Every finding on record at Avamere Rehabilitation of King City

Based on interview and record review, the facility failed to provide required discharge paperwork to residents and failed to ensure safe discharge plans were in place for 3 of 3 sampled residents (#s 1, 2 and 4) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include: 1. Resident 1 admitted to the facility in 5/2026 with diagnosis including lymphedema. Resident 1 discharged from the facility on 6/24/26. There was no evidence a recapitulation of Resident 1's stay in the facility was provided to Resident 1 at discharge or that written notice of discharge was provided as soon as practicable. Resident 1's Discharge Instructions documented an appointment with a primary care physician on 7/23/26. Resident 1's discharge instructions and Discharge order documented the need for home health PT and OT at discharge from the facility and the start of care was pending. On 8/12/26 at 1:29 PM Staff 4 (LPN) stated she did not review follow up appointments to Resident 1 or other residents at discharge, but she provided a copy of the Discharge Instructions for the resident to read and sign. On 8/13/26 at 10:47 AM Staff 8 (Social Services Director) stated the facility did not provide a written notice of discharge to residents. Staff 8 stated Resident 1 called the facility on 7/2/26 stating home health had not started. Staff 8 stated Resident 1's home health did not start timely due to her/him not having a PCP to follow during home health and this was not explained to Resident 1 prior to discharge. On 8/13/26 at 11:22 AM Staff 1 (Administrator) stated a written notice of discharge was not provided to Resident 1. On 8/13/26 at 11:32 AM Staff 9 (RNCM) stated the facility did not provide a recapitulation of stay with Resident 1 at discharge. On 8/13/26 at 12:22 PM Staff 2 (DNS) confirmed Resident 1's discharge from the facility was not safe based on the lack of ensuring the resident was connected with services outside the facility. 2. Resident 3 admitted to the facility on [DATE] with diagnosis including acute kidney failure. There was no evidence in Resident 3's clinical record that a written notice of discharge was provided to Resident 3.On 8/13/26 at 10:47 AM Staff 8 (Social Services Director) stated the facility did not provide a written notice of discharge to residents. On 8/13/26 at 11:22 AM Staff 1 (Administrator) stated a written notice of discharge was not provided to Resident 3. 3. Resident 4 admitted to the facility on [DATE] with diagnosis including stroke. There was no evidence in Resident 4s clinical record that a written notice of discharge was provided to Resident 4.On 8/13/26 at 10:47 AM Staff 8 (Social Services Director) stated the facility did not provide a written notice of discharge to residents.On 8/13/26 at 11:22 AM Staff 1 (Administrator) stated a written notice of discharge was not provided to Resident 4.

Based on interview and record review, it was determined the facility failed to assess a resident and communicate with the provider regarding management of resident symptoms for 1 of 3 sampled residents (#1) reviewed for changes of condition. This placed residents at risk of worsening symptoms. Findings include: Resident 1 admitted to the facility in 5/2026 with diagnoses including lymphedema and pain in left and and right ankles and feet.a. Resident 1's progress notes revealed the following:-On 5/25/26 at 8:03 PM Staff 3 (RN) documented Resident 1 requested to speak with Staff 3 regarding increased swelling to both of Resident 1's feet/ankles and Resident 1 was wondering about the use of a diuretic to manage the swelling. Staff 3's documented assessment sent to the provider indicated bilateral lower extremity swelling observed/reported.-On 5/29/26 at 10:04 PM Staff 3 documented Resident 1 requested to speak with the provider regarding her/his general care and needs.-There was no documented evidence Staff 3 assessed Resident 1. -On 5/31/26 at at 5:22 PM Staff 7 (RN) documented Resident 1 reported pain in lower limbs. She documented Resident 1 stated she/he had reported this to another nurse on 5/28/26 and was told a provider would see her/him. Resident 1 reported she/he had not been seen yet by the provider.There was no documented evidence Staff 7 assessed Resident 1.-On 6/1/26 at 12:54 AM Staff 3 documented Resident 1 reported her/his symptoms of swelling and pain had increased related to lymphedema and requested to be seen by the provider. Staff 3's documented assessment to the provider stated Resident 1 reported 7/10 pain.There was no documented evidence Staff 3 appropriately assessed Resident 1's feet or ankles.-On 6/1/26 at 11:20 AM Staff 7 documented she set up a virtual phone consultation with a provider.*On 6/1/26 at 11:39 AM PM Staff 5 (RN) documented a communication from the nurse practitioner on 5/28/26 that Resident 1's lab results were reviewed and no new orders were provided.-On 6/1/26 at 2:33 PM Staff 8 (Social Services Director) documented Resident 1 filed a grievance due to not being seen by a provider despite requests and reported having swelling in her/his legs that may prevent her/him from being discharged .-On 6/2/26 at 2:07 PM Staff 9 (RNCM) called the provider, who reviewed notes from the previous day and gave new orders for lasix (a diuretic) and gabapentin (a medication for the treatment of nerve pain).-On 6/3/26 at 5:14 PM Staff 9 documented she and Staff 2 (DNS) attempted to assess Resident 1 but were unable to as she/he was socializing with other residents. Staff 9 documented Resident 1 was seen by a provider in the morning, Resident 1's ambulation status had changed and no visible edema was noted on her/his foot or part of the leg.-On 6/4/26 at 10:35 AM The provider's note with date of service 6/3/26 documented Resident 1 was seen by the provider and may need more therapies depending on therapy assessment today based on functional needs.-On 6/8/26 at 11:14 AM A provider's note with date of service 5/28/26 and a plan including ongoing edema assessments.b. Resident 1's daily skilled notes included related to lymphedema included the following:-5/16/26 through5/23/26: Staff 7 and Staff 10 (RN) documented Resident 1 did not have edema.-5/24/26: Staff 2 (DNS) documented Resident 1 had non-pitting edema.-5/25/26: no edema documented by Staff 11 (RN)-5/26/26: pitting edema documented by Staff 12 (RN)-5/27/26: pitting edema documented by Staff 4 (LPN)-5/28/26: pitting edema documented by Staff 4 -5/29/26: pitting edema documented by Staff 4 -5/30/26: pitting edema documented by Staff 4 There was no documented evidence that staff completed any measurements to quantify the severity of the edema, assessed for color of the skin or any other signs of edema.On 8/12/26 at 12:53 PM Staff 3 stated the appropriate way to assess edema was to determine pitting and degree, measure leg girth, assess skin color and warmth. She stated this should be documented in the skilled charting or progress notes to track progress, and a provider should be notified of changes. Staff 3 stated her 5/25/26 and 6/1/26 assessments of Resident 1 and provider notifications were incomplete and she could not recall the appearance of Resident 1's legs.On 8/12/26 at 1:29 PM Staff 4 stated edema could be tracked by using a marker to trace the outline of the swelling, documenting the color and girth and how far up the leg the edema went. She stated this information should be included in the assessment and communication with the provider. She stated Resident 1 had edema continuously from the time she/he admitted , but she never measured them herself and stated the information should have been included in her 5/27/26 through 5/30/26 daily skilled charting.On 8/13/26 at 8:28 AM Staff 6 (Nurse Practitioner) stated she saw Resident 1 in the facility on 5/28/26 for ankle pain, swelling and history of lymphedema and to follow up on lab work that had been done. Staff 6 stated she was unaware if her/his edema was worse or better on that visit and stated she signed an order for an orthotic. She stated she did not order any new medications. Staff 6 stated she did not sign the note for her 5/28/26 visit until 6/8/26 so it was likely not available to the facility until 6/8/26.On 8/13/26 at 9:48 AM Staff 7 stated lymphedema assessments should include documentation of severity of swelling and signs or symptoms of infection, such as redness, drainage, and pain. She stated swelling could have been measured with measuring tape and assessed for pitting and to what degree. She stated Resident 1 always had edema, and her documentation in the daily skilled charting as no edema, was done by mistake. She stated on 5/31/26 Resident 1 complained of pain due to lymphedema, complained she/he had not been seen by a provider and offered to send her/him to the hospital. She stated she did not document her assessment and did not look to see if Resident 1 had been seen by a provider recently. She stated on 6/1/26 she set up a virtual consult with a provider but could not locate the provider's note from the visit in Resident 1's chart.On 8/13/26 at 11:32 AM Staff 9 (RNCM) stated nurses should document measurements for edema and use marker to document areas of swelling. She stated the facility did not have access to the provider's note from the virtual consult on 6/1/26.On 8/13/26 at 12:22 PM Staff 2 (DNS) stated all nurses were expected to complete a head-to-toe assessments and should be appropriately documented in the clinical record and the provider was to be notified of changes. Staff 2 acknowledged Resident 1's assessments were incomplete and inaccurate. She stated the facility did not have access to Staff 9's 5/28/26 provider note until 6/8/26 and could not locate a provider note for the 6/1/26 virtual consult with a provider.

Based on interview and record review, the facility failed to write, sign and date progress notes at each provider visit for 1 of 3 residents reviewed for change of condition (#1). This placed residents at risk for inaccurate and incomplete medical records. Findings include: Resident 1 admitted to the facility in 5/2026 with diagnoses including lymphedema and pain in both ankles and feet.Resident 1's Progress Notes documented the following:-On 6/1/26 at 11:20 AM Staff 7 documented she set up a virtual phone consultation with a provider.-On 6/8/26 at 11:14 AM A provider's note with date of service 5/28/26 and a plan including ongoing edema assessments.Staff 6's (Nurse Practitioner) note dated 5/28/26 was signed on 6/8/26, 11 days after the visit.There was no documented evidence in Resident 1's clinical record of the 6/1/26 virtual consultation with a provider.On 8/13/26 at 8:28 AM Staff 6 stated she did not sign the 5/28/26 visit note until 6/8/26.On 8/13/26 at Staff 2 (DNS) could not locate the 6/1/26 virtual phone consultation provider note in Resident 1's clinical record and agreed the 5/28/26 provider note was not signed at the time of visit and was not signed until 6/8/26.Refer to F684

Based on interview and record review, the facility failed to complete and maintain accurate medical records for 1 of 3 residents reviewed for change of condition (#1). This placed residents at risk for not having accurate medical records. Findings include:Resident 1 admitted to the facility in 5/2026 with diagnoses including lymphedema and pain in both ankles and feet.Resident 1's daily skilled notes documented the following:-On 5/17/26 Staff 7 (RN) charted no edema;-On 5/18/26 Staff 7 charted no edema;-On 5/31/26 Staff 7 charted no edema; and-On 6/1/26 Staff 7 charted no edema.Resident 1's 6/1/26 at 11:20 AM Progress Note indicated Staff 7 documented she set up a virtual phone consultation with a provider.There was no documented evidence in Resident 1's clinical record of the 6/1/26 virtual consultation with a provider.On 8/13/26 at 9:48 AM Staff 7 stated Resident 1 had edema for the duration of her/his stay, and her documentation was a mistake and not accurate.Resident 1's 6/1/26 at 11:20 AM Progress Note indicated Staff 7 documented she set up a virtual phone consultation with a provider.On 8/13/26 at Staff 2 (DNS) stated she could not locate the 6/1/26 virtual phone consultation provider note in Resident 1's clinical record and confirmed Resident 1's clinical record was inaccurate and not reflective of her/his ongoing edema.Refer to F684 and F711

Based on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of 3 sampled residents (#4) reviewed for change of condition. This placed residents at risk for a decline in overall functioning. Findings include:The facility's 3/2018 Acute Condition Changes-Clinical Protocol policy documented the nurse shall assess and document/report the following baseline information: vital signs, neurological status, current pain level, level of consciousness, and onset, duration and severity of condition. Resident 4 was re-admitted to the facility in 12/2025 with diagnoses including multiple sclerosis and opioid use. Resident 4's Quarterly MDS dated 1/2026 documented a BIMS score of 15 indicating the resident was cognitively intact. Resident 4's assessment also indicated she/he had chronic pain.The 11/25/25 Blood Pressure Summary Report documented Resident 4's blood pressure was 86/53 at 5:00 AM by Staff 6 (LPN). Resident 4's 11/25/25 Progress Note at 6:50 AM, indicated Staff 6 charted Resident 4's blood pressure as 70/50. Staff 6 called provider and 911. No additional information was documented. On 2/18/26 at 2:32 PM, Staff 6 (LPN) stated she had cared for Resident 4 during the night shift on 11/24/25 through 11/25/25. Staff 6 stated the morning of 11/25/25 staff was unable to wake Resident 4. Staff 6 stated Resident 4's blood pressure was abnormal and low. Staff 6 called the provider then called 911. A Fire and Rescue Public Incident Report documented that a call from the facility was received on 11/25/25 at 6:46 AM stating Resident 4 was found with altered mental status. Paramedics arrived at the facility at 6:50 AM. Staff 6 (LPN) reported to the paramedics that Resident 4 was found altered at 5:00 AM. Paramedics administered Narcan (an antidote for opioids), and Resident 4's vital signs improved. Resident 4 was transported to the hospital. On 2/20/26 at 10:19 AM, Staff 14 (CNA) stated she had cared for Resident 4 during the night shift on 11/24/25 through 11/25/25. Staff 14 stated Resident 4 appeared to be sleeping through-out the night. Staff 14 stated when she took Resident 4's blood pressure at 5:00 AM it was very low. Staff 14 alerted Staff 6 (LPN) and Resident 4's blood pressure was rechecked and continued to be low. Staff 14 stated Staff 6 assisted her in providing incontinence care to Resident 4. Staff 14 stated it was odd Resident 4 did not wake up during care because the resident usually woke up when staff laid the resident flat. Staff 14 stated Resident 4 sometimes would stay awake for three days and then slept hard. Staff 14 stated Resident 4 did not respond to them. Staff 14 stated Staff 6 called the provider and 911.The 12/2/25 Hospital Discharge Summary revealed Resident 4 was admitted to the hospital for septic shock due to UTI, acute kidney injury, acute metabolic encephalopathy and acute hypoxic/hypercapnic respiratory failure.On 2/20/26 at 2:46 PM, Staff 1 (Administrator) acknowledged there was a delay by staff in responding to Resident 4's change of condition and Resident 4's progress notes did not include the baseline information regarding her/his change of condition.

Based on observation, interview and record review it was determined the facility failed to acquire the correct route for an emergency (Narcan) medication for 1 of 3 sampled residents (#4) reviewed for pharmaceutical services. This placed residents at risk for not receiving the correct route for their emergency medication. Findings include: Resident 4 was re-admitted to the facility in 12/2025 with diagnoses including multiple sclerosis, diabetes and opioid use. Resident 4's 11/2025 Physician Orders included an order for naloxone HCL (Narcan-an antidote medication for opioids) nasal liquid 4mg/0.1ML to be administered in both nostrils as needed for decreased responsiveness. On 2/19/26 at 12:34 PM, observations of the facility's emergency kit found Narcan as an intravenous route rather than the nasal route as prescribed for Resident 4. On 2/20/26 at 2:46 PM, Staff 1 (Administrator) acknowledged the facility did not have the correct Narcan route administration (nasal) for Resident 4.

Based on observation, interview, and record review, it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled residents (#s 4, 5, and 20) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include:The facility's 11/2025 Activities Policy revealed the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. The facility provided an activities program that addressed the intellectual, social, spiritual, creative, and physical needs, capabilities, and interests of each resident. 1. Resident 4 was admitted to the facility in 2021 with diagnoses including major depressive disorder and dementia. Resident 4's Activities Care Plan, revised on 7/11/25, indicated the following: -Resident 4 liked music, pet therapy, one-on-one conversations, reminiscing, stuffed animals, gardening, flowers, and birds. -Resident 4 was to have one-on-one bedside visits and activities to include music, animal visits, bird watching discussions, manicures, hand massages, and assistance looking through magazines. -Resident 4 was Christian, and the Activities Department was to provide gospel music. Resident 4's 10/15/25 Significant Change MDS revealed the resident had severe cognitive impairment. Her/his activity preferences indicated it was somewhat or very important to do her/his favorite activities, be around animals, and participate in religious services and practices. Resident 4's 11/4/25 through 12/4/25 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation for one-on-one visits and one refusal on 12/1/25 for group participation. A review of Resident 4's electronic health record contained no evidence the resident participated in any activities. A review of the facility's activities calendar revealed five different activities each day between 8:30 AM and 6:00 PM From 12/1/25 through 12/4/25 Resident 4 was observed awake in her/his room with the blinds closed and not engaged in any activities on 9 occasions. On 12/4/25 at 10:19 AM Staff 24 (CNA) stated Resident 4 did not get out of bed, and she/he got confused when out of her/his room. Staff 4 stated she has not seen any activities occurring in Resident 4's room, and she was not aware of any one-on-one activities being done. Staff 24 stated Resident 4 would benefit from one-on-one activities. On 12/4/25 at 11:24 AM Staff 25 (CNA) stated Resident 4 spent her/his day in bed and would benefit from one-on-one activity visits. On 12/4/25 at 12:34 PM Staff 11 (Activities Director) stated she was the only person in the activities department, and was responsible for completing all care conferences, Activity MDS Assessments, Activities admission Profiles, shopping for residents, delivering mail, engaging residents in group and one-on-one person-centered activities, as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends or when she was not in the facility. Staff 11 was unable to provide dates or times of any specific activities completed with Resident 4 and confirmed no activities documentation was completed. Staff 11 stated she did not have enough time to meet all residents' activity needs. On 12/5/25 at 8:41 AM Resident 4 stated she/he liked to look out of her/his window, listen to music, bird watch, and visit with pets. On 12/5/25 at 9:54 AM Staff 1 (Administrator) stated her expectations were that all residents received activities according to their person-centered care plan. Staff 1 stated she was actively recruiting for an additional activities assistant position. 2. Resident 20 admitted to the facility in 10/2025 with diagnoses including malignant neoplasm (cancerous tumor) of the brain. Resident 20's 10/16/25 admission Activity Profile, completed by Staff 11 (Activity Director) identified the resident was in the facility for Hospice/End of life care. Resident 20 enjoyed listening to music, family visits and reminiscing. Resident 20's 10/17/25 admission MDS assessed music was very important and it was somewhat to participate in religious services and/or practices and participate in her/his favorite activities. She/he was identified to have hospice services with a life expectancy of less than six months. On 12/3/25 at 8:24 AM and 10:50 AM Resident 20 was observed to lie in her/his dark room, no television or music playing, with eyes open and she/he was unresponsive to verbal stimuli. At 12:32 PM her/his family was visiting and Witness 9 (Family) stated the television was broken, and she/he had no music opportunities in the room. On 12/3/25 at 2:23 PM Staff 29 (CNA) stated they obtained the information to provide care including activities from the care plan. Resident 20 listened to music on her/his television and they took her/him to the activity room sometimes to listen to music. Staff 29 stated the Activity Director did not invite residents unless CNAs took the residents down to the activity room. On 12/4/25 at 12:08 PM Resident 20 was observed in her/his bed with family visiting. The family brought in a music device to listen to while they were visiting as the television still was not working and the facility did not provide any alternative way to listen to music. A care plan dated 12/4/25 revealed Resident 20 was dependent on staff for participation in activities. Activities such as music, one on one visits, television and group activities were to be offered per the resident's choice and as tolerated. On 12/4/25 Resident 20's past 30 days of activity participation revealed no one on one visit were documented as offered and it was documented she/he attended three group activities. On 12/4/25 at 12:33 PM Staff 11 stated she was unaware Resident 20 received hospice services and confirmed she completed the Activity Profile which indicated hospice services were received upon admission. Staff 11 confirmed the lack of activity participation documentation for Resident 20 and acknowledged the group activity documented for 12/2/25 was an in-room pet visit by a volunteer. She was unable to express meaningful one on one visits with Resident 20 or engaging group activities. Staff 11 stated she was unaware Resident 20's television was broken as she did not see the resident this past week because she was too busy with everything to get to all residents. On 12/4/25 at 1:24 PM Witness 9 stated they were aware Resident 20 would sit in front of the television in the dining room while music played but no engagement or interactions occurred. On 12/5/25 at 10:42 AM Staff 1 (Administrator) stated she expected Resident 20 to be offered, as tolerated, resident centered, meaningful and engaging activities, especially since she/he was on hospice. Staff 1 expected all activities to be provided and documented. 3. Resident 5 admitted to the facility in 2020 with diagnoses including major depression. Resident 5's most recent Activity Profile assessment dated [DATE], identified her/his leisure interests as fishing, camping, outdoors, car shows, outdoor shows, radio with music from the past, reading horror and documentaries, card games, bingo game, mechanics, art, drawing, painting and bible studies. Resident 5's 8/26/25 Significant Change MDS assessed her/him to be cognitively intact with little interest or pleasure in doing things and feeling down. The Activity Preferences section identified the only activity preferences were to do her/his favorite activities and to go outside. On 12/3/25 at 8:27 AM, 10:20 AM, 12:40 PM, 2:43 PM and 12/4/25 at 10:11 AM Resident 5 was observed to lie in her/his bed, with a hat over her/his eyes in a dark, quiet room and not engaged in any diversional leisure activities. On 12/4/25 at 12:16 PM Staff 32 (CNA) stated Resident 5 did not participate in activities and she never saw the Activities Director interact with the resident. On 12/4/25 at 12:22 PM Resident 5 stated she/he asked for reading glasses several months ago and did not receive them. His room was observed not to have any reading books of horror or documentaries, and she/he stated she/he would read if the glasses and books were available. Resident 5 stated she/he could make her/his own leisure decisions but wanted access to more leisure items of interest to occupy her/his time as she/he was bored often. Resident 5 stated she/he did not get asked to attend groups, except for this week and even if she/he wanted to attend groups this week the November 2025 acalendar was still up in her/his room so she/he did not know the daily activities. Resident 5's 12/4/25 Care Plan directed staff to offer one on one activities, provide supplies to facilitate independent activities such as birdseed, squirrel food, gardening supplies and to sit outside. The 12/4/25 Activity Task for participation for the last 30 days revealed Resident 5 participated in no self-directed activities, no one on one activities and refused two groups activities. On 12/4/25 at 12:33 PM Staff 11 confirmed the lack of activity participation documentation. Staff 11 could not express Resident 5's offered opportunities of an ongoing resident centered activities program which incorporated the resident's interests, hobbies and cultural preferences which was integral to maintaining and/or improving the resident's physical, mental, and psychosocial well-being and independence. On 12/5/25 at 10:42 AM Staff 1 (Administrator) stated she expected Resident 5 to be offered and provided supplies for resident centered, meaningful and engaging activities.

Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 1 sampled resident (#74) reviewed for dignity and respect. This placed residents at risk for lessened quality of life. Findings include:Resident 74 readmitted to the facility in 2024 with diagnoses including depression and anxiety.A 9/11/24 Facility Reported Incident indicated on 9/9/24 an incident between Resident 74 and Staff 9 (Former Medical Records) occurred outside in the garden area of the facility. Staff 8 (Housekeeping Manager) heard Staff 9 call Resident 74 a Goddamn fucking liar. The incident was witnessed by several residents and Staff 11 (Activities Director).The facility incident report indicated on 9/9/24 Resident 74 was outside in the garden. Resident 74 and Staff 9 were heard arguing about a plant that was allegedly uprooted and thrown in the garbage by the resident. Resident 74 denied the allegation and indicated another resident asked her/him to uproot the plant and move it to a different area for it to grow. The facility concluded staff 9 did not treat Resident 74 with dignity and respect. Facility interviews indicated the following:- Resident 74 indicated she/he was being blamed and was called a [NAME] by Staff 9. Resident 74 indicated she/he started the yelling because she/he was upset for being blamed for something she/he didn't do.- Staff 11 indicated she saw Staff 9 and Resident 74 yelling at each other over the plant. Staff 11 indicated Resident 74 insisted she/he did not throw the plant away and Staff 9 called the resident a liar. Staff 11 indicated heated words were exchanged between Staff 8 and Resident 74.- Staff 8 indicated she heard yelling in the garden area and heard Staff 9 call Resident 74 a goddamn fucking liar and went to de-escalate the situation. - Staff 9 denied calling Resident 74 a liar and indicated another resident called her/him a liar. Staff 9 indicated Resident 74 started yelling at her. Staff 9 indicated her voice may have been raised.On 12/2/25 at 10:23 AM Staff 11 stated the incident between Staff 9 and Resident 74 occurred in the garden area. Staff 11 stated she heard the resident and Staff 9 getting into an argument about plants being pulled and thrown away. Staff 11 stated she heard Staff 9 call Resident 74 a liar. Staff 11 stated it was inappropriate for Staff 9 to call the resident a liar and the incident was uncomfortable for everyone. Staff 11 stated she could not recall if profanities were used by Staff 9.On 12/2/25 at 10:25 AM Staff 8 stated the incident occurred outside in the garden. Staff 8 stated she heard Staff 9 say either shut the fuck up or shut the hell up to Resident 74. Staff 8 stated Staff 9 and Resident 74 were yelling at each other, and she went outside and told them both to calm down.On 12/4/25 at 9:01 AM Staff 9 stated another resident told her Resident 74 pulled out plants. Staff 9 stated she told Resident 74 that no one called her/him a liar. Staff 9 denied raising her voice and stated she used her mother tone with Resident 74 and only repeated back what Resident 74 had said, fucking liar.On 12/1/25 at 9:59 AM Staff 1 (Administrator) acknowledged the lack of dignity and respect occurred between Staff 9 and Resident 74 on 9/9/24.On 9/17/24 the facility provided information to indicate an action plan to prevent future occurrences was completed; audits, education and an in-service was completed related to treating resident with respect and dignity. The deficient practice was determined to be past non-compliance, corrected on 9/17/24.

Based on interview and record review it was determined the facility failed to include and inform residents in advance of a change in pain medication for 1 of 1 sampled resident (#60) reviewed for pain. This placed the residents at risk for the inability to participate in their plan of care for pain management. Findings Include:Resident 60 admitted to the facility in 7/2025 with a diagnosis of Atherosclerosis (hardening of arteries) of left leg with rest pain.Resident 60's 7/15/25 Quarterly MDS indicated the resident was cognitively intact.Resident 60's 11/10/25 Physician Order indicated Resident 60's morphine was to be changed from TID to BID.Resident 60's health record revealed no evidence the decrease in morphine was discussed with the resident.A Progress Note dated 11/15/25 completed by Staff 20 (RN) indicated Resident 60 expressed frustration regarding recent medication changes and those changes were made without her/his consent.On 12/1/25 at 12:54 PM Resident 60 reported her/his morphine pain medication was recently reduced and reported she/he was not included in the decision.On 12/3/25 at 4:04 PM Staff 3 (LPN Resident Care Manager) reviewed Resident 60's health record and acknowledged that the resident was not included and informed in the decision to change the resident's pain medication.On 12/4/25 at 3:27 PM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 stated when a resident's pain medication was changed, the resident was to be included and informed.

Based on observation, interview, and record review, it was determined the facility failed to provide mobility bars as ordered for 1 of 1 sampled resident (#16) reviewed for accommodation of needs. This placed residents at risk for loss of ability to reposition independently. Findings include:Resident 16 was admitted to the facility in 1/2024 with diagnoses including type 2 diabetes mellitus. Resident 16's 8/5/25 physician order indicated the use of bilateral bed mobility bars.Resident 16's Care Plan, revised on 9/3/25, revealed bilateral mobility bars were to be used to increase resident participation with bed mobility.Resident 16's 11/2025 Annual MDS revealed Resident 16 was cognitively intact and required one-person assistance with mobility.Multiple observations from 12/1/25 through 12/4/25 between the hours of 11:01 AM to 3:33 PM revealed there was one mobility bar on the right side of Resident 16's bed.On 12/1/25 at 11:01 AM and 12/3/25 at 1:29 PM Resident 16 stated she/he was told she/he would have two mobility bars placed on her/his bed, but was only provided with one mobility bar. Resident 16 stated mobility bars would help her/him reposition herself/himself in bed.On 12/3/25 1:43 PM Staff 12 (CNA) stated Resident 16 used the mobility bar on her/his bed to assist with transfers and had only seen one mobility bar.On 12/4/25 at 10:32 AM Staff 24 (CNA) stated Resident 16 needed help adjusting herself/himself in bed when she/he was weak. Staff 24 stated the resident was care planned for one mobility bar according to Resident 16's Kardex (a system used by CNA staff to communicate important information).On 12/4/25 at 11:12 AM Staff 3 (LPN Resident Care Manager) confirmed Resident 16 was supposed to have two mobility bars on her/his bed.On 12/5/25 at 9:54 AM Staff 1 (Administrator) stated her expectation was Resident 16's care plan and physician orders for two mobility bars would be followed. Staff 1 confirmed Resident 16 only had one mobility bar on her/his bed.

Based on observation, interview, and record review it was determined the facility failed to provide nonpharmacological interventions prior to the use of a PRN psychotropic medication and provide a rationale for indications for use of a PRN psychotropic medication for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for unnecessary psychotropic medication use and adverse side effects. Findings include:Resident 2 was admitted to the facility in 4/2025 with diagnoses including dementia. The resident's care plan for cognitive impairment, updated on 8/9/25, indicated behavioral disturbance and anxiety. Behavioral interventions included: assessing needs, creating a safe environment, offering activities, and reassuring the resident. The 10/9/25 Quarterly MDS identified Resident 2 was assessed to have no behaviors. Resident's 2's 11/2025 MAR revealed an order for PRN lorazepam (anti-anxiety) every four hours as needed for agitation, anxiety, restlessness, or nausea. The MAR indicated the PRN lorazepam was administered 20 times. No evidence or documentation was found in Resident 2's health record which demonstrated the use of nonpharmacological interventions prior to the administration of lorazepam, or a rationale for the use of lorazepam. From 12/2/25 through 12/5/25 between the hours of 8:42 AM and 3:15 PM the resident was observed to be in her/his room either in a wheelchair sleeping or awake and without behaviors. On 12/4/25 at 1:20 PM Staff 13 (CNA) reported Resident 2 occasionally had behaviors such as screaming or hitting at people but was easily redirected by watching television and drinking hot cocoa. On 12/4/25 at 1:39 PM Staff 32 (CNA) was able to identify strategies of giving hot cocoa and offering care choices as appropriate options for managing Resident 2's behaviors. Staff 32 said resident could be aggressive at times but was typically good natured. On 12/5/25 at 9:59 AM Staff 33 (CNA) identified Resident 2's behaviors occurred about twice per week when the resident wanted attention or hot cocoa. Staff 33 said the resident was redirected by putting on movies, braiding hair, or providing hot cocoa. On 12/5/25 9:49 AM Staff 19 (LPN) stated Resident 2's behaviors related to the use of lorazepam included yelling out if something was in her/his way, repeatedly asking for ice cream, and putting herself/himself on the floor. Staff 19 said the resident was redirected with music and watching DVDs. On 12/5/25 10:09 AM Staff 3 (LPN Resident Care Manager) said the expectation was for nurses to document each time behaviors occurred and resulted in the administration of PRN lorazepam. Staff 3 acknowledged the need for staff to utilize nonpharmacological interventions prior to administering PRN lorazepam.

Based on observation, interview and record review it was determined the facility failed to evaluate and manage increased pain after a pain medication change for 1 of 1 sampled resident (#60) reviewed for pain. This placed residents at risk for increased and unmanaged pain. Findings include:Resident 60 admitted to the facility in 7/2025 with a diagnosis of Atherosclerosis (hardening of arteries) of left leg with rest pain.Resident 60's 7/15/25 Quarterly MDS indicated the resident was cognitively intact, had almost constant pain and received scheduled and PRN pain medication.Resident 60's 10/17/25 Pain Care Plan included to attempt non-medication interventions prior to administration of pain medication, provide pain medications per the physician's orders, provide diversional activities, and to report complaints of pain to the nurse.The 10/17/25 Pain Evaluation specified Resident 60 received scheduled and PRN pain medication. The pain was reported as neuropathic, aching and burning in her/his lower back and left lower extremity. The pain was almost constant and was rated 7 out of 10 on the pain scale.Resident 60's 11/10/25 Physician Order indicated Resident 60's morphine changed from TID to BID.Progress Notes dated 11/11/25-12/4/25 noted Resident 60's complaints of increased pain. Resident 60 expressed concerns to staff that the pain was not adequately controlled and requested to speak with a provider.There was no documentation in Resident 60's health record to indicate the provider followed up regarding the ongoing pain complaints.On 12/1/25 at 12:54 PM Resident 60 reported her/his morphine pain medication was recently reduced and stated since the reduction she/he experienced increased phantom pain, restless leg symptoms, and difficulty sleeping. Resident 60 stated she/he reported increased pain to staff and asked to talk to the provider. Resident 60 stated the provider did not speak with her/him. Resident 60 was observed sitting up in bed and periodically rubbed her/his left leg.On 12/3/25 at 2:58 PM Staff 29 (CNA) reported Resident 60 complained of pain while using the bed pan or turning in bed.On 12/3/25 at 4:04 PM Staff 3 (LPN Resident Care Manager) reviewed Resident 60's health record and acknowledged Resident 60 complained of increased pain from 11/11/25 through 12/3/25. Staff 3 stated the provider was notified of the increased pain on 11/11/25. Staff 3 acknowledged there was no follow up after that date. Staff 3 stated she expected the increased pain to be addressed within a few days of the provider notification.

Based on interview and record review, it was determined the facility failed to comprehensively assess and develop mood and behavior interventions specific to expression of suicidal ideations for 1 of 1 sampled resident (#47) reviewed for behavioral/emotional health. This placed residents at risk for increased behaviors and a decline in psychosocial well-being. Findings include: The facility's 8/2025 Behavioral Health Services Policy revealed residents who exhibited signs of emotional/psychological distress received services and support to address their individual needs and goals for care.Resident 47 was admitted to the facility in 10/2025 with diagnoses including major depressive disorder. Resident 47's 10/11/25 hospital History and Physical Exam revealed Resident 47 had a diagnosis of suicidal ideations.Resident 47's 10/17/25 Social History Evaluation revealed Resident 47 stated she/he had a history of suicidal ideations.Resident 47's Care Plan dated 10/17/25 did not have interventions for suicidal ideations.On 12/1/25 at 9:51 AM Resident 4 stated she/he tried to commit suicide in the past and had suicidal thoughts occasionally since admission to the facility. Resident 4 stated, I have told them I am ready to go.On 12/4/25 at 10:03 AM Staff 24 (CNA) stated she was unaware of Resident 47's suicidal ideations. On 12/4/25 at 11:36 AM Staff 25 (CNA) stated Resident 47's mood and behaviors fluctuated and included dysregulation of mood, yelling, rude and sexual comments, and demanding behaviors. Staff 25 was unaware of Resident 47's suicidal ideations.On 12/4/25 at 1:37 PM Staff 10 (Social Services Director) stated she did not know Resident 47 had suicidal ideations. Staff 10 stated she reviewed the Social History Evaluation for Resident 47 but did not review it closely enough to notice the suicidal ideations mentioned in the evaluation. Staff 10 stated she would have referred Resident 47 to the facility's mental health provider right away, talked to family and Resident 47 about her/his suicidal ideations right away, and would have added care plan interventions immediately, if she knew about Resident 47's suicidal ideations. Staff 10 stated she did not speak with Resident 47 beyond one meeting regarding behaviors in therapy.On 12/4/25 at 1:51 PM Staff 28 (Social Services Coordinator) stated Staff 10 reviewed the Social History Evaluation before it was finalized. Staff 28 stated she noted suicidal ideations on Resident 47's 10/17/25 Social History Evaluation, but no follow-up occurred. She stated she did not speak to Resident 47 except for discharge planning.On 12/5/25 at 9:54 AM Staff 1 (Administrator) stated she expected residents with a diagnosis or statements of suicidal ideation to be immediately and comprehensively assessed the resident and determined what services were needed.

Based on interview and record review it was determined the facility failed to ensure an account of all controlled drugs was maintained for 1 of 1 sampled resident (#2) reviewed for drug diversion. This placed residents at risk for drug diversion. Findings include:On 10/13/25 a FRI was received that indicated on 10/11/25 at 10:00 PM it was discovered that Resident 2 was missing methadone (narcotic medication). The facility investigation indicated on 10/12/25 two staff members counted narcotic medication at the end of their shift and found Resident 2 had 18 tablets of missing methadone. A staff member indicated she may have thrown away the medication. The facility was unable to locate the missing medicationThe 300 hall Controlled Substance Book number 29, page 108 revealed methadone had 18 tablets remaining on 10/11/25. There was no indication of the disposition of the remaining medication.On 12/4/25 at 8:24 AM Staff 12 (CMA) stated she worked a double shift on 10/11/25 and may have accidentally thrown the medication away. Staff 12 stated there were no discrepancies when counting with the oncoming CMA, Staff 23 (CMA) and they did not compare the narcotic pages to the narcotic cards.On 12/4/25 at 2:27 PM Staff 23 (CMA) stated she counted narcotics with Staff 12 on 10/11/25 and did not find a discrepancy because the narcotic pages were not compared with the narcotic cards.On 12/4/25 at 8:53 AM Staff 2 (DNS) acknowledged Resident 2 had 18 doses of methadone that were unaccounted for and Staff 12 and Staff 23 failed to reconcile narcotic medication.On 12/5/25 the facility provided information to indicate an action plan to prevent future occurrences was completed; audits, education and an in-service was completed related to controlled medication storage, controlled medication administration and abuse. The deficient practice was determined to be past non-compliance, corrected on 11/19/25.

Based on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's 10/2019 Staffing Policy indicated the facility provided an on-going review of resident acuity and ensured adequate staffing to meet scheduled and unscheduled needs of the residents. 1. A review of the Resident Council notes revealed the following: -The 9/2024 Resident Council notes revealed resident concerns about call light wait times. -The 10/2024 Resident Council notes revealed residents call lights were deactivated without providing care. -The 12/2024 Resident Council notes revealed residents stated the 300 Hall required heavy care. The residents felt more staff was needed and the residents stated they had to wait a long time for food trays to be removed. The facility's 9/2024 through 12/2024 Direct Care Staff Daily reports revealed the facility was understaffed for CNAs for 39 of 116 days reviewed for the state minimum staffing requirements. On 1/7/25 the facility had a census of 60 residents. On 1/7/25, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers:16; -Were dependent for ADLs: 13; -Were considered high fall risks: 21 and -Were at risk for elopement: 3 On 1/9/25 at 2:45 PM Staff 20 (Scheduling Coordinator) confirmed, from 9/7/24 through 12/31/24, CNA staffing was short on many shifts. On 1/10/25 at 1:32 PM Staff 1 (Administrator) acknowledged the facility struggled to maintain adequate staffing levels and made efforts to meet the state minimum CNA requirements. 2. On 10/22/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs resulting in long call light response times and basic care not being met. On 10/25/24 three public complaints were received by the State Agency which alleged the facility was short staffed CNAs on 9/28/24, 10/6/24 and 10/7/24 resulting in decreased quality of care, requests not met timely, safety of residents at risk for a fall, and long call light response times. It was reported that residents were anxious, agitated, and worried they would not receive the care they needed. On 12/26/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on 12/24/24 and 12/26/24 resulting in residents not receiving showers and long call light response times. On 12/30/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs resulting in residents not receiving showers, lack of timely incontinence care and long call light response times of over an hour. On 1/7/25 at 11:26 AM and 11:35 AM Staff 23 (CNA) and Staff 3 (CNA) stated the evening shift often ran short staffed CNAs. Staff 23 stated several residents required two person assistance and some residents were at risk for elopement. Staff 3 stated residents' scheduled showers often were not completed when the facility ran short staffed. On 1/7/25 at 1:34 PM, 3:19 PM and 3:36 PM Staff 10 (CNA), Staff 17 (CNA) and Staff 16 (CNA) stated when the facility ran short staffed CNAs on the evening and night shifts they were directed to provide residents with basic care, which resulted in increased behaviors from residents. On 1/8/25 at 2:32 PM Staff 24 (RN) stated the night shift on weekends ran short staffed of CNAs and there were several residents who are up all night. On 1/8/25 at 2:43 PM Staff 25 (CNA) stated evenings and weekends tended to have longer call light wait times due to the short staffed CNAs. On 1/8/25 at 3:02 PM and at 3:08 PM Staff 26 (CNA) and Staff 14 (CNA) stated due to short staffed CNAs the staff did not receive their scheduled breaks and lunches. Staff 14 stated it was very tough to complete tasks like showers. On 1/9/25 at 10:12 AM Staff 21 (CMA) stated on 12/24/24 the evening shift was short staffed CNAs; only three CNAs arrived for work. Staff 21 stated ADL tasks were not offered and documentation in resident medical records was not completed. On 1/9/25 at 2:45 PM Staff 20 (Scheduling Coordinator) stated she staffed CNAs based on the census and by the CNA mandatory minimum staffing ratios. Staff 20 confirmed, from 9/7/24 through 12/31/24, CNA staffing was short on many shifts. On 1/10/25 at 1:32 PM Staff 1 (Administrator) acknowledged the facility struggled to maintain adequate staffing levels and made efforts to meet the state minimum CNA requirements. Staff 1 stated he was unaware of residents not receiving scheduled showers due to short staffing. 3. Resident 6 was admitted to the facility in 2019 with diagnoses including fibromyalgia and diabetes. The 10/26/24 Quarterly MDS indicated Resident 6 was cognitively intact and required substantial assistance with showering. On 12/30/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on 12/24/24 and 12/26/24 resulting in residents not receiving showers. A review of the 12/2024 shower log revealed the resident was not available and did not receive a shower on 12/26/24, and the last shower received was on 12/22/24. A review of the 12/26/24 progress notes revealed Resident 6 was offered a shower by the CNA and refused. On 1/8/25 at 2:31 PM Witness 2 (Complainant) stated the facility was often understaffed, especially on evening shift. Witness 2 stated Resident 6 did not receive a scheduled shower on 12/26/24 due to short staffed CNAs. On 1/9/25 at 11:40 AM Staff 19 (CNA) stated they worked the evening shift on 12/26/24 and the facility was short staffed three CNAs. Staff 19 stated Resident 6's scheduled shower was not completed due to low staffing and the resident required two-person assistance. Staff 19 stated Resident 6 never refused a shower on 12/26/24. On 1/9/25 at 1:04 PM Resident 6 stated she/he did not receive a shower on 12/26/24 as the facility was short staffed CNAs so the shower was skipped. The resident stated that was a common occurrence. On 1/9/25 at 11:52 AM Staff 2 (Regional RN) confirmed Resident 6 did not receive a shower on 12/26/24. On 1/10/25 at 12:40 PM Staff 22 (RN) stated they worked the evening shift on 12/26/24 and recalled the facility was short staffed CNAs that shift. Staff 22 stated Resident 6 required two-person assistance with showering and that was difficult to complete when they are short staffed. On 1/10/25 at 1:33 PM Staff 1 (Administrator) stated he was unaware of residents not receiving scheduled showers due to short staffing. 47005 4. Resident 15 was admitted to the facility in 6/24/24 with diagnoses including urinary tract infection and diabetes. The 12/29/24 Quarterly MDS indicated Resident 15 was cognitively intact and required substantial assistance with showering. On 1/9/25 at 1:08 PM Resident 15 stated her/his shower days were on Tuesdays and Fridays and was unsure if she/he missed any showers. Resident 15's December 2024 shower log revealed the resident received a shower on 12/13/24, refused a shower on 12/17/24, and received showers on 12/20/24 and on 12/27/24. Resident 15 went seven days between showers for two weeks. On 1/10/25 at 11:32 AM Staff 16 (CNA) stated Resident 15 did not receive a shower due to staffing shortage. Staff 16 stated Resident 15 was scheduled for a shower on 12/24/24, however, due to staffing shortage, no scheduled showers were completed on that day. On 1/10/25 at 12:16 PM Staff 2 (Regional RN) stated it was her expectation that all showers were completed as scheduled. If a shower was refused or missed, it would be completed at the next shift or next day. Staff 2 confirmed Resident 15 received three showers in two weeks. 50928 5. Resident 10 admitted to the facility 2014 with a diagnosis of a stroke. Resident 10's 9/30/24 Annual MDS revealed a BIMS score of 15 (cognitively intact). A review of the updated 12/24/24 Facility Shower Schedule indicated showers were given to Resident 10 on Tuesdays and Fridays. A review of the Documentation Survey Report from 12/2024 revealed a shower were not provided to Resident 10 on 12/24/24. On 1/9/25 at 12:22 PM Staff 16 (CNA) stated they worked the evening shift on 12/24/24 with two other CNAs. Staff 16 stated with three CNAs during the evening and a census of 58 it was impossible to complete ADL tasks for the residents. Staff 16 stated during the evening shift on 12/24/24 showers were not provided to any residents. On 1/9/25 at 12:34 PM Staff 18 (CNA) stated during the evening shift on 12/24/24 showers were not provided to residents due to being understaffed. On 1/10/25 at 12:09 PM Staff 2 (Regional RN) acknowledged a shower was not provided to Resident 10 on 12/24/24. Staff 2 confirmed the expectation for the facility was to offer residents showers as scheduled and if the facility was short staffed the resident must be offered a shower the next day.

Based on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 7/25/24 the facility had a census of 62 residents. On 7/18/24, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers: 23; -Required one or two-person extensive or total assistance for bathing: 47; -Required one or two-person extensive or total assistance for toileting: 47; -Required one or two-person extensive or total assistance for dressing: 49; -Required two person assistance at all times for all care: 11; -Had behavioral healthcare needs which required monitoring: 28; -Were at risk for elopement: 5 and -Were considered high fall risks: 14 1. On 2/1/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts resulting in residents not being toileted timely, long call light response times and basic care not being met. The complaint indicated the facility had been short staffed for months. On 2/12/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs on all shifts but evening shift was impacted the most, staff were unable to provide showers and, in general, resident care was diminished. On 4/8/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs which resulted in residents not receiving showers and staff not being able to properly monitor residents who required supervision when eating. On 5/20/24 a public complaint was received by the State Agency which alleged the facility was short staffed CNAs, especially on night shift which resulted in residents not getting needed care. On 6/17/24 two public complaints were received by the State Agency which alleged the facility was short staffed CNAs for the past several months resulting in staff not being able to properly monitor and supervise residents during meals and some residents were unable to be showered. On 7/15/24 at 11:16 AM Resident 35 stated she/he sometimes waited over 30 minutes, pretty much daily, for someone to answer her/his call light. Resident 35 stated long call light times occurred across all shifts. On 7/15/24 at 1:15 PM Resident 22 stated call light response times could take up to one hour. Resident 22 stated the facility was short-handed, especially on the weekends. Resident 22 stated, I filled my diaper a couple of times because they didn't get here in time. On 7/15/24 at 1:24 PM Resident 36 stated the facility needed more staff. Resident 36 stated she/he required two persons using a mechanical lift to transfer her/him and sometimes she/he was told there were not enough staff to transfer her/him to the chair. On 7/16/24 at 8:34 AM Witness 4 (Complainant) reported since 2/2024 there was constant low CNA staffing. Witness 4 stated the facility was often three to four CNA staff short. Witness 4 stated staffing was bad which resulted in increased falls, residents missing showers and residents having to remain up in their chairs longer than they should. On 7/16/24 at 8:21 AM Witness 3 (Complainant) reported CNA staffing was bad, especially on weekends, since approximately 2/2024. Witness 3 stated the facility was three or four CNA staff short on many shifts in 2/2024 and 3/2024 and now CNA staffing was often one to two CNAs short on many shifts. Witness 3 stated when CNA staffing was low, call light response times were longer and CNA staff did not have time to provide showers to residents. On 7/16/24 at 1:28 PM Witness 1 (Complainant) stated the facility did not staff CNAs to meet the mandatory CNA minimum staffing ratio requirements. Witness 1 stated CNAs were frequently working one to two CNAs short, especially on the weekends. Witness 1 stated low staffing occurred off and on for months. Witness 1 stated low CNA staffing impacted staff's ability to monitor residents which resulted in increased falls. Witness 1 stated the facility continued to admit new residents even though they were unable to meet CNA staffing ratios, which had the potential to result in injuries to the resident and/or staff. On 7/16/24 at 2:58 PM Witness 2 (Complainant) stated low CNA staffing was ongoing since 1/2024, especially on the weekends. Witness 2 stated staff were unable to provide showers to residents or properly supervise residents who were identified to be at high risk for aspiration (inhaling food or liquids into the lung). Witness 2 stated she was concerned residents might choke. Witness 2 stated the facility had many residents who required two person assistance with transfers but many times transfers were completed with only one person due to a lack of available staff. Witness 2 reported the facility continued to accept new admits even when they knew they were unable to adequately staff CNAs. On 7/17/24 at 4:51 PM Witness 5 (Complainant) stated staffing was horrible and many CNA staff quit. Witness 5 stated when CNA staffing was low, staff could not provide showers, staff were unable to complete two person mechanical lift transfers and staff were unable to toilet residents in a timely manner which resulted in a lack of dignity for the residents. Witness 5 stated CNA staffing was a dumpster fire since 1/2024. Witness 5 reported many staff did not get their breaks. Witness 5 stated the facility did not have the right staffing for the level of acuity of the residents. On 7/17/24 at 7:52 AM, 8:08 AM and 8:16 AM Staff 16 (CNA), Staff 10 (CNA) and Staff 14 (CNA) reported the facility was consistently short staffed one to two CNAs, especially on the weekends. Staff 16 and Staff 14 reported CNA staff often did not get their breaks or lunches. Staff 16 and Staff 14 stated residents who required two person mechanical lift transfers often had to wait a long time, showers got bumped and staff were unable to provide supervision to residents who ate in their rooms. Staff 10 reported the facility had difficulty retaining CNA staff. On 7/18/24 at 9:14 AM Staff 18 (Staffing Coordinator) stated she staffed CNAs based on the census and by the CNA mandatory minimum staffing ratios. Staff 18 stated she heard there were staffing concerns. Staff 8 confirmed, from 2/2024 through 7/14/24, CNA staffing was short on many shifts. On 7/19/24 at 9:14 AM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. 2. Resident 22 was admitted to the facility in 1/2024 with diagnoses including a fractured hip. A 6/23/24 5-Day MDS indicated Resident 22 had no cognitive impairment and assistance levels ranged from moderate to maximal assistance from staff for multiple ADLs. Review of Resident 22's 6/1/24 through 7/17/24 Call Light Tracking Sheet revealed the following call light response times: -6/1/24 at 9:37 PM: call light response time 38 minutes; -6/4/24 at 5:54 AM: call light response time 32 minutes; -6/6/24 at 3:00 AM: call light response time 24 minutes; -6/6/24 at 5:27 PM: call light response time 23 minutes; -6/6/24 at 3:54 PM: call light response time 16 minutes; -6/8/24 at 9:58 AM: call light response time 20 minutes; -6/9/24 at 3:37 AM: call light response time 20 minutes; -6/9/24 at 9:09 PM: call light response time 18 minutes; -6/10/24 at 5:38 AM: call light response time 40 minutes; -6/10/24 at 2:33 PM: call light response time 37 minutes; -6/12/24 at 12:23 AM: call light response time 17 minutes; -6/12/24 at 5:37 AM: call light response time 18 minutes; -6/12/24 at 11:50 AM: call light response time 17 minutes; -6/19/24 at 1:24 PM: call light response time 23 minutes; -6/19/24 at 8:18 PM: call light response time 40 minutes; -6/20/24 at 6:22 AM: call light response time 27 minutes; -6/20/24 at 2:23 PM: call light response time 16 minutes; -6/23/24 at 8:03 PM: call light response time one hour; -6/23/24 at 9:19 PM: call light response time 21 minutes; -6/24/24 at 3:58 PM: call light response time 18 minutes; -6/24/24 at 9:38 PM: call light response time 19 minutes; -6/27/24 at 5:03 AM: call light response time 22 minutes; -6/27/24 at 9:44 AM: call light response time 16 minutes; -6/29/24 at 10:40 AM: call light response time 24 minutes; -7/2/24 at 2:38 PM: call light response time 20 minutes; -7/3/24 at 7:17 AM: call light response time 21 minutes; -7/6/24 at 8:14 AM: call light response time 29 minutes; -7/9/24 at 10:30 AM: call light response time 19 minutes; -7/10/24 at 3:51 PM: call light response time 17 minutes; -7/11/24 at 8:21 AM: call light response time 24 minutes; -7/15/24 at 7:44 AM: call light response time 16 minutes and -7/15/24 at 9:56 AM: call light response time 20 minutes. On 7/15/24 at 1:15 PM Resident 22 stated call light response times could take up to one hour. Resident 22 stated the facility was short-handed, especially on the weekends. Resident 22 stated, I filled my diaper a couple of times because they didn't get here in time. On 7/19/24 at 9:14 AM and 12:45 PM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. Staff 1 stated he would like to see call light response times no longer than 15 minutes and anything longer than 15 minutes would be an issue. 3. Resident 25 was admitted to the facility in 10/2022 with diagnoses including a stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body). Resident 25's 10/31/22 Fall Prevention Care Plan instructed staff to remind the resident to wait for staff assistance when she/he was up in her/his chair and to ensure the call light was within Resident 25's reach. A 5/30/24 Quarterly MDS indicated Resident 25 had no cognitive impairment and assistance levels ranged from maximal to dependent assistance from staff for multiple ADLs. Review of Resident 25's 6/1/24 through 7/17/24 Call Light Tracking Sheet revealed the following call light response times: -6/2/24 at 11:46 AM: call light response time 16 minutes; -6/3/24 at 5:00 PM: call light response time 40 minutes; -6/5/24 at 4:20 AM: call light response time 43 minutes; -6/6/24 at 2:47 AM: call light response time 24 minutes; -6/9/24 at 1:22 PM: call light response time 22 minutes; -6/13/24 at 2:04 PM: call light response time 21 minutes; -6/15/24 at 2:40 AM: call light response time 23 minutes; -6/16/24 at 1:28 PM: call light response time 16 minutes; -6/17/24 at 10:39 PM: call lighte response time 29 minutes; -6/18/24 12:06 AM: call light response time 17 minutes; -6/18/24 at 1:50 AM: call light response time 17 minutes; -6/18/24 at 9:41 PM: call light response time 16 minutes; -6/25/24 at 7:42 AM: call light response time 25 minutes; -6/25/24 at 11:21 AM: call light response time 29 minutes; -6/26/24 at 5:28 PM: call light response time 32 minutes; -6/30/24 at 12:04 PM: call light response time 22 minutes; -7/1/24 at 7:13 AM: call light response time 17 minutes; -7/2/24 at 6:02 AM: call light response time 36 minutes; -7/2/24 at 2:54 PM: call light response time 18 minutes; -7/4/24 at 11:33 AM: call light response time 21 minutes; -7/4/24 at 6:39 PM: call light response time 17 minutes; -7/6/24 at 10:52 AM: call light response time 16 minutes; -7/6/24 at 6:00 PM: call light response time 24 minutes; -7/7/24 at 6:54 PM: call light response time 49 minutes; -7/10/24 at 11:18 AM: call light response time 36 minutes; -7/11/24 at 9:25 AM: call light response time 26 minutes; -7/11/24 at 6:48 PM: call light response time 18 minutes; -7/12/24 at 10:55 AM: call light response time 17 minutes; -7/12/24 at 4:47 PM: call light response time 22 minutes; -7/16/24 at 4:53 AM: call light response time 16 minutes and -7/16/24 at 6:32 PM: call light response time 20 minutes. On 7/15/24 at 1:11 PM Resident 25 stated her/his call light response times were up to 30 to 40 minutes, at times. On 7/19/24 at 9:14 AM and 12:45 PM Staff 1 (Administrator) stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels. Staff 1 stated he would like to see call light response times no longer than 15 minutes and anything longer than 15 minutes would be an issue.

Based on observation, interview and record review it was determined the facility failed to ensure beverages were labeled and stored in a manner to minimize spoilage and bulk food items were stored in a manner to minimize cross contamination in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness. Findings include: On 7/15/24 at 9:49 AM during the initial tour of the kitchen dry storage area, a plastic scoop was observed to be partially buried in the bulk sugar. Staff 24 acknowledged the scoop was not stored appropriately and stated it should be in the provided holster above the sugar rather than in the supply of sugar, to minimize the risk of cross contamination. On 7/15/24 at 9:57 AM the following items were observed to be stored in the snack refrigerator in the facility's 100 hallway: -A previously-opened liter container of nectar-thick lemon water dated 6/23 -A previously-opened liter container of nectar-thick lemon water dated 6/4 -A previously-opened liter container of nectar-thick orange juice labeled Use by 6/26 Staff 24 acknowledged the manner in which these items were labeled was unclear as they did not indicate if the dates referred to when they were opened or when they should be discarded. He stated these items should be discarded as it was unsafe to store and use juice beyond seven days after it was opened. Staff 24 stated he was not clear about who was supposed to monitor and discard outdated items in the snack refrigerator. On 7/19/24 at 1:12 PM Staff 1 acknowledged the deficiencies observed in the kitchen's dry storage area and in the snack refrigerator. He stated he expected the facility staff to label items when they were opened and when they should be discarded in order to reduce the risk of spoilage. He stated he also expected staff to store dry goods in a manner to avoid cross contamination.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled dependent residents (#s 9, 24 and 47) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 2/2005 Activities Policy revealed the facility was to encourage each resident to maintain normal leisure activity. The facility would provide an activities program that addressed the intellectual, social, spiritual, creative and physical needs, capabilities and interests of each resident. The activity program would promote each resident's self-respect by providing activities that supported self-expression and choice. 1. Resident 9 was admitted to the facility in 5/2021 with diagnoses including major depressive disorder and dementia. Resident 9's 6/11/21 and revised 11/16/21 Activities Care Plan indicated the following: -Resident 9 liked music, pet therapy, visiting with the chaplain, gardening, flowers and birds. -Resident 9 was to have one-on-one bedside visits and activities to include music, animal visits, bird watching discussions, manicures, hand massages and assistance looking through magazines. -Resident 9 was Christian and the Activities Department was to provide gospel music and set-up Chaplain visits as needed. Resident 9's 6/24/24 Significant Change MDS revealed the resident had severe cognitive impairments. Her/his activity preferences indicated it was somewhat or very important to have books, newspapers and magazines to read, do favorite activities, participate in religious services and practices and be around animals. Resident 9's 6/16/24 through 7/16/24 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation. A review of Resident 9's electronic health record contained no evidence the resident participated in any activities. The facility's 7/2024 Activity Calendar revealed the following scheduled activities: Monday, 7/15/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Birdhouse Building & Painting -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Tuesday, 7/16/24: -8:30 AM Morning Room Rounds -11:30 AM Resident Shopping -1:00 PM Gardening Club -3:00 PM Afternoon Rounds & Mail -6:00 PM Featured Movie (CNA led) Wednesday, 7/17/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Resident Council -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM and 7:30 PM revealed Resident 9 was in her/his room, typically with the blinds closed and the lights low, and was not engaged in any activities. No magazines, books or newspapers were observed; no music was playing and no one-on-one activities took place. On 7/16/24 at 2:30 PM Resident 9 stated she/he liked to play bingo and the balls. Resident 9 stated she/he loved to read anything I can get my hands on. On 7/17/24 at 7:40 AM Staff 9 (CNA) stated Resident 9 rarely got up out of bed. She stated she had not seen any activities occurring in Resident 9's room and she was not aware of any one-on-one activities being done in residents' rooms, just group activities being conducted in the dining room. On 7/17/24 at 8:16 AM Staff 14 (CNA) stated she had never seen Resident 9 engaged in any one-on-one activities in the resident's room. On 7/18/24 at 8:33 AM Staff 6 (Activities Director) stated she was the only person in the activities department and she was responsible for completing all of the care conferences, Activity MDS Assessments, Activity Admission Profiles, shopping for the residents, delivering mail, engaging residents in group and one-on-one person-centered activities; as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends. Staff 6 was unable to provide dates or times of any specific activities completed with Resident 9 and confirmed no activities documentation was completed. On 7/19/24 at 9:40 AM Staff 1 (Administrator) stated his expectation was all residents received activities according to their person-centered care plan and he needed to work on getting additional help in the activities department. 2. Resident 24 was admitted to the facility in 10/2023 with diagnoses including dementia. Resident 24's 10/30/23 Activity Profile indicated the resident spoke Farsi/Arabic and required a translator. Resident 24's 11/8/23 and revised 11/16/23 Activities Care Plan indicated the following: -Resident 24 liked visits from her/his spouse, eating ice cream and other comfort foods, watching television and reading. -Resident 24 was to have twice weekly social visits for special updates on activities and assistance with self-directed activities. Resident 24's 4/30/24 Significant Change MDS revealed the resident had short and long term memory deficits. Her/his activity preferences indicated it was somewhat or very important to listen to music, be around animals, go outside to get fresh air when the weather was good, do things with groups of people, do favorite activities and participate in religious services or practices. Resident 24's 6/16/24 through 7/16/24 Group Activity Task Log and One-On-One Activity Task Log contained no data regarding activity participation. A review of Resident 24's electronic health record revealed no evidence the resident participated in any activities. The facility's 7/2024 Activity Calendar revealed the following scheduled activities: Monday, 7/15/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Birdhouse Building & Painting -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Tuesday, 7/16/24: -8:30 AM Morning Room Rounds -11:30 AM Resident Shopping -1:00 PM Gardening Club -3:00 PM Afternoon Rounds & Mail -6:00 PM Featured Movie (CNA led) Wednesday, 7/17/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Resident Council -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Observations from 7/15/24 through 7/18/24 between the hours of 8:00 AM and 8:00 PM revealed the resident was in her/his room with no music, books or materials to complete self-directed activities. Resident 24 was typically awake in bed with her/his television on without sound and closed captioning (text that reflects an audio track that can be read while watching visual content) on in English. On one occasion in the evening, Resident 24 was observed up in her/his wheelchair in a lobby area, placed in front of a television being broadcast in English, with four other residents. No one-on-one activities were observed during any observations. On 7/17/24 at 9:53 AM Staff 4 (CNA) stated she tried to get an I-Pad for Resident 24 to watch television on because her/his room television did not have Arabic channels but she was not successful getting an I-Pad. Staff 4 stated she had not seen any one-on-one activities occurring with Resident 24 and the resident just sits in her/his room unless her/his spouse comes to visit. On 7/18/24 at 8:33 AM Staff 6 (Activities Director) stated she was the only person in the activities department and she was responsible for completing all of the care conferences, Activity MDS Assessments, Activity Admission Profiles, shopping for the residents, delivering mail, engaging residents in group and one-on-one person-centered activities; as well as assisting with many resident requests. She stated there was no one to provide activities on the weekends. Staff 6 was unable to provide dates or times of any specific activities completed with Resident 24 and confirmed no activities documentation was completed. On 7/19/24 at 9:40 AM Staff 1 (Administrator) stated his expectation was all residents received activities according to their person-centered care plan and he needed to work on getting additional help in the activities department. 47000 3. Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/23/23 Activity Profile indicated the resident spoke Vietnamese and was unable to communicate or answer questions in English. Resident 47's 11/27/23 Admission MDS indicated the resident experienced short-and-long-term memory loss and identified the following as activity preferences for the resident: -Reading books, newspapers or magazines; -Listening to music; -Being around animals such as pets; -Keeping up with the news; -Doing things with groups of people; -Participating in favorite activities; and -Spending time outdoors. Resident 47's 2/27/24 Social Determinants of Health Form indicated the resident spoke Vietnamese, she/he needed or wanted an interpreter to communicate with a doctor or health care staff and she/he sometimes felt lonely or isolated from those around her/him. Resident 47's 3/17/24 Activity Care Plan revealed the following: -The resident's activity goal was to attend/participate in activities of choice two-to-three times per week. -The resident was dependent upon staff for activities. -The resident's activity interests included passively participating in large group activities, watching television, one-to-one conversation and chair exercises. -One-to-one in-room activities were needed if the resident was unable to attend out of room events. -The resident required an escort to activity functions. A review of Resident 47's 6/17/24 through 7/15/24 activity participation records revealed no evidence the resident participated in a group, one-to-one or self-directed activity during this timeframe. The facility's 7/2024 Activity Calendar revealed the following scheduled activities: Monday, 7/15/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Birdhouse Building & Painting -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Tuesday, 7/16/24: -8:30 AM Morning Room Rounds -11:30 AM Resident Shopping -1:00 PM Gardening Club -3:00 PM Afternoon Rounds & Mail -6:00 PM Featured Movie (CNA led) Wednesday, 7/17/24: -8:30 AM Morning Room Rounds -11:00 AM Large Group: Exercises -1:00 PM Resident Council -3:00 PM Afternoon Rounds & Mail -6:00 PM Independent Activities (CNA led) Observations of Resident 47 conducted from 7/15/24 to 7/17/24 between 9:41 AM through 4:28 PM revealed the resident to be in bed in her/his room or in her/his wheelchair in her/his room or in the dining room. The resident's eyes were observed to be closed during each observation. When the resident was observed in her/his room, no television or music played and no books, magazines or newspapers were observed. Resident 47's roommate's television could be heard from the hallway and the content was in English. When the resident was observed in the dining room, the television was on and content played in English. On 7/15/24 at 1:04 PM, 7/17/24 at 9:41 AM and 7/17/24 at 11:31 AM the resident verbally responded to the surveyor's greeting with her/his eyes closed. On 7/15/24 at 1:13 PM Witness 6 (Family Member) stated Resident 47's native language was Vietnamese and the resident spoke and understood limited English. Witness 6 stated the resident was able to communicate only her/his basic needs in English. On 7/17/24 at 10:19 AM Staff 14 (CNA) stated she was unaware of any activity interests for Resident 47. Staff 14 stated since the resident came to the facility, it was just room to dining room for meals and back to [her/his] room to lay down. Staff 14 further stated the resident never participated in group activities, went outside, had the television or music on in her/his room or had books, newspapers or magazines available to read. On 7/17/24 at 10:45 AM Staff 20 (CNA) stated Resident 47 spent all of her/his time either sleeping or eating. Staff 20 stated the resident did not participate in group activities or go outside. Staff 20 further stated she had never seen the resident with books, newspapers or magazines. On 7/17/24 at 11:00 AM Staff 27 (CNA) stated she thought Resident 47 enjoyed listening to music and watching television but it was difficult for her/him to do either in her/his room because the resident's roommate's television was really loud. Staff 27 stated Resident 47 did not open her/his eyes often. On 7/17/24 at 11:17 AM a group of residents was observed in the facility's dining room and participated in an exercise activity with a ball and parachute. Resident 47 was observed at this time in her/his room in bed with the lights and television off. On 7/17/24 at 11:31 AM Resident 47 was observed in her/his room and sat in her/his wheelchair with her/his eyes closed. The State Surveyor, with the assistance of a Vietnamese translator attempted an interview at this time. As soon as the resident heard the translator speak in Vietnamese, the resident pulled opened her/his eyelids with her/his hand and verbally engaged in the interview. Resident 47 stated I don't do anything here. Resident 47 stated she/he would love to participate in group activities and go outside when the weather was nice but no one offered these activities. Resident 47 further stated she/he enjoyed reading, songs, exercise and pets but no one at the facility had ever asked her/him about her/his likes and preferences. On 7/17/24 at 4:09 PM Staff 6 (Activity Director) stated she did not attempt the Preferences for Customary Routine and Activities interview required at the time of Resident 47's 11/27/23 Admission MDS Assessment with the resident because she was informed the resident did not speak English, so she interviewed Witness 6 instead. Staff 6 stated she typically added the resident activity preferences and interests she learned from this interview to the resident's care plan and stated Resident 47's activity care plan needed to be updated. Staff 6 stated she completed one-to-one visits with Resident 47 during mealtimes when she would primarily ask the resident in English about her/his meal. Staff 6 stated she did not use a translator during her interactions with Resident 47. Staff 6 stated she documented resident activity participation in each resident's clinical record which included any refusals and if the resident was sleeping. Staff 6 acknowledged Resident 47 did not have any activities, refusals or instances of sleeping documented from 6/17/24 to 7/15/24 and stated she sometimes did not get to charting at the end of the day. Staff 6 stated CNAs were responsible to turn on Resident 47's television when she/he was in her/his room and the resident watched television with English programming when in the dining room. Staff 6 further stated she did not invite Resident 47 to the group exercise activity this morning because the resident's eyes were closed and she did not like to bother residents if they were sleeping. On 7/17/24 at 4:40 PM Staff 2 (DNS) stated she expected resident activity participation to be documented daily and staff to utilize a translation service when interacting with Resident 47. Staff 2 further stated she expected books, newspapers and magazines to be provided to Resident 47, television and music to be available to Resident 47 and one-to-one visits to be offered to Resident 47 daily, all in Vietnamese.

Based on interview and record review it was determined the facility failed to ensure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 1 sampled resident (#45) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services. Findings include: Resident 45 was admitted to the facility in 6/2023 with diagnoses including stroke and schizophrenia (a mental disorder). A review of the resident's electronic health record revealed no evidence Resident 45 had a screening Level I PASARR completed prior to admission. On 7/17/24 at 11:13 AM Staff 11 (Medical Records) and Staff 1 (Administrator) confirmed they were unable to locate a screening Level 1 PASARR for Resident 45.

Based on observation, interview and record review it was determined the facility failed to accurately assess a resident's cognition for 1 of 1 sampled resident (#47) reviewed for communication. This placed residents at risk for unassessed needs. Findings include: Resident 47 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 47's 11/27/23 Admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated the resident's preferred language was Vietnamese, and the resident needed or wanted an interpreter to communicate with a doctor or health care staff, was usually able to understand others and was usually able to make her/himself understood. Resident 47's 11/27/23 Admission MDS, 2/27/24 Quarterly MDS and 5/29/24 Quarterly MDS Assessments indicated a BIMS interview was not attempted with the resident as the resident was rarely/never understood. No evidence was found in Resident 47's clinical record to indicate an interpreter was utilized to help assess the resident's cognition during the 11/27/23 Admission MDS, 2/27/24 Quarterly MDS or 5/29/24 Quarterly MDS Assessments . On 7/17/24 at 11:31 AM Resident 47 was observed in her/his room in her/his wheelchair. With the assistance of a Vietnamese translator, Resident 47 stated she/he felt as if no one at the facility understood her/him. On 7/17/24 at 12:24 PM Staff 25 (Social Services Director) stated when she evaluated Resident 47's cognition, she completed a staff assessment instead of using a translator with the resident. On 7/17/23 at 12:36 PM Staff 23 stated he was unaware of Resident 47's preference for an interpreter when communicating with health care staff. Staff 23 confirmed he completed all MDS interviews with the resident in English and without an interpreter. On 7/17/24 at 4:40 PM Staff 2 (DNS) acknowledged the findings and stated she expected staff to utilize a translator during all interactions with Resident 47, especially when completing interviews required for the MDS.

Based on observation, interview and record review it was determined the facility failed to thoroughly investigate and rule out incidents of potential sexual abuse without adequate evidence for 1 of 2 sampled residents (#100) reviewed for abuse. This deficient practice was determined to be an immediate jeopardy situation and placed Resident 100 at risk of sexual abuse. Findings include: Resident 100 was admitted to the facility in 2/2022 with diagnoses including hypertensive chronic kidney disease (a condition caused by damage to the blood flow of the kidneys). Resident 100's 2/6/23 MDS identified resident with a BIMS score of 5 (severe cognitive impairment). Resident 101 was admitted to the facility in 2/2019 with diagnoses including cellulitis of the left lower limb (a condition caused by painful, swollen, and inflamed legs). Resident 101's 1/25/23 MDS identified resident with a BIMS score of 15 (cognitively intact) A 3/19/23 Facility Document indicated around 12:30 PM, Staff 3 (CNA) discovered Staff 4 (RA) in room [ROOM NUMBER]-B with Resident 100. Resident 100's pants were observed to be down to her/his ankles. Staff 4 indicated he was about to perform (ROM) exercises for the resident. Staff 3 asked why Resident 100's pants were down; Staff 4 became defensive and left the room. Staff 3 (CNA) reported the matter to Staff 5 (Resident Care Manager). On 3/19/23 at 1:40 PM, Staff 5 (Resident Care Manager) documented that Resident 100 was discovered with her/his pants below their ankles, Staff 5 instructed Staff 3 and Staff 4 to return to work. Staff 5 indicated the incident was a he said, she said situation and did not believe the sitatuation warrented an investigation. Staff 5 stated she did not determine how Resident 100's pants were removed. A review of facility records revealed no investigation report was created to determine cause of incident, no FRI was reported to the State Agency, Resident 101 was not monitored for safety, and Staff 4 was not reassigned or removed from the facility. On 3/22/23 at 10:19 AM, Resident 101 stated she/he felt unsafe with Staff 4 (RA) performing cares on her/him due to inappropriate verbal conversations and touching of her/his arms. Resident 101 stated she/he reported this to the facility but Resident 101 indicated she/he still felt scared due to Staff 4's continuance to access her/his room even though Staff 4 was reassigned to a different hall. On 3/22/23 at 11:25 AM, Staff 6 (CNA) indicated he performed care and a brief change with Resident 100 exactly 30 minutes prior to the date of the 3/22/23 incident. Staff 6 stated he witnessed an argument occur between the Staff 3 and Staff 4. Staff 6 was asked by Staff 3 to enter the room and discovered Resident 100's pants were below the resident's ankles with Staff 4 present in the room. Staff 6 stated that the incident was reported to Staff 1 (Administrator) and Staff 2 (DNS), but Staff 4 was not removed from the floor. On 3/22/23 at 11:40 AM, Staff 1 (Administrator) confirmed Resident 100 was discovered to have her/his pants down in the resident's room. The Administrator stated no investigation was conducted to rule out abuse and no FRI was submitted on the basis that no abuse had occurred as no marks were discovered on Resident 100 upon completion of Resident Care Manager's assessment. Staff 1 stated that Staff 4 (RA) was not placed on suspension and was still on the schedule. Staff 1 stated that no additional investigation was necessary, and the resident was not placed on behavior monitoring as they believed no abuse had occurred. On 3/22/23 at 11:40 AM, Staff 1 (Administrator) confirmed Staff 4 was not placed on suspension and is currently still on the schedule working the floor. On 3/22/23 at 4:41 PM Staff 4 confirmed he was in Resident 100's room with the resident's pants down but denied the allegation. On 3/22/23 at 2:34 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 3/22/23 at 4:29 PM the facility submitted an acceptable immediacy removal plan. The immediacy removal plan included the following: Res A.A is still a resident of this facility. Assessment will be completed of resident for any signs or symptoms of any type of physical assault. This will be documented in the resident's HER. Resident will be placed on alert for the next 72 hours to monitor for any adverse potential effects. Admin/DNS or designee will complete thorough investigation into reported incident. CNA/RA (LP) involved in the potential incident has been removed from the schedule and has been informed that he is not allowed on the facility premises until otherwise notified by Admin. All current interviewable residents will be interviewed by Department managers in regard to care and concerns they may have. Any issues brought forth will be immediately investigated and reported (FRI) if appropriate. This will be completed within the next 24 hours. Department manages will be in-serviced by Regional Nurse Consultant in regards to company and state policy regarding how to complete an investigation. This will be completed within the next 24 hours. Admin/DNS or designee will complete 5 random resident interviews weekly utilizing the abaqis resident interviews. Any issues or concerns will be investigated and reported as appropriately outlined in the policy. These audits will continue weekly for 2 months and then every 2 weeks. Results of these audits will be brought to monthly QAPI until substantial compliance has been met for 3 consecutive months On 3/23/23 at 2:00 PM observations, record reviews and interviews were completed which verified the immediacy removal plan was fully implemented on 3/23/23.

1. Based on observation, interview, and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 13 residents (#1) identified at risk for aspiration and who was to be supervised while eating. Resident 1 was observed to be left unattended with her/his meal and/or fluids two times during continuous observations. Resident 1 was able to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 9/2021 Dysphagia Diets and Aspiration Precautions policy statement indicated residents who were identified as close supervision and 1:1 supervision levels were not to be left unattended with the food tray. Resident 1 was admitted to the facility in 12/2012 with diagnoses including [CONDITION(S)], dysphagia (difficulty swallowing), and pneumonitis (lung infection) due to inhalation of food and vomit. Resident 1's 6/24/21 physician order indicated Resident 1 was on aspiration precautions with close supervision, no water pitcher or thin liquids at bedside, and small bites, small sips, and slow rate. Resident 1's 6/29/21 Quarterly MDS indicated the resident was cognitively intact, required supervision with eating and required set up assistance with meals. On 9/20/21 the following was observed during continuous observations: *12:27 PM Resident 1 was observed to have fluids at her/his bedside within reach. The Survey Team asked Staff 3 (Speech Pathologist) about Resident 1's aspiration status. Staff 3 removed the liquids in front of Resident 1 and confirmed there was both juice and water at bedside. Staff 3 stated Resident 1 required close supervision with meals and fluids, but Resident 1 often wanted the door closed and did not like staff watching her/him eat. Staff 3 asked Resident 1 if she/he experienced any choking while drinking and Resident 1 stated I would not tell you if I did. *Resident 1 was observed to have a pink sign above the bed which indicated the resident was on aspiration precautions and required close supervision with meals and to encourage small bites, small sips, and slow rate. *12:42 PM Staff 4 (CNA) was observed exiting Resident 1's room and closed the door. Staff 4 stated Resident 1 had food in her/his room, just set the resident up, and she/he was eating independently. *12:43 PM Surveyors and Staff 4 entered Resident 1's room and observed the resident eating a pureed meal independently. Staff 4 stated Resident 1 was supposed to be supervised while eating, but the resident refused all the time. Staff 4 was unable to state other residents who required supervision with eating as she was new to working at the facility. *12:52 PM Surveyor knocked on Resident 1's closed door, looked in the room and observed Resident 1 continuing to feed her/himself with no staff present. Two drinks were also observed within reach of the resident. *12:58 PM Staff 5 (LPN Resident Care Manager) stated Resident 1 required intermittent supervision and the facility was in the process of changing the resident's care plan. Staff 5 removed the two drink cups from Resident 1's bedside. Surveyors asked for a copy of Resident 1's updated aspiration precautions and care plan. *1:00 PM Resident 1's Aspiration Precaution sign was provided and indicated the resident was intermittent supervision with meals. On 9/20/21 at 12:54 PM Staff 3 (Speech Pathologist) stated she made the aspiration precaution recommendations and the resident care managers filled out the Aspiration Precautions form. Staff 3 stated she was unaware of what intermittent supervision meant. Staff 3 stated she had not assessed Resident 1 in awhile and had not upgraded her/his supervision status or precautions. Staff 3 further stated nursing staff were unable to upgrade residents' supervision status without a speech assessment or a physician order. On 9/20/21 at 1:47 PM Staff 2 (DNS) was asked for the assessment or order for intermittent supervision for Resident 1. Staff 2 stated she was unable to find an assessment or order indicating Resident 1 required intermittent supervision. On 9/20/21 at 2:48 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the most recent signed physician orders were correct and indicated Resident 1 was close supervision with meals and no liquids at bedside. Staff 2 confirmed Resident 1 had not been assessed by the speech pathologist since 4/2020. Staff 1 and Staff 2 confirmed intermittent supervision was inaccurate. A copy of Resident 1's Risks versus Benefits form related to aspiration precautions was requested by surveyors. On 9/20/21 at 4:21 PM Staff 1 (Administrator) stated there was no Risk versus Benefit documented for Resident 1 related to aspiration precautions. On 9/20/21 at 5:44 PM Staff 1 and Staff 2 were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. An immediate plan of correction (POC) was requested. On 9/20/21 at 7:19 PM the facility submitted a final POC. The IJ Removal Plan included: -All residents with aspiration precautions will be reviewed to ensure their orders, care plans, and precaution signs all reflect the same information. -All nursing staff will be in-serviced on the policy of aspiration precautions, what it means, the importance of following these precautions, and staff will be asked to verbally return demonstration. The in-service would be completed by 9/22/21. -If any resident refused the precautions, they would be re-evaluated by speech therapy, the physician would be notified and a Risk versus Benefits assessment would be completed by them or their representative. -All agency staff and nursing new hires would be in-serviced, oriented, and submit competencies prior to the beginning of their shift and would demonstrate back understanding. -The DNS or designee would complete weekly audits of all residents on aspiration precautions to ensure staff were following physician orders. On 10/4/21 at 9:40 AM Staff 1 and Staff 29 (Regional RN) were notified the immediacy was removed based on observations, staff interviews, and record review that the IJ abatement plan was fully implemented. Refer to F658 and F725 2. Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from fall related accidents for 3 of 4 residents (#s 5, 17, and 25) reviewed for falls. This failure resulted in Resident 17 sustaining a lumbar fracture and requiring hospitalization , Resident 5 sustaining a face laceration requiring hospitalization and medical interventions, and this placed other residents at risk for other fall related injuries. Findings include: Resident 17 admitted to the facility on [DATE] with diagnoses including diabetes and a history of repeated falls. Resident 17 discharged from the facility on 4/30/21. The 3/8/21 Admission Fall Assessment indicated Resident 17 was at high risk for falls due to incontinence, medication use, and experienced multiple falls prior to admission. The Resident's 3/9/21 Baseline Fall Care Plan indicated Resident 17 was (high, moderate, low) risk for falls related to: the resident had an actual fall with no injury, minor injury, serious injury. Interventions included: monitor for decline or improvement in mobility, wear non-skid socks, and ensure the call light was within reach at all times. The resident required two staff-person assistance with transfers. The resident sustained falls in the facility on 3/15/21, the morning of 3/29/21, and the evening of 3/29/21. The Admission MDS was not completed until 4/10/21, over a month after the resident admitted to the facility and sustained three falls. a The 3/22/21 Fall Care Plan indicated to notify the physician and family/responsible party of any fall and to not leave the resident unsupervised in the bathroom/on the bedside commode. The care plan was not updated again until 3/30/21. The intervention of frequent visual checks was not added to the care plan until 3/31/21. The 3/29/21 Fall Investigation indicated Resident 17 had an unwitnessed fall and was found on the floor lying on her/his back in the assisted dining room at approximately 8:15 PM with no staff present. The resident reported she/he tried to transfer from the locked wheelchair to a dining room chair. Resident 17 reported her/his baseline low back pain worsened significantly after the fall with 6/10 pain noted. The resident had fallen earlier that morning and was on neurological checks. Staff 57 (CNA) stated Resident 17 was restless and attempting to get out bed, so he wheeled the resident to the assisted dining room to sit with two other residents. Staff 56 (CNA) stated she last visualized the resident in the dining room at 8:00 PM while walking by and the resident was not attempting to transfer. The summary indicated the care plan was followed. Resident 17 was sent to the hospital and was diagnosed with a lumbar fracture. Hospital records indicated Resident 17 was hospitalized from 3/29/21 through 4/6/21 and sustained closed compression fractures of the L2 and L3 vertebra and noted baseline low back pain was worse after the fall on 3/29/21. On 10/1/21 at 2:20 PM Staff 34 (CNA) stated Resident 17 was at times impulsive with transfers. Staff 34 stated concerns related to monitoring residents due to staffing shortages and staff attempted to monitor residents, but a lot of times staff were so busy they were unable to check on the residents. On 10/4/21 at 2:59 PM Staff 57 (CNA) stated he could not recall specifics regarding Resident 17's fall but stated there were issues with staff not being able to monitor residents who were at risk for falls. On 10/5/21 at 11:45 AM Staff 55 (CNA) stated he worked with the resident frequently and the resident was impulsive and tried to self-transfer. Staff 55 stated a few times he caught [Resident 17] in the act of transferring and at times caught the resident sitting on edge of the bed attempting to get up. Staff 55 stated Resident 17 often did not use her/his call light. Staff 55 stated as long as staff sat and talked with the resident and reassured her/him that staff were there to help, the resident was less impulsive. Staff 55 stated there were issues monitoring residents during the time Resident 17 was in the facility due of staffing shortages. On 10/4/21 at 10:53 AM Staff 26 (LPN Resident Care Manager) stated when a resident fell the charge nurse was responsible to put new interventions in place, but there was a lot of 'turn around and a lot of time it was not done until Staff 26 did them. Staff 26 stated during the time Resident 17 was in the building she was pulled to work the floor as a nurse. Staff 26 confirmed the 3/29/21 fall was the second unwitnessed fall that day. Staff 26 stated staff monitoring resident, especially on night shift, was harder due to staffing shortages, and more falls happened at night because of this. Staff 26 confirmed assessments of the efficacy of fall interventions were not completed for Resident 17 and fall care plans were not person-centered for Resident 17. Staff 26 confirmed Resident 17 sustained a back fracture related to the fall on 3/29/21. Refer F600, F609 and F725. b. A fall investigation indicated on 3/15/21 Resident 17 had an unwitnessed fall and was found under her/his bathroom sink by Witness 11 (Former Physical Therapist) shortly after working with physical therapy. The resident reported there was no new pain, but had continued left shoulder, hip, and back pain. The pain was rated 6/10; which later worsened to 8/10 pain. The resident was transferred to the hospital on 3/17/21 for decreased cognition and increased back pain. The investigation indicated concerns regarding Witness 10 (Former LPN) not assessing Resident 17 post fall. The investigation summary indicated neglect could not be ruled out. Facility witness statements completed by staff who assisted the resident post fall included: Witness 12 (Former Occupational Therapist), Witness 13 (Former CNA), Witness 14 (Former CNA), Witness 15 (Former Maintenance Director), Witness 16 (Former CNA), and Witness 17 (Former LPN). Staff indicated after the fall, Resident 17 was in significant pain when transferred back to bed and the resident's cognition had worsened from baseline. Witness 14 stated the resident was confused, and she never saw Witness 10 assess the resident post fall or during the rest of her shift. Additionally, Witness 14 notified Witness 10 of approximately five abnormal vital signs for Resident 17. Witness 17 stated Resident 17 reported 8/10 pain at 3:30 PM and later that night requested more pain medications. Witness 17 stated during observations she witnessed CNA staff attempting to make the resident more comfortable due to her/his pain. Multiple statements indicated the resident was confused and kept stating I don't want to go to jail, when asked about being transferred to the hospital. The resident was also noted as clammy and complained of head and back pain. The neurological flow sheets for Resident 17 were incomplete for 3/15/21. Witness 12, Witness 13, Witness 14, and Witness 17 were contacted for an interview with no responses. On 9/29/21 at 1:36 PM Witness 16 stated after Resident 17's fall, she helped transfer the resident to bed. Resident 17 complained her/his head hurt but Witness 10 instructed staff to put the resident to bed and failed to assess Resident 17. Witness 16 stated Resident 17 was confused and when Witness 10 asked if the resident needed to go to the hospital the resident replied: I don't want to go to jail. On 10/5/21 at 12:20 PM Witness 11 (Former Physical Therapist) stated Resident 17 completed therapy and was told to wait in her/his room. When Witness 11 entered the room, Resident 17 was on the floor wedged under the sink and had pulled part of the shelving down. Resident 17 had attempted to self-transfer. Resident 17 was unresponsive, eyes open and glazed so Witness 11 checked her/his vitals, performed sternal rubs, and called out for help. Witness 11 stated Witness 10 stood by the door and asked the resident a few questions, but never assessed the resident or performed neurological checks. Witness 11 further stated Witness 10 asked CNA staff and maintenance staff to put the resident back to bed. A change in cognition was noted after the fall by Witness 11. The resident was confused stated, I don't want to go to Jail when asked about going to the hospital. On 9/29/21 at 1:58 PM Witness 10 (LPN) stated she was notified of Resident 17's fall and when she entered the room, Resident 17 who was on the ground with a pillow behind her/his head with Witness 11 present. Witness 10 stated she completed a head to toe assessment and the resident was responding, but when she asked if the resident needed to go to hospital the resident replied, I don't want to go to Jail. Witness 10 stated she was in the room the whole time and only left when nursing staff got the resident up in the mechanical lift to put her/him into bed. Witness 10 stated she completed neurological checks and during the night Resident 17 stated she/he had back pain, but Witness 10 stated this was not new pain for the resident. On 10/6/21 at 12:10 PM Staff 1 (Administrator) acknowledged the findings and stated the allegation Witness 10 did not assess Resident 17 appropriately post fall was correct and stated Resident 17 was transferred to the hospital for increased pain the next day [317/21, two days later]. Staff 1 stated witness statements from the facility's investigation regarding Resident 17's fall on 3/15/21 were accurate per his knowledge. Refer to F697 3. Resident 5 admitted to the facility in 9/2019 with diagnoses including [CONDITION(S)], Alzheimer's Disease, and muscle weakness. The 7/15/21 Quarterly MDS indicated Resident 5 had a significant cognitive impairment. Resident 5's fall care plan was initiated and last updated on 6/2/21. The resident was noted as a high risk for falls due to a history of multiple falls. Interventions included: call light within reach, keep bed in lowest position, place padded mat on both sides of the bed, non-skid footwear as tolerated, notify the family/responsible party and the physician of any fall, use gait belt with transfers, review and update fall assessment quarterly, post any fall and PRN. The resident required two-person staff assistance with transfers. A fall investigation indicated on 8/17/21 at approximately 5:30 AM, Resident 5 was found on the floor, on the fall mat next to the bed, facing the foot of the bed. Resident 5 was observed frail, quiet, and bloody. The resident sustained an upper lip and forehead laceration with copious amounts of blood noted. Resident 5 was non-verbal; pain was assessed as 3/10. A witness statement completed by Staff 54 (CNA) indicated the resident's brief was changed at 12:30 AM, the resident was last observed at 3:00 AM and then not observed again until 5:30 AM. The investigation summary indicated falls continued to be difficult to prevent and the facility would continue to care plan against major injury. There was no indication what position the bed was in or if Resident 5 was soiled. Abuse and neglect were ruled out. The resident was transferred to the hospital. On 8/17/21 Hospital Records indicated Resident 5 required sutures to repair her/his head laceration. The 8/19/21 Fall Assessment indicated Resident 5 was a high fall risk and had multiple falls (more than two) in the past six months at the facility. On 9/23/21 at 1:40 PM Staff 54 (CNA) stated Resident 5 sustained a fall with injury due to staff being really busy and him not being able to check on the resident until after 5:00 AM. Staff 54 stated Resident 5 sometimes slept through the night but sometimes was impulsive and moved around a lot in bed and staff had to watch her/him closely. On 10/6/21 at 10:13 AM Staff 5 (LPN Resident Care Manager) acknowledged there was no indication if the bed was in a low position or if Resident 5 was soiled. Staff 5 acknowledged Resident 5 was a high falls risk and able to pull her/himself up in bed. Staff 5 acknowledged the investigation indicated Resident 5 was last changed around 12:30 AM, which was a very long time. Staff 5 acknowledged the resident was last visualized two and a half hours prior to being found on the floor and the expectation for high fall risks was frequent checks, which she stated was every fifteen minutes. Refer to F609, F657, and F725. 4. Resident 25 admitted to the facility in 2019 with diagnoses including [CONDITION(S)], dementia and a history of falls. On 10/1/21 at 10:02 AM Resident 25 was observed in her/his room at the end of the hall lying halfway off the bed. The 9/19/21 Annual MDS Fall CAA revealed Resident 25 was at risk for falls related to impaired gait and balance, a history of falls and the use of anti-depressant medication. The CAA indicated Resident 25 had difficulty with ambulation and periods of increased confusion. The 9/19/21 Annual Dementia CAA revealed Resident 25 needed reminders and cueing for some ADL's and general supervision for safety due to impaired functional mobility and being a fall risk. It further indicated Resident 25 had impaired safety awareness and was not always cognizant of her/his mobility limitations. The 9/30/20 Fall Care Plan revealed Resident 25 was at risk for falls related to decreased mobility, activity intolerance and poor safety awareness secondary to [CONDITION(S)] and associated cognitive impairment and deconditioning. Interventions included to continue RA (restorative aide) program, frequent checks for safety, to offer assistance when transferred and to wear non-skid socks. The facility fall incident report revealed Resident 25 sustained five falls in a 27 day look-back period between 9/7/21 through 10/4/21. The 9/7/21 Fall Investigation indicated Resident 25 was found on the floor in her/his room. Resident 25 indicated she/he slid out of bed when she/he attempted to transfer to the wheelchair. The 9/9/21 Fall Investigation indicated Resident 25 was found lying on the floor in her/his room next to the bed with one arm wrapped around the assistive transfer pole. Resident 25 was disoriented and confused. Resident 25 had attempted to transfer into the wheelchair, slipped on the floor and hit her/his head. Resident 25 was last checked on one and a half hours prior to the incident. Resident 25 was transferred to the hospital. The 9/28/21 2:28 AM Fall Investigation indicated Resident 25 was found on the floor of her/his room yelling for help. Resident 25 indicated she/he attempted to stand-up to urinate, slipped and fell to the floor. The investigation indicated Resident 25 wore regular socks and was last seen 40 minutes prior to the fall. The 9/28/21 8:50 AM Fall Investigation indicated Resident 25 was found on the floor next to the bed and transfer pole. Resident 25 indicated she/he slid off the bed when she/he attempted to get up to use the urinal. The investigation indicated Resident 25 was last seen approximately one hour before the fall. A 10/4/21 Progress Note indicated Resident 25 was found on the floor by her/his bed. Resident 25 indicated she/he slid out of bed onto the floor when she/he reached for the urinal. [The Fall Investigation was not yet completed.] On 9/29/21 at 1:55 PM Staff 56 (CNA) indicated Resident 25 needed to be monitored more frequently due to being a fall risk. Staff 56 indicated she/he and other staff informed the administrative staff on multiple occasions of the concern. Staff 56 stated the resident should not be left unassisted due to her/his multiple falls but the administrative staff had not updated her/his plan of care. On 10/1/21 at 9:58 AM Staff 12 (CNA) stated Resident 25's room was at the end of the hall, there was not enough staff to monitor Resident 25, and she/he was very impulsive and a fall risk. Staff 12 stated she had repeatedly informed management of this concern until she was blue in the face, however Resident 25's plan of care did not change. On 10/1/21 at 1:21 PM Staff 26 (LPN Resident Care Manager) stated Resident 25 was constantly falling and she was running out of ideas how to update her/his plan of care. Staff 26 acknowledged no fall interventions were updated in 9/2021 after any of the falls. Staff 26 stated frequent checks were every two hours and further stated this was not ideal. Staff 26 verified Resident 25 did not receive RA per the care plan interventions and the 9/30/20 Fall Care Plan interventions were not evaluated or revised in a timely manner. Staff 26 verified Resident 25 required more supervision but the facility could not accommodate this need due to current staffing levels. Refer F725.

Based on interview and record review it was determined the facility failed to ensure a program of systemic identification, analysis and action was in place related to residents at risk for aspiration and falls for 1 of 1 QAA (Quality Assessment and Assurance) committee reviewed for quality assurance. This failure resulted in Resident 1 who was identified as an aspiration risk with a previous history of aspiration to be observed alone with food and liquids on 9/20/21. Additionally, twelve residents were identified as an aspiration risk and 33 residents were identified to be at risk for falls and hospitalization . This was determined to be an Immediate Jeopardy (IJ) situation. Findings include: The 2/2020 Quality Assurance and Performance Improvement (QAPI) Program policy statement revealed the committee would measure current and potential indicators for outcomes of care and quality of life, establish and implement performance improvement projects to correct identified negative or problematic indicators, reinforce and build upon effective systems and processes related to the delivery of quality care and services and establish systems to monitor and evaluate corrective actions. The committee would meet monthly. Review of the facility documents revealed from 1/2020 through 10/4/21 the QAA committee met on 1/28/20, 10/21/20 and 4/1/21. The 9/2021 Dysphagia Diets and Aspiration Precautions policy statement indicated residents who were identified as close supervision and 1:1 supervision levels were not to be left unattended with the food tray. The 3/18/21 Fall policy statement indicated staff would assess and identify residents at risk for falls, identify pertinent interventions to prevent subsequent falls, monitor and follow-up with the IDT's (interdisciplinary team's) involvement. Refer to F689. On 10/4/21 at 9:20 AM Staff 1 (Administrator) stated the QAA committee met quarterly and the QAA committee identified quality care deficiencies by reviewing a checklist from each department and reviewing grievances. Staff 1 indicated fall trends were tracked and reviewed and short staffing levels were identified. Supporting documentation of the QAA meetings was requested. On 10/4/21 at 11:45 AM Staff 1 stated he knew the QAA meetings were required to be held at minimum every three months. Staff 1 further stated between 1/2020 through 10/4/21 only three QAA meetings were held on 1/28/20, 10/21/20 and 4/1/21. On 10/4/21 at 3:10 PM Staff 2 (DNS) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months, did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration or falls. On 10/4/21 at 3:15 PM Staff 48 (Social Services) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months, did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration or falls. On 10/4/21 at 4:16 PM Staff 1, Staff 2, and Staff 29 (Regional RN) were informed of the identified Immediate Jeopardy for the failure to ensure the facility had a QAA program of systemic identification, analysis and action in place related to aspiration precautions and falls. The QAA committee did not identify Resident 1, who was at high risk for aspiration, was not supervised along with twelve additional residents at risk for aspiration. The QAA committee did not identify the 33 identified residents at risk for falls and hospitalization . The facility did not have a working system in place to address the residents at high risk for aspiration and falls. On 10/4/21 at 5:28 PM the IJ Abatement Plan was received and approved. The Plan included: -All residents with aspiration precautions would be re-evaluated by the contract SLP by 10/6/21. -All staff would be in-serviced regarding aspiration precautions, policy and procedures for aspiration precautions and definitions related to types of supervision. -QAPI meeting would be held with the IDT and Medical Director on 10/5/21. Root cause analysis would be completed by Staff 1, Staff 2, Staff 5 (LPN Resident Care Manager) or Staff 26 (LPN Resident Care Manager). -Monthly QAA meetings would be held and review any issues or concerns regarding staffing or any other issue brought up. Resident safety would be a priority. Administration would bring all concerns forward to QAPI with issues, concerns and corrective plans. This information would be reviewed monthly for six months and brought to QAPI for no less than two quarters. -Staffing Coordinator and Staff 1 would meet to review staffing needs no less than three times per week. The Staffing Coordinator would keep a log of all attempts made to cover any call off shifts which occurred. Staff 1 would review agency contracts to establish contracts with other [staffing] agencies. The staffing coordinator would document the number of available shifts on a weekly basis and log the corrective actions taken and bring to QAPI quarterly. Staff 1 would set up a blind survey for staff to participate in to request any concerns or suggestions they had. These concerns would be brought to the monthly QAA and quarterly QAPI meetings. On 10/6/21 at 12:07 PM observation, interview and record review verified the IJ Abatement Plan for the residents at risk for aspiration and falls were implemented. Review of the IJ Abatement Plan revealed the plan was fully implemented.

Based on interview and record review it was determined the facility failed to have the QAA (Quality Assessment and Assurance) committee meet quarterly for 1 of 1 QAA Committees reviewed for quality assurance. This failure resulted in falls with hospitalization and a fracture, and placed residents at increased risk of aspiration. Findings include: The Quality Assurance and Performance Improvement Program policy and procedure revealed the QAA committee was to meet monthly to review reports, evaluate data, monitor QA related activities and make adjustments to the plan. Review of the facility documents revealed from 1/2020 through 10/4/21 the QAA committee met on 1/28/20, 10/21/20 and 4/1/21. On 10/4/21 at 3:10 PM Staff 2 (DNS) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months. She further stated the QAA committee did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration precautions or falls. On 10/4/21 at 3:15 PM Staff 48 (Social Services) stated the last QAA committee she attended was in 4/2021 and verified the QAA team had not met for over six months. She further stated the QAA committee did not monitor any concerns and no action plans were in place for residents who were at risk for aspiration precautions or falls. On 10/4/21 at 11:45 AM Staff 1 (Administrator) stated he was aware the QAA committee was supposed to meet at minimum quarterly and verified the QAA committee only met three times between 1/2020 and 10/4/21. Refer to F689 and F867.

Based on interview and record review it was determined the facility failed to ensure physician ordered 1:1 meal supervision was provided for 1 of 3 sampled residents (#1) reviewed for aspiration. On [DATE] Resident 5 was being fed in her/his room and Staff 1 (CNA) left the room without first removing the food tray. Upon Staff 1's return to Resident 1's room, the resident was found to be unresponsive with food blocking her/his airway and required emergency treatment and hospitalization . Findings include: Resident 1 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. On [DATE] at 9:18 AM Witness 1 (Adult(NAME)Home RN) indicated she worked in the AFH in which Resident 1 resided. The resident was able to eat independently and would inhale her/his food. To prevent aspiration the AFH staff provided the resident a small spoon to eat with, cut food into dime size bites and provided 1:1 supervision. Witness 1 indicated the resident was hospitalized in November after she/he was a passenger of a motor vehicle accident. Witness 1 stated Resident 1 did not aspirate during the six years the resident resided at the AFH. The [DATE] hospital Discharge Summary and associated notes indicated the resident had a history of [REDACTED]. The resident's head of the bed was to be elevated and her/his food was to be cut, liquids were to be thickened and the resident required 1:1 supervision for meals. The [DATE] hospital Skilled/Intermediate Nursing Facility Transfer Orders revealed the resident was on a fat and cholesterol modified diet (cut up), nectar thick liquids and supervise meals (choking risk). The [DATE] Admission CAAs indicated the resident was alert, able to make needs known, was motivated to return to her/his prior living arrangement and get back to work. The resident was assessed to require set up and supervision for meals. The Care Plan initiated on [DATE] revealed the resident required supervision during meals, was to eat in the Assisted Dining Room and was on aspiration precautions. The [DATE] Speech Language Pathology Evaluation and Plan of Treatment indicated the resident was impulsive and was not able to independently implement safe intake strategies. Aspiration signage was posted in the resident's room and the interdisciplinary team was notified. Staff 5 (Speech Therapist) indicated Resident 1 was admitted to the facility without speech therapy orders. Staff requested an evaluation because the resident would shovel food into her/his mouth and did not have impulse control. The staff were to provide 1:1 supervision to ensure the resident ate slowly and chewed the food. On [DATE] Staff 3 (DNS) provided a blank meal ticket from the [DATE] evening meal. Staff 3 indicated the resident was provided the hamburger and sweet potato fries as a soft chew diet. The [DATE] FRI and associated documents indicated on [DATE] Resident 1 was offered to go to the dining room on two occasions but declined. Resident 1's head of the bed was elevated to 90 degrees and Staff 1 supervised the resident to eat. During the meal another resident's position change alarm sounded and Staff 1 left Resident 1's room to ensure the other resident was safe. As Staff 1 started to return to Resident 1's room a visitor stopped Staff 1 in the hall and requested a drink for their family member. Staff 1 went to the dining room to request another staff to provide the drink. While in the dining room Staff 1 saw Resident 1's room mate had finished eating and brought the resident's room mate back to the resident's room. The total estimated time Resident 1 was not provided 1:1 supervision was three to five minutes. When Staff 1 returned to the resident's room she observed Resident 1 to be choking. Staff 1 and Staff 6 (CNA) called for the nurse and requested someone call 911. Staff 2 (LPN) entered the room, the resident was assessed to have a pulse, the head of the bed was lowered, Staff 2 attempted to perform abdominal thrusts and Resident 1 spat out sweet potatoes. The medics arrived, took over care and intubated the resident. The resident remained unresponsive and the resident was transported to the hospital for continued care. On [DATE] at 10:34 AM, with Staff 3 (DNS) present, Staff 1 indicated she was familiar with Resident 1. Resident 1 was able to feed her/himself but required cueing to eat slower. The resident usually ate in the assisted dining room but on [DATE] the resident was up in her/his wheelchair very early in the morning, was tired and declined to transfer out of bed to go to the dining room to eat. Staff 1 indicated she obtained Resident 1's meal tray, placed the head of the bed up to a 90 degree angle, cut the resident's food into small pieces and supervised the resident as she/he ate. While Resident 1 ate another resident's position change alarm sounded, she quickly left the room to ensure the other resident was safe. Staff 1 indicated she was trained to respond to alarms as soon as possible to ensure resident safety. The resident whose alarm sounded was observed to be safe and as she headed back to Resident 1's room, a family member stopped her and asked for a beverage for their family member. Staff 1 indicated she went to the dining room and asked Staff 6 (CNA) to take a beverage to the family member. Staff 1 stated she saw Resident 1's room mate in the dining room, the resident was done eating and she brought the roommate back to Resident 1's room. Staff 1 stated she did not supervise Resident 1 for approximately five minutes. As Staff 1 entered Resident 1's room Resident 1 was observed to be choking. She called for help and Staff 2 (LPN) came to assist. Resident 1 was in bed and had sweet potatoes in her/his mouth. The resident was breathing and had a pulse. Staff 2 started to do abdominal thrusts until the medics took over. Staff 1 indicated she knew the resident required supervision, instinctually reacted to the sound of the position change alarm and did not remove the meal tray. Staff 1 stated she should have removed the food tray from Resident 1 before leaving the room. On [DATE] at 11:41 PM Staff 2 stated she was urgently called to Resident 1's room. As she went to Resident 1's room another nurse called 911. Resident 1's eyes were open, had a weak pulse and was not breathing. Staff 2 saw food in the resident's mouth but was unable to remove the food because the resident's mouth would close. Staff 2 started to do abdominal thrusts until the medics arrived. The medics were able to remove more food from the resident's mouth. On [DATE] at 9:39 AM with Staff 3 (DNS), Staff 7 (Corporate Administrator) and Staff 4 (Administrator), Staff 4 indicated Resident 1 had Down's Syndrome (genetic disorder with delayed physical growth and mild to moderate intellectual disability). On [DATE] Staff 1 left the resident's room for approximately three minutes. During her absence Resident 1 was unsupervised, ate independently and choked. The staff immediately called Staff 4 and he and Staff 3 came to the facility and they started to investigate the incident. It was determined the resident had the correct food texture, had an aspiration precaution sign above the head of the bed and the care plan was reflective of the resident's intervention for 1:1 supervision for meals. Staff 7 indicated all staff were re-trained before their next shift on meal supervision requirements. Staff 3 indicated Staff 1 neglected to remove the meal tray before she checked the safety of the resident whose position change alarm sounded. The [DATE] Ambulance Patient Care Report indicated upon arrival to the facility staff were at the Resident 1's bedside and were performing abdominal thrusts. The resident was observed to have Obvious food obstruction, food and secretions were suctioned from the resident's mouth and then the resident was intubated. The resident was unresponsive, did not have a pulse, was transferred to the ground and CPR (Cardiopulmonary Resuscitation) was initiated. The resident was then transported to the hospital. The [DATE] hospital Discharge Summary indicated on [DATE] the resident was assessed to have ARDS ([DIAGNOSES REDACTED]), oxygen saturations dropped despite prone ventilation (resident positioned face down during mechanical ventilation), the resident was repositioned to her/his back and hamburger was cleared from her/his upper airway. A brain scan was performed which demonstrated swelling consistent with severe [MEDICAL CONDITIONS] ([MEDICAL CONDITION] caused by oxygen deprivation) The resident was declared brain dead on [DATE]. On [DATE] at 11:02 and Staff 1 (Administrator) was notified the incident on [DATE] was an immediate jeopardy situation. As the facility had identified the deficient practice, instituted corrections and maintained the correction, this was determined to qualify for designation as past non-compliance. Survey determined the facility instituted the following interventions: -All staff were provided verbal and written instructions as follows: *Staff were to check the Care Plans before the start of their shift *Care Plans were to be followed *A resident must be supervised at all times while eating if indicated to require 1:1 on the care plan *Follow the direction of the aspiration form Pink Form located above the head of the bed. The Immediate jeopardy was determined to be removed [DATE]. On [DATE] both Residents 2 and 3 were identified to be at risk for aspiration and were observed to have the correct supervision required at meals. Staff in-service was implemented with the last in-service to staff provided on [DATE].

Based on interview and record review, it was determined the facility failed to ensure residents were free from abuse for 1 of 2 sampled residents (#217) reviewed for abuse. This resulted in Resident 217 experiencing psychosocial harm, being physically restrained, and physically injured during a resident to staff incident. Findings include: A complaint intake dated 1/12/18 revealed Witness 3 (Son) reported early in the morning of 1/11/18, the facility called Witness 2 (Spouse) and stated Resident 217 was screaming, violent and aggressive, and wanted to see if Witness 2 could calm her/him down. When Witness 2 arrived at the facility she/he was informed by Resident 217 she/he needed to go to the bathroom and staff were rough with her/him. Witness 2 stayed with the resident for seven hours and after she/he left the resident became aggressive and police were called. The resident was later transported to the hospital, evaluated and found to have a rib fracture. A complaint intake dated 1/18/18 from the King City Police Department indicated an officer was called out to the facility on [DATE] and spoke with Staff 20 (Former Administrator) about Resident 217 reporting six to seven staff members sitting on her/him the previous night and breaking her/his ribs. Staff 20 had initiated an investigation and was in process of gathering information. The officer spoke with the resident and observed bruising on the resident's hands and forearms. No bruising or marks were observed on her/his ribs. The resident reported five to six staff members came into her/his room and sat on her/him while she/he was lying in bed. The resident also reported staff bit her/him. The officer did not observe any bite marks. The resident was unable to describe the amount of pain she/he was experiencing. The officer referred the incident to the Department of Human Services office for further review. The facility's 4/2010 Unmanageable Residents Policy and Procedure indicated if a residents behavior becomes abusive, hostile, assaultive or unmanageable in any way which would jeopardize her/his safety or the safety of others the nurse must immediately provide for the safety of all concerned, notify the resident's attending physician for instructions, notify the DNS and notify the resident's representative. The policy further stated local law enforcement agencies may be called for assistance. Resident 217 was admitted to the facility in (YEAR), with [DIAGNOSES REDACTED]. The 12/13/17 Admission MDS indicated Resident 217 had a BIMS (cognitive assessment) score of 15 (cognitively intact) and no behaviors during the look-back period. The Pain CAA indicated a fall had brought her/him to the hospital where no fractures or other injuries were noted other than hip pain and chronic back pain. The CAA indicated the resident was able to report when she/he was in pain and was confused but easily redirectable. The Communication CAA revealed Resident 217 had dementia but was able to express her/himself and make her/his needs known. A 1/9/18 Physician Routine Visit progress note revealed Resident 217 had a Slums (cognitive assessment) score of 10/30 which indicated moderate dementia. A 1/11/18, 2:07 AM nursing care note revealed Resident 217 became very agitated this shift. CNA yelled for nurse assistance. The nurse entered the resident's room and assisted the CNA with the very uncooperative resident to the wheelchair so staff could escort the resident to the bathroom. The resident tried to grab nearby objects and staff. A second CNA entered the room to assist. The resident was assisted to the wheelchair and then to the bathroom. The resident was cooperative during the first part of the transfer from the wheelchair to the toilet and then grabbed and pulled down on the bathroom call light. The resident hit the wall and light switch with her/his closed fist three times. Staff assisted the resident back to the wheelchair and into bed. The resident attempted to get out of bed several times and started yelling and grabbing CNAs and kicking them. Witness 2 (spouse) was called and informed the staff had a difficult time managing the resident's behaviors. Witness 2 asked to speak with the resident, the call was transferred into the resident room however the resident used the phone to try and hit a CNA so the call was discontinued. Witness 2 attempted to call again however the resident screamed and attempted to hit the CNA. Witness 2 agreed to come to the facility. The nurse had all staff but one CNA leave the room in attempt to calm the resident. The resident continued to try to grab and kick the nurse and CNA before eventually falling asleep. A 1/11/18, 6:03 AM nursing care note indicated Witness 2 called the nurse into Resident 217's room, showed the nurse bruises on the resident's right outer wrist and upper arm and informed the nurse the resident stated staff had bit her/him and sat on her/him which the resident claimed had broken her/his ribs. A skin assessment was performed and noted the following skin impairments (bruises): right back of hand 2.0 x 2.0 cm; 6.0 cm long bruise going down back of right hand and wrist; 2.0 x 1.5 cm bruise on right wrist below thumb; 3.0 x 1.5 cm bruise on arm below right wrist; 1.0 cm bruise on right thumb, first knuckle; 2.0 x 2.0 cm bruise to left hand second knuckle; 1.5 x 1.5 cm bruise to left hand below ring and pinkie fingers; 1.0 x 1.0 cm bruise to left wrist; 1.0 x 0.3 cm right upper arm bruise which the resident stated was a bite mark. A 1/11/18, 2:16 PM nursing care note revealed Resident 217 was sent to the hospital for evaluation. A 1/11/18, 5:15 PM nursing care note indicated the hospital reported Resident 217 had a closed fracture of a right rib and was sending the resident back to the facility with new orders for pain medication. A 1/12/18, 7:09 AM nursing care note revealed Resident 217 complained of chest/rib pain. A 1/11/18 emergency room Visit Summary indicated Resident 217 had a suspected nondisplaced [MEDICAL CONDITION] aspect of the right third rib. The 1/2018 MAR indicated [REDACTED]. The 1/11/18 Incident report revealed Resident 217 had behaviors during the night shift which multiple staff had to intervene with. The resident reported to Witness 2 staff sat on top of her/him and broke her/his ribs. Bruises were noted on the resident's arm and hand. Witness 2 indicated she/he was skeptical of the reported behaviors because the resident was always a very gentle man and never had behaviors before. Witness 2 questioned why the resident would have developed bruises on the inner wrist from hitting the door. The following staff statements were documented: * Staff 24 (CNA) indicated he was called into the room by Staff 23 (CNA) to assist with a transfer into the bathroom. The resident appeared confused and alarmed. While in the bathroom the resident began resisting staff attempts to provide care and began to refuse care and fight with staff. Staff 22 (RN) entered the bathroom at some point. The resident's aggression escalated and she/he slammed her/his right arm into the bathroom light switch about four times then began to hit, grab and attempt to bite staff. Staff 24 indicated the staff attempted to coax the resident to sit down but the resident refused, so with the Staff 22's permission Staff 24 forced the resident to turn and sat her/him back down in the wheelchair. Staff then attempted to get the resident back into bed where staff believed the resident would be safe until she/he calmed down. The resident fought, grabbed, hit and tried to bite staff. The resident continued to hit the wall and grab and throw anything she/he could reach. Staff removed everything in the residents reach when the room phone rang. Staff 23 answered the phone, it was Witness 2 who hung up because staff could not control the resident adequately. Staff 22 exited the room to document the behaviors and call Witness 2 back. Staff 23 and 25 (CNA) attempted to restrain the resident while Staff 24 restored the bedding. The resident continued to fight so staff decided to just get the resident back into the bed. The resident was standing and refused to move. The resident would not turn towards the bed or sit back down in the chair. Staff 24 indicated for the second time, I eventually had to force the resident to move. Staff 24 forced the resident to turn and sit down in bed. Once the resident was in bed staff tried to calm him her/him down however the resident attempted to throw her/himself out of bed. Staff 24 indicated both Staff 23 and Staff 25 attempted to restrain the resident in bed when he heard Staff 25 state get (her/him) off me. The resident had gripped Staff 25's thumb and bent it backwards. Staff 24 indicated he was afraid the resident would break Staff 25's thumb so he dug into the residents fingers with his own to force the resident to let Staff 25 go. After that (Staff 25) stated that she was going to 'do what we did in the state/mental hospital' and she laid on top of (her/him), perpendicular to (her/his) body and pinned (her/his) arms between (her/his) chest and hers. Staff 24 indicated the resident started screaming at the top of (her/his) lungs. Staff 25 was unable to keep the resident fully restrained and the resident attempted to grab and bite both Staff 23 and Staff 25. Staff 24 indicated Staff 25 stated don't bite me, bite your own hands and twisted the residents hands against her/his own mouth instead of hers. Staff 24 indicated he was extremely uncomfortable with the resident being pinned down in such a manner and indicated Staff 25 swore loudly. Staff 24 indicated the resident was clearly terrified. Staff 24 indicated he disliked forcing the resident to move against her/his will and to have potentially injured Resident 217's hands when attempting to prevent the resident from breaking Staff 25's thumb. Staff 24 indicated in hindsight, the best thing would have been to just leave him alone. * Management clarification of Staff 24's previous statement indicated Staff 25 was leaning against the residents side, putting weight on the resident's arms and chest to keep the resident pinned in the bed. Further clarification of the terms forced and restrained indicated the restraint involved holding the resident's arms to prevent the resident from hitting and holding the resident in place while she/he was standing. Additional clarification with Staff 2 (DNS) revealed when Staff 24 stated he forced the resident, it meant he pressed the residents body against his to guide her/him and make the resident turn and sit. The resident continued to fight and Staff 24 made the resident move. Staff 24 indicated staff had to physically stop him from doing the things she/he was doing or wanted to do. The resident tried to hit and hurt us and we had to physically stop him. * Staff 22 (RN) indicated she did not see any staff pinning the resident down. She called Witness 2 and when she returned to the room the bed was in a low position and Staff 25 was leaning on the side of the bed holding both resident's hands to the resident's chest. Staff 22 indicated she sat on the the end of the bed and placed one hand on the resident's leg to prevent the resident from kicking Staff 25. * Staff 25 (CNA) indicated after the resident was in bed, the resident continued to try to break staff's fingers, bite and kick staff, so she used a protective non-invasive hold on the resident. Staff 25 indicated Staff 22 was present in the room. Staff 25 indicated she learned the hold from working in a mental health hospital and it involved laying her body across (the) residents stomach, but not pining (sic) him down. Staff 25 stated this was the same hold that SACU (Stabilization and Crisis Unit) used. The Incident further indicated law enforcement arrived on 1/11/18 at approximately 1:00 PM to investigate the alleged occurrence. The facility investigation was completed on 1/22/18 with abuse and neglect being ruled out. The charge nurses were educated in situations like this 911 could be called to assist with behavior crisis management. Staff 25 was counseled and educated on the use of non-invasive hold in nursing facilities and residents with dementia. The facility indicated it did not recognize the non-invasive hold and would not apply it in the nursing home setting. Staff 25 indicated it was possible some of the bruising on the resident could be caused by staff interventions during the incident. Staff 30 (Medical Director) indicated in his opinion, the rib fracture was an old and healing fracture. In summary, Resident 217 suffered psychosocial and physical harm during a resident to staff incident. Resident 217 was described in the incident report and staff interviews as clearly terrified, fearful and screaming when staff attempted to physically restrain the resident. Resident 217 had bruising to her/his right arm and both hands and was later evaluated in the hospital emergency room where a rib fracture was newly diagnosed . Staff actions were a response to Resident 217's dementia related behaviors. On 4/27/18 at 12:00 PM, Witness 6 (Education and Development Manager - Stabilization and Crisis Unit/SACU) was interviewed to clarify statements previously made by Staff 25 regarding the non-invasive hold. Witness 6 indicated there was no such term as a non-invasive hold and at any time movement was restricted it was invasive. Witness 6 stated SACU does not teach or authorize a non-invasive hold and no one should hold any person down when they are in a supine (laying down) position because it was very dangerous. On 4/27/18 at 12:09 PM, Witness 7 (Master Instructor - SACU) indicated he was an instructor with the Oregon Intervention Service (OIS) training team and SACU considered any move on a supine person an abusive measure. Witness 7 stated the training states specifically not to hold any person in a supine position and never to be used on a person with combative or aggressive behaviors. On 4/27/18 at 2:23 PM, Staff 23 (CNA) stated she witnessed Staff 25 put the non-invasive hold on Resident 217. Staff 23 stated Resident 217's arms were crossed over her/his chest and Staff 25 was physically holding both arms down and the resident was resisting to the point where she/he did get out of Staff 25's grip one time. Staff 23 verified Staff 24 dug his fingers into the resident to get the resident to let go of her (not Staff 25 as previously indicated). Staff 23 further stated Resident 217's chest area was touched and bumped when staff transferred her/him in the wheelchair, when staff attempted to have the resident sit down and when transferring the resident with the gait belt to the chair. On 4/27/18 at 3:13 PM and 4/29/18 at 10:37 PM, Staff 22 (RN) indicated Resident 217's bruising to her/his hands and wrists probably happened when Staff 24 tried to loosen the residents grip on a CNA. Staff 22 verified she did not notify Witness 2 of the non-invasive hold and did not report the incident to Resident 217's physician. At 4/27/18 at 5:00 PM, Staff 24 (CNA) stated he entered Resident 217's room to assist with a transfer to the bathroom and the resident became fearful and combative. The resident was afraid of the situation and staff. Staff 25 forced the resident into bed flat on her/his back when she/he then started screaming and became more confrontational. Staff 24 stated Staff 25 physically restrained the resident so she/he could not get out of bed and was angled with her head near the resident's head and her feet near the resident's feet. Staff 24 stated Staff 25's shoulder and upper right arm were touching the resident's chest. This hold resulted in the resident having her/his arms locked down. Resident 217 was screaming for help and to get off. When (she/he) wasn't screaming with words (she/he) was just screaming. Staff 24 stated he notified Staff 22 what had happened. Staff 24 verified he forced the resident to move in a direction the resident did not want to go during transfers three times and verified he had dug his fingers into the resident's hand to get the resident to let go of another CNA. Staff 24 stated digging his fingers into the resident and being pinned down by Staff 25 could have caused pain and fear and was a traumatizing experience for Resident 217 and some of the bruising could have been a result of both his and Staff 25's actions. Staff 24 also verified Staff 25 instructed Resident 217 to bite her/his own hands at one point during the staff to resident incident. Staff 24 stated in hindsight the staff should have backed off as the measures staff used to keep the resident safe were more harmful than if the resident were to crawl around on the floor. On 4/29/18 at 10:38 PM, Staff 25 stated she had received abuse training when hired by the facility however had no idea what she had been trained on and stated she had not received facility training on how to work with combative residents or residents with dementia related behaviors. Staff 25 verified she placed a non-invasive hold on Resident 217 which she had been trained on by OIS. Staff 25 could not state when she received the training but had a copy of the written training and would email it to this surveyor. No further written information was supplied to the surveyor. Staff 25 stated on 1/11/18, she entered the room when other staff were struggling to get Resident 217 into bed. Staff 25 stated she decided to perform the non-invasive hold when the resident was attempting to get out of bed, because the resident was a fall risk. Staff 25 would only verify she put her arms across the resident and touched her/him. Staff 25 verified she performed the non-invasive hold when the resident was in a supine position and her SACU training said it was acceptable to hold a resident down who was combative or aggressive in a supine position. Staff 25 verified this hold was performed due to the residents aggression. Staff 25 stated she did not remember her thumb being bent backwards by the resident and perhaps it was another CNA. On 4/30/18 at 10:34 AM, Witness 3 (Son) stated when Witness 2 got a phone call at 1:30 AM or 1:50 AM to come to the facility and arrived 30 minutes later. Resident 217 was hysterical and stated staff sat on her/him and attacked her/him. Later in the day when the resident was evaluated at the hospital, she/he was diagnosed with [REDACTED]. On 4/30/18 at 10:44 AM, Staff 20 (Former Administrator) stated she did not know what time the incident occurred other than it was after midnight. She stated she knew Staff 2 (DNS) was informed around 4:00 AM and she was informed around 7:30 AM. Staff 20 stated the facility did not approve of the use of Staff 25's non-invasive hold and verified she understood this hold would minimize the resident's arm movements. Staff 20 acknowledged a definition of physical restraints by the manual method indicated holding down a resident in response to a behavioral symptom was a physical restraint. Staff 20 did not remember discussing the physical restraint staff used on Resident 217 with Witness 2. Staff 20 further stated Staff 24 was educated on how he could have responded differently. Staff 25 was suspended pending the investigation and later counseled. In an interview on 4/30/18 at 12:03 PM, with Staff 1 (Administrator), Staff 2 (DNS) and Staff 21 (RN Consultant) the 1/11/18 incident was discussed. Staff 2 stated the incident occurred the morning of 1/11/18 around 2:00 AM. Staff 2 verified the facility did not sanction the use of the non-invasive hold and Staff 25 was suspended and counseled. The definition of physical restraint and manual method were reviewed and included anything attached or against the residents body, could not be removed easily by the resident and restricted the residents freedom of movement with an example of a physical restraint included but not limited to holding down a resident in response to a behavioral symptom or during the provision of care if the resident is resistive or refusing the care. Staff 2 verified there was no documentation Witness 2 was notified of the physical restraint used by staff and comprehensive documentation of the incident including what the resident was doing, what happened which presented imminent danger, interventions that were attempted, response to those interventions, whether the resident was transferred to another setting for evaluation, whether the use of physical restraint was ordered by the physician and the medical symptoms and causes was not completed. Staff 2 verified Staff 25 did not follow facility policy when she preformed the non-invasive hold and acknowledged the hold restricted the residents movements. Staff 2 stated she did not remember the occurrence of Staff 24 digging his fingers into the resident. Staff 2 verified the facility's Unmanageable Resident Policy and Procedure was not followed by staff.

Based on interview and record review, it was determined the facility failed to ensure residents were treated with respect and dignity and free from physical restraints for 1 of 2 sampled residents (#217) reviewed for abuse. This resulted in Resident 217 experiencing psychosocial harm, being physically restrained, and physically injured during a resident to staff incident. Findings include: A complaint intake dated 1/12/18 revealed Witness 3 (Son) reported early in the morning of 1/11/18, the facility called Witness 2 (Spouse) and stated Resident 217 was screaming, violent and aggressive, and wanted to see if Witness 2 could calm her/him down. When Witness 2 arrived at the facility she/he was informed by Resident 217 she/he needed to go to the bathroom and staff were rough with her/him. Witness 2 stayed with the resident for seven hours and after she/he left the resident became aggressive and police were called. The resident was later transported to the hospital, evaluated and found to have a rib fracture. A complaint intake dated 1/18/18 from the King City Police Department indicated an officer was called out to the facility on [DATE] and spoke with Staff 20 (Former Administrator) about Resident 217 reporting six to seven staff members sitting on her/him the previous night and breaking her/his ribs. Staff 20 had initiated an investigation and was in process of gathering information. The officer spoke with the resident and observed bruising on the resident's hands and forearms. No bruising or marks were observed on her/his ribs. The resident reported five to six staff members came into her/his room and sat on her/him while she/he was lying in bed. The resident also reported staff bit her/him. The officer did not observe any bite marks. The resident was unable to describe the amount of pain he was experiencing. The officer referred the incident to the Department of Human Services for further review. The facility's 4/2010 Unmanageable Residents Policy and Procedure indicated if a residents behavior becomes abusive, hostile, assaultive or unmanageable in any way which would jeopardize her/his safety or the safety of others the nurse must immediately provide for the safety of all concerned, notify the resident's attending physician for instructions, notify the DNS and notify the resident's representative. The policy further stated local law enforcement agencies may be called for assistance. Resident 217 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 12/13/17 Admission MDS indicated Resident 217 had a BIMS (cognitive assessment) score of 15 (cognitively intact) and no behaviors during the look-back period. The Pain CAA indicated a fall had brought her/him to the hospital where no fractures or other injuries were noted other than hip pain and chronic back pain. The CAA indicated the resident was able to report when she/he was in pain and was confused but easily redirectable. The Communication CAA revealed Resident 217 had dementia but was able to express her/himself and make her/his needs known. A 1/9/18 Physician Routine Visit progress note revealed Resident 217 had a Slums (cognitive assessment) score of 10/30 which indicated moderate dementia. A 1/11/18, 2:07 AM nursing care note revealed Resident 217 became very agitated this shift. CNA yelled for nurse assistance. The nurse entered the resident's room and assisted the CNA with the very uncooperative resident to the wheelchair so staff could escort the resident to the bathroom. The resident tried to grab nearby objects and staff. A second CNA entered the room to assist. The resident was assisted to the wheelchair and then to the bathroom. The resident was cooperative during the first part of the transfer from the wheelchair to the toilet and then grabbed and pulled down on the bathroom call light. The resident hit the wall and light switch with her/his closed fist three times. Staff assisted the resident back to the wheelchair and into bed. The resident attempted to get out of bed several times and started yelling and grabbing CNAs and kicking them. Witness 2 (spouse) was called and informed the staff had a difficult time managing the resident's behaviors. Witness 2 asked to speak with the resident, the call was transferred into the resident room however the resident used the phone to try and hit a CNA so the call was discontinued. Witness 2 attempted to call again however the resident screamed and attempted to hit the CNA. Witness 2 agreed to come to the facility. The nurse had all staff but one CNA leave the room in attempt to calm the resident. The resident continued to try to grab and kick the nurse and CNA before eventually falling asleep. A 1/11/18, 6:03 AM nursing care note indicated Witness 2 called the nurse into Resident 217's room, showed the nurse bruises on the resident's right outer wrist and upper arm and informed the nurse the resident stated staff had bit her/him and sat on her/him which the resident claimed had broken her/his ribs. A skin assessment was performed and noted the following skin impairments (bruises): right back of hand 2.0 x 2.0 cm; 6.0 cm long bruise going down back of right hand and wrist; 2.0 x 1.5 cm bruise on right wrist below thumb; 3.0 x 1.5 cm bruise on arm below right wrist; 1.0 cm bruise on right thumb, first knuckle; 2.0 x 2.0 cm bruise to left hand second knuckle; 1.5 x 1.5 cm bruise to left hand below ring and pinkie fingers; 1.0 x 1.0 cm bruise to left wrist; 1.0 x 0.3 cm right upper arm bruise which the resident stated was a bite mark. A 1/11/18, 2:16 PM nursing care note revealed Resident 217 was sent to the hospital for evaluation. A 1/11/18, 5:15 PM nursing care note indicated the hospital reported Resident 217 had a closed fracture of a right rib and was sending the resident back to the facility with new orders for pain medication. A 1/12/18, 7:09 AM nursing care note revealed Resident 217 complained of chest/rib pain. A 1/11/18 emergency room Visit Summary indicated Resident 217 had a suspected nondisplaced [MEDICAL CONDITION] aspect of the right third rib. The 1/2018 MAR indicated [REDACTED]. The 1/11/18 Incident report revealed Resident 217 had behaviors during the night shift which multiple staff had to intervene with. The resident reported to Witness 2 staff sat on top of her/him and broke her/his ribs. Bruises were noted on the resident's arm and hand. Witness 2 indicated she/he was skeptical of the reported behaviors because the resident was always a very gentle man and never had behaviors before. Witness 2 questioned why the resident would have developed bruises on the inner wrist from hitting the door. The following staff statements were documented: * Staff 24 (CNA) indicated he was called into the room by Staff 23 (CNA) to assist with a transfer into the bathroom. The resident appeared confused and alarmed. While in the bathroom the resident began resisting staff attempts to provide care and began to refuse care and fight with staff. Staff 22 (RN) entered the bathroom at some point. The resident's aggression escalated and she/he slammed her/his right arm into the bathroom light switch about four times then began to hit, grab and attempt to bite staff. Staff 24 indicated the staff attempted to coax the resident to sit down but the resident refused, so with the Staff 22's permission Staff 24 forced the resident to turn and sat her/him back down in the wheelchair. Staff then attempted to get the resident back into bed where staff believed the resident would be safe until she/he calmed down. The resident fought, grabbed, hit and tried to bite staff. The resident continued to hit the wall and grab and throw anything she/he could reach. Staff removed everything in the residents reach when the room phone rang. Staff 23 answered the phone, it was Witness 2 who hung up because staff could not control the resident adequately. Staff 22 exited the room to document the behaviors and call Witness 2 back. Staff 23 and 25 (CNA) attempted to restrain the resident while Staff 24 restored the bedding. The resident continued to fight so staff decided to just get the resident back into the bed. The resident was standing and refused to move. The resident would not turn towards the bed or sit back down in the chair. Staff 24 indicated for the second time, I eventually had to force the resident to move. Staff 24 forced the resident to turn and sit down in bed. Once the resident was in bed staff tried to calm him her/him down however the resident attempted to throw her/himself out of bed. Staff 24 indicated both Staff 23 and Staff 25 attempted to restrain the resident in bed when he heard Staff 25 state get (her/him) off me. The resident had gripped Staff 25's thumb and bent it backwards. Staff 24 indicated he was afraid the resident would break Staff 25's thumb so he dug into the residents fingers with his own to force the resident to let Staff 25 go. After that (Staff 25) stated that she was going to 'do what we did in the state/mental hospital' and she laid on top of him, perpendicular to his body and pinned his arms between his chest and hers. Staff 24 indicated the resident started screaming at the top of (her/his) lungs. Staff 25 was unable to keep the resident fully restrained and the resident attempted to grab and bite both Staff 23 and Staff 25. Staff 24 indicated Staff 25 stated don't bite me, bite your own hands and twisted the residents hands against her/his own mouth instead of hers. Staff 24 indicated he was extremely uncomfortable with the resident being pinned down in such a manner and indicated Staff 25 swore loudly. Staff 24 indicated the resident was clearly terrified. Staff 24 indicated he disliked forcing the resident to move against her/his will and to have potentially injured Resident 217's hands when attempting to prevent the resident from breaking Staff 25's thumb. Staff 24 indicated in hindsight, the best thing would have been to just leave (her/him) alone. * Management clarification of Staff 24's previous statement indicated Staff 25 was leaning against the residents side, putting weight on the resident's arms and chest to keep the resident pinned in the bed. Further clarification of the terms forced and restrained indicated the restraint involved holding the resident's arms to prevent the resident from hitting and holding the resident in place while she/he was standing. Additional clarification with Staff 2 (DNS) revealed when Staff 24 stated he forced the resident, it meant he pressed the residents body against his to guide her/him and make the resident turn and sit. The resident continued to fight and Staff 24 made the resident move. Staff 24 indicated staff had to physically stop him from doing the things she/he was doing or wanted to do. The resident tried to hit and hurt us and we had to physically stop him. * Staff 22 (RN) indicated she did not see any staff pinning the resident down. She called Witness 2 and when she returned to the room the bed was in a low position and Staff 25 was leaning on the side of the bed holding both resident's hands to his chest. Staff 22 indicated she sat on the the end of the bed and placed one hand on the resident's leg to prevent the resident from kicking Staff 25. * Staff 25 (CNA) indicated after the resident was in bed, the resident continued to try to break staff's fingers, bite and kick staff, so she used a protective non-invasive hold on the resident. Staff 25 indicated Staff 22 was present in the room. Staff 25 indicated she learned the hold from working in a mental health hospital and it involved laying her body across (the) residents stomach, but not pining (sic) him down. Staff 25 stated this was the same hold that SACU (Stabilization and Crisis Unit) used. The Incident further indicated law enforcement arrived on 1/11/18 at approximately 1:00 PM to investigate the alleged occurrence. The facility investigation was completed on 1/22/18 with abuse and neglect being ruled out. The charge nurses were educated in situations like this 911 could be called to assist with behavior crisis management. Staff 25 was counseled and educated on the use of non-invasive hold in nursing facilities and residents with dementia. The facility indicated it did not recognize the non-invasive hold and would not apply it in the nursing home setting. Staff 25 indicated it was possible some of the bruising on the resident could be caused by staff interventions during the incident. Staff 30 (Medical Director) indicated in his opinion, the rib fracture was an old and healing fracture. In summary, Resident 217 suffered psychosocial and physical harm during a resident to staff incident. Resident 217 was described in the incident report and staff interviews as clearly terrified, fearful and screaming when staff attempted to physically restrain the resident. Resident 217 had bruising to her/his right arm and both hands and was later evaluated in the hospital emergency room where a rib fracture was newly diagnosed . Staff actions were a response to Resident 217's dementia related behaviors. On 4/27/18 at 12:00 PM, Witness 6 (Education and Development Manager - Stabilization and Crisis Unit/SACU) indicated there was no such term as a non-invasive hold and at any time movement was restricted it was invasive. Witness 6 stated SACU does not teach or authorize a non-invasive hold and no one should hold any person down when they are in a supine (laying down) position because it was very dangerous. On 4/27/18 at 12:09 PM, Witness 7 (Master Instructor - SACU) indicated he was an instructor with the Oregon Intervention Service (OIS) training team and SACU considered any move on a supine person an abusive measure. Witness 7 stated the training states specifically not to hold any person in a supine position and never to be used on a person with combative or aggressive behaviors. On 4/27/18 at 2:23 PM, Staff 23 (CNA) stated she witnessed Staff 25 put the non-invasive hold on Resident 217. Staff 23 stated Resident 217's arms were crossed over her/his chest and Staff 25 was physically holding both arms down and the resident was resisting to the point where she/he did get out of Staff 25's grip one time. Staff 23 verified Staff 24 dug his fingers into the resident to get the resident to let go of her (not Staff 25 as previously indicated). Staff 23 further stated Resident 217's chest area was touched and bumped when staff transferred her/him in the wheelchair, when staff attempted to have the resident sit down and when transferring the resident with the gait belt to the chair. On 4/27/18 at 3:13 PM and 4/29/18 at 10:37 PM, Staff 22 (RN) indicated Resident 217's bruising to her/his hands and wrists probably happened when Staff 24 tried to loosen the residents grip on a CNA. Staff 22 verified she did not notify Witness 2 of the non-invasive hold and did not report the incident to Resident 217's physician. At 4/27/18 at 5:00 PM, Staff 24 (CNA) stated he entered Resident 217's room to assist with a transfer to the bathroom and the resident became fearful and combative. The resident was afraid of the situation and staff. Staff forced the resident into bed flat on her/his back when she/he then started screaming and became more confrontational. Staff 24 stated Staff 25 physically restrained the resident so she/he could not get out of bed and was angled with her head near the resident's head and her feet near the resident's feet. Staff 24 stated Staff 25's shoulder and upper right arm were touching the resident's chest. This hold resulted in the resident having her/his arms locked down. Resident 217 was screaming for help and to get off. When (she/he) wasn't screaming with words (she/he) was just screaming. Staff 24 stated he notified Staff 22 what had happened. Staff 24 verified he forced the resident to move in a direction the resident did not want to go during transfers three times and verified he had dug his fingers into the resident's hand to get the resident to let go of another CNA. Staff 24 stated digging his fingers into the resident and being pinned down by Staff 25 could have caused pain and fear and was a traumatizing experience for Resident 217 and some of the bruising could have been a result of both his and Staff 25's actions. Staff 24 also verified Staff 25 instructed Resident 217 to bite her/his own hands at one point during the staff to resident incident. Staff 24 stated in hindsight the staff should have backed off as the measures staff used to keep the resident safe were more harmful than if the resident were to crawl around on the floor. On 4/29/18 at 10:38 PM, Staff 25 stated she had received abuse training when hired by the facility however had no idea what she had been trained on and stated she had not received facility training on how to work with combative residents or residents with dementia related behaviors. Staff 25 verified she placed a non-invasive hold on Resident 217 which she had been trained on by OIS/SACU. Staff 25 could not state when she received the training but had a copy of the written training and would email it to this surveyor. No further written information was supplied to the surveyor. Staff 25 stated on 1/11/18, she entered the room when other staff were struggling to get Resident 217 into bed. Staff 25 stated she decided to perform the non-invasive hold when the resident was attempting to get out of bed, because the resident was a fall risk. Staff 25 would only verify she put her arms across the resident and touched him. Staff 25 verified she performed the non-invasive hold when the resident was in a supine position and her OIS/SACU training said it was acceptable to hold a resident down who was combative or aggressive in a supine position. Staff 25 verified this hold was performed due to the residents aggression. Staff 25 stated she did not remember her thumb being bent backwards by the resident and perhaps it was another CNA. On 4/30/18 at 10:34 AM, Witness 3 (Son) stated when Witness 2 got a phone call at 1:30 AM or 1:50 AM to come to the facility and arrived 30 minutes later. Resident 217 was hysterical and stated staff sat on her/him and attacked her/him. Later in the day when the resident was evaluated at the hospital, she/he was diagnosed with [REDACTED]. On 4/30/18 at 10:44 AM, Staff 20 (Former Administrator) stated she did not know what time the incident occurred other than it was after midnight. She stated she knew Staff 2 (DNS) was informed around 4:00 AM and she was informed around 7:30 AM. Staff 20 stated the facility did not approve of the use of Staff 25's non-invasive hold and verified she understood this hold would minimize the residents arm movements. Staff 20 acknowledged a definition of physical restraints by the manual method indicated holding down a resident in response to a behavioral symptom was a physical restraint. Staff 20 did not remember discussing the physical restraint staff used on Resident 217 with Witness 2. Staff 20 further stated Staff 24 was educated on how he could have responded differently. In an interview on 4/30/18 at 12:03 PM, with Staff 1 (Administrator), Staff 2 (DNS) and Staff 21 (RN Consultant) the 1/11/18 incident was discussed. Staff 2 verified the incident occurred the morning of 1/11/18 around 2:00 AM. Staff 2 verified the facility did not sanction the use of the non-invasive hold and Staff 25 was suspended and counseled. The definition of physical restraint and manual method were reviewed and included anything attached or against the residents body, could not be removed easily by the resident and restricted the residents freedom of movement with an example of a physical restraint included but not limited to holding down a resident in response to a behavioral symptom or during the provision of care if the resident is resistive or refusing the care. Staff 2 verified there was no documentation Witness 2 was notified of the physical restraint used by staff and comprehensive documentation of the incident including what the resident was doing, what happened which presented imminent danger, interventions that were attempted, response to those interventions, whether the resident was transferred to another setting for evaluation, whether the use of physical restraint was ordered by the physician and the medical symptoms and causes was not completed. Staff 2 verified Staff 25 did not follow facility policy when she performed the non-invasive hold and acknowledged the hold restricted the residents movements. Staff 2 stated she did not remember the occurrence of Staff 24 digging his fingers into the resident. Staff 2 verified the facility's Unmanageable Resident Policy and Procedure was not followed by staff.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures which prevented abuse of residents for 1 of 2 sampled residents (#217) reviewed for abuse. This resulted in Resident 217 experiencing psychosocial harm, being physically restrained and physically injured during a resident to staff incident. Findings include: The facility's 4/2010 Unmanageable Residents Policy and Procedure indicated if a residents behavior becomes abusive, hostile, assault or unmanageable in any way which would jeopardize her/his safety or the safety of others the nurse must immediately provide for the safety of all concerned, notify the resident's attending physician for instructions, notify the DNS and notify the resident's representative. The policy further stated local law enforcement agencies may be called for assistance. Resident 217 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 217's medical and hospital records, incident and police reports and complaint intake #s and revealed Resident 17 suffered psychosocial and physical harm during a resident to staff incident. Staff actions were a response to Resident 217's dementia related behaviors. In an interview on 4/30/18 at 12:03 PM, with Staff 1 (Administrator), Staff 2 (DNS) and Staff 21 (RN Consultant), the 1/11/18 incident was discussed. Staff 2 verified Staff 25 (CNA) did not follow facility policy when she physically restrained Resident 217. Staff 2 stated she did not remember the occurrence of Staff 24 (CNA) digging his fingers into the resident. Staff 2 verified the facility's Unmanageable Resident Policy and Procedure was not followed by staff. Refer to F 600 and F 604

Based on interview and record review, it was determined the facility failed to ensure abuse training was completed annually by facility staff for 1 of 2 staff members (#25) reviewed for abuse training. This resulted in Resident 217 experiencing psychosocial harm, being physically restrained, and physically injured during a resident to staff incident. Findings include: Review of Staff 25's personal record indicated Staff 25 was hired by the facility in 3/2017 and completed abuse prevention training on 3/7/17. No further abuse training was completed by Staff 25. The personal record also included a blank copy of the yearly performance review. On 4/30/18 at 12:03 PM, Staff 2 (DNS) verified Staff 25 did not have any documented abuse training after her date of hire and her yearly performance review was not completed. Refer to F 600, F 604 and F 607.

Based on observation, interview and record review it was determined the facility failed to notify nursing timely when a resident experienced falls for 1 of 3 sampled residents (# 2) reviewed for falls. Resident 2 sustained a fracture as a result of the falls. Findings include: Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides Conduct Unbecoming a Nursing Assistant 851-063-0090 A CNA, regardless of job location, responsibilities, or use of the title "CNA," who, in the performance of nursing related duties, may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Conduct unbecoming a nursing assistant includes but is not limited to: (2) Conduct related to other federal or state statutes/rule violations: (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (3) Conduct related to communication: (a) Inaccurate recordkeeping in client or agency records; (c) Falsifying a client or agency record; including but not limited to filling in someone else's omissions, signing someone else's name, recording care not given, fabricating data/values; (g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriate person in a timely manner. Resident 2 was admitted to the facility in 2/2007 and had [DIAGNOSES REDACTED]. The resident was care planned for one person, extensive assistance with transfers. An 8/7/11 incident report revealed Staff 12, CNA, reported toileting the resident after lunch. When Staff 12 transferred the resident off the toilet, the resident reported "my knee popped." Staff 12 guided the resident to the floor with the gaitbelt. Staff 12 reported Staff 10, CMA, came in to help lift the resident back on the toilet and then to the wheelchair, followed by Staff 11, CNA, assisting the resident back to bed. Staff 5, LPN, was notified of the incident and found the resident in bed. The resident's knee was assessed, there was no swelling, redness or bruising. The resident had no complaints of pain at that time, however, when Staff 5 asked the resident what had happened, the resident stated "I felt my knee pop when she was transferring me and its sore". The 8/7/11 6:45 pm Interdisciplinary Progress Note disclosed the resident complained of 10 out of 10 level pain in the left knee, and swelling and purple bruising were noted to the inside aspect of the knee. The physician was contacted and the resident was sent to the hospital. The 8/7/11 hospital records revealed the resident was accidentally dropped during a transfer during toileting, landing directly on the left knee. The resident had severe pain with the left knee. The resident was found to have a [MEDICAL CONDITION] and fibula. Per the facility's 8/16/11 summary of the fall investigation, after reviewing the hospital records, the investigation was re-opened. The facility determined that two separate falls had occurred while the resident was being toileted, before being transferred back into bed and Staff 12, CNA, had not given an accurate account of the falls. Staff 12 later acknowledged the reason for the initial lowering of the resident was due to the resident's legs buckling. When asked why she reported it as knee popping, she stated "I don't know, maybe I wrote the statement to cover myself. Shame on me." When asked why she did not immediately get the nurse, she replied "because the resident wasn't hurt." The facility's investigation noted that when Staff 10, CMA, was asked why he did not ask a nurse to assess the resident prior to moving her/him, Staff 10 stated that Staff 12, CNA, told him the resident had not fallen, but was just lowered, so they helped the resident back to the toilet. "I didn't see need for a nurse." The facility's investigation disclosed that Staff 11, CNA, stated to Staff 12, CNA, the resident did not look good and she should report it to the nurse. The facility determined Staff 10, 11 and 12 had violated the Standard of Practice for a CNA. In interviews on 8/22/11 at 9:23 am and 10:59 am, the resident was observed in bed, appeared somewhat confused and had a brace on the left leg. When asked what happened to her/his leg, the resident stated she/he broke it. When asked how, the resident stated she/he slipped and kept slipping. When asked if someone was with her/him during the falls, the resident could not remember. The resident reported having pain with the leg, which was better when it was not moved. In interviews on 8/22/11 at 2:51 pm and 8/23/11 at 9:37 am, Staff 5, LPN, stated Staff 12, CNA, reported to her the resident reported feeling her/his knee pop during a transfer and lowered her/him to the floor. When Staff 5 went to assess the resident, the resident was already in bed and was not painful nor had swelling at that time. Staff 5 stated she found out later there had been a couple of falls/transfers, but was not told anything about it until after the resident was back in bed. Staff 5 stated prior to the fracture, the resident used to get up for two meals, but stayed in the room the rest of the time. Staff 5 stated the resident was currently not getting up as much, depending on the pain level. In interview on 8/23/11 at 10:05 am, Staff 17, Administrator, stated the facility determined the standard of practice was not followed and the CNA covered up her actions of the second transfer. In interview on 8/23/11 at 2:48 pm, Staff 12, CNA, stated the facility was short staffed that day and reported feeling "frazzled." When asked if she reported to anyone she was having problems, she stated she did that every day, "they could see it on our faces." Staff 12 stated she had told others that she was having a hard time keeping up and that everyone was very helpful, but at times could not find anybody. Staff 12 stated she had taken the resident to the bathroom, "there was BM all over the place" and while she was pulling the resident up to clean her/him off the resident was bending down, sitting. Staff 12 did a controlled lowering of the resident to the floor. "There was such a mess" of BM. She went out in the hall and asked Staff 11, CNA, to help with the resident. After the first fall, the resident did not complain about pain and when asked why she moved the resident after the falls, Staff 12 stated "everything looked fine on (the resident), but that's not for me to say." When asked if she had notified the nurse for an assessment after the first fall, Staff 12 stated "no...was my misjudgment." Staff 12 stated when the resident was placed in bed after the second fall, the resident complained of her/his knees hurting while moving her/his legs to float the heels. Staff 12 notified the nurse and later found out about the fracture. Staff 12 stated she had "lied to her bosses" that she had to perform two controlled falls as "people were getting fired." Staffing records for 8/7/11 were reviewed. The facility met the minimum required staffing level. In interview on 8/24/11 at 8:45 am, Staff 10, CMA, stated he was passing medications and was called into Resident 2's room for help, the resident was on the bathroom floor, sitting on her/his bottom, in front of the toilet and Staff 12, CNA, was standing by the resident. The resident looked anxious and tired and his first reaction was to get the resident off the floor. He lifted the resident up and placed the resident on the toilet, then went back to passing medications. He later went back into the room and helped the resident transfer to the wheelchair. When asked if he had told anyone the resident was on the floor, Staff 10 stated when he first got to the room, Staff 12 told him the resident had not fallen but was lowered to the floor and the resident did not look like she/he had fallen. After he assisted with the resident's transfer to the wheelchair, he told Staff 12 to report it to the charge nurse, then went back to passing medications. In interview on 8/24/11 at 1:42 pm, Staff 11, CNA, stated when she entered the room, the resident was on the floor in the bathroom, she and Staff 12, CNA, lifted the resident up and placed the resident on the toilet, then later with assistance from Staff 10, CMA, they transferred the resident to the wheelchair. Staff 11 stated the resident did not look good, was fearful and complained of pain when she/he was transferred to the toilet and wheelchair. Staff 11 stated that she did not assist with transferring the resident to bed and that Staff 12 did it by herself. Staff 11 stated she did not know if Staff 12 had informed nursing of the incident. Refer to F323

Based on observation, interview and record review it was determined the facility failed to notify nursing timely when a resident experienced falls or follow care planned interventions for 2 of 3 sampled residents (#s 2 & 3) reviewed for falls. Resident 2 sustained a fracture as a result of the falls. Findings include: 1. Resident 2 was admitted to the facility in 2/2007 and had [DIAGNOSES REDACTED]. The resident was care planned for one person, extensive assistance with transfers. An 8/7/11 incident report revealed Staff 12, CNA, reported toileting the resident after lunch. When Staff 12 transferred the resident off the toilet, the resident reported "my knee popped." Staff 12 guided the resident to the floor with the gaitbelt. Staff 12 reported Staff 10, CMA, came in to help lift the resident back on the toilet and then to the wheelchair, followed by Staff 11, CNA, assisted the resident back to bed. Staff 5, LPN, was notified of the incident and found the resident in bed. The resident's knee was assessed, there was no swelling, redness or bruising. The resident had no complaints of pain at that time, however, when Staff 5, asked the resident what had happened, the resident stated "I felt my knee pop when she was transferring me and its sore". The 8/7/11 6:45 pm Interdisciplinary Progress Note disclosed the resident complained of 10 out of 10 level pain in the left knee, and swelling and purple bruising were noted to the inside aspect of the knee. The physician was contacted and the resident was sent to the hospital. The 8/7/11 hospital records revealed the resident was accidentally dropped during a transfer during toileting, landing directly on the left knee. The resident had severe pain with the left knee. The resident was found to have a fracture of the tibia and fibula. Per the facility's 8/16/11 summary of the fall investigation, after reviewing the hospital records, the investigation was re-opened. The facility determined that two separate falls had occurred while the resident was being toileted, before being transferred back into bed and Staff 12 had not given an accurate account of the falls. Staff 12 later acknowledged the reason for the initial lowering of the resident was due to the resident's legs buckling. When asked why she reported it as knee popping, she stated "I don't know, maybe I wrote the statement to cover myself. Shame on me." When asked why she did not immediately get the nurse, she replied "because the resident wasn't hurt." The facility's investigation noted that when Staff 10, CMA, was asked why he did not ask a nurse to assess the resident prior to moving her/him, Staff 10 stated that Staff 12, CNA, told him the resident had not fallen, but was just lowered, so they helped the resident back to the toilet. "I didn't see need for a nurse." The facility's investigation disclosed that Staff 11, CNA, stated to Staff 12, CNA, the resident did not look good and she should report it to the nurse. Staff 11 stated she did not help Staff 12 place the resident back to bed. In interviews on 8/22/11 at 9:23 am and 10:59 am, the resident was observed in bed, appeared somewhat confused and had a brace on the left leg. When asked what happened to her/his leg, the resident stated she/he broke it. When asked how, the resident stated she/he slipped and kept slipping. When asked if someone was with her/him during the falls, the resident could not remember. The resident reported having pain with the leg, which was better when it was not moved. In interviews on 8/22/11 at 2:51 pm and 8/23/11 at 9:37 am, Staff 5, LPN, stated Staff 12, CNA, reported to her the resident reported feeling her/his knee pop during a transfer and lowered her/him to the floor. When Staff 5 went to assess the resident, the resident was already in bed and was not painful nor had swelling at that time. Staff 5 stated she found out later there had been a couple of falls/transfers, but was not told anything about it until after the resident was back in bed. Staff 5 stated prior to the fracture, the resident used to get up for two meals, but stayed in the room the rest of the time. Staff 5 stated the resident was currently not getting up as much, depending on the pain level. In interview on 8/23/11 at 10:05 am, Staff 17, Administrator, stated the facility determined the standard of practice was not followed and Staff 12 covered up her actions of the second transfer. In interview on 8/23/11 at 2:48 pm, Staff 12, CNA, stated the facility was short staffed that day and reported feeling "frazzled." When asked if she if she reported to anyone she was having problems, she stated she did that every day, " they could see it on our faces." Staff 12 stated she had told others that she was having a hard time keeping up and that everyone was very helpful, but at times could not find anybody. Staff 12 stated she had taken the resident to the bathroom, "there was BM all over the place" and while she was pulling the resident up to clean her/him off the resident was bending down, sitting. Staff 12 did a controlled lowering of the resident to the floor. "There was such a mess" of BM. She went out in the hall and asked Staff 11 to help with the resident. After the first fall, the resident did complain about pain and when she was asked why she moved the resident after the falls, she stated "everything looked fine on (the resident), but that's not for me to say." When asked if she had notified the nurse for an assessment after the first fall, Staff 12 stated "no...was my misjudgment." Staff 12 stated when the resident was placed in bed after the second fall, the resident complained of her/his knees hurting while moving her/his legs to float the heels. Staff 12 notified the nurse and later found out about the fracture. Staff 12 stated she had lied to her bosses that she had to do two controlled falls as "people were getting fired." Staffing records for 8/7/11 were reviewed. The facility met the minimum required staffing level. In interview on 8/24/11 at 8:45 am, Staff 10, CMA, stated he was passing medications and was called into the room for help, the resident was on the bathroom floor, sitting on her/his bottom, in front of the toilet and Staff 12, CNA, was standing by the resident. The resident looked anxious and tired and his first reaction was to get the resident off the floor. He lifted the resident up and placed the resident on the toilet, then went back to passing medications. He later went back into the room and helped the resident transfer to the wheelchair. When asked if he had told anyone the resident was on the floor, Staff 10 stated when he first got to the room, Staff 12 told him the resident had not fallen but was lowered to the floor and the resident did not look like she/he had fallen. After he assisted with the resident's transfer to the wheelchair, he told Staff 12 to report it to the charge nurse, then went back to passing medications. In interview on 8/24/11 at 1:42 pm, Staff 11, CNA, stated when she entered the room, the resident was on the floor in the bathroom, she and Staff 12, CNA, lifted the resident up and placed the resident on the toilet, then later with assistance from Staff 10, they transferred the resident to the wheelchair. Staff 11 stated the resident did not look good, was fearful and complained of pain when she/he was transferred to the toilet and wheelchair. Staff 11 stated that she did not assist with transferring the resident to bed and that Staff 12 did it by herself. Staff 11 stated she did not know if Staff 12 had informed nursing of the incident. 2. Resident 3 was admitted to the facility in 8/2011 with [DIAGNOSES REDACTED]. The 8/5/11 Admission Nursing Data Base disclosed the resident was at risk for falls and was to have a pressure alarm in place at all times. The CNA's Care Plan included the use of the pressure alarm at all times. An 8/17/11 Interdisciplinary Progress Note revealed the resident was found sitting on the floor in his/her room at 11:45 am, no injuries were noted. The facility's investigation disclosed the resident had been self propelling in the wheelchair, attempting to maneuver around the roommate and pulled himself/herself out of the wheelchair. The alarm was in place but not sounding as the cord was not attached to the box. The resident had last been seen by a therapist, who stated seeing the alarm pad under the resident, but "didn't see the wire connected to the box." After the therapy session, the therapist brought the resident to an activity and did not notify anyone about the "missing box". The therapist acknowledged she had worked with the resident on the previous day and saw the alarm in place. The therapist was educated regarding reporting issues to nursing, such as fall interventions not being in place and that she was expected to have an updated copy of the status form with her. In interview on 8/22/11 at 12:38 pm, Staff 7, Physical Therapy Assistant, stated she had worked with the resident prior to the fall from approximately 10:00 am to 10:45 am. After the therapy treatment was completed, Staff 7 took the resident to a church service and told the CNA were the resident was. When asked if she had noted the alarm, Staff 7 stated she did not see an alarm on the wheelchair, but there was a grey cushion, which Staff 7 thought was a cushion rather than the alarm pad. Staff 7 stated she did not know the resident was care planned for the use of an alarm. Staff 7 stated she did not report to nursing the alarm was not in place as she did not think it was needed due to not seeing the resident exhibit any unsafe behavior. In interview on 8/23/11 at 9:25 am, Staff 9, CNA, stated the resident's roommate turned the call light on, he went into the room and found the resident on the floor and then called the charge nurse to assess the resident. Staff 9 stated the resident was care planned for a sensor alarm in the bed and chair and when asked if it was plugged into the box at the time of the fall, Staff 9 stated "apparently not." Staff 9 stated the resident had therapy at 10:00 am and he took his break at that time. Staff 9 stated the alarm was in place before therapy as he always confirmed that the box was in place on the wheelchair. In interview on 8/23/11 at 9:42 am, Staff 8, RNCM, stated she expected Staff 7 to know the resident's fall precautions.

Based on observation, interview and record review it was determined that the facility failed to provide timely assessment and monitoring for 1 of 3 sampled residents (#1) who had surgical incisions. The incision became infected and required further surgical intervention. Findings include: Resident 1 was admitted to the facility from the hospital on [DATE] following surgical repair of bilateral tibia fractures. He was admitted to the facility for rehabilitation services and wound care. The 12/28/10 Admission MDS revealed the resident did not have memory problems and was independent with decision making skills. He required extensive assistance with bed mobility and transfers. admission orders [REDACTED]. The dressings of the lower extremities were to be changed initially every 72 hours and as needed. The 12/17/10 Admission Skin Assessment record revealed, " 2+ [MEDICAL CONDITION] to feet bilat, bruising to feet bilat, 3 clean dry and intact dressings on (L) leg, 2 clean dry and intact dressings on (R) leg." The surgical incisions were not visualized and therefore a baseline assessment had not been done. The facility's policy and procedure included the assessment was to be done on admission. On 12/18/10 at 3:00 am the nursing note revealed the dressings were clean, dry and intact and the incisions were without signs/symptoms of infection. Nursing notes dated 12/24/10 through 12/27/10 did not include an assessment of the incisions and only included that the dressings were dry and intact. On 12/28/10 the nursing notes revealed, "Pt stated bilateral feet seem more swollen this am. Has tried to elevate both legs ....Notified MD ....Stitches intact and dry without s/s infection." The nursing notes of 12/29/10 revealed serosanguineous drainage was noted on the lower incision of the left leg (the resident had two incisions on the lower left leg). The sutures were removed and no signs/symptoms of infection were noted. Documentation of 12/30/10 again revealed no signs/symptoms of infection and the presence of a scant amount of serosanguineous drainage. From 12/31/10 through 1/4/11 an assessment of the wound had not been done. On 1/5/11 the nursing notes revealed the resident had [MEDICAL CONDITION] of both lower extremities, yellow drainage noted and the skin around the wound was red with some skin breakdown. The documentation did not clarify where the drainage was found, a description of the redness or skin breakdown. On 1/6/11 nursing notes revealed the right lower extremity was [MEDICAL CONDITION], weeping "sang" drainage. On 1/7/11 nursing notes revealed increased [MEDICAL CONDITION] of the left lower extremity. "Leg assessed 3+ ankle, feet, mid calf (L) leg wound red with red bumps around. Will clean daily and apply [MEDICATION NAME] and cover with ABD and Kerlix. Notified MD if need antibiotic." The physician was sent a fax and informed that the wound bed had some slough and "seemed angry red." An order was received on 1/7/11 at 6:10 pm to administer Keflex (antibiotic) 500 mg for one week. The antibiotic was not initiated until 1/9/11 at 12:00 pm. On 1/9/11 the nursing notes revealed both lower extremities were red and the left lower extremity wound was weeping. The nursing notes from 1/10/11 through 1/17/11 did not include an assessment of the incisional wounds and only included drainage that had been moderate to dressing being saturated and the [MEDICAL CONDITION] of his lower extremities. A description of the incisional wounds had not been included. Documentation did not include if changes were noted with the administration of the antibiotic. On 1/18/11 the physician examined the resident and found both of his legs with advanced [DIAGNOSES REDACTED] and serous drainage of both legs with acute [MEDICAL CONDITION] changes. He wrote in the progress note, "I am worried about possible infection." He ordered wound cultures of both legs which were collected on 1/19/11. On 1/22/11 the results were reported to the facility which revealed the culture of the resident's left leg grew out [MEDICAL CONDITION]-resistant Staphylococcus aureus. Nursing notes revealed the physician gave an order to send the resident to the hospital. He left the facility at approximately 3:00 pm. Nursing notes revealed, "mod amount sang drainage, (L) LE draining more." There was no assessment of the incisional sites on his day of discharge. The Emergency Department notes revealed, "This patient presents with worsening infection noted to [MEDICAL CONDITION] of his bilateral lower extremities....concern with deeper infection on the left lower extremity with non-healed wounds with some purulent discharge. Left foot with significant [DIAGNOSES REDACTED] over the anterior leg. There are 2 areas of incomplete wound healing, one over the medial malleolus and another over the anterior shin. The one over the lower anterior shin has some purulence over the area." The resident had surgery performed on 1/23/11 for an incision and drainage of his left lower extremity with a placement of a wound vac along the proximal of the two incisions and open packing of the distal incision. A hospital report of 1/26/11 revealed, "....has orthopedic fixation hardware in his left ankle. He presented to the hospital and found to have exposed hardware at the malleolus." The report further revealed the two incisions were dehisced and when the distal wound was opened there was exposed plate and hardware seen. The orthopedist recommended the resident undergo amputation of his left lower extremity below the knee. The report further revealed if the resident chose not to have the amputation he would require ongoing antibiotic therapy. In interview on 2/9/11 at 8:30 am, Witness 1, complainant, stated the resident reportedly had not been provided with the necessary care and services related to his surgical incisions. "It was reported the resident provided his own care of his surgical incisions and no one was paying attention as to what was going on." In interview on 2/9/11 at 11:10 am, Staff 2, RNCM, reviewed the resident's closed record and confirmed the documentation was either lacking or incomplete. Staff 2 stated they should have documented due to the condition of the wounds and ongoing changes. In interview on 2/9/11 at 11:50 am, Staff 3, RN (Treatment Nurse), stated she changed the resident's dressings one to two times daily when the wound started draining. She reported the two incisions of the left lower leg were approximately 5 cm in length. On the day the resident was transported to the hospital she stated she observed the wounds. Staff 3 stated, "Both legs were reddened and hot to touch. They were draining a sero-sang and I did not see any purulent drainage." She confirmed the assessments of the wounds either had not been done or the descriptions were incomplete. In interview on 2/9/11 at 12:05 pm, Staff 4, CNA, stated the resident complained he was not being taken care of. Staff 4 stated, "Could become angry and very demanding. I could never please him no matter what I did. I did not see him change his dressings at any time. Sometimes he would take the dressings off." In interview on 2/9/11 at 1:30 pm, Staff 1, DNS, confirmed documentation of the assessments of the surgical wounds were either not done or were incomplete. On 2/10/11 at 9:52 am, Staff 5, RN was interviewed related to the physician order [REDACTED]. to it." Staff 5 stated that it is hard to get to the fax box as they are busy and struggle to get everything done. "I write on the physician order [REDACTED]." The resident did not return to the facility following his discharge to the hospital.