities of daily living (ADL's) which included transfers, toileting, and showering.
R193's fall risk assessment dated [DATE], identified R193 was a high fall risk related to functional impairments and a fall in the past 30 days. Further identified R193 was not able to transfer safely or safely sit in a shower/tub chair.
R193's care plan dated 3/19/24, identified R193 was at significant risk for falls related to medication use and obesity. Care plan instructed to encourage use of emergency call-light system as needed, for immediate and urgent staff assistance.
During an interview on 7/30/24 at 11:39 a.m., R193 confirmed she used the toilet independently in the multi-resident bathroom and at times used the shower in the multi-resident bathroom independently. R193 stated she would not be able to reach the emergency call light if she fell on the floor while using the toilet or the shower. R193 stated she had a history of falls and feels it was important for her to be able to reach the call light from the floor in the bathroom.
R39
R39's quarterly MDS dated [DATE], identified R39 had intact cognition and diagnosis which included schizophrenia, asthma, and hyponatremia (low sodium blood levels). MDS identified R39 was independent with activities of daily living (ADL's) which included transfers, toileting, and showering.
R39's fall risk assessment dated 1/1024, identified R39 was a moderate risk for falls relation to medication use.
R39's care plan dated 9/14/21, identified R39 was at risk for falls related to clutter. Care plan lacked evidence of the use of the emergency call system.
During an interview on 7/30/24 at 11:44 a.m., R39 stated she used the toilet independently in the multi-resident bathroom. R39 stated she was unsure if she would be able to reach the call light if she was on the floor in the bathroom but felt it was important for her to be able to reach the call light from the floor in the bathroom.
During a joint interview on 7/30/24 at 12:10 p.m., mental heath worker (MHW) and licensed practical nurse (LPN)-A verified R135 and R193 were all fall risk and used both the toilet and the shower independently in the multi-resident bathroom and R39 was also a fall risk and used the toilet independently in the multi- resident bathroom. MHW and LPN-A stated all three residents were able to use the call system but would not be able to access the call light system if they were on the floor in the bathroom.
During an interview on 7/30/24 at 3:07 p.m., director of nursing (DON) stated call lights may not be within reach in the multi- resident bathroom if R135, R193, or R39 were on the floor. [NAME] further stated she was unsure if there was a need for a resident to be able to access the call light from the floor because of the highly ambulatory population of the residents.
A facility policy titled Emergency Monitoring System dated 4/23/14, identified pull station transmitters were located in resident rooms, bathroom, and other common areas. Further identified all activations of the system shall be responded to in a timely fashion by staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to conduct regular inspections of hospital bed frames, mattresses and bed rails as part of a preventative maintenance program for 1 of 1 resident (R49) reviewed who had a broken bed rail affixed to the frame.
Findings Include:
R49's quarterly Minimum Data Set (MDS) dated [DATE], identified R49 had severe cognitive impairment and was independent with all activities of daily living.
R49's diagnoses sheet printed 8/1/24 listed the pertinent diagnoses of undifferentiated schizophrenia (experiences psychotic symptoms) and lymphedema (swelling caused by buildup of lymph fluid).
R49's care plan dated 6/14/23, indicated R49 was at risk for falls with an intervention of utilizing a hospital bed (electric adjustable bed) with transfer assist bars for sleeping.
During observation on 7/29/24 at 3:05 p.m., R49's bed had two pivoting assist devices (PAD) attached to the adjustable bed frame. The left PAD was in the upright position. The right PAD was swung down where the top of it was touching the floor. The right PAD was not in the line with the frame and pulled away from the bed. The PADs were connected to the bed frame by one bolt and utilized a pivot stop handle (pull out to rotate) as the locking mechanism.
During observations on 7/30/24 at 7:57 a.m. and 12:52 p.m., the PAD positions remained unchanged.
During interview on 7/31/24 at 8:10 a.m., registered nurse (RN)-A verified the right PAD was broken and did not know how long it was in that condition. RN-A confirmed staff round in the rooms daily and someone should have seen this.
During interview on 7/31/24 at 9:38 a.m., maintenance engineer (ME)-A stated there were no scheduled maintenance checks for R49's bed and they kept no logs. ME-A stated the normal process was to wait on a call from the floor to address concerns. ME-A stated that the right PAD on R49's bed was broken due to a sheared bolt.
During a follow up observation and interview on 7/31/24 at 10:46 a.m., ME-A was tightening the bolt on the left PAD on R49's bed. ME-A stated they had not reviewed the manual first and they do not have the manual because the director of nursing (DON) does. When asked about proper installation of the left PAD, ME-A replied, I don't know, it's just bolts.
During interview on 8/1/24 at 8:07 a.m., the account manager (AM)-C for Direct Supply was unable to verify how often the Direct Supply Panacea 1000 adjustable-Height Low Bed and Direct Supply Panacea Pivoting Assist Device should be inspected. AM-C stated they would have to reach out to their manufacturing group to find out what periodic meant from the user manual. A clarification call-back was requested but not received.
During interview on 8/1/24 at 9:30 a.m., the DON stated the bed went in use the same date as the care plan intervention, 6/14/23.
A bed maintenance policy and maintenance bed inspection logs were requested but were not received.
Owner's manual regarding Direct Supply Panacea 1000 Adjustable-Height Low Bed dated 8/13, recommended periodic inspections which included inspecting all bolts and fasteners and visual examination of all bed components for damage or excessive wear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure dishware and cooking utensils were properly sanitized (i.e., high temperature) in 1 of 1 commercial dishwashers observed in the main production kitchen. This had potential to affect all 206 residents, visitors, and staff who consumed food from the kitchen.
Findings include:
On 7/31/23 at 11:31 a.m., an initial kitchen tour was completed. A single ProPower commercial dishwasher machine was present in the kitchen and dishwasher (DW)-A was removing various items, including various dishware and cooking utensils, which had just been put through the machine for cleaning and sanitization. A series of three white-colored gauges were present on the machine which displayed wash temperature(s) and one labeled, Final Rinse. On the soiled side of the machine (i.e., dirty), DW-B loaded another hard plastic rack with various kitchen items and loaded them into the machine for cleaning and sanitization; however, when the final rinse of the soiled cookware had completed the white-colored gauge displayed the final rinse temperature was only 178 F (Fahrenheit). DW-B then loaded another rack with various dishware and loaded it into the machine; however, the final rinse temperature gauge displayed the final rinse temperature as only 176 F. DW-B was interviewed and expressed they were not sure if the machine was a high-temperature or chemical sanitization method adding nobody had ever directed or instructed them to check the gauges on the machine during the wash and rinse cycles. DW-B added they knew nothing about the gauges. DW-A continued to remove the cleaned items and place them back in shelving and cupboards for future use.
On 8/2/23 at 8:38 a.m., a subsequent kitchen tour was completed. The same commercial dishwasher was in use with food service worker (FSW)-A loading various dishware and cooking utensils into the machine for cleaning. The machine completed the wash cycle and then activated the final rinse, however, the final rinse temperature displayed on the analog gauge was only 175 F. FSW-A loaded another rack with other, soiled kitchenware and dishware items and placed it into the machine. However, again, the final rinse temperature displayed on the gauge was 175 F. FSW-A was interviewed and expressed they were unsure if the machine was a high temperature or chemical sanitization method adding, That's a good question. FSW-A then left the dishwasher area and returned with the food service manager (FSM) who reviewed the machine. FSM verified the dishwasher was a high-temperature sanitization method and the white-colored gauges were the ones used to monitor and check the machine' function. FSM then loaded a rack with soiled silverware and an empty silverware basin and ran it through the machine, however, the final rinse temperature only recorded 174 F which FSM verified. FSM stated the final rinse cycle should be reaching 180 F to ensure the dishware was properly cleaned adding the machine had not been serviced in awhile but was due. FSM explained the staff had been using test strips on various loads to ensure it was reaching proper temperature, and retrieved these strips from the dining room before handing them to the surveyor. FSM stated they tested the machine using these strips on a weekly basis.
A package of orange-colored [NAME] test strips were provided with directions to attach a test strip to a utensil or rack and washing the items with the strip attached. It directed, If the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. These strips were removed and were orange-colored with large font present reading, 180 F, and, Pass When Blue Bar Turns Orange.
At 8:58 a.m., the food service director (FSD) joined the interview and demonstration of the dishwasher. A test strip was attached to a metallic utensil and ran through the machine on a rack. The final rinse, again, did not hit 180 F and the attached strips remained with a blue-tint upon exiting the machine. FSD stated they believed the machine to be functioning correctly and hitting the correct temperature adding the issue was more than likely the gauge being incorrect. A three compartment sink was adjacent to the dishwasher machine which FSD stated used the same hot water lines which fed the dishwasher. A new test strip was placed under the running hot water of the three compartment sink, and the strip turned orange with no blue-tint present on the strip as had been the result when ran through the dishwasher. FSD acknowledged the strip color difference between the two but expressed they felt it was only faintly different adding the test strips used for quality monitoring on the dishwasher were not saved and immediately discarded.
A clipboard with a Dish Machine Temperature Log, dated 8/2023, flow sheet attached was then provided. The flow sheet identified a series of rows and columns which provided space to recorded the wash temperature, rinse temperature, and initials of staff recording the data for three meals on each respective calendar day with the third meal labeled, Dinner, including an additional column labeled, Surface Temp Reading. The rinse column identified the temperature should be, min[imum] of 180, and all the recorded temperatures ranged 180-181 F. The only recorded surface temperature was listed as, 160. An additional Dish Machine Temperature Log, dated 7/2023, flow sheet was included outlined the same series of rows and columns to record the data for the machine. The final rinse column recorded temperatures which ranged 180 F to 182 F, and the surface temperatures recorded ranged from 155 F to 181 F.
FSD stated they had not been told and were unaware of any concerns with the commercial dishwasher not getting to 180 F during the final rinse cycle, but expressed it was important the machine did to kill the bacteria and germs which could remain on the dishware and cooking items. FSD reiterated the 180 F temperature importance, and stated a company was scheduled to review the dishwasher the same day (8/2/23) as the machine had developed some sheeting and was not removing rinse aide correctly which resulted in spotting on some pans and dishware. FSD stated the machine was supposed to be serviced every four months, however, had not been serviced in seven [or] eight months now due to the outside company having various issues.
When interviewed on 8/2/23 at 9:43 a.m., the registered dietician (RD) explained the facility' dishwasher was a high-temperature sanitization machine, and it had been on our radar off and on for several months due to the gauges potentially not reading correctly. RD stated the water entering the machine was kept at 180 F so they were not sure how the temperature could be falling out of range. RD explained they were onsite at the center the previous week and, at the time, the machine had been hitting the temperatures required (i.e., 180 F). RD stated they would recommend the machine, including the gauges, be inspected to ensure proper function adding they didn't realize the machine had been temping out that low as the surveyor observation. RD verified the test strips being used (i.e., [NAME]) should turn bright orange if the temperature was obtained and FSD had also been testing the surface temperature of various dishware to ensure the rack level minimum temperature (i.e., 160 F) was obtained on the final rinse cycle. RD verified the final rinse cycle should be hitting 180 F (via gauge) or 160 F (via rack level) as that's when the sanitization happens to reduce the risk of foodborne illness adding, It's clearly an important step.
On 8/2/23 at 1:29 p.m., a return visit to the kitchen was completed with FSD and FSM present. FSD verified they had been testing the surface temperature (i.e., rack level) of the machine and retrieved a handheld yellow-colored, infrared-style thermometer from the dining room area. A metallic pan was then loaded into a rack and ran through the dishwasher with the gauge labeled, Final Rinse, again only hitting 175 F. Immediately as the metallic pan emerged from the dishwasher, FSD then used the thermometer to check the surface temperature of the dishware which resulted, 156 [F], at the highest point. FSD verified the surface temperature did not hit, at minimum, the 160 F to demonstrate proper rack level rinse temperature.
A provided Cleaning and Sanitizing Food Contact Surfaces policy, undated, identified a purpose of preventing foodborne illness by ensuring all food contact surfaces were properly cleaned and sanitized. A section labeled, 6. If a dishmachine is used, directed to check with the manufacturer to ensure the data plate (i.e., gauges) was correct and to use the data plate to determine wash and final rinse temperatures, if applicable. Further, the policy outlined, Ensure that food contact surfaces reach a surface temperature of 160 F or above if using hot water to sanitize.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure reported complaints of neuropathic (i.e., nerve) and joint pain were comprehensively assessed and, if needed, interventions to promote comfort provided for 1 of 2 residents (R188) reviewed who reported severe pain during the survey.
Findings include:
R188's quarterly Minimum Data Set (MDS), dated [DATE], identified R188 had intact cognition, demonstrated no delusional behavior, and had several medical diagnoses including diabetes mellitus and schizophrenia. The MDS outlined R188 received both scheduled and as-needed (PRN) medication for pain during the review period, and he reported severe pain on a frequent basis which, at times, caused trouble sleeping at night.
On 7/31/23 at 2:22 p.m., R188 was interviewed, and explained he had pain in the left hip which stemmed from a childhood accident. R188 stated he felt the pain was not adequately controlled as the staff were only giving him Tylenol for it adding the medication was not doing a thing. R188 explained he repeatedly had told staff the pain was bad and not controlled; however, their only response was telling him (R188) to stay off my hip and lay down. R188 stated a physician appointment was scheduled offsite for his painsometime in August, however, there had been no discussion on what interventions, if any, were able to be done in the meantime to help provide comfort until the physician appointment could be completed. R188 stated the pain, at times, caused poor sleep and rated the pain eight or nine [on 0/10 scale] at it's worst over the past weeks.
R188's MDS Quarterly Assessments Review, dated 7/14/23, identified a section labeled, Pain Assessment, which outlined there had been a change since the previous annual assessment adding, [R188] denied chronic pain concerns on admit although he has a diagnosis of [diabetes mellitus] w/ [with] diabetic neuropathy. Today he reports pain due to neuropathy . a comprehensive pain assessment will be completed and the intervention for this added to this care plan. The evaluation provided spacing to answer if the care plan had been updated which was recorded with a, X marking next to, Yes.
However, R188's corresponding Pain - Comprehensive Nursing Assessment, dated 7/14/23, was identified in the electronic medical record (EMR) and reviewed. The assessment provided spacing to record various aspects of R188's pain care needs and evaluation including the quality of the pain, location of pain, when it began, what improves or worsens the pain, and other various factors. However, the entire assessment was left blank and not completed.
R188's Physician Orders, dated 8/2023, identified R188's current medication regimen. This included Neurontin (an anti-convulsant used to treat nerve pain) 900 milligrams (mg) three times a day. There were no orders listed for Tylenol on the provided order set. R188's Medication Administration Record (MAR), dated July 2023, identified an order for acetaminophen 650 mg by mouth every four hours as needed (i.e., PRN) for pain or fever. A total of 14 administrations of the medication were recorded, with nine of them being given after the facility had identified potential pain concerns (MDS Quarterly Review, dated 7/14/23) which had not been comprehensively assessed. The associated reason for each administration was listed which included foot pain and hip pain, and the order had a written start date listed, 7-20-23.
R188's care plan, dated 5/29/23, identified R188 had diabetes, associated diabetic neuropathy, and severe psychiatric symptoms. However, the care plan lacked any recorded problem statements, goals, or interventions for R188's pain despite complaints of pain being identified several weeks prior, and the completed MDS review outlining the care plan had been updated to reflect these complaints. Further, R188's entire medical record lacked evidence R188's reported pain had been comprehensively assessed and, if needed, any interventions developed or implemented despite this pain being identified as a change (i.e., new pain) and R188 using multiple doses of PRN pain medication since it was identified on 7/14/23.
When interviewed on 8/1/23 at 12:21 p.m., registered nurse (RN)-A explained R188 was very independent with cares and had an active wound on their foot due to an excessive walking episode a few weeks prior. RN-A stated R188 did no complain of pain to their knowledge, however, if such complaints were received then the nurses would do an assessment if the complaints were less routine [new]. RN-A explained the assessment would be nursing' responsibility to complete adding any complaints other staff are hearing should be reported as, If somebody's not telling me, I can't do anything. RN-A reviewed R188's MAR and verified there was no formal pain monitoring in place, and explained care planning within the care center would likely be the MDS nurse' responsibility.
On 8/1/23 at 12:34 p.m., RN-B was interviewed and reviewed R188's medical record. RN-B stated they were the person who loaded R188's Pain - Comprehensive Nursing Assessment (dated 7/14/23) and knew it still had to be done, however, they got busy and just ran out of time. RN-B stated they would complete the assessment soon and explained such assessments were typically done immediately when pain was identified, however, they had dropped the ball. RN-B reviewed R188's care plan and verified it had not been updated with any interventions for pain adding it was likely due to the assessment not yet being completed. RN-B stated any formal pain monitoring would also be considered on a case by case basis, which was usually done after the pain assessment was completed as staff then have a much better idea on pain control issues and subsequent needs. RN-B stated it was important to ensure complaints of pain were acted on immediately and assessed to help provide the best possible care. RN-B added, This just got away from me.
During and interview on 8/3/23 at 1:35 p.m. the MD stated because the facility was designated a MHI, no care providers were able to go into the facility and therefore, all residents had their own psychiatrist who handled their mental health and a separate primary care provider (PCP) who handled the resident's medical conditions. The MD stated all PCPs had 24 on-call services the staff could contact in the event of a medical emergency; however, many psychiatrists do not have 24 hour availability; therefore the staff could call the MD 24 hours a day and she would help them problem solve. The MD stated if she was unable to problem solve with the staff, the resident could wait until the following day, or the staff could send the resident to the emergency department. The MD stated in a very rare case she may refill a psychiatric medication over the weekend, but she only provided consultation to staff regarding resident psychiatric care. The MD stated she did not provide medical care for the residents and was not involved in the development of any medical policies or procedures such as diabetic or seizure care; and did not know who was.
A provided Pain Management Program policy, dated 11/2022, identified psychiatric symptoms could likely not be adequately addressed until a resident was free of physical distress, including pain, and each resident had a right to pain management. The policy outlined, Residents presenting with pain at other times [after admission] are assessed by the Floor Nurse and, if indicated, are referred to the Health Educator/MDS Coordinator for in-depth assessment, utilizing the Comprehensive Pain Assessment [underlined]. The information gathered would then be used to determine what, if any, interventions were needed for managing pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to show proper infection control processes were in place when visibly soiled personal laundry was left unattended on top of a communal washing machine. This had the potential to affect all 206 residents residing in the facility with access to the washing machine.
Findings include:
During observation and interview on 8/2/23 at 8:10 a.m., the 2nd floor locked laundry room contained two stackable washer and dryer units. Approximate dimensions of laundry room was five feet by five feet. On top of washing machine labeled, #1 was a pile of visibly soiled personal laundry. On the very top of the pile of laundry was one blue undergarment with three visibly dried dark red stains that included the elastic of both leg openings into the crotch panel. To the right of this was a blue leopard print undergarment with dried dark amber colored stain of crotch panel. On the floor of the laundry room was another light dusty rose colored undergarment with dried dark yellow stained crotch panel. During interview with social services (SS)-A stated dirty linen should not be here on the unit and left. SS-A stated the laundry room is shared by all the residents and soiled linen is not sanitary.
During interview with facility infection control preventionist (IP) on 8/2/23 at 10:47 a.m., IP stated laundry procedures with residents are reviewed upon admission to the facility. IP stated visibly dirty laundry should never be left unattended in the unit laundry rooms due to infection control risk. IP stated soiled or dirty laundry can cause outbreaks in this facility. IP stated new admissions are instructed on facility laundry procedures and expectations.
R143's quarterly Minimum Data Set (MDS) dated , 5/10/23, indicated intact cognition.
During interview with R143 on 8/2/23 at 12:26 p.m., R143 stated she was informed on admission to facility on expectations of residents to perform their own laundry. R143 stated, I cannot leave my dirty laundry unattended. You can't put it up there (pointing to the washing machine lid) and leave.
During interview with program director (PD) on 8/2/23 at 1:45 p.m., PD stated, there should never be soiled personal laundry sitting on top of the washer machine because it is communally used and is a risk for infection. PD stated the facility uses a checklist for all new residents to explain to them the process and expectation of doing their personal laundry.
During interview with facility's maintenance director (MAD) on 8/3/23 at 8:46 a.m., MAD stated the expectation was soiled personal laundry should not be allowed to be left out. It is not ok.
Form titled, Resident Orientation Checklist dated 3/20/23 stated day 5 is when Laundry Procedures: 1. Linen Day, 2. Use of floor washing machines, 3. Use of [NAME] laundry services is reviewed with all new admissions. Form titled Resident Use of Floor Laundry Facilities dated 6/22/09 stated, 7. Each resident is expected to leave the Laundry Room and the laundry facilities clean and in order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation, interview and document review the facility failed to reassess a resident for safe smoking practices to prevent acute injury for 1 of 1 resident (R1) reviewed for smoking.
Findings include:
R1's annual Minimum Data Set, dated , 6/21/23 indicated R1 was cognitively intact and was independent with activities of daily living (ADLs).
R1's Client Diagnosis Report dated 9/8/1993, indicated R1 was admitted to the facility with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
R1's most current smoking assessment dated [DATE], indicated R1 was assessed safe to smoke independently.
R1's progress notes dated 7/25/23, indicated a burn hole was noticed on R1's shirt by facility staff during a weekly meeting. R1 stated it was from tobacco and it was documented her speech became pressured and R1 further stated, it happens too much. I'm klutzy with my smoking, it ruins my clothes and I hate it.
During an interview and observation on 7/31/23 at 12:59 p.m., R1 stated she often goes outside to smoke during the day independently. R1 had multiple holes in her shirt that were circular in nature approximately the size of a pencil eraser with charred, blackened edges.
During an interview on 8/1/23 at 1:08 p.m., social worker (SW)-B stated smoking assessments are done annually which would include a safe smoking assessment, observation of the resident smoking, and education on safe smoking practices. SW-B stated the expectation would be to reassess at any time if changes were noticed in a resident's condition or concerns were noticed such as burn holes in a resident's clothing. SW-B confirmed the most recent smoking assessment was 7/21/22.
During an interview on 8/3/23 at 8:48 a.m., program manager (PM) and social worker (SW)-C stated it was the PM who would conduct the safe smoking assessment to ensure the resident was not at risk for acute injuries from smoking materials.
SW-C stated he did not know the specific threshold for reassessment but stated if staff were seeing burn holes in a resident's clothing, it should be brought to the interdisciplinary team and the resident should be reassessed for safe smoking practices.
During an interview on 8/3/23 at 12:21 p.m., the assistant director of nursing (ADON) stated she was unaware of the smoking assessment policy and expectation as the program managers managed that.
A policy titled Smoking and Vaping Policy and Procedure, dated 11/18/22, indicated residents were assessed for safe smoking upon admission to the facility and quarterly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure hospital discharge records were reviewed to provide continuity of care and appropriate medication administration for 1 of 1 residents (R113) after they returned to the facility from the emergency department (ED). In addition, the facility failed to comprehensively assess and provide care in accordance with professional standards for 1 of 1 residents (R113) who had repeated episodes of hypoglycemia (low blood sugar).
Findings include:
Continuity of care
R113's discharge Minimum Data Set (MDS) dated [DATE], indicated R113 did not have a Brief Interview for Mental Status (BIMS) completed and was independent with all activities of daily living (ADLs). R113's diagnoses included anxiety, depression, post traumatic stress disorder (PTSD), attention deficit disorder (ADD), alcohol abuse, diabetes, insomnia, transient ischemic attack (TIA) and cerebral infarction (causing temporary stroke symptoms and injury to the brain due to a lack of blood flow), high blood pressure, asthma, right knee replacement, polyneuropathy (decreased sensation to multiple extremities) and chronic pain.
R113's care plan dated 12/21/22, indicated R113 had pain related to a total right knee replacement, lower back disc degeneration, left shoulder pain and neuropathy. Interventions included administering medications as ordered. R113 also had high blood pressure. Interventions included receiving medications as ordered and promoting physical activity. R113 also had a history of drug (opioid) and alcohol abuse. The care plan also indicated R113 had neuropathy related to diabetes. Goals included managing R113's pain to maintain function of ADLs and participation in activities. Interventions included promoting diabetes management. R113 also had impaired memory related to a TIA and PTSD. Goals included maintaining her current level of functioning. No further interventions were indicated. The care plan lacked indication of, and interventions for, R113's use of antipsychotic medications, or R113's history of anxiety and depression.
R113's Care Area Assessment (CAA) dated 12/30/22, indicated R113 triggered for cognitive loss/dementia, ADL function, psychosocial well-being, behavior symptoms, falls, activities, psychotropic drug use, and pain.
R113's orders dated 12/21/22, indicated R113 took the following afternoon and evening medications:
-Furosemide 40 milligrams (mg) at 9:00 p.m., a diuretic (to control fluid retention) for high blood pressure.
-Montelukast sodium 10 mg at 9:00 p.m., for asthma.
-Lyrica 150 mg at 4:00 p.m. and 9:00 p.m., for polyneuropathy.
-Propranolol 80 mg at 9:00 p.m., for high blood pressure.
-Rosuvastatin 20 mg at 9:00 p.m., for high cholesterol.
-Methocarbamol 500mg at 4:00 p.m. and 9:00 p.m., for muscle spasms.
-Tylenol 1000mg at 4:00 p.m. and 9:00 p.m., for chronic pain.
-Quetiapine fumarate 100 mg at 9:00 p.m., for anxiety.
-Amitriptyline 100 mg at 9:00 p.m. for depression.
-Trazadone 200 mg at 9:00 p.m., for depression.
-Buspirone 30 mg at 9:00 p.m., for anxiety.
-Clonazepam 1 mg at 9:00 a.m. and 4:00p.m., for anxiety.
During an observation on 8/1/23 at approximately 12:00 p.m., R113 was seen unconscious, lying face up on the floor outside the fifth-floor elevators. Staff assessing R113 reported her oxygen level to be 90% and all other vital signs within normal limits. No trauma was noted; 9-1-1 was called and R113 was transported to the hospital.
R113's ED provider note dated 8/1/23, indicated R113 was discharged with no medication changes and received only 1000 milliliters of intravenous normal saline fluid while in the ED. No other medications were indicated as being administered.
R113's progress note dated 8/2/23 at 6:45 a.m., indicated R113 returned from the ED at approximately 11:00 p.m. without discharge paperwork. R113 requested, and was given, an as-needed (PRN) Percocet (an opioid) for pain. At 11:30 p.m., R113 requested propranolol and Clonazepam, stating she did not receive any medications while in the ER. The note indicated Due to the lack of paperwork so staff could not determine what, if anything, she received at the hospital, as well as the late hour, it was determined to provide her with the propranolol, but not the Clonazepam.
During an interview on 8/2/23 at 7:59 a.m., R113 was in bed with a blanket covering her body and pulled over her head while a nurse was administering her insulin. R113 stated when she returned from the hospital the previous night, staff would not give her her afternoon or evening medications because it was too late and they could not call the hospital to verify what she received while she was there. R113 stated she was feeling anxious and just bad all over because she had missed her medications.
R113's progress note dated 8/2/23 at 3:30 p.m., indicated R113 did not see the exercise specialist that morning and declined her physical therapy appointment that day due to 7/10 pain.
During an interview on 8/2/23 at 9:45 a.m., registered nurse (RN)-C stated when R113 returned from the hospital on 8/1/23 at around 11:00 p.m., the phone line they usually call would have been closed. Although, RN-C verified the staff could have called the ED to clarify what medications R113 was given while she was there. RN-C further stated staff had access to the hospital's computer system and could have looked up R113's hospital medical record and discharge summary to determine what had occurred during R113's hospital visit and what medications she had received, if any.
During an interview on 8/3/23 at 10:21 a.m., the assistant director of nursing (ADON) stated there was always a nurse at the facility who had access to the hospital medical record system. The ADON also stated staff should have looked at R113's hospital record to see what medications and treatments she received to ensure she did not overdose or miss doses of her medications, and to ensure continuity of care.
A facility policy regarding resident transfers from the hospital was requested but not received.
Hypoglycemia management.
The Centers for Disease Control and Prevention webpage titled, Diabetes dated 12/30/22, indicated standard blood sugar (BS) levels were:
-80-130 milligrams per deciliter (mg/dl) before a meal.
-Less than 180 mg/dl two hours after a meal.
BS levels below 54 mg/dl were classified as severe and may lead to altered mental status, seizures, vision changes and weakness.
The CDC webpage also indicated uncontrolled BS levels can lead to serious health problems including heart disease, vision loss, kidney disease, coma, and death.
R113's care plan dated 12/21/22, indicated R113 had a chronic foot ulcer related to diabetes that resulted in the amputation of four toes and osteomyelitis and a history of hypoglycemia. Interventions included administering medications as ordered, promoting well-balanced meals to include protein and non-concentrated sweets, consulting medical professionals as needed, doing blood sugar (BS) checks as ordered, promoting daily physical activity. The care plan also indicated R113 had neuropathy related to diabetes. Goals included managing R113's pain to maintain function of ADLs and participation in activities. Interventions included promoting diabetes management. R113 also had impaired memory related to a TIA and PTSD. Goals included maintaining her current level of functioning. No further interventions were indicated.
R113's orders dated 12/21/22, indicated R113 had a Dexcom sensor device for glucose data management (a small device attached to the body with adhesive and a sensor wire just below the skin to monitor blood glucose levels. (The device alarms when BS levels are outside the resident's normal range and can be accessed through the resident's smart phone.) The orders also indicated to administer 1 milliliter (ml) of glucagon intramuscularly (IM) for signs of hypoglycemia and repeat after 15 minutes if signs persisted. The orders further indicated accuchecks (finger sticks) to be completed as needed for signs of hyper/hypoglycemia (high or low blood sugar). The orders indicated R113 was to have an A1c (blood test used to determine blood sugars over a period of time) drawn every three months to monitor her long-term blood sugar levelsand the next lab draw was ordered for 6/21/23.
R113's Lab Medication Administration Record (MAR) dated June 2023, lacked indication R113 had a blood draw completed for her ordered A1c on 6/21/23.
R113's diabetic progress note dated 6/8/23 at 3:45 a.m., indicated R113's Dexcom alarmed and indicated her BS was 41 mg/dl and a verifying fingerstick indicated it was 61 mg/dl. R113 ate a fig bar and drank apple juice and milk. The progress note lacked indication of R113's signs and symptoms. At 4:15 a.m., R113's Dexcom indicated a BS of 66 mg/dl. No further notes were documented to indicate further monitoring, treatment, or provider notification were done.
During an interview on 8/3/23 at 1:09 p.m., the assistant director of nursing (ADON) stated she was unable to find documentation that R113's provider was notified of her low BS on 6/8/23.
R113's diabetic progress note dated 6/24/23, indicated R113 missed her 7:00 a.m., BS check and insulin due to resident sleeping and not responding to three attempts to wake her. After R113 woke up at 9:00 a.m., R113's BS was checked, and she was administered insulin.
R113's diabetic progress note dated 7/26/23, indicated at 12:45 a.m., R113's BS was 41 mg/dl and she was displaying signs of hypoglycemia including altered mental status and lethargy. R113 was given a glucagon IM injection and at 12:50 a.m., R113's BS was 52 mg/dl. R113 was given Boost (a nutritional drink) and at 12:55 a.m., R113's BS was 76 mg/dl and no longer symptomatic. No further monitoring or treatment was documented, and no note was written to indicate R113's provider was notified.
R113's interdisciplinary (ID) progress note dated 7/26/23, indicated R113's roommate notified staff R113's Dexcom monitor was beeping, and showing R113 had a BS of 41 mg/dl. Upon entry to R113's room, staff found R113 difficult to awaken. Staff injected glucagon IM at 12:50 a.m., and at 12:55 a.m., R113 was more alert and able to chew a glucose tab and drink Boost. At 12:55 a.m., R113's BS was 76 mg/dl and her mental status was at baseline. R113 then went outside to smoke and was given more glucose tabs to chew in case her BS dropped again. At 1:45 a.m. R113's fingerstick was 174; however, at 3:30 a.m. her BS was down to 106. Staff indicated they would recheck R113's BS in two hours. The note lacked indication R113's provider was notified.
R113's ID progress note dated 7/26/23 at 7:03 a.m., indicated when staff attempted to recheck resident's BS at 5:30 a.m., they were unable to find where R113's the Dexcom monitor was located on her body and therefore did not recheck her BS; however, R113 appeared to be sleeping with no issue. At 6:30 a.m., R113 was no longer on the unit.
R113's ID note dated 7/27/23 at 2:29 p.m., indicated R113 had been experiencing multiple episodes of hypoglycemia and had declined physical therapy that day due to being tired.
R113's IDT note dated 7/28/23 at 1:50 a.m., indicated at 11:32 a.m., R113 had a BS of 55 mg/dl and was dizzy, lethargic and confused. At 11:43 a.m., R113's BS was 115 and R113 was asymptomatic. Dexcom and fingerstick do not always match.
Review of a facsimile dated 7/28/23, indicated R113's provider was notified R113 had a recent increase in hypoglycemic episodes. R113's provider responded on 8/1/23, with an order to decrease R113's Novolog (insulin) from 50 units to 40 units at bedtime and to make an appointment with endocrinology (hormone/diabetic specialist).
During an interview on 8/2/23 at 9:45 a.m., registered nurse (RN)-C stated providers were sometimes notified of a resident's change in condition by a facsimile (fax) or a phone call. Staff were expected to write a progress note or on the back of the resident's paper, diabetic MAR to indicate if a provider was notified. When a resident's blood sugar (BS) level was between 55-70 milligrams/deciliter (ml/dl), and the resident was able to swallow, staff were to provide a snack with a mix of carbohydrates and protein, then recheck their BS after 15 minutes to ensure the resident maintained their BS above 70 mg/dl. If the resident's BS remained below 70 mg/dl, staff were to continue to provide snacks, notify the provider, and consider sending the resident to the emergency room. RN-C also stated giving only sugary snacks would be a concern because the resident's BS would increase initially but drop again after a short period of time. RN-C further stated staff were expected to attempt to wake a resident to check their BS, by knocking on the door and/or nudging them three times. No further instructions were provided if staff were unable to wake the resident.
During an interview on 8/3/23 at 10:21 a.m., the ADON stated if a resident's BS was 40 mg/dl they should be given food if they were able to eat or an intramuscular (IM) glucagon injection and their BS should be checked 15 minutes later, and the resident should continue to be monitored. The ADON stated she was unaware of a protocol for monitoring a resident who had low BS throughout the night but that it should be checked. The ADON further stated because the Dexcom monitor was not always accurate, any BS below 70 mg/dl should have been verified with a fingerstick.
During an interview on 8/3/23 at 2:00 p.m. R113 stated although she occasionally did not respond when staff attempted to wake her to check or recheck her BS, and if staff were unable to access her Dexcom, she wanted staff to do a fingerstick to ensure she was not hypoglycemic, causing her to be unconscious rather than sleeping.
R113's medical provider was not available for an interview.
During and interview on 8/3/23 at 1:35 p.m. the MD stated because the facility was designated a MHI, no care providers were able to go into the facility and therefore, all residents had their own psychiatrist who handled their mental health and a separate primary care provider (PCP) who handled the resident's medical conditions. The MD stated all PCPs had 24 on-call services the staff could contact in the event of a medical emergency; however, many psychiatrists do not have 24 hour availability; therefore the staff could call the MD 24 hours a day and she would help them problem solve. The MD stated if she was unable to problem solve with the staff, the resident could wait until the following day, or the staff could send the resident to the emergency department. The MD stated in a very rare case she may refill a psychiatric medication over the weekend, but she only provided consultation to staff regarding resident psychiatric care. The MD stated she did not provide medical care for the residents and was not involved in the development of any medical policies or procedures such as diabetic or seizure care; and did not know who was.
The facility Management of Hypoglycemia Protocol indicated the following procedures:
-Level 1 = BS >/= 55 mg/dl but < 70mg/ml
-Level 2 = BS < 55 mg/dl
-Level 3 = A resident displaying altered mental status or a physical status requiring emergent intervention for the treatment of hypoglycemia.
Level 1 treatment included:
-Following interventions as noted by the resident's physician.
- Provide oral glucose (15-20 grams). The procedure lacked indication to withhold oral glucose if the resident had difficulty swallowing or had altered mental status.
-If BS remains below 70 mg/dl, repeat oral glucose and notify the physician. Also see Standing Orders.
Level 2 treatment included:
-Following intervention as noted by the resident's physician.
-Administer IM glucagon and repeat one time after 15 minutes if BS remains below 55 mg/dl or the resident remains symptomatic. See Standing Orders.
-Re-check BS within 15 minutes.
-If BS is within the established reference range, provide a meal or snack
-If BS remains below 70 mg/dl repeat oral glucose and notify the physician for further orders.
-Notify the provider.
Level 3 treatment included:
-Follow interventions as noted by the resident's physician.
-Call 911
-Administer IM glucagon and repeat one time after 15 minutes if BS remains below 55 mg/dl or the resident remains symptomatic. See Standing Orders.
-Notify the provider.
-Documentation should include the resident's BS before and after interventions, notification of the provider, any provider orders for treatment, plan of care for acute or chronic conditions, and a complete
assessment. The frequency and duration of continued monitoring will be determined by nursing clinical assessment and/or consultation with management and in conjunction with the resident's provider.
The facility Standing Orders dated 5/18/22, indicated to administer glucose 4 gram tabs (chew four tabs) for hypoglycemia and recheck BS after 15 minutes. Repeat if BS remains below 70 mg/dl. Administer 1 mg of IM glucagon for hypoglycemia: may repeat x 1 after 15 minutes if the resident remains symptomatic.
No further instructions were present regarding what hypoglycemia symptoms were or withholding oral treatment in the event the resident had altered mental status or difficulty swallowing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure use of a continuous positive airway pressure (CPAP) machine was assessed or, if needed, managed to reduce the risk of complication (i.e., respiratory infection) for 1 of 2 residents (R163) observed to have such device present at their bedside.
Findings include:
R163's quarterly Minimum Data Set (MDS), dated [DATE], identified R163 had intact cognition and had several medical diagnoses including non-traumatic brain dysfunction.
On 7/31/23 at 1:51 p.m., R163 was observed laying in bed while in their room. R163 had a dresser next to her bed which had a black-colored [NAME] II CPAP sitting on top. The device had visible, thick dust build up on the exterior and buttons, and the water chamber had visible water droplets on the walls (i.e., evaporation) inside of the chamber. A mask was attached to the machine and draped across the dresser. R163 stated she used the CPAP on a nightly basis and had used it for many years. R163 stated she cleaned, maintained and used the device on her own without staff involvement. When questioned on how she cleaned the machine (i.e., step by step process), R163 abruptly responded, I know how to do it.
R163's care plan, dated 8/26/22, identified R163 had insomnia and sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) and listed a goal which read, Resident will achieve restful sleep, 7 of 7 nights, along with various interventions to help R163 meet this goal including, Use and clean CPAP as directed. However, the care plan lacked any further information on the CPAP use, including if R163 managed/used the device on their own (i.e., set-up, cleaned, used).
R163's Physician Orders, dated 8/2023, identified R163 had insomnia and obstructive sleep apnea. The orders listed R163's medication regimen, however, lacked any directions or orders for CPAP use, including if R163 was able to manage the medical device on her own (i.e., self administration). In addition, R163's medical record was reviewed and lacked evidence R163's use of a CPAP had been comprehensively assessed for safety and ability; nor evidence the nursing staff were overseeing use of the device to ensure it was regularly cleaned and maintained to help prevent misuse or potential respiratory infection.
When interviewed on 8/2/23 at 10:18 a.m., licensed practical nurse (LPN)-A stated they had worked with R163 before and described them as kind of isolative in nature. LPN-A stated they were unsure if R163 used the CPAP present at their bedside adding it was a good question. LPN-A explained the center' nursing team should be cleaning and maintaining the machine adding it should be listed on the MAR to ensure it was not missed. LPN-A reviewed R163's MAR and stated the CPAP use and cleaning was not here [listed], and reiterated they were not sure if the device was being used or not. LPN-A stated if the nursing staff weren't managing the cleaning of the device then nobody, including R163, was likely cleaning it regularly. LPN-A stated they would check into it and follow up.
During subsequent interview, on 8/2/23 at 12:28 p.m., LPN-A stated R163 used to be a nurse prior to admission, however, had cognitive diagnoses present which could impair her cognition and recall. LPN-A stated they visited with R163's program manager, and explained R163 admitted to the center with the CPAP adding they don't know why the device use and cleaning weren't listed on the MAR. LPN-A explained they followed up with R163 who reported using the device, so LPN-A showed R163 where to locate the distilled water and going forward will set-up nursing reminders for R163 to ensure the device is cleaned and maintained. LPN-A then pointed to the mask, tubing, and water chamber which they had removed and placed in soapy water for cleaning at the nursing station. LPN-A stated they were uncertain if the center had a process or documented assessment to be completed if a resident was self-using devices like a CPAP; however, added such an evaluation would be good to complete as competency needs to be known.
On 8/2/23 at 12:41 p.m., registered nurse (RN)-B was interviewed. RN-B explained CPAP use and cleaning was typically tracked on the MAR and R163's CPAP must have just got missed. RN-B stated R163 likely needed some help or cues to safely use the device and ensure it was cleaned regularly. RN-B explained there was not a formal assessment to evaluate a resident' ability to manage a CPAP on their own as the discussion was more informal amongst the team. During subsequent interview, on 8/2/23 at 1:55 p.m., RN-B verified there was no formal assessment process to evaluate a resident' ability to self-manage a CPAP. RN-B stated there was no facility policy, to their immediate knowledge, regarding the self-use of the devices but there likely will be going forward. Further, RN-B stated it was important to ensure CPAP devices were maintained and cleaned on a regular basis to reduce the risk of infection and ensure patient safety.
A [NAME] II CPAP / [NAME] II Auto CPAP User Manual, dated 7/2018, identified several cautions and warnings to be considered with use of the device to prevent malfunction or patient injury. A section labeled, 17. Cleaning, directed regular cleaning of the device and it's accessories was . very important for the prevention of respiratory infections. The manual directed to use mild soap to clean the device, and the water chamber was recommended to be cleaned on a daily basis.
A provided Use and Cleaning of Continuous Positive Airway Pressure (CPAP) Unit policy, dated 11/1999, identified the purpose of the document was to ensure residents using a CPAP was . properly instructed in the application and use of the unit, and that cleaning instructions [were] performed by staff as scheduled. The policy directed the nurse would instruct the resident on placing the device on a flat, sturdy surface, plugging in the unit, connect the tubing and headgear as instructed in the manual, and positioning the tubing to loop over the forehead and bed board without kinks. A section labeled, Safety/Cleaning, directed each CPAP model varies but . every unit needs to be cleaned regularly. However, the policy lacked information on how resident self-use, including the steps listed in the policy, would be assessed or documented in the medical record to ensure competency and safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure structural repair recommendations from an outside pest control contractor were acted upon and completed timely to reduce the risk of rodent or pest entrance into the care center. This had potential to affect all 206 residents, visitors and staff at the facility.
Findings include:
A Centers for Disease Control (CDC) How to Control Wild Rodent Infestations article, dated 1/2023, identified rats and mice were known to carry various diseases which could be spread to a human population. These diseases included salmonellosis, monkeypox, and tularemia. Further, the article outlined it was important to seal gaps or holes in exterior walls adding, mice can fit through a hole the width of a pencil (1/4 inch or 6 millimeters in diameter).
R106's annual Minimum Data Set (MDS), dated [DATE], identified R106 had intact cognition. On 7/31/23 at 1:58 p.m., R106 was interviewed and expressed the care center had a little bit of a mouse problem. R106 explained they had seen mice within the nursing home, off and on, for a couple months including within the dining room which was next to the kitchen. R106 stated they thought the home had brought in an outside company to help address the issue, and explained even the food service director (FSD) had reported they turn the lights on in the dining room and the mice just scatter in the early morning hours. R106 stated they felt the issue had resolved until just last week when another female in the home screamed aloud they had saw a mouse run into the kitchen from the dining room.
R165's quarterly MDS, dated [DATE], identified R165 had intact cognition. On 7/31/23 at 2:29 p.m., R165 was interviewed. R165 stated the care center had mice and, as a result, they had several traps present within their room. R165 stated they had reported mice activity to the maintenance department who, in turn, then placed additional traps in their room but expressed nothing else about plans to correct the issue.
When interviewed on 8/3/23 at 8:19 a.m., living skills instructor (LSI)-A stated a male resident on the 2nd floor had reported a mouse in their room just a day or two prior, which had been reported to the maintenance department. LSI-A stated they had not noticed or heard of concerns with mice or rodents prior.
On 8/3/23 at 8:26 a.m., mental health worker (MHW)-A was interviewed, and expressed they had never personally observed mice or rodents at the center, however, residents had complained about them off and on adding they had last heard a complaint a few months prior. MHW-A stated the maintenance department would be notified of any such complaints and then it was in their hands after that.
When interviewed on 8/3/23 at 8:30 a.m., FSD stated they had seen mice in the dining room area but felt it had been awhile, adding the last time was at least a month ago. FSD stated the maintenance department was aware of the issue and, as a result, had EcoLab (an outside company) coming in and addressing it to their knowledge.
On 8/3/23, the reports from the outside pest control agency were requested and a blue-colored binder was provided. Inside, a series of paperwork was identified for each month work and/or inspection had been completed. These included:
A printed Ecolab Customer Service Report, dated 4/25/23, identified the care center was serviced and listed a section, Pest Activity Found, which outlined no rodent activity had been located adding, Spoke with and showed [[NAME]] structural concerns and findings related to rodent activity . informed me of rodent catches in patient rooms and sightings in kitchen/dining area. A section was labeled, Structural Concerns, which outlined a hole/gap was located around the wires entering the building for ventilation and fans on the East side of the building adding, Gaps are large enough for rodent entry. Please seal to prevent pest entry. A corresponding column labeled, Action Taken/Needed, identified, Seal to prevent pest entry . will reduce the numbers of pests entering the area. The report was signed by both the EcoLab service technician and maintenance personnel (MP)-A.
An additional printed EcoLab Customer Service Report, dated 5/16/23, identified the care center was again serviced and listed a section, Pest Activity Found, which identified rodent activity was found in the exterior of the building, inside a storage room, and in the ceilings. The section labeled, Structural Concerns, identified a hole/gap on the East side of the building was identified surrounding the area where air conditioning (AC) hoses entered the building, and a gap under the double doors by the garbage area which lead into the building. The report directed both areas should be sealed to prevent rodent entry and harborage. The report was signed by both the EcoLab service technician and maintenance personnel (MP)-A.
Further, a subsequent Ecolab Customer Service Report, dated 7/13/23, identified the care center was serviced and listed a section, Pest Activity Found, which outlined mice had been found in exterior stations (i.e., traps). These traps were inspected and serviced. The section labeled, Structural Concerns, outlined a hole/gap was found near the wall/ground junction on the northeast side of building between the AC unit and side door into the center. The area was treated and temporarily sealed with added dictation, Please seal hole with more permanent material. The corresponding area marked, Action Needed/Taken, outlined, Seal to prevent pest entry or harborage . measures here will reduce the number of pests entering the area. The report continued and another concern was listed which outlined a hole/gap was located in the back of the building next to the garbage area at the right base of the double doors entering the care center due to worn away concrete. This area was also treated and temporarily sealed which dictation present, Please seal permanently. The report was signed by both the EcoLab service technician and maintenance personnel (MP)-A.
On 8/3/23 at 10:55 a.m., the maintenance director (MAD) and director of operations (DOO) were interviewed. MAD stated they had just started working the center about two months prior, and MP-A would likely the best person to visit with about follow-up to the printed Ecolab reports as they had typically walked with the technician for each visit. DOO stated there had been a more expansive issue with mice and rodents during the pandemic as residents were eating more in their rooms. As a result, they had a building walk-through with an outside pest control agency who, at that time, helped seal up various openings and fix identified structural concerns. DOO explained the technician would review the reports with them at the end of each visit adding the previous MAD was more involved with the process. MAD and DOO both expressed any needed follow-up from the reports was Ecolab's responsibility to address adding the care center maintenance department had not acted to address any of the recommendations on the reports (dated 4/2023, 5/2023, 7/2023). However, DOO expressed they felt the mice and rodent situation at the center had improved tremendously from years prior.
A telephone call was placed to the EcoLab service technician on 8/3/23, with the request of a return call. However, a return call was never received.
On 8/3/23 at 11:42 a.m., an exterior tour of the care center was completed with MP-A and the MAD present. MP-A explained they tracked mouse or rodent reports using a flowsheet and, when reported, would place sticky traps on the patient rooms or area until the next Ecolab visit happened. MP-A verified they typically walked with the EcoLab technician and observed the areas outlined on the reports with the surveyor. The East side of the building had a large AC unit placed in the landscaping with black-colored wires running into the brick building, along with other empty holes present in the brick. MP-A observed this area and expressed it had been sealed at one time, however, the mice had chewed it up again. MP-A stated the area did not appear sealed or patched within the past several months as any work the Ecolab technician completed typically was more evident and of better quality. The area next to the garbage dumpster, located outside a double door which lead into the hallway/kitchen area of the center, was then observed. A gray-colored metallic tubing was visible entering the building with a dark-gray colored material present on one-half of the hole in the brick. However, the tubing was moveable and not secured which lead to visible openings between the material and tubing. In addition, the identified area under the double doors where concrete had been worn away had a piece of steel wool shoved inside with no other visible, more permanent, sealing material present. MP-A verified they had not completed any of the repairs, as outlined the the printed Ecolab reports, as the repairs were Ecolab's responsibility adding that's what we're paying them for.
A provided Insect and Rodent Control in the Food Service Area policy, dated 6/2016, identified the director of support services would ensure a licensed pest control performed inspections and pest control procedures on, at minimum, monthly basis. However, the policy lacked wording or dictation outlining who would make or was responsible for any needed repairs or actions.