Every finding on record at Bella Terra St George (Black Rock Health and Rehab

Based on interview and record review, the facility did not ensure that residents did not receive psychotropic drugs pursuant to an as needed (PRN) order unless that medication was necessary to treat a diagnosed specific condition that was documented in the clinical record; and PRN orders for psychotropic drugs were limited to 14 days. Specifically, for 1 out of 32 sampled residents, a resident taking a PRN psychotropic did not have that psychotropic limited to 14 days and the prescribing practitioner did not document their rationale in the resident's medical record for the PRN order to be extended beyond the 14 days. Resident identifier: 8.Findings included: Resident 8 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, psychophysiologic insomnia, circadian rhythm sleep disorder, insomnia, major depressive disorder, and anxiety disorder.A physician's order dated 11/14/25, documented traZODone HCl [hydrochloride] Oral Tablet 50 MG [milligrams] (Trazodone HCl) Give 1 tablet by mouth every 18 hours as needed for insomnia. The order had an end date of indefinite.The Medication Administration Record for November 2025, December 2025, and January 2026 was reviewed. Resident 8 had received one dose of trazodone in December. On 1/8/26 at 10:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 8 originally had a PRN order for the trazodone that had a 14 day stop date and that was prior to resident 8 going to the hospital. The DON stated that resident 8 went to the hospital for behaviors and was there for about a month. The DON stated when resident 8 came back to the facility the hospital did not send discharge orders. The DON stated she spoke to the facility provider and he instructed staff to reactivate resident 8's previous orders. The DON stated when they finally received the hospital discharge orders the trazodone was scheduled. The DON stated that resident 8 was on some pretty heavy medications already. The DON stated when the provider saw resident 8 he recognized the scheduled PRN trazodone. The DON stated a psychotropic meeting was held upon resident 8's return and it was noted the trazodone was PRN and there were no other recommendations. The DON stated that resident 8 had taken the trazodone once and resident 8's average sleep was between 8 and 9 hours a day. The DON stated they were calling the provider to inquire about discontinuing the medication.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, for 2 out of 32 sampled residents, a resident's insulin was administered when it should have been held per the physician ordered parameters, and a resident's Midodrine was administered when it should have been held per the physician ordered parameters. Resident identifiers: 4 and 42.Findings included: 1. Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis of type II diabetes mellitus. On 5/5/25, resident 4's physician ordered Insulin Aspart Injection Solution, Inject 16 unit subcutaneously four times a day related to type 2 diabetes mellitus. Hold for blood sugar (BS) less than 150. Resident 4's December 2025 Medication Administration Record (MAR) documented the insulin was administered when it should have been held per the physician ordered parameters on the following dates: a. 12/1/25, PM dose BS 97 b. 12/4/25, AM dose BS 118 c. 12/6/25, AM dose BS 139 d. 12/6/25, hour of sleep (HS) dose BS 128 e. 12/8/25, BS 126 f. 12/11/25, PM BS 149 g. 12/12/25, AM BS 148 h. 12/13/25, PM BS 146 i. 12/15/25, HS BS 133 On 1/7/26 at 9:35 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a medication had hold parameters it would be viewable in the order summary. RN 1 stated that resident 4's insulin medication should be held if the BS was under 150. On 1/7/26 at 9:41 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurse would see the parameters for holds in the order details. The DON stated that the nurses should be following the order parameters for medication administration. 2. Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm of the frontal lobe, shock, and hypotension. A physician order dated 10/22/25, documented that two Midodrine Hydrochloride 5 milligram tablets were to be administered three times a day for hypotension. And the Midodrine was to be held for a systolic blood pressure (SBP) of greater than 115. Resident 42's November and December 2025 MAR was reviewed and documented the Midodrine was administered outside of the physician ordered parameters on the following dates: a. 11/6/25, AM dose SBP 121 b. 11/6/25, Afternoon dose SBP 140 c. 11/13/25, AM dose SBP 116 d. 11/17/25, AM dose SBP 124 e. 11/20/25, AM dose SBP 160 f. 11/20/25, Afternoon dose SBP 126 g. 11/21/25, Afternoon dose SBP 129 h. 11/22/25, Afternoon dose SBP 125 i. 11/26/25, Afternoon dose SBP 138 j. 11/28/25, Afternoon dose SBP 125 k. 12/1/25, AM dose SBP 118 l. 12/11/25, Afternoon dose SBP 126 m. 12/13/25, AM dose SBP 120 n. 12/13/25, Afternoon dose SBP 122 o. 12/26/25, Afternoon dose SBP 131 p. 12/29/25, PM dose SBP 118 Resident 42's January 2026 MAR was reviewed and documented the Midodrine was administered outside of the physician ordered parameters on 1/1/26, AM dose SBP 122 On 1/8/25 at 10:06 AM, an interview was conducted with the DON who stated she expected the staff to follow the orders as they were written by the physician. The DON stated if there were parameters the nurses were supposed to only administer the medication within the ordered parameters. The DON stated she had educated her staff on how to administer Midodrine but the nurses who were administering the Midodrine outside of the ordered parameters were new to the facility and had not yet received the education.

Based on interview and record review, it was determined for 7 out of 65 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level, Another resident experienced unwanted sexual contact from another resident. In addition, a resident without capacity was able to leave the facility against medical advice and was charged with trespassing. The last 2 examples were cited at a harm level. Resident identifiers: 6, 49, 54, 67, 121, 319, 419. Findings included: Notice: On 11/7/24 at 7:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally and in writing to the facility Administrator, Director of Nursing, Regional [NAME] President, [NAME] President of Clinicals, Director of Acquisitions and Risk Managment, President of the Operations and the Owners. On 11/8/24 at 7:10 PM, the Director of Acquisitions and Risk Managment provided the following abatement plan for the removal of the IJ effective on 11/8/24 at 8:00 PM. Immediate Actions Taken to Correct Deficient Practices Director of Nursing (DON) has implemented a one-to-one staff member assigned to ensure that resident 54 is prevented from perpetuating further sexual abuse of resident 121 or other residents. This will ensure that resident 121 is protected from resident 54. DON will inservice the one-to-one staff member regarding their job responsibilities to verify understanding of their one- to-one assignment. DON or designee will complete a Sexual Activity Capacity for Consent (SACC) assessment for residents 54 and 121 with appropriate revisions made to the plan of care as indicated based on the outcome of those assessments. Regional [NAME] President of Operations (RVPO) or designee will complete a Sexual Activity Survey of all current residents to identify any residents who express or exhibit a desire to engage in sexual activity with others, to identify any residents who have experienced sexual activity with another person while admitted in the facility, and to ensure a Sexual Activity Capacity for Consent assessment is completed as indicated for those individuals with appropriate care plan development or revision as indicated. RVPO will ensure that any resident who reports experiencing sexual activity with another person while admitted to the facility will be evaluated using the Trigger Event program for the need to report and investigate that sexual encounter as an allegation of abuse. Measures to Ensure the Deficient Practice Does Not Recur Director of Risk Management (DRM) completed education with DON and Minimum Data Set (MDS) Coordinator on the Sexual Activity Capacity for Consent (SACC) assessment for residents, including definition of capacity, definition of sexual activity and how to appropriately complete the assessment with residents, including assessment schedule. President of Operations completed education regarding the facility's abuse policy with the facility abuse coordinator and other interdisciplinary team members. This included education on the definitions of different types of abuse and reporting requirements, with an emphasis on sexual abuse. RVPO will complete education regarding the facility's abuse policy with all staff of the facility currently on shift. RVPO will complete education with all staff not currently working on or before their next shift. This will include education on the definitions of different types of abuse and reporting requirements, with an emphasis on sexual abuse. President of Operations has initiated a Trigger Event program to provide oversight of the facility's abuse program, wherein the abuse coordinator or designee is required to notify RVPO, Regional Nurse Consultant and assigned corporate staff member of any resident situations that have potential to be an allegation of abuse or other reportable incident as immediately as possible for group review and decision making. President of Operations has completed training with Nursing Home Administrator, DON, RVPO and RNC on the Trigger Event program. Beginning 11/8/24, RVPO or designee will complete the Risk Management audit daily Monday-Friday x 2 weeks then 3 times weekly x 2 months to ensure allegations of abuse are identified and reported timely. Beginning 11/8/24, DON or designee will complete a progress note audit daily Monday-Friday x 2 weeks then 3 times weekly x 2 months to ensure all allegations of abuse are recognized from the information entered into the medical records of residents and reported timely. Beginning 11/9/24, RVPO or designee will perform a Sexual Activity Survey audit daily Monday-Friday x 2 weeks then weekly x 2 months to ensure residents who wish to engage in sexual activity have been identified and appropriately assessed with a plan of care implemented and residents who have experienced sexual activity with another person while admitted in the facility are identified and evaluated appropriately using the Trigger Event program to ensure appropriate reporting and investigation of allegations of abuse. Measures to Monitor and Ensure Corrective Action is Achieved and Sustained QAA committee under the direction of the RVPO or RNC will review the findings from the risk management audit, progress note audit and sexual activity survey audit monthly until a lesser frequency is determined to be appropriate. Any ongoing problems with residents of the facility regarding abuse allegations, including appropriate reporting and investigation of abuse allegations, will be addressed with modifications to the plan of correction implemented at the direction of the QAA committee. The facility alleges removal of immediate jeopardy on 11/8/24 at 20:00. On 11/11/24 at 2:00 PM, while completing a recertification survey an onsite revisit to verify the removal of the Immediate Jeopardy was completed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/8/24 at 8:00 PM. Immediate Jeopardy: The facility's Abuse Policy revised on 6/11/24, was reviewed and revealed the following: Definitions .3. Sexual abuse: Non-consensual sexual contact of any type with a resident . Abuse Prevention .4. This facility honors a resident's right to engage in consensual sexual relationships. a. A licensed nurse or social worker shall complete the facility's designated assessment in the resident's medical record to determine whether the resident has the capacity to consent upon becoming aware that a resident wishes to engage in a consensual sexual relationship with another individual. b. The facility will re-evaluate a resident's capacity to consent as needed based on changes in the individual resident's physical, mental and psychosocial needs. c. If a resident has a legal or other designated representative to make decisions on his or her behalf, it is important for the resident, resident representative and facility staff to understand the types and scope of decision-making authority of the representative . 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. On 4/23/24 a Brief Interview for Mental Status (BIMS) assessment was conducted on resident 54. Resident 54 scored a 12. A score of 8-12 indicated moderately impaired cognition. A review of resident 54's care plan revealed, Focus: Resident has mental health diagnoses of TBI [traumatic brain injury] and adjustment disorder with aggression and depression as well as impulsive sexual behaviors. He uses of [sic] anti-depressant, anti-anxiety, anti-psychotic medications. Date initiated: 3/28/24 Revision on 5/16/24 Interventions included the following: a. Administer medication per physician order. Monitor for side effects and notify MD [medical doctor] of any adverse or consistent side effects that occur r/t [related to] psychotropic drug use. Date initiated: 3/28/24 b. Document target symptoms Q [every] shift. Notify MD of any new/worsened symptoms of mental illness that are not effectively managed with current pharmacological and non-pharmacological interventions. Date initiated: 3/28/24 c. If resident's mental health symptoms become unmanageable in-house or a mental health crisis occurs, call the crisis line or notify the MD to obtain transfer orders for a psychiatric evaluation in the hospital setting. Date initiated: 3/28/24 d. MD will perform a medication review and make adjustments to medication regimen as indicated to target impulsive sexual behaviors that have not responded to non-pharmacological approaches. Date initiated: 5/15/24 e. Obtain informed consent for use of psychotropic medication. Medication regimen including black box warnings will be reviewed in each care conference meeting. Date initiated: 3/28/24 f. Psychotropic committee will review the medication regimen, target symptoms and side effects at least quarterly and make recommendations as indicated. Date initiated: 3/28/24 g. Staff should use the following non-pharmacological interventions to help manage resident's behavioral symptoms: 1) Provide opportunities for socialization 2) Provide encouragement, support and active listening 3) Provide reminders about appropriate interactions with others. Set boundaries and reminder [sic] resident about boundaries for interactions with others as needed. 4) Due to religious beliefs, resident's RP [responsible party] prefers that resident not have materials provided to him to be able to self-express sexual needs. 5) Involve resident's family in care. Family to take resident out of facility on outings as able. Resident's dad identified that working out is a helpful outlet for sexual frustration. Date initiated: 5/16/24 Revision on 5/16/24 A review of resident 54's progress notes revealed the following: a. On 4/24/24 at 4.46 PM, a social service note documented, Note Text: RA [resident advocate] met with RT [resident] and RT father to discuss RT being physical with one of facilities NA [nursing aides]. RT apologized for this and promised to not do it again. RT would like to apologize to NA and RA will facilitate this meeting. RT father explained to RT in office that this is not allowed and also apologized to facility for this happening. RA spoke with RT about sexual health and keeping it private. Father said that he is going to start taking RT to the gym more to help provide an outlet for RT. Pend [sic] b. On 5/6/24 at 9:49 AM, a social service note documented, Late Entry: Note Text: RA interviewed [resident 54] separately and asked what happened? [resident 54] stated he hugged [resident 319] and then grabbed her breast. RA asked resident why he would grab a woman's breast without consent? [resident 54] replied 'because I am a guy.' RA explained that just because he is a guy he cannot grab another woman's body without consent. [resident 54] stated 'I see a tit I grab one.' RA explained that the victim of this could press charges and call the police for assault, [resident 54] then reminded RA that his father is a retired police man. Resident then told RA that he was sorry. c. On 5/22/24 at 11:23 AM, an alert charting note documented, Note Text: Helped get resident some water and medications for the morning. Ensured that call light was in reach and asked if there was anything else I could get him. He asked 'can I see your tits?' I told him no and that it was not an appropriate thing to ask. d. On 5/23/24 at 5: 27 PM, an alert charting note documented, Note Text: Resident asked CNA [Certified Nurses Aide] who was helping him to shower 'it is not fair that I have to be naked' and you are not. 'You should also get naked'. Also tried to spray CNA with the shower hose. When to talked to Resident and explained that it is not appropriate this type of comments and that it is also not appropriate to try to get CNA wet with the shower hose . It is becoming hard for female CNA to provide care for this resident who continue to be have inappropriate behavior. e. On 5/23/24 at 11:45 PM, a general progress note documented, Note Text: Resident continuously tried to convince aide to go out on a date with him. Aide continued to tell him no. Educated resident that this behavior is inappropriate. Resident apologized and went to his room. f. On 5/24/24 at 1:00 AM, a provider encounter note documented, .Patient seen today for behaviors. Nurses report patient has been having low moods and inappropriate sexual behaviors . g. On 5/31/24 at 6:02 PM, an alert charting note documented, Note Text: Resident is fixated on a female CNA. She reported that he is following her in the Facility. When confronted by CNA to stop this behavior, resident just continue [sic] following her. Resident has to be re- directed several times according to CNA by managementsand [sic] nurses but resident continue to pursed [sic] her unwanted attention. h. On 6/1/24 at 1:15 AM, a general progress note documented, Note Text: Aide reported to nurse that she and other aides have previously experienced inappropriate behaviors from resident while assisting with showers. Aide stated that when giving the resident a shower, resident began to inappropriately touch himself, aide told resident that it was inappropriate and resident stated 'he was almost finished', aide said she would return when he was ready to get out of shower. Aide did not report this until hearing of his continued behavior because she was scared she would get in trouble for leaving resident alone. i. On 6/1/24 at 6:13 PM, an alert charting note documented, Note Text: During lunch in Dinning [sic] room A CNA dropped something on the floor. When she bend down to pick it up resident make [sic] a comment 'Nice ass'. This unsolicited comment made the female CNA very uncomfortable. CNA told resident that those type of comments are very inappropriate. I also when to talk to resident privately about this comment and explain again that his actions and comments are very inappropriate towards females. j. On 6/1/24 at 11:07 PM, an alert charting note documented, .Pt [patient] kept staring at a female cna this evening. Pt kept asking female cna about her boyfriend. Made female cna feel uncomfortable . k. On 6/3/24 at 1:00 AM, a provider encounter documented, .Today I was also informed by the staff that patient has been displaying inappropriate sexual behaviors toward female staff at the facility, such as groping an underage CNA. When speaking to patient about this she [sic] denies doing anything wrong. At this point after discussion with the facility management we will arrange a care coordination meeting with the patient's power of attorney to help decide on the best course of action. This could possibly include additional medications to help suppress his behavior, or a possible referral to the behavioral health unit . l. On 6/4/24 at 5:32 PM, an alert charting note documented, Note Text: Resident is to be male only when preforming [sic] cares due to hypersexual behaviors. Must have 2 females present if female staff is preforming [sic] cares. m. On 6/28/24 at 9:00 PM, an alert charting note documented, Note Text: Resident had call light on. When CNA entered room and asked what he wanted he said 'your number.'CNA asked if he actually needed anything and resident started to use his urinal in front of her. CNA told resident to call when he was done and left the room. n. On 11/7/24 at 10:40 AM, a communication with resident note documented, Resident [resident 54] was observed kissing resident [resident 121] in his room. Administration met separately with [resident 54] to discuss his relationship with [resident 121]. [Resident 54] stated that they are just friends and confirmed that that both she and [resident 54] consented to the kiss. A review of resident 54's Monitoring Record revealed the following number of episodes of inappropriate sexual comments every shift: a. On 5/23/24 PM shift- 2 b. On 5/25/24 PM shift- 2 c. On 5/26/24 AM shift- 2 d. On 6/14/24 AM shift- 1 e. On 6/21/24 AM shift- 4 f. On 6/28/24 PM shift- 1 g. On 9/1/24 AM shift- 2 h. On 9/1/24 PM shift- 2 i. On 9/7/24 PM shift- 1 j. On 9/9/24 AM shift- 1 k. On 9/10/24 AM shift- 2 l. On 9/16/24 AM shift- 2 m. On 9/16/24 PM shift- 2 n. On 9/17/24 AM shift- 1 o. On 9/22/24 AM shift- 2 p. On 9/23/24 AM shift- 2 q. On 9/24/24 AM shift- 1 r. On 9/29/24 AM shift- 2 s. On 9/30/24 AM shift- 1 t. On 10/1/24 AM shift- 1 u. On 10/1/24 PM shift- 1 v. On 10/5/24 AM shift- 2 w. On 10/6/24 AM shift- 2 x. On 10/7/24 AM shift- 2 y. On 10/13/24 AM shift- 1 z. On 10/14/24 AM shift- 1 aa. On 10/15/24 AM shift- 1 bb. On 10/20/24 AM shift- 2 cc. On 10/21/24 AM shift- 2 dd. On 10/22/24 AM shift- 2 ee. On 10/26/24 AM shift- 2 ff. On 10/27/24 AM shift- 2 gg. On10/28/24 AM shift- 1 hh. On 11/3/24 AM shift- 2 ii. On 11/4/24 AM shift- 2 jj. On 11/4/24 PM shift- 2 kk. On 11/5/24 AM shift- 2 2. Resident 121 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, type 2 diabetes mellitus with hypoglycemia, acute respiratory failure with hypoxia, iron deficiency anemia, other seizures, unspecified dementia, restlessness and agitation, and mild neurocognitive disorder due to known physiological condition with behavioral symptoms. Resident 121's medical record was reviewed. On 9/30/24 a BIMS assessment was conducted on resident 121. Resident 121 scored a 10. A score of 8-12 would indicate moderately impaired cognition. A review of resident 121's care plan revealed, Focus: The resident has a behavior problem of angry outburst, wandering, hallucinations and delusions at times Date initiated: 10/25/24 Revision on: 11/5/24 Interventions included teh following: a. Anticipate and meet The resident's needs. Date initiated: 10/25/24 b. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date initiated: 10/25/24 c. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date initiated: 10/25/24 d. Praise any indication of The resident's progress/improvement in behavior. Date initiated: 10/25/24 e. Provide a program of activities that is of interest and accommodates residents status. Date initiated: 10/25/24 Another care plan revealed, Focus: The resident has an alteration in neurological status r/t disease process MILD NEUROCOGNITIVE DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH BEHAVIORAL DISTURBANCE Date initiated: 11/4/24 Revision on 11/4/24 Interventions included the following: a. Allow the resident a rest period when she is upset. Date initiated: 11/4/24 b. Cueing, reorientation as needed. Date initiated: 11/4/24 c. Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Date initiated: 11/4/24 d. Give medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 11/4/24 e. Provide emotional support when the resident appears agitated. Date initiated: 11/4/24 f. Special attention provided when the resident has contact with her mother. Date initiated: 11/4/24 A review of resident 121's progress notes revealed the following: a. On 9/25/24 at 3:35 AM, an admission progress note documented, 9/25/2024 03:35 (3:35 AM) Admission Progress Note admitted /Time:: 9/24/2024 1930 (7:30 PM) admitted from/Transported by:: [Hospital Name] transported by mother Primary diagnosis for admission:: Pneumonitis Secondary diagnoses:: DM2 [diabetes mellitus type 2], Acute Respiratory Failure with hypoxia Hx [history] of methamphetamine abuse Vital signs upon admission:: 150/93 bp [blood pressure] 96 pulse 24 rr [respiratory rate] 97.5 t [temperature] 96 o2 [oxygen] 61 inches tall 148.5 lbs Pain level/interventions administered as applicable:: na [not applicable] Mental status upon admission:: Resident was very anxious and hysterically crying. Resident stated she was angry her mom left her here. Mother brought a few belongings in, and told the staff good luck and left facility. Pt very stressed and pacing in the halls. CNA showered resident andpt [sic] calmed down. During assessment patient was oriented and answered questions appropriately, but gets distracted and confused easily. Mobility status/mobility devices:: patient ambulates independently. States she used a walker in the hospital and is requesting a walker to use.Special devices used:: na Oriented to facility. b. On 9/25/24 at 11:45 AM, a skilled charting note documented, Late Entry: Note Text: Resident is A/A/O [sic] [alert and oriented] x 2 with intermittent confusion with auditory and visual hallucinations noted. c. On 9/26/24 at 12:28 AM, an alert charting note documented, Note Text: Pt very anxious at beginning of shift. Returned from an outing with her mother and was very upset and crying. pt stated her mom doesn't care about her and only wants to visit her so she can lecture her about using drugs. Nurse took pt to her room and talked to her for a few minutes while giving her, her medications. Pt took medications and stated she needed to go walk the halls because she continued to be so upset with her mom. After pacing the halls for 20 minutes patient returned to room to watch tv [television]. d. On 9/30/24 at 11:15 PM, a skilled charting note documented, Note Text: Resident alert and oriented to self. no resp [respiratory] distress noted, lungs clear. Denies pain at this time. Requires frequent redirection. talks to self and wanders up and down the hallways, yelling at self and staff and other residents. Neighbor reports she was kicking at the walls in the middle of the night last night. pt skin turgor supple, intact. continent of bowel and bladder. good appetite, eats rapidly. takes fluids well. e. On 10/1/24 at 8:00 AM, a psychological provider note documented, [resident 121] exhibits poor cognition throughout interview including poor attention, distractibility, poor memory, poor social understanding or decreased complex attention. She is unable to explain how she became homeless or how she took care of herself prior to or during homelessness. She is unable to verbalize a plan after discharge. [Resident 121] has persistent abnormal movements including rubbing at her face, neck and arms. She is unable to remain still. Subjective interview and objective assessment of MOCA [Montreal Cognitive Assessment] scoring 14 indicate Major Neurocognitive Disorder, most likely drug induced from many years of alcohol and methamphetamine abuse . f. On 10/1/24 at 9:19 AM, a skilled charting note documented, Note Text: pt had overdose on meth [methamphetamine] use. pt currently on augmentin for s/s [signs and symptoms] of resp [respiratory] infection. no resp distress noted. lungs clear. room air sats [saturations] at 97. Denies pain this am. needs redirected often. talks to self and wanders up and down the hallways, yelling at self and other staff and residents. pt educated to stop slamming doors and raising her voice at others. pt skin turgor supple, intact. continent of bowel and bladder. good appetite, eats rapidly. takes fluids well. Today pt reported by management that pt is going to be staying long term. g. On 10/6/24 at 9:27 AM, a skilled charting note documented, Note Text: pt wandering up and down hallways, talking loudly to self and arguing with staff and other residents. unable to redirect pt. h. On 10/7/24 at 1:34 AM, a skilled charting note documented, Late Entry: Note Text: Pt returned to facility from outing with mom and granddaughter. Pt very agitated and crying stating her mother makes her super upset. Pt states she does not want mother or granddaughter into the facility. Pt very upset and pacing the halls yelling at her self for 30 min [minutes]. i. On 10/18/24 at 11:21 PM, a skilled charting note documented, Note Text: Resident is alert and oriented x 2-3. Often confused, not oriented to situation. Pleasant with staff. Wanders hallways often. Good appetite. Compliant with BS [blood sugar] checks and insulin administration. Takes pills whole. Denies pain. Has not slept well the past two nights. j. On 10/27/24 at 3:36 PM, an alert charting note documented, Note Text: Corporate nurse found pt walking by street in front of facility this afternoon, nurse was able to direct pt back into the facility. notified DON [Director of Nursing] k. On 10/29/24 at 1:57 PM, a skilled charting note documented, Note Text: Resident is alert and oriented x 2 self, situation. Resident has episodes of confusion. Resident shows signs of anxiety and sadness. Resident is found often pacing the hallways and talking to self. Resident was redirected and invited to multiple activities during the day. Resident has redness under pannus. Resident is a limited assistance with dressing ADL [activities of daily living] and toileting. WCTM [will continue to monitor]. l. On 10/31/24 at 4:00 PM, a skilled nursing note documented, Late Entry: Note Text:. No changes in LOC [level of consciousness]. Resident did have multiple verbal outburst. Resident was upset because mother would not take her trick or treating. Resident was given time to calm down and verbalize why she was upset. Resident calmed and went to socialize with other residents in theactivity [sic] room. WCTM. m. On 11/8/24 at 8:49 AM a COMMUNICATION - with Resident note documented, Note Text: Resident [121] was observed kissing resident [54] in his room. Administration met separately with [resident 121] to discuss her relationship with [resident 54]. [Resident 121] stated that they are just friends and confirmed that both she and [resident 54] consented to the kiss. 3. Resident 319 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on [DATE] with diagnoses which included metabolic encephalopathy, hypothyroidism, bipolar II disorder, anxiety, disease of blood and blood-forming organs, hypertension, and traumatic brain injury. Resident 319's medical record was reviewed 11/3/24 through 11/13/24. A quaterly MDS dated [DATE] revealed resident 319's BIMS score was 13 which indicated congitively intact. A social services note dated 5/6/24 at 9:45 AM revealed a late entry RA met with [resident 121] to inquire about report that [resident 54] grabbed her breast. [Resident 121] stated that she was coming down 200 hall towards the gym area and stopped to give [resident 54] a hug and as he hugged her he moved his hand down her body and grabbed her breast, [resident 121 stated that she immediately told [resident 54] no and he said he was sorry and continued moving away from her towards 300 hall and she went outside. That was the end of it. A social services note dated 5/6/24 at 9:47 AM was a late entry created on 5/14/24. The note revealed, RA met with RT again and asked if RT would like to press charges against RT for what she reported? RT stated 'No, I don't want to cause trouble for anyone.' RA asked RT if she was sure, and maybe wanted to think about it longer? RT replied 'I am sure, I don't want to press charges, period.' Potiential for Harm 4. Resident 6 was admitted to the facility on [DATE] with diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, other abnormalities of gait and mobility, aphasia, dysphagia following cerebral infarction, epilepsy, cognitive communication deficit, and major depressive disorder. On 11/3/24 at 6:14 PM, an observation was made of resident 49 pushing resident 6 in her wheelchair in the 100 hallway. On 11/3/24 at 6:45 PM, an interview was conducted with resident 49. Resident 49 was sitting in the dining room when resident 6 entered the dining room in a wheelchair. Resident 6 was observed to sit at resident 49's table. Resident 49 pointed to resident 6 and stated that was his girlfriend. Resident 6 was observed to move her head in a yes motion and smiled. On 11/6/24 at 3:37 PM, an observation was made of resident 49 and resident 6 in the activity room. Resident 6 and resident 49 were sitting on a sofa. Resident 6 was observed to have her head on resident 49's chest and resident 49 had his arm around resident 6. Both residents were observed with their eyes closed. Resident 6's medical record was reviewed. On 2/6/24 a BIMS assessment was completed on resident 6. Resident 6 scored a 9. A score of 8-12 would indicate moderately impaired cognition. A review of resident 6's sexual activity capacity for consent dated 2/21/24 revealed: a. Describe resident's stated choice: She stated, 'I love him' she said and likes to cuddle with him, but does not want a sexual relationship. She does not want any sexual touching. A review of resident 6's care plan revealed Focus: MOOD & BEHAVIOR: [Resident 6] has potential for mood and coping issues due to desire to have a romantic relationship with another resident. [Resident 6's] outside medical provider [name redacted] has been consulted and confirmed [resident 6] has capacity to make her own decisions and provide consent. Date initiated: 5/29/24 Revision on 6/26/24 Interventions included the following: a. Assess [resident 6's] capacity to give consent for romantic relations with another resident. Date initiated: 5/29/24 Revision on: 5/29/24 b. If any other resident requests romantic encounter with [resident 6], staff will verify if [resident 6] also wants encounter and if she doesn't, staff will make sure her rights are protected. Staff will make sure other resident respects [resident 6's] wishes. Date initiated: 5/29/24 c. Offer psychosocial support as needed Date initiated: 5/29/24 Revision on: 5/29/24 d. Whenever [resident 6] elects to spend time with other resident, staff will ask and verify that spending time is what she wants and that there is no coercion involved. Reinforce that any kind of romantic and/or sexual expression is her choice. Date initiated: 5/29/24 Revision on: 5/29/24 Another care plan revealed Focus: [Resident 6] has an on again off again relationship with another consenting resident. Date initiated: 6/26/24 An intervention included [Resident 6] will only have romantic companionship with other consenting residents. Staff will verify that 321B is interested in a romantic encounter with [resident 6] PRN [as needed]. [Resident 6] and 321B will confine their romantic relations to a location that is appropriate and separate from other residents. [Resident 6] and 321B will be respectful of other resident's and their rights. Date initiated: 6/26/24 A review of resident 6's progress notes revealed the following: a. On 3/4/24 at 11:22 AM, a social service note documented, RA met with resident and confirmed resident no longer wants to associate with [resident 49] after the incident at church yesterday. RA asked if resident has attempted to talk with resident since, and resident stated no. RA asked resident to notify staff if she feels unsafe. RA will meet with [resident 49] and talk with him about no contact with [resident 6]. b. On 3/4/24 at 1:27 PM, a social service note documented, [TRUNCATED]

Based on observation, interview and record review it was determined, for 45 out of 65 sampled residents, that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, deficient practice identified during the survey regarding abuse was found to have occurred at an Immediate Jeopardy level. Additionally, deficient practice identified during the survey regarding involuntary seclusion, pressure ulcers, accident hazards, bowel and bladder incontinence, sufficient staffing, competent nursing staff, behavioral health services and sufficient dietary personnel were found to have occurred at a harm level. Resident identifiers: 1, 3, 4, 5, 6, 9,10, 13, 14, 15, 16, 18, 20, 22, 24, 26, 27, 28, 29, 30, 32, 34, 36, 38, 44, 45, 46, 49, 50, 51, 52, 53, 54, 55, 57, 60, 61, 65, 67, 120, 121, 269, 319, 371, and 419. Findings included: 1. Based on interview and record review, it was determined for 7 out of 65 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level, Another resident experienced unwanted sexual contact from another resident. In addition, a resident without capacity was able to leave the facility against medical advice and was charged with trespassing. The last 2 examples were cited at a harm level. Resident identifiers: 6, 49, 54, 67, 121, 319, 419. (Cross refer to F600) 2. Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility failed to ensure the resident was free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, a resident was relocated to the locked memory care unit for not following the smoking policy. Resident identifier: 46. (Cross refer to F603) 3. Based on record review and interview it was determined, for 1 of 65 sampled residents, based on the comprehensive assessment of a resident the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically a resident's wound Vacuum-Assisted Closure (VAC) was not working for approximately 24 hours and the physician was not notified until the resident was somnolent. Resident identifier: 371. (Cross refer to F686) 4. Based on observation, interview, and record review, it was determined for 5 of 65 sampled residents that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident fell as a result of the use of damaged medical equipment; no updated interventions were implemented after resident falls, with one resident having sustained a major injury; neurological assessments were not completed after falls and a call light was not within reach. Resident identifiers: 1, 5, 13, 18, 51, 52 and 60. (Cross refer to F689) 5. Based on observation, interview and record review, for 3 of 65 sampled residents, the facility did not ensure a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or became such that continence was not possible to maintained. Specifically, a resident had a urine analysis (UA) obtained and 12 days later staff obtained the results and treatment was started for a urinary tract infection (UTI). The resident complained of flank pain during the 12 days and was administered Tylenol. Another resident was occasionally incontinent of bladder upon admission was not provided a bladder retraining program. In addition, the same resident was observed to have a call light on for 8 minutes, yelling for help, and another resident found staff to clean him up after having a bowel movement. Those 2 examples will be cited at a harm level. Another resident had an antibiotic for a UTI discontinued prior to finishing the course of the antibiotic. Resident identifiers: 1, 52, 55 and 60. (Cross refer to F690) 6. Based on interview, observation and record review it was determined, for 7 of 65 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, a resident was soiled and calling for help, incontinence cares were not being completed every 2 hours, showers were not provided to residents, there were complaints of staff not answering call lights and resident council minutes revealed complaints of not enough staff. Resident identifiers: 15, 26, 27, 49, 52, 55, 60 and 120. (Cross refer to F725) 7. Based on observation, interview and record review it was determined that the facility did not have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, inadequate oversight by the Director of Nursing resulted in multiple system failures in resident care areas which placed residents at harm. Resident identifiers: 1, 3, 4, 5, 9, 10, 13, 15, 16, 20, 26, 27, 28, 29, 32, 34, 38, 45, 46, 49, 51, 52, 53, 55, 57, 61, 65, 120, 269, and 371. (Cross refer to F726) 8. Based on interview and record review it was determined, for 1 of 65 sampled residents, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with a history of suicidal ideation's had a traumatic life event occur with no behavioral health services provided. The resident was found to have taken 4 to 5 bottles of Tylenol and was sent to the emergency room for an overdose. Resident identifier: 45, 57. (Cross-refer 740) 9. Based on observation, interview and record review it was determined, for 17 of 65 sampled residents, that the facility did not employ sufficient staff with the appropriate competencies and skills set to carry out the function of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, meals were observed to be served over an hour later than the posted meal times, a resident was observed to be yelling he was hungry, residents were in the hallways waiting for food, residents were upset in the dining room waiting for meals and residents council minutes revealed complaints of late meals. Resident 16 will be cited at a harm level. Resident identifiers: 9, 13, 14, 16, 22, 24, 26, 27, 30, 32, 36, 38, 44, 50, 52, 55 and 120. (Cross refer to F802) 30563

Based on interview, observation and record review it was determined, for 7 of 65 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, a resident was soiled and calling for help, incontinence cares were not being completed every 2 hours, showers were not provided to residents, there were complaints of staff not answering call lights and resident council minutes revealed complaints of not enough staff. Resident identifiers: 15, 26, 27, 49, 52, 55, 60 and 120. Findings included: 1. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, dementia. On 11/3/24 at 4:03 PM, an interview was conducted with resident 60. Resident 60 stated there were not enough staff and he wet his pants waiting for staff to come and help him to the bathroom. Resident 60 stated he might be able to get to the bathroom if there were enough staff to answer his call light timely. Resident 60 stated that he had fallen waiting for staff to answer his call light. Resident 60 stated he got himself up to go to the bathroom and had fallen. On 11/7/24 at 11:54 AM, an interview was conducted with resident 60. Resident 60 was asked if there were enough staff to meet his needs. Resident 60 responded Oh [expletive removed] his call light was on for a while and he needed to use the restroom. Resident 60 stated he had to get himself up and ambulated to the bathroom on his own usually. Resident 60 stated sometimes he waited for 15 to 20 minutes before getting himself up to get to the bathroom. On 11/7/24 at 11:16 AM, an observation was made of resident 60's call light flashing outside resident 60's room. Resident 60 was observed in bed trying to pull himself to a seated position using the side rails. Resident 60 was observed yelling he needed help. Resident 60 was observed to get himself to a seated position. Resident 60 stated he wants help to get up. Resident 52 was observed to exit her room and look in resident 60's room and ask resident 60 if he needed help. Resident 60 stated he needed assistance. Resident 60 was observed to yell an expletive. Resident 52 stated to resident 60 to not get out of bed and just stay there. At 11:20 AM, a nurse, Administrator, and Corporate staff were observed to walk past resident 60's room. There was a strong bowel movement odor into the hallway. At 11:22 AM, resident 52 stopped the Administrator and stated resident 60 needed assistance. Resident 60 was observed to have bowel movement on him. The Administrator was observed to ask CNA (Certified Nursing Assistant) 6 to assist resident 60. On 11/12/24 at 10:34 AM, an observation was made of resident 60's room. The call light was observed to be wrapped up on the nightstand on the other side of his privacy curtain. The call light was not within reach of resident 60. (Cross Refer to F690 and F689) 2. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance and anxiety. On 11/3/24 at 6:32 PM, an interview was conducted with resident 49. Resident 49 stated he Can't find a CNA when he needed one. Resident 49 stated if he pushed the call light, staff did not come. Resident 49 stated he talked to the Administrator and he was a good guy but he ran this facility like a union shop. Resident 49 stated the staff had the attitude of No one wants to do more than they are assigned to do. Resident 49 stated he had to go to the nurses station to get help and CNA's would say it was not their area. Resident 49 stated he wanted showers more often. On 11/3/24 through 11/8/24, an observation was made of resident 49. Resident 49 was observed in the same clothing those days. Resident 49 was observed to have stubby facial hair. On 11/11/24, an observation was made of resident 49. Resident 49 was observed in the same clothing he was wearing the week before. Resident 49 was observed to have different clothing on 11/13/24. Resident 49's medical record was reviewed. A Brief Interview for Mental Status (BIMS) assessment was completed on 5/3/24 and locked on 5/22/24. The BIMS score was 15 which indicated resident 49 was cognitively intact. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 49 required supervision or touching assistance with bathing. A quarterly MDS dated [DATE] revealed resident 49 had a BIMS of 15. The Certified Nursing Assistant (CNA) documentation in the plan of care tasks section for shower and bathing revealed the following: a. On 10/14/24, it was documented as not applicable (N/A), b. On 10/16/24, the shower was provided, c. On 10/22/24, the shower was refused, d. On 10/23/24, the shower was provided, e. On 10/31/24, it was documented as N/A, f. On 11/5/24, the shower was refused, g. On 11/6/24, the shower was provided, h. On 11/8/24, the resident was unavailable, i. On 11/11/24, the shower was documented as N/A. On 11/12/24 at 11:06 AM, an interview was conducted with CNA 8. CNA 8 stated she was not sure which days resident 49 was scheduled to have showers. CNA 8 stated if a resident did their own shower then N/A might be marked by CNA's. CNA 8 stated she was not sure if resident 49 needed assistance with showering. On 11/12/24 at 1:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 49 should get showers twice per week. The DON stated she was unsure why showers for resident 49 were marked as N/A. On 11/13/24 at 8:54 AM, an interview was conducted with License Practical Nurse (LPN) 3. LPN 3 stated that resident 49 was scheduled for a shower during the night shift, so she was not sure if resident 49 was getting showered. LPN 3 stated if a resident refused a shower, then staff tried to make accommodations for the resident to shower when they wanted. LPN 3 stated on 11/12/24 CNA 6 told her resident 49 needed a shower. LPN 3 stated she asked to see resident 49's Lidocaine patch and she told resident 49 his back was dirty and smelled, so she offered to shower him. LPN 3 stated resident 49 told her she could shower himself. LPN 3 stated she was not sure the last time resident 49 had showered prior to 11/12/24. LPN 3 stated she sometimes did not notice when resident smelled, but she did notice resident 49 smelled. LPN 3 stated resident 49 was pleasant, fine and picked out his own clothing. LPN 3 stated she had no problem getting resident 49 to shower. (Cross refer to F676) 38031 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which included hereditary ataxia, cognitive communication deficit, dysphagia, hypothyroidism, major depressive disorder, anemia, peripheral neuropathy, dysarthria and anarthria, speech disturbance, wedge compression fracture of third lumbar, edema, and insomnia. On 11/3/24 at 2:04 PM, an interview was conducted with resident 15. Resident 15 stated she was incontinent and wore a brief. Resident 15 stated that the brief was changed approximately every 3 hours, but that she needed it changed more frequently than that. Resident 15 stated that she did not currently have any issues with a urinary tract infection. A strong odor of urine was noted from resident 15 during the interview. On 9/11/24, resident 15's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 15 required a two-person extensive assist for bed mobility, transfer, and toilet use. The assessment documented that the resident was not on a toileting program for urinary or bowel continence. On 11/5/24 at 12:48 PM, an interview was conducted with Certified Nurse Assistant 6. CNA 6 stated that resident 15 was a two-person assist for repositioning, hoyer use, transfer, and incontinence care. CNA 6 stated that resident 15 was incontinent of bowel and bladder. CNA 6 stated that they provided resident 15 with brief changes every 2 hours unless she called for assistance before that. CNA 6 stated that resident 15's briefs were usually saturated with urine at the time of incontinence care. CNA 6 stated that they documented brief changes and incontinence care in the electronic medical records. CNA 6 stated that he was usually able to complete his tasks during a shift. CNA 6 stated that it was always helpful to have more staff. CNA 6 stated that sometimes it was difficult to provide incontinence care every two hours, but they made sure to get it done before shift change. CNA 6 stated that all incontinent residents were changed at least once a shift. On 11/06/24 at 8:10 AM, a continuous observation was started for resident 15. At 8:17 AM, a breakfast meal tray was delivered to resident 15 by CNA 4. Resident 15 was seated in bed in a high fowlers position with the bedside table positioned over their lap. No incontinence care was provided by CNA 4. At 8:46 AM, CNA 5 delivered bed sheets to resident 15's room and placed them at the bedside. No incontinence care was provided by CNA 5. At 9:17 AM, CNA 5 removed resident 15's breakfast tray from the bedside. No incontinence care was provided by CNA 5. At 10:49 AM, the DON and LPN 3 walked by resident 15's room. No incontinence care was provided. At 10:50 AM, CNA 5 was observed to enter resident 15's room. CNA 5 was interviewed upon exit of the room. CNA 5 stated that resident 15 was sleeping and she checked to ensure that the resident was okay. No incontinence care was provided by CNA 5. At 11:51 AM, resident 15's continual observation was completed. It should be noted that a continual observation was conducted of resident 15 from 8:10 AM to 11:51 AM and no observations of incontinence care were provided. On 11/6/24 at 3:17 PM, an interview was conducted with CNA 5. CNA 5 stated that she and another aide got resident 15 up at approximately noon. CNA 5 stated that resident 15's brief was saturated with urine, she doesn't soak that bad. On 11/6/24 at 3:26 PM, an interview was conducted with the DON. The DON stated that incontinence care expectations were that staff rounded on the residents every 2 hours and checked to see if briefs needed to be changed. The DON stated that staff should check with any resident that required assistance with toileting every 2 hours for toileting needs. (Cross refer to F676) 4. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 11/3/24 at 2:48 PM, an interview was conducted with resident 51. Resident 51 stated that she had fallen previously in the morning when attempting to get up and toilet herself. Resident 51 stated that sometimes she had to change her brief because the staff did not come to help her. Resident 51 stated that the call light did not always work either. Resident 51 stated that she could put a pull up brief on by herself but she could not put the tab briefs on by herself. It should be noted that resident 51 had hemiplegia and hemiparesis of the left side that limited her ability to perform toileting tasks independently. Resident 51 stated that she waited 2 hours the other night for assistance. Resident 51 stated that she requested pull up briefs a couple of days ago but never received them. Resident 51's call light was pushed at the bedside and in the bathroom and both were observed not functioning. Resident 51's medical record was reviewed. On 10/9/24, resident 51's MDS Assessment documented a BIMS score of 14, which indicated that the resident was cognitively intact. The assessment documented that the resident was a one-person limited assist for bed mobility and eating, and a one-person extensive assist for transfers and toilet use. The assessment documented that the resident was not on a urinary or bowel toileting program. On 11/5/24 at 12:53 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 51 required a one-person assist for incontinence care due to the resident's visual impairment and paralysis in the left arm. CNA 6 stated that resident 51 was incontinent of bowel and bladder. CNA 6 stated that they used either pull up briefs or tab briefs for resident 51 and that resident 51 did not have a preference. CNA 6 stated that resident 51 would inform them when she needed a brief change. On 11/6/24 at 8:10 AM, a continuous observation was started for resident 51. No incontinence care was provided by CNA 5. At 8:28 AM, a breakfast meal tray was delivered to resident 51 by CNA 5. No incontinence care was provided. At 9:17 AM, an observation was made of CNA 4 assisting resident 51 with dressing. CNA 4 then removed resident 51's breakfast tray from the bedside. No incontinence care was provided by CNA 4. At 10:04 AM, CNA 5 entered resident 51's room and placed clean linen on the bedside table. CNA 5 assisted resident 51 into bed. No incontinence care was provided by CNA 5. At 10:34 AM, a continual observation continued of resident 51. At 10:49 AM, the DON and LPN 3 walked by resident 51's room. No incontinence care was provided. At 10:50 AM, CNA 5 was observed to enter resident 51's room. CNA 5 was interviewed upon exit of the room. CNA 5 stated that resident 51 was sleeping and she checked to ensure that the resident was okay. No incontinence care was provided by CNA 5. At 11:51 AM, resident 51's continual observation was completed. It should be noted that a continual observation was conducted of resident 51 from 8:10 AM to 11:51 AM and no observations of incontinence care were provided. (Cross-refer F676) 5. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, type 2 diabetes mellitus, tremor, and unsteadiness on feet. On 11/4/24 at 8:47 AM, an interview was conducted with resident 55. Resident 55 stated there were not enough staff. Resident 55 stated if he pushed the call light, he had to wait about 20 minutes. 6. Resident 26 was admitted to the facility on [DATE] with diagnoses which include facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:43 PM, an interview was conducted with resident 26. Resident 26 stated that there was less and less staff working at the facility. Resident 26 stated that she required assistance with showers and they were not getting completed because she wanted to be showered by female staff. Resident 26 stated that the meal times had not been consistent and every day meals were getting served later and later. Resident 26 stated that there were usually only CNA's that were working at a time in the facility. Resident 26 stated that the CNA's did not have time to provide her with water and she had to get it for herself. Resident 26 stated that activities at the facility were late or canceled because of the lack of staff. (Cross refer to 676 and F802) 7. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On 11/4/24 at 8:19 AM, an interview was conducted with resident 27. Resident 27 stated there was not enough staff especially at night. Resident 27 stated that she never pushed her call light anymore because she knew it would not get answered by staff and she had waited almost 90 minutes for the call light to be answered. 8. Resident 120 was admitted to the facility on [DATE] with diagnoses which include, but not limited to lymphedema, superficial mycosis, cellulitis of right lower limb, activated protein c resistance, cellulitis of left lower limb, and morbid (severe) obesity due to excess calories. On 11/3/24 at 2:18 PM, an interview was conducted with resident 120. Resident 120 stated that she had to wait over 90 minutes for the call light to be answered by staff. Resident 120 stated that there had been times that there were only two CNA's to cover all the hallways in the facility. Resident 120 stated that activities were late because of late meal times from the kitchen. Resident 120 stated she required assistance to get out of bed and there had been times she had been incontinent because the call lights were not getting answered. A review of the facility resident council notes revealed the following: a. June 2024: .RC [resident council] Pres. [president] heard nursing staff are slow to answer call lights. Other concerns mentioned about frequency of (and services offered during) showering, to be followed up with each individual's situation by RA [Resident Advocate] with Nurse Management. b. July 2024: .Call light issues: seems broken/not regularly working .Nurse Management addressed issue of longer call-light response time and asked if there were any trends residents have noticed and residents responded that night shift seems to take longer to respond . c. August 2024: .yesterday's all-staff a training in-service was conducted to educate staff on physically rounding every 2 hours . d. October 2024: . pointed out that residents have been injured and unable to reach their call light, so not found until later, because they aren't heard calling out .asked if a staff could be stationed in the 400/500 hall for more attentive/close care to those residents . On 11/6/24 at 3:00 PM, the facility resident council meeting was attended. Several residents stated that the facility needed more staff and felt that the facility was understaffed at night. A resident stated that if she woke up in the middle of the night with low blood sugar no staff responded to the call lights. Several resident stated that the 100 hallway did not get 2 hour rounding done by staff. The Facility assessment dated [DATE] revealed the facility census for from August 2023 until July 2024 ranged from 57 to 72 residents. The Acuity section revealed 58 to 60 resident required 1 or 2 person staff assistance and 10 residents were dependent of staff for Activities of Daily Living. The Staff Type employed or Contracted staff revealed Nursing services included the Director of Nursing (DON), Assistant Director of Nursing/MDS (Minimum Data Set) Nurse, RN and CNA. The Staffing plan section revealed direct care Licensed Nurses (LN) and there were 3 LN's on day shift from 6 am to 10 pm and 3 LN's from 10 pm to 6 AM. CNA's would be between 1.5 and 2.0 hours per resident day. The distribution of hours across shifts was determined by specific patient needs. Other nursing personnel included DON who was 1 full time RN, primarily days; ADON which was 1 full time; and MDS coordinator which was 1 full time. According to the individual Staff Assignments section Direct care staff: Licensed nurses and nurses aides are assigned to the same residents sections each day they work whenever possible. Every effort is made to have consistent staff assignments for each resident. Residents with specific requests regarding staff involved in their care will be managed on an individual basis by the nurse management team. According to the Staff Training/Education and Competencies section revealed Licensed nurses and CNA's are required to complete a competency checklist as part of the orientation process. Staff is observed by a qualified trainer performing the tasks on the competency checklist. The facility assessment further revealed a section titled Policies and procedures for provision of care. The section revealed Evaluation of policies and procedures for the provision of patient care is initiated and conducted by the facility QAA [Quality Assessment and Assurance] committee, determinations will be made regarding the need for changes to existing policies or the adoption of new policies. Support from [Name of Company] corporate nursing and administrator consultants will also be used in identifying changes that may be needed for the provision of care in order to assure that the highest quality of care possible is being provided to our residents. On 11/7/24 at 10:24 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that she was responsible for 23-25 residents daily. LPN 2 stated that she had been asked to stay late after her shift on more than one occasion. LPN 2 stated that the facility should be staffed with at least 4 CNA's. LPN 2 stated that she had heard from multiple residents that there was not enough staff in the facility and that residents had to wait a long time for staff to respond. On 11/7/24 at 10:38 AM, an interview was conducted with Certified Nurse Aide (CNA) 8. CNA 8 stated that lately she had been responsible for 20 or more residents daily. CNA 8 stated that resident showers have not been completed on residents because she did not have time to complete them. CNA 8 stated that she had tried to ask for help from other staff but all staff were very busy and could not always help. On 11/7/24 at 11:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there were 6 CNA's scheduled during the day and 4.5 CNA's during the night. The DON stated that if there were call outs that management would fill in the shifts. The DON stated that she had had staff come to her with workload concerns. The DON stated that her expectation from staff was to reach out and let management know they needed help. The DON stated that if resident showers were not completed during the day then this should be passed on to the night shift to get completed and she was unaware if that was being completed. On 11/7/24 at 12:04 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated staffing needs was based off of the acuity of the residents in the facility. The ADMIN stated that if staff call out then a member of the management team would come in and cover the shift. The ADMIN stated that the facility was fully staffed and all nursing positions were filled. The ADMIN stated that he heard about residents concerns with staffing when he attended the November resident council meeting held on 11/6/24. The ADMIN stated that he was not sure how to review call light logs, but believed there was a system for it. 50200

Based on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 1, 3, 4, 5, 6, 9,10, 13, 14, 15, 16, 18, 20, 22, 24, 26, 27, 28, 29, 30, 32, 34, 36, 38, 44, 45, 46, 49, 50, 51, 52, 53, 54, 55, 57, 60, 61, 65, 67, 120, 121, 269, 319, 371, and 419. Findings included: 1. Based on interview and record review, it was determined for 7 out of 65 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level, Another resident experienced unwanted sexual contact from another resident. In addition, a resident without capacity was able to leave the facility against medical advice and was charged with trespassing. The last 2 examples were cited at a harm level. Resident identifiers: 6, 49, 54, 67, 121, 319, 419. (Cross refer to F600) 2. Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility failed to ensure the resident was free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, a resident was relocated to the locked memory care unit for not following the smoking policy. Resident identifier: 46. (Cross refer to F603) 3. Based on record review and interview it was determined, for 1 of 65 sampled residents, based on the comprehensive assessment of a resident the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically a resident's wound Vacuum-Assisted Closure (VAC) was not working for approximately 24 hours and the physician was not notified until the resident was somnolent. Resident identifier: 371. (Cross refer to F686) 4. Based on observation, interview, and record review, it was determined for 5 of 65 sampled residents that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident fell as a result of the use of damaged medical equipment; no updated interventions were implemented after resident falls, with one resident having sustained a major injury; neurological assessments were not completed after falls and a call light was not within reach. Resident identifiers: 1, 5, 13, 18, 51, 52 and 60. (Cross refer to F689) 5. Based on observation, interview and record review, for 3 of 65 sampled residents, the facility did not ensure a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or became such that continence was not possible to maintained. Specifically, a resident had a urine analysis (UA) obtained and 12 days later staff obtained the results and treatment was started for a urinary tract infection (UTI). The resident complained of flank pain during the 12 days and was administered Tylenol. Another resident was occasionally incontinent of bladder upon admission was not provided a bladder retraining program. In addition, the same resident was observed to have a call light on for 8 minutes, yelling for help, and another resident found staff to clean him up after having a bowel movement. Those 2 examples will be cited at a harm level. Another resident had an antibiotic for a UTI discontinued prior to finishing the course of the antibiotic. Resident identifiers: 1, 52, 55 and 60. (Cross refer to F690) 6. Based on interview, observation and record review it was determined, for 7 of 65 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, a resident was soiled and calling for help, incontinence cares were not being completed every 2 hours, showers were not provided to residents, there were complaints of staff not answering call lights and resident council minutes revealed complaints of not enough staff. Resident identifiers: 15, 26, 27, 49, 52, 55, 60 and 120. (Cross refer to F725) 7. Based on observation, interview and record review it was determined that the facility did not have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, inadequate oversight by the Director of Nursing resulted in multiple system failures in resident care areas which placed residents at harm. Resident identifiers: 1, 3, 4, 5, 9, 10, 13, 15, 16, 20, 26, 27, 28, 29, 32, 34, 38, 45, 46, 49, 51, 52, 53, 55, 57, 61, 65, 120, 269, and 371. (Cross refer to F726) 8. Based on interview and record review it was determined, for 1 of 65 sampled residents, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with a history of suicidal ideation's had a traumatic life event occur with no behavioral health services provided. The resident was found to have taken 4 to 5 bottles of Tylenol and was sent to the emergency room for an overdose. Resident identifier: 45, 57. (Cross-refer 740) 9. Based on observation, interview and record review it was determined, for 17 of 65 sampled residents, that the facility did not employ sufficient staff with the appropriate competencies and skills set to carry out the function of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, meals were observed to be served over an hour later than the posted meal times, a resident was observed to be yelling he was hungry, residents were in the hallways waiting for food, residents were upset in the dining room waiting for meals and residents council minutes revealed complaints of late meals. Resident 16 will be cited at a harm level. Resident identifiers: 9, 13, 14, 16, 22, 24, 26, 27, 30, 32, 36, 38, 44, 50, 52, 55 and 120. (Cross refer to F802) On 11/13/24 at 2:41 PM, an interview was conducted with the Administrator (ADMIN) and the Regional [NAME] President (RVP). The RVP stated he was the Administrator at the facility until July 2024. The ADMIN stated he started July 2024 at the facility. The ADMIN stated the department heads and Medical Director attended the Quality Assurance and Performance Improvement (QAPI) meeting that was held quarterly. The ADMIN stated the pharmacist and Registered Dietitian were invited but had not attended. The ADMIN stated for the QAPI meeting each department reviewed any issues. The ADMIN stated if there were issues identified, then a root cause analysis was completed, then the committee looked to see what to do to fix the issues and a plan was put into place to resolve it. The ADMIN stated the Dietary department was brought up as an issue in the October 2024 meeting. The RVP stated that it was identified in a QAPI meeting in April 2024 that there were dietary concerns. The RVP stated that things were backed up in the kitchen because everything bottled necked at the dish machine, so the facility replaced the dish machine July 2024. The ADMIN stated the QAPI identified that they needed qualified staff members with experience and staff needed education. The ADMIN stated he checked the kitchen almost daily. The ADMIN stated falls and allegations of abuse that were reported to the State Survey Agency and staffing were discussed in QAPI. The ADMIN stated bowel and bladder programs had not been discussed.

Based on observation, interview and record review it was determined that the facility did not have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, inadequate oversight by the Director of Nursing resulted in multiple system failures in resident care areas which placed residents at harm. Resident identifiers: 1, 3, 4, 5, 9, 10, 13, 15, 16, 20, 26, 27, 28, 29, 32, 34, 38, 45, 46, 49, 51, 52, 53, 55, 57, 61, 65, 120, 269, and 371. Findings included: 1. Based on interviews and record review, for 8 of 65 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident's care plan was not updated to reflect current ostomy care and wound care being provided, a resident did not have a care plan regarding bowel and bladder care, care plan interventions were not updated after resident falls, and a resident's care plan did not reflect the need for supervised eating. Resident identifiers: 1, 3, 13, 34, 38, 51, and 55. [Cross-refer F656] 2. Based on interview and record review it was determined, for 4 of 65 residents sampled, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, resident's were not provided bathing/shower assistance, nail care, and incontinence care for over 3 hours. Resident identifier: 15, 49, 51 and 60. [Cross-refer F676] 3. Based on record review and interview it was determined, for 1 of 65 sampled residents, based on the comprehensive assessment of a resident the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically a resident's wound Vacuum-Assisted Closure (VAC) was not working for approximately 24 hours and the physician was not notified until the resident was somnolent. Resident identifier: 371. [Cross-refer F686] 4. Based on observation, interview, and record review, it was determined for 5 of 65 sampled residents that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident fell as a result of the use of damaged medical equipment; no updated interventions were implemented after resident falls, with one resident having sustained a major injury; neurological assessments were not completed after falls and a call light was not within reach. Resident identifiers: 1, 5, 13, 51, and 60. [Cross-refer F689] 5. Based on observation, interview and record review, for 3 of 65 sampled residents, the facility did not ensure a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or became such that continence was not possible to maintained. Specifically, a resident had a urine analysis (UA) obtained and 12 days later staff obtained the results and treatment was started for a urinary tract infection (UTI). The resident complained of flank pain during the 12 days and was administered Tylenol. Another resident was occasionally incontinent of bladder upon admission was not provided a bladder retraining program. In addition, the same resident was observed to have a call light on for 8 minutes, yelling for help, and another resident found staff to clean him up after having a bowel movement. Those 2 examples will be cited at a harm level. Another resident had an antibiotic for a UTI discontinued prior to finishing the course of the antibiotic. Resident identifiers: 1, 52, 55 and 60. [Cross-refer F690] 6. Based on observation, interview and record review, for 1 of 65 sample residents, the facility did not ensure a resident who required colostomy services received care consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. Specifically, the facility ran out of colostomy supplies and when the supplies were ordered, the wrong item was ordered leaving the resident without colostomy supplies. Resident identifier: 3. [Cross-refer F691] 7. Based on observation, interview and record review, for 4 of 65 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, residents meal portion sizes were not adequate, residents weights were not obtained and residents nutrition assessments were not being completed. Resident identifiers: 3, 4, 55, 60, and 65. [Cross-refer F692] 8. Based on observation, interview, and record review it was determined that the facility did not provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, it was determined that the facility did not provide sufficient nursing staff to meet the residents' needs in the areas of assistance with toileting, providing hydration to residents, and answering call lights in a timely manner. Resident identifiers: 15, 26, 27, 51, 60, 120. [Cross-refer F725] 9. Based on interview and record review it was determined, for 1 of 65 sampled residents, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with a history of suicidal ideations had a traumatic life event occur with no behavioral health services provided. The resident was found to have taken 4 to 5 bottles of Tylenol and was sent to the emergency room for an overdose. Resident identifier: 45, 57. [Cross-refer F740] 10. Based on interview, and record review it was determined, for 1 out of 64 sampled residents, that the facility did not ensure that it had sufficient staff who provided direct services with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, a resident experienced a traumatic life event and staff were not provided education on how to help resident through the traumatic life event. The resident overdosed on Tylenol after the traumatic life event. Resident identifier: 57. [Cross-refer F741] 11. Based on interview and record review it was determined, for 1 out of 64 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, staff reported ignoring resident behaviors and were not able to identify person-centered interventions or non-pharmacological approaches to resident's dementia care. Resident identifier: 65. [Cross-refer F744] 12. Based on observation, interview and record review it was determined, for 6 of 65 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, residents with food allergies and intolerances were served food containing identified allergens, and one resident who was admitted on [DATE] had not been questioned about food allergies until 11/5/24. Resident identifiers: 1, 10, 16, 26, 28, and 38. [Cross-refer F806] 13. Based on observation, interview and record review, it was determined for 1 of 65 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, a resident with a physician's order for thickened liquids was observed to have thin water at the bedside. Resident identifier: 60. [Cross-refer F808] 14. Based on observation, interview and record review it was determined, for 12 of 65 sampled residents, the facility failed to provide each resident with 3 meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Additionally, snacks were not provided to residents who wanted to eat at non-traditional times or outside of the scheduled meal service times and consistent with the resident plan of care. Specifically, meals were not served according to meal times, meal times were changed without resident input, snacks were not being provided regularly. Resident identifiers: 9, 13, 16, 26, 27, 29, 32, 49, 53, 55, 60, and 120. [Cross-refer F809] 15. Based on observation, interview, and record review, it was determined for 1 of 64 sampled residents, that the facility failed to provide special eating equipment and utensils for residents who needed them to ensure that the resident could use the assistive devices when consuming meals and snacks. Specifically, one resident was not provided with a lipped plate when identified as needing one. Resident identifier: 5. [Cross-refer F810] 16. Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not ensure that the hospice services met professional standards and principles that applied to individuals providing services in the facility, and to the timeliness of those services. Specifically, facility staff documented they were unable to contact hospice, the facility did not obtain from the hospice provider the nursing notes and there were no coordination of care notes. Resident identifier: 4. [Cross-refer F849] 17. Based on observation, interview and record review it was determined, for 2 of 65 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff not performing hand hygiene during meal service and medication pass, food was delivered to resident rooms uncovered, and the facility did not have a Legionella prevention and monitoring plan in their water management program. Resident identifiers: 20 and 46. [Cross-refer F880] 18. Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, a resident was treated for a urinary tract infection (UTI) with an antibiotic that the organism was resistant to. Resident identifier: 1. [Cross-refer F881] 19. Based on interview and record review it was determined, for 3 of 5 sampled residents, that the facility did not ensure that residents were offered the influenza and pneumococcal immunizations and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunizations documentation in their medical records. Resident identifiers: 49, 61, and 269. [Cross-refer F883] 20. Based on interview and record review it was determined, for 3 of 5 sampled residents, that the facility did not ensure that residents were offered the COVID-19 immunization and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunization documentation in their medical records. Resident identifiers: 49, 61, and 269. [Cross-refer F887]

Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility failed to ensure the resident was free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, a resident was relocated to the locked memory care unit for not following the smoking policy. Resident identifier: 46. Findings included: Resident 46 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, aphasia, cognitive communication deficit, chronic obstructive pulmonary disease with acute exacerbation, lack of coordination, acute kidney failure, major depressive disorder and anxiety. On 11/4/24 at 2:20 PM, an observation was made of resident 46 in the smoking area behind the facility with Medical Records (MR) staff and two other residents. Resident 46 was observed being brought into the facility via wheelchair by MR staff and handed her cigarette box to MR staff. Resident 46 appeared calm and cooperative during observation. On 11/5/24 at 1:27 PM, an observation was made of resident 46 being taken by staff via wheelchair outside to the smoking area. On 11/5/24 at 2:28 PM, an observation of resident 46 was made. Resident 46 was observed smoking outside in front of the building in an open parking spot, while she was sitting in her wheelchair. No staff were observed outside. Resident 46's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) assessment, dated 8/8/24, indicated the Brief Interview for Mental Status (BIMS) was not conducted due to the resident being rarely or never understood. It further indicated, Staff Assessment for Mental Status, Short-term Memory OK Seems or appears to recall after 5 minutes 0. Memory OK, Long-term Memory OK Seems or appears to recall long past 0. Memory OK. A Smoking Safety Screen, dated 5/9/24 at 11:56 PM, indicated resident 46 was not smoking in the proper areas and hid cigarettes and a lighter in her bra/room. A Wander/Elopement Risk Evaluation, dated 5/9/24 at 11:58 PM, indicated, Resident is not currently an elopement risk. A General Progress Note, dated 7/2/24 at 4:22 PM, indicated, Behavior/Smoking Note: Resident was observed as non compliant with facility smoking policy. Per this policy, resident is placed back on restrictions and has cigarettes and lighter locked at nursing station. Resident has been informed of violation and was reeducated on smoking safety and facility policy. Resident was reeducated on resident smoke break times (times when the facility staff aides residents who are on smoking restrictions to the smoking area, allowing them to smoke.) Resident has also had an increase in verbal abuse towards staff. Resident was told that this behavior is not tolerated at this facility. Resident denied behavior, but agreed that using foul language towards staff was to not be tolerated. Nursing management, resident, nursing staff, RA [Resident Advocate], and administrator made aware of behavior and violation of smoking policy. An Alert Charting note, dated 7/6/24 at 12:24 PM, indicated, pt [patient] found out front smoking again, pt was already on smoking restrictions, removed 3 boxes of cigarettes from her and a lighter again today. management notified. An Alert Charting note, dated 8/11/24 at 1:40 PM, indicated, .pt did have episode of aggressive [sic] behaviors today and demanding other residents cigarettes. A Progress note, dated 8/14/24 at 11:33, indicated, Caught resident smoking outside of the smoking area. Told her she needed to put out her cigarette, resident complied. Educated resident verbally about smoking policy and smoking area. A Nursing Monthly Summary dated 9/6/24 at 9:55 PM, indicated, Resident with expressive aphasia. Uses hand gestures to communicate. No memory concerns or seizure activity. It further indicated a mental status of alert and fully oriented and that resident 46 understood verbal content with a clear comprehension. It further indicated, No new diagnoses. Frustration with communication difficulties r/t [related to] expressive aphasia. Does have some anxious behaviors. It further indicated, Resident continues to be non-compliant with smoking policy. Has also had some issues with taking things that are not hers. An Alert Charting note, dated 9/11/24 at 5:07 PM, indicated, Resident caught outside not following the smoking policy. Resident put cigarette out and came back inside. Was very agitated she was caught smoking the [sic] in the front of the building. Yelling out '[expletive redacted]'. A Social Service Note, dated 9/13/24 at 1:38 PM, indicated, RA contacted RT [resident] daughter [name redacted]- LMTC [left message to contact] regarding move RT to behavior unit due to RT refusal to follow smoking policy. An Alert Charting note, dated 9/29/24 at 5:46 PM, indicated, pt upset with nurse that her meds are given whole or crushed in a/s [applesauce] and or yogurt as pt was witnessed checking her meds last week. attempted to give pt her 1800 [6:00 PM] pain meds and she spit at nurse, pt than [sic] apologized and nurse got new norco [pain medication] ready, had 2nd nurse witness attempt to give pt her pain med at this time. pt also found out front smoking and educated again not allowed. cigarettes locked in med room that the pt daughter brought in. A Nursing Monthly Summary dated 10/08/24 at 1:13 AM, indicated, Resident with expressive aphasia. Uses hand gestures to communicate. No memory concerns or seizure activity. It further indicated, Resident has had increased agitation, episodes of pocketing medications, taking items that are not hers and non-compliance with smoking policy. It further indicated a mental status of alert and fully oriented and that resident 46 understood verbal content with a clear comprehension. It further indicated, No new diagnoses. Frustration with communication difficulties r/t expressive aphasia. Does have some anxious behaviors. It further indicated, Resident continues to be non-compliant with smoking policy. Has also had some issues with taking things that are not hers. She has had increased agitation. A Psych Follow Up note, dated 10/8/24 at 6:00 AM, indicated, Discussion Notes Pt is seen today for follow up. She was recently moved to memory care unit as she was not compliant with rules surrounding smoking. This has been a somewhat hard transition for her. However, staff report that she seems to be doing better and meds are well tolerated at this time . It further indicated, .[Resident 46] is seen today for follow up. She is in her new room in the memory care unit. She is unhappy about this move but seems to understand that it is d/t [due to] her non compliance with smoking rules. She reports her mood as being stable and without concerns Staff report that [resident 46] was upset about move but remained non compliant with rules. She does not have cigarettes at this time which increases her frustration. They report that she seems to be doing better however with less crying spells and anxiety. Medications seems effective at this time. An Alert Charting note, dated 10/20/24 at 5:34 PM, indicated, pt non-compliant with smoking times, keeps putting her finger over her mouth in the 'shhh motion' tells nurse not to tell and let her have cigarettes have educated pt multiple times today she must smoke at designated times and has to be supervised. pt keeps telling nurse to 'F' off and wont leave nurse alone at the nurses station even after nurse has asked her multiple times to please quit asking to smoke when it is not time and to go sit in her room or find an activity to do. pt remains at nurses station telling nurse to 'F' off. A Smoking Safety Screen, dated 10/21/24 at 11:02 AM, indicated, Resident has been noncompliant with smoking in the smoking area. It further indicated, Resident is able to safely mobilize to the designated smoking area; Resident is able to safely handle lit smoking materials, including handling of ashes/embers; Resident is able to safely interact with others while smoking; and Resident is able to safely extinguish and/or dispose of smoking material in the designated receptacle when finished smoking. It further indicated, Resident has difficulty moving to the smoking area. An Alert Charting note, dated 10/21/24 at 5:20 PM, indicated, Pt caught outside smoking 3 times today unsupervised with packs of cigarettes in her bra. pt non-compliant with staff, resident scratched nurses arms and told her to [expletive redacted] off multiple times today. spoke with pt daughter [name redacted] about pt behaviors today and reported to management. A Psych Follow Up note, dated 10/22/24 at 6:00 AM, indicated, .[resident 46] is seen today for follow up. She has been moved back to previous room. She is sleeping late into the afternoon. When spoken to she opens her eyes, shakes her head and points to the door for me to leave. On 11/5/24 at 1:27 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated resident 46 was on supervised smoking because she was caught smoking out front and hiding cigarettes and lighters in her bra. On 11/5/24 at 6:04 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the only place residents could smoke was in the back of the facility and if they broke the rules they became supervised smokers. The DON stated resident 46 required supervision when she smoked and had been caught continuing to smoke by herself. On 11/6/24 at 3:15 PM, an interview was conducted with CNA 4. CNA 4 stated residents could not smoke out front because they had to be 25 feet from the entrance. CNA 4 stated residents used to be able to smoke out front but the policy changed about one year ago. CNA 4 stated resident 46 was on supervised smoking and that she could only go out at the designated smoking times. CNA 4 stated the facility had rules and if a resident was caught smoking in a non-designated area that they were put on supervised smoking. On 11/7/24 at 10:33 AM, an interview was conducted with RN 2. RN 2 stated that resident 46 was moved into the memory unit because of her smoking behaviors. RN 2 stated resident 46's family was not happy when resident 46 was found in here [interview was conducted in the memory care unit]. RN 2 stated residents who were prone to elopement or had memory problems were placed in the memory care unit. On 11/7/24 at 11:38 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the number one thing he did with resident 46 was to help her go smoke. The MDS Coordinator stated that resident 46 was able to understand that she was not supposed to smoke out front but that she was non-compliant with smoking. The MDS Coordinator stated resident 46 was put into the memory care unit to help her quit smoking in non-designated areas. The MDS Coordinator stated the residents in memory care were wanderers, at risk for elopement or dementia residents. The MDS Coordinator stated that resident 46 was moved into the memory care unit on 10/2/24 and moved back out on 10/17/24. On 11/7/24 at 12:13 PM, a telephone interview was conducted with the Resident Advocate (RA). The RA stated resident 46 had a hard time following the smoking policy and that she would smoke right in front of the entrance doors, so she was placed on supervised smoking. The RA stated the facility had a designated smoking area so others did not have to be exposed to second-hand smoke. The RA stated resident 46 had a history of chain smoking and that staff would take her to smoke at scheduled and off-times, but that she would request to smoke more often than the staff were able to take her. The RA stated she would have other residents buy her cigarettes and convince them to give her a lighter. The RA stated she would hide the cigarettes in her bra. The RA stated they had a meeting with her daughter and a friend and discussed moving resident 46 to the locked unit because they were at a loss. The RA stated the daughter said she wanted her mom to stay out of the memory unit. The RA stated resident 46 continued to break the rules so he and the ADMIN and DON decided to move her to the memory unit. The RA stated he tried to notify the daughter about the move but she did not answer the phone. The RA stated resident 46's daughter did call him back and then came to the facility and was shown the memory unit. The RA stated the daughter did not like the fact that resident 46 was moved but knew it was necessary. The RA stated resident 46 was in the memory unit for a few weeks and was moved out because her daughter came in and wanted us to consider moving her back out. On 11/7/24 at 12:44 PM, a telephone interview was conducted with resident 46's daughter. She stated that she was very upset about her mom being placed in the memory care unit. She stated they called it isolation and they did it to punish her. She stated one staff member called her to warn me that they were going to do this because she was not following the rules. The daughter stated that the following week she showed up and her mom had been moved into the memory care unit and that staff had moved her there two hours before the daughter got to the facility. She stated she had told them that she did not want her mom moved into the memory care unit. The daughter stated her mom was very upset and crying the first time she saw her in the memory care unit. The daughter stated she worked with the ADMIN to get her mom moved out of the memory care unit. She stated when the ADMIN heard she wanted to move resident 46 to a different facility, she told him she wanted her mom moved out and she was moved out that day. The daughter stated her mom was a depressed person, so her behavior was not that different than her normal when resident 46 was in the memory care unit and after she had been moved out. On 11/7/24 at 1:17 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated resident 46 was put into the memory care unit because she was noncompliant with the smoking policy. The ADMIN stated she should be able to understand the smoking policy. The ADMIN stated she was moved out of the memory care unit because her daughter was upset that the doors were locked and wanted her moved out. On 11/12/24 at 3:37 PM, an interview was conducted with the DON. The DON stated a wander risk assessment and an Interdisciplinary Team (IDT) meeting would need to be completed prior to moving a resident in or out of the memory care unit. The DON stated resident 46 was safe to be outside by herself.

Based on record review and interview it was determined, for 1 of 65 sampled residents, based on the comprehensive assessment of a resident the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically a resident's wound Vacuum-Assisted Closure (VAC) was not working for approximately 24 hours and the physician was not notified until the resident was somnolent. Resident identifier: 371. Findings included: Resident 371 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paraplegia, cognitive communication deficit, and pressure ulcer of sacral region. Resident 371's medical record was reviewed 11/12/24 through 11/13/24. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 371 had a Brief Interview of Mental Status (BIMS) score of 11 which suggested moderate cognitive impairment. The MDS further revealed resident 371 had one unhealed stage 3 pressure ulcer and one stage 4 pressure ulcer. The MDS revealed skin and ulcer treatments were pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, and application of non-surgical dressing other than to feet. A care plan dated 5/23/24 and revised on 6/20/24 revealed, resident 371 had a Documented pressure ulcer. The care plan did not list a goal. The care plan's only intervention included, Provide wound care per treatment order. On 5/9/24 a physician wrote an order for wound care to be completed every Monday, Thursday, and Friday with the wound VAC pressure set at a constant setting. On 5/23/24 at 5:53 PM, a skin/wound progress note revealed that resident 371 was seen by the wound specialist physicians assistant, and wound care was completed which included an increase in the wound vac pressure setting. On 5/29/24 at 1:00 AM, a physician documented a progress note that revealed, that they were informed by nursing staff, that resident 371's wound VAC had not been working for at least 24 hours and resident 371 had been somnolent for most of the day. The physician noted that resident 371 had a recent bout of sepsis due to this previously. The physician then immediately went to check resident 371's and upon entry of the room the smell from patient's wounds was overwhelming. The physician assessed the wound and resident 371's mental status, resident 371 was arousable to pain only. The physician called 911 and had resident 371 transferred to a local Emergency Department (ED) due to possible septic shock. [It should be noted that there was no documentation indicated that the physician was contacted about the malfunctioning wound VAC.] On 5/29/24, resident 371 was admitted to a local hospital. The document revealed the wound VAC had broken at some point in the last few days. In the physical exam the skin assessment revealed the physician was unable to assess the ulcer as the patient was unable to roll all the way over, however there was a foul odor distinguishable . A Computed Tomography (CT) obtained in the hospital revealed resident 371 had an abscess in the left gluteal region, findings were suspicious for osteomyelitis., an abscess in the posterior sacral soft tissue, and inflammation in the right gluteal. The hospital documents revealed, resident 371 was diagnosed with osteomyelits of the sacrum and placed on antibiotics. On 11/13/24 at 2:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated wound VAC's are just checked when they are being changed. The DON stated that if the wound VAC was not working then the nurses should troubleshoot, check for adequate battery, look for a replacement and if none of that helped then the nurses should contact the provider. The DON stated when the nurses contact the provider they should document the response in the progress note. The DON stated the nurses should have contacted the provider for resident 371's wound VAC.

Based on observation, interview, and record review, it was determined for 5 of 65 sampled residents that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident fell as a result of the use of damaged medical equipment; no updated interventions were implemented after resident falls, with one resident having sustained a major injury; neurological assessments were not completed after falls and a call light was not within reach. Resident identifiers: 1, 5, 13, 18, 51, 52 and 60. Findings included: Harm 1. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, paralysis of vocal cords and larynx, congestive heart failure, and major depressive disorder. Resident 5's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) Admission assessment Section GG- Functional Abilities and Goal, dated 10/21/24, indicated resident 5 had impairment on one side of his upper extremity and impairment on both sides of his lower extremities and used a wheelchair. It further indicated, Chair/bed-to-chair transfer: The ability to safely come to a standing position from sitting in a chair or on the side of the bed .Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. An Alert Charting note, dated 11/8/24 at 2:55 AM, indicated, Resident was being lifted up in the hoyer sling x2 CNAs [Certified Nurse Assistant] from wheelchair to bed placed in bed to go to sleep. CNA's Stated that sling snapped and Pt [patient] slid onto floor. Pt was assessed by nurse and took Pt vitals were WNL [within normal limits] BP [blood pressure]= 133/80, P [pulse]=73, O2 [oxygen]= 93, R [respirations]=20. Pt got skin tear to Left arm. no other injury appeared at this time. dressing applied by nurse. no other issues were noted at this time. An Alert Charting note, dated 11/8/24 at 1:05 PM, indicated, Resident denies c/o [complaints of] pain/discomfort r/t [related to] fall last night. New order for wound care to skin tear on LFA [left forearm]. Silvadene and dressing change QD [every day]. A physician order, dated 11/8/24 at 10:14 AM, indicated, Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to L [left] arm topically one time a day for skin tear Cleanse arm with NS [normal saline] or wound cleanser; apply silvadene and cover with a bordered dressing QD until healed. An IDT (Interdisciplinary Team) note, dated 11/9/24 at 1:47 PM, indicated, Data: Resident had a fall due to hoyer sling breaking during transfer. Action: All hoyer slings investigated to determine if there are any ones that need to be thrown away. New slings ordered Response: IDT team met to discuss fall and care plan updated. On 11/13/24 at 8:48 AM, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he fixed the facility's medical equipment and that he had not heard about any hoyer lifts that needed repair. On 11/13/24 at 9:21 AM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that after resident 5's fall occurred, the CNA Coordinator trained him about what to do when he used a hoyer sling and what to check for. CNA 6 stated the main problem found for the fall was wear and tear of the sling. A concurrent observation was conducted in room [ROOM NUMBER]. Resident 18 was laying in bed and a hoyer sling was laying on a wheelchair next to the bed. The hoyer sling had a ripped strap loop which was not intact at any point. CNA 6 stated that the strap was ripped and that he would not use that on the resident. CNA 6 stated if he found that sling, he would notify the CNA Coordinator. CNA 6 stated resident 18 used that sling multiple times a day to get in and out of her bed to her wheelchair. On 11/13/24 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they had a mishap with the hoyer lift sling and that it was broken on one of the strap loops, which led to resident 5's fall. The DON stated that after the fall, all of the hoyer lift slings were observed and any damaged slings were taken out of use. The DON stated she did not know how many slings the facility had. The DON stated that the CNA's were then educated to look for any tears or damage before using a sling and that if they noticed any issues they should not use it and notify the CNA Coordinator. The DON stated she was not aware if the facility had a process for this prior to resident 5's fall. The DON stated that the CNA Coordinator, headed that up and that she was not directly involved in the corrective action plan. The DON was notified of the broken hoyer lift sling found in room [ROOM NUMBER]. The DON stated she was not aware of the broken hoyer lift sling in room [ROOM NUMBER] before the surveyor [NAME] it up to staff. On 11/13/24 at 1:41 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that another sweep of hoyer lift slings was completed today through the whole building and that the hoyer lift sling in room [ROOM NUMBER] was removed from use. On 11/13/24 at 1:45 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that after resident 5's fall, the CNA's were educated to look for any frayed or damaged slings and to not use them and give them to her. The CNA Coordinator stated the CNA's were to check for damage on the slings before use every time they were used. The CNA stated they did a sweep of all hoyer lift slings in the facility, removed any damaged slings, and ordered new ones. A Quality Assurance and Performance Improvement Plan (PIP), dated 11/13/24, was provided to the State Agency. 43212 2. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, long term use of anticoagulants, personal history of pulmonary embolism, muscle weakness, history of falling, and chronic pain. On 11/3/24 at 4:04 PM, an interview was conducted with resident 13. Resident 13 stated that she had been told that she needed assistance but that staff were too busy to help her. Resident 13 stated she was provided a walker after her last fall. Resident 13 stated her knees buckled on her contributing to her falls. On 11/4/24 at 11:10 AM, an interview was conducted with resident 13. Resident 13 stated she had several falls while in the facility, including a fracture of her right arm and nose. Resident 13's medical record was review between 11/3/24 and 11/13/24. On 6/11/24, an admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating normal cognition. Resident 13's care plan revealed: a. Pain medication therapy use r/t [related to] multiple comorbidities including radiculopathy and muscle weakness. Date initiated: 10/12/2022, Revision on: 10/12/2022. The goal was, The resident will be free of any discomfort or adverse side effects from pain medication through review date. Interventions included, Administer ANALGESIC medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]; Monitor for increased fall risk for falls. Date initiated: 10/12/2022. b. Risk for falls r/t neuropathy, gout, dependence on supplemental oxygen, impaired mobility with use of assistive device, hx [history] of falls. Date initiated: 7/18/2022, Revision on: 6/26/2023. The goal was, The resident will be free of falls with injury through the review date. Date initiated: 7/18/2022, Revision on: 4/12/2024, Target date: 2/7/2025. Interventions included, 1/22/2023 Patient had a fall in the community. Educated patient to be more aware of her surroundings when accessing the community. Date initiated: 7/28/2023; 5/27/2024-unwitnessed fall, risk management done, resident educated. Date initiated: 5/28/2024; 6/26/2023- Resident educated and encouraged to ask for staff assistance with toileting so safety reminders/prompts can be provided as needed. Date initiated: 6/26/2023. Anticipate and meet the resident's needs. Keep frequently used items within reach. Date initiated: 7/18/2022. Educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing. Date initiated: 7/18/2022. Follow facility fall protocol if a fall occurs. Date initiated: 7/18/2022. Order placed for no transfers without assistance to prevent falls/injury d/t [due to] weakness. Date initiated: 10/1/2024. Orient resident to call light. Keep the resident's call light. Keep the resident's call light within reach and encourage the resident to use it for assistance as needed. Date initiated: 7/18/2022. C. The resident has had an actual fall. Poor Balance, Poor safety awareness. 10/12/24. Date initiated: 8/30/2024, Revision on: 10/21/2024. The goal was, Resident will not have a fall with major injury. Date initiated: 8/30/2024, Target Date: 2/7/2025. Interventions included, Carryout additional orders from PCP [Primary Care Physician]. Date initiated: 8/30/2024, Encourage resident to participate in her fall prevention. Date initiated: 8/30/2024. Monitor/document/report PRN [as needed] x 72 h [hours] for MD [Medical Doctor] for s/sx [signs and symptoms]: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date initiated: 8/30/2024, Revision on: 8/30/2024, Neuro-checks x 72 hours. Date initiated: 8/30/2024, Revision on: 8/30/2024, Promote participation in activities to help encourage and teach safety awareness. Date initiated: 8/30/2024. Provide activities to promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Date initiated: 8/30/2024. Resident currently in therapy with additional therapy evaluation, for safety and education. Date initiated: 8/30/2024. Resident reminded of the importance of using call button and therapy to evaluate. Date initiated: 10/21/2024. Vital signs QSHIFT [every shift]/PRN. Take BP [blood pressure] lying/sitting/standing x1 in first 24 hr. Date initiated: 8/30/2024, Revision on: 8/30/2024. Resident 13's progress notes revealed: a. On 5/27/24 at 4:45 AM, an alert note revealed, Found pt laying on her bed with a hematoma to her forehead. Pt with laceration to her nose. Severe pain to her right shoulder and pain and bruising to her left knee. Pt states that her pant leg got caught on her electric w/c [wheelchair] and she fell forward. Pt got herself up into her bed and then called for assistance. Pt requested to go to ER [emergency room ] for evaluation of her right shoulder. Non-emergent ambulance called. Notified physician on call and pt's daughter. Pt sent out at this time. It should be noted that information of resident 13's vital signs, assessment or neuro checks could not be found in the resident's medical record or progress notes. b. On 6/4/24 at 6:46 PM, an alert note revealed, Pt readmitted to facility via facility transport. A/O [alert and oriented] x 4. Able to verbalize needs. Continent of bowel and bladder. Resident using sling to R shoulder. Has bruises to: forehead, L knee, Rt shoulder, LFA [left forearm], L elbow, 2 small bruises on bilat [bilateral] ankle, RFA [right forearm]. She has small scan [sic] on bridge of nose. Incision to R chest area intact, no s/s [signs or symptoms] of infection. Uses motorized w/c for mobility. Last BM [bowel movement] 6/3/24. C/O [complains of] pain to R shoulder Oriented to facility. Call light within reach. c. On 6/6/24 at 10:17 PM, an alert note revealed, Resident c/o high pain this evening. She states she isn't able to move R arm or hand. Gave PRN medication and placed ice pack on shoulder. d. A Work/School Release document dated 6/7/24 revealed, This notice verifies that [resident 13] was seen in the emergency department on 6/7/2024. The accompanying discharge handout revealed, Diagnosis from Today's Visit: 1. Humeral head fracture; 2. Shoulder dislocation. Tests performed included x-ray of right shoulder, EKG (electrocardiogram)/Cardiovascular. e. On 6/7/24 at 7:18 PM, a discharge note revealed, Discharge progress note: Date/time of discharge/transfer: 6/7/2024 7:45 PM; Discharge/transfer location: [hospital ER]. Mode of transportation at time of discharge/transfer: [ambulance provider]. Reason for transfer/discharge: uncontrolled pain. Discharge teaching/instructions completed during discharge/transfer process: n/a [not applicable]. Discharge paperwork released with resident at time of discharge/transfer: transfer sheet, order summary, polst. Resident's response to discharge/transfer process: resident requested. How were resident's personal effects stored/handled at time of discharge/transfer? Kept at facility. Name of individual to whom report was provided at new location: n/a. Name of resident representative notified (if resident is not self-responsible) daughter was present when resident requested transfer. Name of physician notified: [provider name]. It should be noted that there was no alert notes indicating a fall on 6/7/24. f. On 6/17/24 at 1:00 AM, a provider encounter note revealed, .Chief complaint/ Nature of presenting problem: New patient history and physical exam/ left wrist pain/ left knee pain .On 27 May 2024 patient presented to the emergency department due to a fall. Patient fell from her wheelchair onto her right shoulder and also striking her head, In the emergency room department imaging of the shoulder showed glenohumeral joint dislocation with fracture of the right humeral head. Patient has a hematoma on her right forehead. CT [computer tomography] of the brain showed no acute bleeding or abnormality. After discussing the case with orthopedic surgery they were unable to reduce the shoulder and immobilize it in the emergency room . Patient would likely benefit from surgical repair. They discussed this with [physician] who is agreed to evaluate patient. Patient was given morphine in the emergency department for pain. Patient was admitted to [facility] rehab on 4 June 2024. Today after speaking the patient states she has had a recent fall. She has a displaced fracture of the proximal humeral head. Patient is also stating that she is having pain in her right wrist and right knee. She is following up with her orthopedic surgeon later today to come up with a plan for surgery. I advised her to mention the wrist and knee so they can get x-rays in office. She states that these are the only things bothering her right now. g. On 8/18/24 at 4:31 PM, an alert charting note revealed, Upon entering the room resident sitting in the floor stating, 'I went down the floor to pick up a something and could not get up.' Called for assistance to help transfer resident during assessment no injuries noted at this time. Resident alert and oriented x 4. Neuro checks started. Educated resident on the importance to ask for assistance. Dr. notified. h. On 8/18/24 at 6:01 PM, an alert charting note revealed, Late Entry: Resident requested to go to the ER due to having severe pain in her right shoulder that has not been able to be managed with her current regimen. On call Dr [name removed] notified of situation and suggested we increase her Oxycodone 10-325 mg [milligram] to 20 mg every 6 hours and prescribe baclofen 10 mg. Resident denied and still requested to go to ER. [Ambulance provider] called and resident picked up at 6:35 PM. i. On 8/19/24 at 1:00 AM, an encounter note revealed, .Today I was informed by the nursing staff patient suffered a ground-level fall yesterday. Patient was seen at the emergency department. Patient does have a large hematoma on the back of her right leg. Patient had a full workup done at the emergency department to include CT brain, right knee x-ray ,and pelvic x-ray. Patient did not have any other acute injury. It was discovered that patient has severe tricompartmental right knee arthritis. Patient will follow-up with her orthopedic provider regarding possible cortisone injections and the knee replacement. Today we will proceed with bracing of the leg. Patient says she does feel unstable on her feet . It should be noted, there was no update to the resident's care plan after this fall. j. On 9/23/24 at 1:00 AM, an provider encounter note revealed, Encounter, Date of service: 9/23/2024, Type of service: Follow up .Chief complaint/Nature of Presenting Problem: Follow-up from hospital visit .On 23 September 2024 patient presents to the emergency department with a chief complaint of fall. Patient states over the last couple days she has been experiencing more frequent falls beyond her baseline. Patient states this morning she had a ground-level fall and experienced a positive loss of consciousness. Patient states that she has had 2 breakthrough DVTs [Deep Vein Thrombosis] and noted some swelling in her legs yesterday associated with pain. Patient states since the fall yesterday she has been experiencing some bruising of her right periorbital region, without any changes in her vision. Patient denies chest pain shortness of breath numbness, back pain, or deformities. On arrival to the ER patient was hemodynamically stable. Exam noted nonpitting edema to bilateral lower extremities, ecchymosis to right side of face. CT images of head/cervical spine/face, chest x-ray, sternum labs ordered that revealed no abnormalities. The only significant injury noted was a nondisplaced nasal bone fracture without any other acute abnormalities. There is a chronic fracture to the right shoulder. Bilateral venous duplex ultrasounds revealed no evidence of DVT to lower extremities All other labs were within normal limits. Patient was readmitted to [facility] on 23 September 2024. Upon speaking with the patient today she states that she is still in a bit of pain. She is currently on a pain management regimen of oxycodone and morphine. Patient does have another follow-up coming up with her orthopedic specialist regarding her shoulder. Patient also states she will be going to see her neurologist about her balance issues. We will place patient on fall precautions at this point. k. On 9/23/24 at 9:01 AM, an alert charting note revealed, Late Entry: resident had witnessed fall, resident reported losing balance when walking in room. Resident hit head and neuro checks started. Resident alert and oriented x 4. VS [vital signs] stable. Resident appears to have a repetitive behavior continue to be lack of self-limitations and safety. Reported to Dr. educated resident on safety measures. Daughter no answer the phone, unable to leave message to report this concern. It should be noted that no neuro checks were found in resident 13's medical record for the fall related to the fall on 9/23/24. l. On 9/23/24 at 10:46 PM, an alert charting note revealed, Pt with fall this morning. Pt was in another pt's room. Pt states that she fell forward and hit her face. Pt with bruising under both eyes. Pt continues to c/o pain in legs. Pt went to ER after infusion appointment today. Pt was afraid that she had a DVT, but no DVT, just inflammation from fluid in her legs. Pt stated that her doctor's are working on a plan of what to do. m. On 9/24/24 at 9:29 AM, an IDT note revealed, IDT met to discuss recent RT fall. See care plan for all updated interventions. Alert charting x72 HR. Reminded RT to use call light for assistance. OT [Occupational Therapy] to evaluate. PT [Physical Therapy] to supply walker for RT to use in room. Staff will continue to monitor as needed. It should be noted there was no update to the resident's care plan after this fall. n. On 9/25/24 at 3:15 AM, an alert charting note revealed, Resident had a fall, and has a bruise on her left cheek. No other injuries noted. States she feels like her legs are giving out and she is concerned about this. Has a dr [doctor] appointment on 9/26 and is wanting to address issue with dr. It should be noted there were no neuro checks found related to this fall and there was no update to the resident's care plan after this fall. o. On 9/30/24 at 9:18 AM, an IDT note revealed, IDT met to discuss recent RT potential fall. See care plan for all updated interventions. Alert charting x 72HR. Action: Reminded Rt to not transfer self without assistance. RT was sent to hospital for an x-ray of her knee. Response: Staff will continue to monitor as needed. p. On 10/12/24 at 10:16 PM, an alert charting progress note revealed, Resident in another resident's room socializing. When this nurse in to see other resident this resident report that before dinner today she was leaning over to get something out of her bookcase and she slid out of her chair and landed on her bottom. Reports that she was able to get herself up by scooting to her recliner, grabbing the back of the seat and pulling herself up. Did not tell any staff until she told this nurse. Denies any pain related to occurrence. Refused skin assessment at this time .Message left for MD, DON notified. On 11/6/24 at 4:06 PM, an interview was conducted with CNA 4 and 5 who stated that resident 13 had injured herself after falling, but mostly just had bruising. CNA 5 stated that resident 13 tried to transfer herself from her bed to her chair without calling for help. CNA 5 stated resident 13 was supposed to call for help. On 11/7/24 at 9:31 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4 who stated that resident 13 fell a lot. LPN 4 stated resident 13 had poor safety awareness and she had been encouraged to call for help. LPN 4 stated resident 13 did not always call when she needed assistance getting out of bed and the falls happened when transferring to a wheel chair. LPN 4 stated the staff asked resident 13 what time she wanted to get up and the residents choose when they want to get out of bed. On 11/7/24 at 11:59 AM, an interview was conducted with the MDS coordinator who stated if a resident had a fall, it would be reviewed in the morning stand up meeting, and then in an IDT meeting. The MDS coordinator stated in the meetings the staff reviewed the fall, what happened, why it happened, and then discuss how it can be prevented. The MDS coordinator stated the IDT meetings typically occurred the next day, unless it was an extremely urgent concern. The MDS stated the incident on 5/27/24 was a result of resident 13's pant leg getting caught on her wheelchair. The MDS stated resident 13 was given verbal education about wheelchair safety on the day of her fall. The MDS stated the education included making sure resident 13 was wearing pants that would not get caught on her chair when she was ambulating. The MDS also stated that staff were given education that would be passed through report to inform them of the interventions being put into place. The MDS stated he personally educated staff members. The MDS stated the care plan intervention that resident should wear non-skid and proper footwear implicated that it should include clothing. The MDS stated resident 13's emergency room visit on 6/7/24 was likely related to her fall on 5/27/24. The MDS stated for the fall resident 13 sustained on 9/23/24, the resident fell on her face again. The MDS stated around 9/18/24, the facility received a concern from resident 13's neurologist about her being over medicated. The MDS stated sometimes talking to outside providers or the pharmacy was hard because they do not want to play fair. The MDS stated a pharmacist should be reviewing resident 13's pain medications each time she attended the pain clinic. The MDS stated reviewing resident 13's pain medications should be an intervention for her falls, but there is not an intervention about going over her medications. It should be noted that IDT meetings regarding resident 13's falls could not be found for the following dates: 5/27/24, 8/18/24, and 10/12/24. On 11/7/24 at 12:46 PM, an observation was made of resident 13 talking with another resident. Resident 13 was sitting in her wheelchair and was noted to be wearing long pants that were falling over the foot rest on her wheelchair. On 11/12/24 at 2:45 PM, an interview was conducted with the DON. The DON stated the MDS coordinator was responsible for updating the resident care plans. The DON stated if he could not do it, she would be responsible. The DON stated for resident 13's frequent falls there should be an evaluation of current interventions and new interventions should be updated. 30563 Potential for Harm 3. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, constipation and dementia. On 11/3/24 at 4:03 PM, an interview was conducted with resident 60. Resident 60 stated that he had fallen waiting for staff to answer his call light. Resident 60 stated he got himself up to go to the bathroom and had fallen with no injuries. Resident 60's bed was about 4 feet off the ground. On 11/7/24 at 8:34 AM, an observation was made of resident 60. Resident 60 was in bed with his bed about 4 feet off the ground. CNA 6 was observed to check if resident 60's bed was in the lowest position. CNA 6 was observed to lower resident 60's bed and stated it was close to the lowest position. On 11/7/24 at 11:16 AM, an observation was made of resident 60's call light flashing outside resident 60's room. Resident 60 was observed in bed trying to pull himself to a seated position using the 1/4 side rails. Resident 60 was observed yelling he needed help. Resident 60 was observed to get himself to a seated position. Resident 60 stated stated he wanted help to get up. Resident 52 was observed to exit her room and look in resident 60's room and ask resident 60 if he needed help. Resident 60 stated he needed assistance. Resident 60 was observed to yell an expletive. Resident 52 stated to resident 60 to not to get out of bed and just stay there. At 11:20 AM, a nurse, Administrator, and Corporate staff were observed to walk past resident 60's room. There was a strong bowel movement odor into the hallway. At 11:22 AM, resident 52 stopped the Administrator and stated resident 60 needed assistance. Resident 60 was observed to have bowel movement on him. The Administrator was observed to ask CNA 6 to assist resident 60. On 11/7/24 at 11:54 AM, an interview was conducted with resident 60. Resident 60 was asked if there were enough staff to meet his needs. Resident 60 responded Oh [expletive removed] his call light was on for a while and he needed to use the restroom. Resident 60 stated he had to get himself up and ambulated to the bathroom on his own usually. Resident 60 stated sometimes he waited for 15 to 20 minutes before getting himself up to get to the bathroom. On 11/12/24 at 10:34 AM, an observation was made of resident 60's room. The call light was observed to be wrapped up on the nightstand on the other side of his privacy curtain. The call light was not within reach of resident 60. Resident 60's medical record was reviewed 11/3/24 through 11/13/24. An admission MDS dated [DATE] revealed resident 60 had a BIMS score of 9 which indicated moderate cognitive impairment. The MDS indicated resident required partial to moderate assistance with mobility and walking 10 feet. Resident 60 had falls prior to admission. Resident 60's care plan revealed The resident is at risk for falls r/t history of falls, weakness, incontinence. The goal was The resident will be free of falls with injury through the review date. Interventions included Anticipate and meet the resident's needs. Keep frequently used items within reach. Date Initiated: 08/27/2024; Bed in lowest position, call light within reach and commonly used items within reach. Remind resident to use call light for assistance. Date Initiated: 09/01/2024; Educate and encourage the resident to wear appropriate footwear, such as nonskid socks or shoes, when ambulating/mobilizing. Date Initiated: 08/27/2024; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 08/27/2024; Follow facility fall protocol if a fall occurs. Date Initiated: 08/27/2024; Orient resident to call light. Keep the resident's call light within reach and encourage the resident to use it for assistance as needed. Date Initiated: 08/27/2024; Refer to therapy for evaluation and treatment as indicated to address fall risk. Date Initiated: 08/27/2024; Reminded to ask for assistance when reaching for items. Date Initiated: 09/25/2024; Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: even floors free from spills and/or clutter; adequate, glare-free light; handrails on walls in the hallway; Date Initiated: 08/27/2024 and revised on: 10/11/2024. Resident 60's progress notes and risk management reports revealed the following: a. On 8/26/24 at 7:39 PM, an alert charting note revealed, Resident admitted to facility, at 1530 (3:30 PM). resident VS stable at this time. alert and oriented x4.Resident requires 1 person assist with ADLS [activities of daily living]. bruises noted in Left leg and other bruised noted right arm. from previous fall. prior to admission. resident high risk for falling due to not asking for assistance. resident accommodating to facility. continuously monitoring resident. b. On 8/29/24 at 12:53 AM, an alert charting note revealed, Resident is able to make needs known. Resident has call light within reach. Resident is pleasant. c. On 8/27/24 at 7:35 PM, an alert charting note revealed, Resident compliant with cares and treatment. resident currently resting in bed with call light in reach. d. On 8/27/24 at 3:31 AM, an alert charting note revealed, Pt asleep in his room in bed with no concerns at this time. Call light within reach and will continue with plan of care. e. On 9/1/24 at 11:55 AM, a risk management report revealed resident calling for help. upon entering room resident is on the floor on his knees. bed was in the lowest position. The resident description reported was I slid of the bed trying to reach for TV remote. The immediate action taken was Assessed resident for injuries. started neuro checks. educated resident to request help when needed. resident Alert X4. continuously monitoring. family and Dr notified. f. On 9/1/24 at 12:59 PM, an alert charting note revealed, resident unwitnessed fall upon entering resident on the floor on his knees reporting 'I slid of the bed trying to reach for Tv remote'. no physical injuries noted. resident alert and oriented x4. neuro checks started. family and Dr notified. A care plan intervention dated 9/1/24 was to have resident 60's bed in lowest position, call light within reach and commonly used items within reach and remind resident to use call light for assistance. There was no neuro checks located in resident 60's medical record. g. On 9/3/24 at 12:27 AM, an alert charting note revealed, Pt shows no new injuries or c/o of pain. VS WNL and pt bed in low position and call light within reach/ Will continue with plan of care. It should be noted there was no other alert charting after the fall. h. On 9/6/24 at 10:02 AM, an IDT note revealed, IDT met to discuss recent RT fall. See care plan for all updated interventions. Alert charting x72HR Action: Care plan updated - call light and commonly used items within reach Response: Staff will continue to monitor as needed. i. On 9/25/24, a risk management report revealed resident 60 was found kneeling beside bed by nurse after roommate reported resident needing help. The resident description revealed resident 60 verbalized picking up the TV remote, but he slid from the bed. The desc [TRUNCATED]

Based on observation, interview and record review, for 3 of 65 sampled residents, the facility did not ensure a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or became such that continence was not possible to maintained. Specifically, a resident had a urine analysis (UA) obtained and 12 days later staff obtained the results and treatment was started for a urinary tract infection (UTI). The resident complained of flank pain during the 12 days and was administered Tylenol. Another resident was occasionally incontinent of bladder upon admission was not provided a bladder retraining program. In addition, the same resident was observed to have a call light on for 8 minutes, yelling for help, and another resident found staff to clean him up after having a bowel movement. Those 2 examples will be cited at a harm level. Another resident had an antibiotic for a UTI discontinued prior to finishing the course of the antibiotic. Resident identifiers: 1, 52, 55 and 60. Findings included: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia without mention of fluctuations, chronic obstructive pulmonary disease, type 2 diabetes mellitus, tremor, and personal history of other infectious and parasitic disease. On 11/4/24 at 8:40 AM, an interview was conducted with resident 55. Resident 55 stated he had pain in his back, that radiated down his right side to his groin and hip. Resident 55 stated he thought it was a pinched nerve but a nurse got a urine sample on 10/28/24. Resident 55 stated he had not heard about the results from his urine and was not sure if he was taking antibiotics. Resident 55 stated the pain from his back to his groin was new. Resident 55 stated that his catheter was removed about a month ago. Resident 55's medical record was reviewed 11/5/24 thought 11/13/24. Resident 55's Admit/Readmit Screener dated 4/29/24 revealed resident 55 had a catheter when admitted . An admission Minimum Data Set (MDS) dated [DATE] revealed resident 55 had an indwelling catheter, was not on a toileting program and was always continent of bowel. The care area assessment revealed resident 55 was care planned for urinary incontinence and indwelling catheter. There was no care plan regarding resident's bowel and bladder. Resident 55's Certified Nursing Assistant (CNA) documentation in POC (point of care) revealed resident 55 was continent of bladder from 10/20/24 until 10/24/24 when there was an incontinent episode. Resident 55 was incontinent on 10/28/24, 10/31/24, 11/4/24, 11/6/24 and 11/13/23. A physician's order dated 5/1/24 (16_ F [french]/ 10_ cc [cubic centimeter] ) (Foley) catheter to down drain for dx [diagnosis] of (urinary retention). May change PRN [as needed] if dislodged or clogged. The order was active and had not been discontinued. Another physician's order dated 10/28/24 revealed UA [urine analysis] C&S [culture and sensitivity] one time only for 1 Day. Progress notes revealed the following entries: a. On 8/4/24 at 5:25 AM, Resident stated he took catheter out himself. Resident states he no longer wants to have one in . b. On 8/4/24 at 6:16 PM, .Refuses foley catheter reinsertion . c. On 8/5/24 at 1:00 AM, .Today patient is being followed up on regarding a catheter displacement. Over the weekend patient's catheter was dislodged. Some how the catheter became tangled up in patient's bed and was dislodged. The catheter has since been replaced. After examination it appears to be placed correctly. There is normal color urine in the bag. Patient states that he feels fine at this point. Patient had no other questions or concerns today. Nursing staff had no new additional concerns on this patient . d. On 8/11/24 at 8:28 PM, Change catheter down drain bag every 2 weeks. e. On 8/26/24 at 1:00 AM, a physician's note revealed .Foley catheter in place . f. On 9/5/24 at 1:00 AM, a physician's note revealed .Foley catheter in place . g. On 10/7/24 at 1:00 AM, a physician's note revealed .Foley catheter in place h. On 10/26/24 at 1:31 AM, patient complained of pain in-between his lower and upper right abdominal quadrant. The skin looked normal upon palpation no abnormal mass could be felt. Pain only increased when pressing in not on release. Patient said he had no nausea; he has passed gas recently and had a recent bowl [sic] movement. Patient said it's been hurting on and off since yesterday. Gave patient 650 mg acetaminophen for pain. i. On 10/28/24 at 1:00 AM, .Today patient is being seen regarding flank pain on his right side. Patient states this came on over the past couple days. He states it is around the area of his right kidney. Patient is concerned he might have some type of infection going on. We discussed options of diagnosis including a urinalysis. Today we will go ahead and obtain a urinalysis with culture. I did encourage the patient to hydrate is [sic] much as possible, as this can be an effective way to help clear an infection as well. We did also discuss the possibility of a kidney stone. Patient states that the pain is not very severe at this point. If urinalysis is inconclusive, we can obtain a kidney ultrasound if patient is still having pain. Patient is okay with this plan. Patient had no additional questions or concerns today. Nursing staff had no new concerns on this patient .Continue Foley catheter use . j. On 10/28/24 at 9:01 PM, New order received from [name removed] NP [Nurse Practitioner] for UA with C&S. This note was created by Registered Nurse (RN) 3. k. On 11/2/24 at 8:36 PM, revealed, Orders -Administration Note: Acetaminophen Oral Tablet Give 650 mg [milligrams] by mouth every 4 hours as needed for Pain, fever c/o [complaints of] pain right lower back and hip. l. On 11/6/24 at 9:21 AM revealed, Orders -Administration Note: Acetaminophen Oral Tablet Give 650 mg by mouth every 4 hours as needed for Pain ,fever C/O back pain. Will monitor for effectiveness. m. On 11/7/24 at 2:15 PM revealed, Resident has redness on his groins, perineal area and under R [right] side of abdominal fold. Cleaned with warm wet wash cloth and hand towel to dry, nystatin applied. n. On 11/10/24 at 1:19 AM revealed, Orders -Administration Note: Acetaminophen Oral Tablet Give 650 mg by mouth every 4 hours as needed for Pain, fever R side flank pain. o. On 11/10/24 at 2:23 AM revealed, Alert Charting: Resident c/o R flank pain 8/10. Denies pain in bladder or with urination but does state that he has urgency and frequency with small amounts of urine. States he provided a urine sample already. Called lab to get results faxed. UA abnormals [sic]: slightly cloudy, leukocytes 500(large), WBCH [white blood cells] >30, RBC [red blood cells] H [high] 5, bacteria 1+. bacteria from culture is aerococcus urinae [sic]. p. On 11/10/24 at 2:34 AM, Alert Charting: Secure message sent to [physician's name removed] and his team regarding symptoms and UA results. q. On 11/10/24 at 12:40 PM, Alert Charting: Called on call provider and got order for abx [antibiotic]. Order added and pulled from stat safe. Faxed to [name removed] Pharmacy. On 11/12/24 at 10:17 AM, an interview was conducted with resident 55. Resident 55 stated he was now taking antibiotics for his urine test. Resident 55 stated he started antibiotics on Sunday (11/10/24) but did not know what the results were. Resident 55 stated he was having back pain on the right side, no burning upon urination, had some incontinent episodes and his brief overflowed during the night. Resident 55 stated it was not normal to have a full brief at night. Resident 55 stated in the last month or so, he had been using a brief at night and it had been overflowing. Resident 55 stated he was using the bathroom every 3.5 to 4 hours. Resident 55 stated he was able to get to the restroom to use the bathroom in the past, but not lately. Resident 55 stated staff had been changing his brief more often. Resident 55 stated he felt like there had been a change to his bladder in the last month or so. Resident 55 stated since starting the antibiotics his back was feeling better. Resident 55 stated his pain in his back was a 7 or 8 and sometimes up to a 9 out of 10. Resident 55 stated he used Tylenol usually but last week the he took Tylenol for his back pain. Resident 55 stated he did not have a catheter for a long time. On 11/12/24 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated if a resident had signs and symptoms of a UTI, she contacted the physician for an order to obtain a urine analysis. RN 3 stated she documented the UA on 10/28/24 for the day shift nurse. RN 3 stated the day shift nurse obtained the physician's order for the UA. RN 3 stated the UA was obtained on 10/28/24. RN 3 stated resident 55 complained of signs and symptoms of a UTI on 11/10/24. RN 3 stated she called the laboratory to obtain the UA results. RN 3 stated she notified the physician and DON about the results. RN 3 stated she passed on in report to the day shift nurse that she found resident 55's UA results. RN 3 stated she was unable to find any follow-up for resident 55 from 10/28/24 until 11/10/24. RN 3 stated a UA results should available by the next day and the culture and sensitivity within 3 days. RN 3 stated there was a glitch in the system with receiving the results from the lab. RN 3 stated the laboratory did not always fax the results to the facility. RN 3 stated nursing staff usually had to call the laboratory and ask for results. RN 3 stated laboratory draws should be passed on verbally during nursing report. RN 3 stated there was a lab book up at nursing station A and with a copy of every lab draw that was done at the facility. RN 3 stated she was not sure if anyone audited the book. RN 3 stated resident 55 complained of flank pain on 11/10/24, some incontinent episodes and frequency of urination with small amounts of urine. RN 3 stated resident 55 told her that a UA probably needed to be done and resident 55 stated he already had his urine collected. RN 3 stated she worked as needed so she worked 10/28/24 and then again on 11/10/24. RN 3 stated resident had a catheter a long time ago but did not have one anymore. On 11/12/24 at 10:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated if someone had signs and symptoms of a UTI, she would ask what the symptoms were. LPN 3 stated she would ask if the resident had flank pain, fever, frequency of urination or burning with urination. LPN 3 stated if the resident was unable to verbalize signs and symptoms, then she would monitor for a change in condition. LPN 3 stated if a resident had signs and symptoms she would encourage fluids, let the physician know, obtain a physician's order for a urine sample, send the sample to lab and monitor for a change in condition. LPN 3 stated she would not want a resident to become septic for not treating a UTI. LPN 3 stated she would enter the physicians order for a UA into the residents medical record and then would report that to the next nurse. LPN 3 stated it was very important to communicate to the oncoming nurse. LPN 3 stated if there was a progress note, then the DON or nurse managers would see it and watch for the results. LPN 3 stated at times she has had trouble getting laboratory results. LPN 3 stated she had obtained a urine sample for a UA, but then the lab had not communicated the results like sometimes the urine was contaminated and that was not reported to the facility. LPN 3 stated usually the results for a UA were ready by the next day. LPN 3 stated the DON, physician and nurse manager had access to results from the hospital laboratory. LPN 3 stated resident 55 was on antibiotics for a UTI and the results were provided on 11/11/24. LPN 3 stated she was not sure when the UA was obtained but resident 55 should not have waited 12 days for the results and treatment. LPN 3 stated she was not sure what happened with the UA and results. LPN 3 stated there were no residents on bowel and bladder retraining program. On 11/13/24 at 12:32 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated resident 55's urinary catheter was replaced on 7/25/24 and then was removed on 7/26/24 and discontinued. On 11/12/24 at 1:24 PM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) 1. The DON stated nurses obtained urine for a UA and then the laboratory picked up the samples twice daily. The DON stated there was a local laboratory and one in Salt Lake City. The DON stated she would expect to get UA results within 1 to 2 days and 3 days for the culture results. The DON stated nurses passed on verbally in report that there was a laboratory draw completed. The DON stated staff should be watching for the results within a few days. The DON stated nurses could call the lab if results were not sent to the facility within a few days. The DON stated results were faxed to the facility but the DON also had access to pull the labs from the lab computer system. The DON stated nurses did not have access to the lab portal. The DON stated if nurses did not receive results within 2 to 3 days, they should be contacting the lab via phone. The DON stated nurses could notify the DON to see if the results were in the system and nurses aware she had access to the portal. The DON stated the culture would provide information to determine the antibiotic that the resident needed. The DON stated the physician will order the antibiotic depending on the culture resulted. The DON stated the nurses entered the antibiotic order into the medical record and staff then monitored for signs and symptoms. The DON stated if the signs and symptoms were not resolved then nurses should contact physician to see if they need another UA or another antibiotic. The DON stated she monitored to ensure the culture was correct. The DON stated the antibiotic and physician notification was on the lab results form that was faxed from the lab and then the lab results form was uploaded into the residents document section of the medical record. The DON stated there was no timeframe to have documents uploaded, it was just when medical records staff had time. RNC 1 stated the facility should have the results of a UA and culture no longer than a week after the sample was obtained and for the results to be uploaded into the system. The DON stated resident 55's UA and culture results were longer than the expected time frame. The DON stated resident 55's catheter was removed but not sure how long ago. 2. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, dementia. On 11/3/24 at 4:03 PM, an interview was conducted with resident 60. Resident 60 stated there were not enough staff and he wet his pants waiting for staff to come and help him to the bathroom. Resident 60 stated he might be able to get to the bathroom if there were enough staff to answer his call light timely. Resident 60 stated that he had fallen waiting for staff to answer his call light. Resident 60 stated he got himself up to go to the bathroom and had fallen. On 11/7/24 at 11:54 AM, an interview was conducted with resident 60. Resident 60 was asked if there were enough staff to meet his needs. Resident 60 responded Oh [expletive removed] his call light was on for a while and he needed to use the restroom. Resident 60 stated he had to get himself up and ambulated to the bathroom on his own usually. Resident 60 stated sometimes he waited for 15 to 20 minutes before getting himself up to get to the bathroom. On 11/7/24 at 11:16 AM, an observation was made of resident 60's call light flashing outside resident 60's room. Resident 60 was observed in bed trying to pull himself to a seated position using the side rails. Resident 60 was observed yelling he needed help. Resident 60 was observed to get himself to a seated position. Resident 60 stated he wants help to get up. Resident 52 was observed to exit her room and look in resident 60's room and ask resident 60 if he needed help. Resident 60 stated he needed assistance. Resident 60 was observed to yell an expletive. Resident 52 stated to resident 60 to not to get out of bed and just stay there. At 11:20 AM, a nurse, Administrator, and Corporate staff member were observed to walk past resident 60's room. There was a strong bowel movement odor into the hallway. At 11:22 AM, resident 52 stopped the Administrator and stated resident 60 needed assistance. Resident 60 was observed to have bowel movement on him. The Administrator was observed to ask CNA 6 to assist resident 60. On 11/12/24 at 10:34 AM, an observation was made of resident 60's room. The call light was observed to be wrapped up on the nightstand on the other side of his privacy curtain. The call light was not within reach of resident 60. Resident 60's medical record was reviewed on 11/3/24 through 11/13/24. An admission MDS dated [DATE] revealed resident 60 was not provided a urinary toileting program. The MDS revealed resident 60 was occasionally incontinent of urine and was occasionally incontinent of bowel. It was marked no to Is a toileting program currently being used to manage the resident's bowel continence? A care area assessment revealed that bowel and bladder would be care planned. A baseline care plan dated 8/26/24 revealed resident 60 was frequently incontinent of bowel and bladder. A care plan dated 8/27/24 revealed Potential for altered skin integrity related to: Diabetes Type 2, falls, incontinence. The goal was Resident will have no s/s of skin breakdown at all times through next 90 day review. The interventions included Encourage good nutritional and oral fluid intake; Staff will help promote clean skin by encouraging/assisting resident to bathe regularly. Dry skin thoroughly after bathing. Keep skin moisturized by applying lotions indicated and Staff will provide prompt peri-care after incontinent episodes and may apply barrier cream as a skin protectant. CNAs may apply unmedicated barrier creams. A care plan dated 8/27/24 revealed The resident is at risk for falls r/t history of falls, weakness, incontinence. The goal was The resident will be free of falls with injury through the review date. The interventions included Anticipate and meet the resident's needs. Keep frequently used items within reach; Bed in lowest position, call light within reach and commonly used items within reach. Remind resident to use call light for assistance and Orient resident to call light. Keep the resident's call light within reach and encourage the resident to use it for assistance as needed. On 11/6/24 at 3:40 PM, an interview was conducted with CNA 5 and CNA 4. CNA 5 and CNA 4 stated resident 60 was continent of bowel and used his call light to call for assistance to the bathroom. CNA 5 and CNA 4 stated resident 60 was incontinent of bladder and was changed every 2 to 2.5 hours. CNA 5 and CNA 4 stated they were not aware of any residents that were on a toileting program. On 11/12/24 at 10:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated there were no residents on bowel and bladder retraining program. On 11/12/24 at 10:47 AM, an interview was conducted with CNA 8. CNA 8 stated resident 60 usually did not press his call light, normally resident 60 yelled out for help. CNA 8 stated he was checked every 2 hours for a brief change. CNA 8 stated she was not aware of a bowel and bladder retraining program. CNA 8 stated resident 60 was not on a bowel and bladder retraining program. On 11/7/24 at 11:26 AM, an interview was conducted with the DON. The DON stated resident 60's cognition depended on the time of day. The DON stated resident 60 was able to use a call light. The DON stated she believed resident 60 was incontinent of bowel and bladder. The DON stated if someone was incontinent, staff should still attempt to get the resident to the bathroom. The DON stated a lot of residents got up on their own, so staff needed to watch them a little closer. The DON stated if a resident was consistently trying to get up, staff could do an hourly rounding checklist that was filled out to see what the resident was doing every hour. The DON stated if a resident needed hourly rounds that would be decided by the interdisciplinary team. The DON stated resident 60 was not on a bowel and bladder retaining program. The DON stated that retraining programs were done when a resident had a catheter removed. The DON stated the facility was working on getting a bladder scanner. The DON stated that resident 60 was potentially a candidate for a bowel and bladder retraining program. The DON stated she had not thought of trying a bowel and bladder retraining program. (Cross Refer to F689 and F725) 38031 3. Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, chronic viral hepatitis C, non-pressure chronic ulcer of left lower leg, mood disorder, encephalopathy, atrial fibrillation, pulmonary embolism, hypospadias, retention of urine, chronic kidney disease, major depressive disorder, pyelonephritis, multiple fractures of ribs, bipolar disorder, dysphonia, insomnia, peripheral vascular disease, chronic pain syndrome, opioid dependence, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, anxiety disorder, polyosteoarthritis, hypertension, gout, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/4/24 at 9:07 AM, an observation was made of resident 1 lying in bed. The bed was positioned with the left side of the bed against the wall. A fall mat was observed on the right side of the bed and was pushed out of the way to accommodate a side table. A sign was posted outside of resident 1's room for enhanced barrier precautions (EBP) and a personal protective equipment (PPE) cart was located outside the door. The cart contained gowns and gloves. On 11/4/24 at 9:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 1 was on EBP for a suprapubic (SP) catheter and had an ongoing extended-spectrum beta-lactamase (ESBL) infection. LPN 3 stated that they obtained a urinalysis (UA) this past weekend for resident 1 and that the resident always had a urinary tract infection (UTI). LPN 3 stated that they pushed fluids but sometimes resident 1 was non-compliant with care. Resident 1's electronic medical records were reviewed. On 8/2/24, resident 1's Minimum Data Set (MDS) Assessment documented a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which would indicate a severe cognitive impairment. The assessment documented that the resident was a two-person total dependence assist for bed mobility, transfer, and toilet use. Resident 1's physician orders revealed the following: a. On 8/19/24, an order was initiated to change the suprapubic catheter monthly, every 30 days. b. On 5/1/24, an order was initiated to perform suprapubic catheter care every shift: cleanse tubing and site, and apply a drain sponge. Ensure the tubing was not kinked, not resting on the ground, and ensure the catheter bag was in a privacy bag. c. On 7/6/24, an order was initiated to change the catheter down drain bag weekly, every night shift on Saturday. d. On 5/10/24, an order was initiated to offer 240 milliliters (ml) of fluid three times a day for hydration. e. On 5/2/24, an order was initiated to change the suprapubic site bandage daily. Cleanse with normal saline (NS), pat dry, and apply t-drain sponge daily. f. On 10/31/24, an order was initiated for a UA with culture (C) and sensitivity (S) for uremia. g. On 10/31/24, an order was initiated for a swab of the purulent drainage on the suprapubic area for possible urine infection. Resident 1's progress notes revealed the following: a. On 10/14/2024 at 3:46 AM, the note documented, 18F [french] / 15 cc [cubic centimeter] suprapubic catheter to down drain for dx [diagnosis] of obstructive uropathy r/t [related to] hypospadias and CKD [chronic kidney disease]. May change PRN [as needed] if dislodged or clogged. CNA [Certified Nurse Assistant] notified nurse that residents brief was soaked with urine. Nurse attempted to flush suprapubic catheter but it was not patent. Catheter was removed and a new 18F 15cc suprapubic catheter was placed with sterile technique and urine return was noted. Resident tolerated the removal and insertion well. Will continue to monitor. b. On 10/14/2024 at 5:09 AM, the note documented, 18F / 15 cc suprapubic catheter to down drain for dx of obstructive uropathy r/t hypospadias and CKD. May change PRN if dislodged or clogged. PRN Administration was: Effective An additional 100cc output noted since insertion. c. On 10/17/2024 at 4:23 PM, the note documented, Resident is able to listen to writer's instruction. Clean his suprapubic catheter site which at first he was covering by hand . His scrotal area is with redness and moist , tried to explain the need to clean it but writer was able to just wiped the groin area. He does not have behavior. Will continue monitor resident. d. On 10/27/2024 at 4:42 AM, the note documented, Residents suprapubic dressing was saturated. Cleansed suprapubic site with NS and redressed area with drain sponge. Will continue to monitor. e. On 10/30/2024 at 1:00 AM, the provider note documented, Since patient's admission he has multiple trips to the emergency department related to urinary tract infection that evolved to sepsis, along with multiple strokes. Lab workup showed normal white blood cell count at 9.5. UA was positive for infection, urine collected yesterday was also positive for infection. Patient's Foley catheter was recently changed out the day before on the 15th. f. On 10/31/2024 at 6:25 PM, the note documented, Resident has a foul smelling drainage from his suprapubic catheter site and his [sic] blood in urine and reported to PCP [primary care provider] via telephone and [doctor's name omitted] ordered a UA and purulent drainage swab test. PCC updated g. On 11/6/2024 at 5:41 AM, the note documented, Nurse assessed patient catheter and it wasn't draining. Attempted to flush catheter and found it to be clogged. Suprapubic catheter was changed using 18F 15cc, and sterile technique with no complications. Old catheter was removed, and bladder drained upon removal. After successful placement of new catheter urine was draining appropriately. Urine continues to be red tinged, with drainage at the suprapubic site. Dr aware. Resident very aggressive and combative throughout night during catheter cares and brief changes. Yelling, kicking, punching, and attempting to bite staff. Educated pt [patient] the need for the brief change as he had a bowel movement, to prevent sores and skin breakdown. h. On 11/6/2024 at 1:19 PM, the note documented, Per [Physician Assistant name omitted] start contact precautions. Infection to supra pubic site w/ [with] MDRO [multidrug-resistant organism]. Precautions implemented. i. On 11/6/2024 at 5:10 PM, the note documented that the culture and sensitivity report was sent to the PA and they were awaiting orders. j. On 11/9/2024 at 12:54 AM, the note documented, Pt on IM [intramuscular] abx [antibiotics] for UTI and po [by mouth] abx for suprapubic cath site infection. Urine yellow with small amount of sediment. Suprapubic cath site dressing changed. No drainage noted. Pt also with recent fall. Pt with a bandage in place on his back and bandage in place to his left leg. Denies pain. 2 people assist with bed mobility and brief changes. Pt's bed in low position and fall mat in place. On 11/1/24, resident 1's suprapubic site culture documented the organisms identified as Staphylococcus aureus Methicillin Sensitive, Escherichia coli ESBL (extended beta-lactamase) producer, Proteus Mirabilis, and Klebsiella pneumoniae ESBL producer. The susceptibility report for the suprapubic site documented that the Staphylococcus was resistant to Penicillin; the Escherichia coli was susceptible to Ertapenem; and the Klebsiella was susceptible to the Ertapenem. The laboratory results had a handwritten note that it was reviewed by the provider on 11/7/24 and Ertapenem 1 gram (gr) daily for 10 days was ordered. It should be noted that the laboratory results were faxed to the facility on [DATE]. On 11/1/24, resident 1's urine culture documented the organisms identified as Proteus Mirabilis and Escherichia coli. The result was documented as reviewed by the provider on 11/7/24 and ordered Ertapenem 1 gr daily for 10 days. The susceptibility report for the urine culture documented that the Proteus Mirabilis and Escherichia coli were susceptible to Ertapenem. Resident 1's November Medication Administration Record (MAR) revealed the following: a. On 11/7/24 at 3:06 PM, an order was initiated for Ertapenem Sodium Injection Solution Reconstituted 1 gram, inject 1 gram intramuscularly one time a day for 10 days related to a local infection of the skin. The order was discontinued on 11/11/24. The medication was documented as administered on 11/7/24 through 11/10/24 for a total of 4 doses administered out of 10 ordered. b. On 11/7/24 at 2:24 PM, an order was initiated for Penicillin V Potassium Oral Tablet 500 milligrams (mg), give 1 tablet by mouth three times a day for 10 days for infection of suprapubic site. The order was discontinued on 11/11/24. The medication was documented as administered on 11/7/24 through 11/11/24 for a total of 12 doses administered out of 30 ordered. On 7/26/24, resident 1 had a care plan initiated for SP catheter use r/t obstructive uropathy and nonfunctioning bladder, Urinary obstruction/stricture with retention complicated by DM [diabetes mellitus], hx [history] false urethral passageway, Failed bladder training attempt, and Urethral dilation 5/22/19. Interventions identified on the care plan included catheter care every shift; change catheter monthly and as needed; obtain a UA with C & S if indicated with each catheter change; follow-up with a urologist when indicated; position catheter bag and tubing below the level of the bladder; check tubing for kinks; cleanse peri area from front to back; monitor for signs and symptoms of discomfort on urination or increased frequency; monitor for pain due to catheter; monitor and report to provider any signs and symptoms of UTI. On 11/6/24 at 3:26 PM, an interview was conducted with the DON. The DON stated that incontinence care expectations were that staff rounded on the residents every 2 hours and checked to see if briefs needed to be changed. The DON stated that staff should check with any resident that required assistance with toileting every 2 hours for toileting needs. On 11/7/24 at 8:45 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she needed to call the lab to see if they had the urine C & S results back for resident 1. On 11/7/24 at 8:53 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 was fully dependent on staff for most all of his ADLs. CNA 3 stated that resident 1 required assistance with incontinence care. CNA 3 stated that resident 1 refused care daily for everything including bed bath, brief changes, linen changes, and eating. CNA 3 stated that resident 1 had his catheter changed recently and since that treatment the resident's urine had been bloody. CNA 3 stated that on average resident 1's urine was cloudy and dark. CNA 3 stated that they encouraged resident 1 to drink fluids but he sometimes ref [TRUNCATED]

Based on interview and record review it was determined, for 1 of 65 sampled residents, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with a history of suicidal ideation's had a traumatic life event occur with no behavioral health services provided. The resident was found to have taken 4 to 5 bottles of Tylenol and was sent to the emergency room for an overdose. Resident identifier: 45, 57. Findings include: 1. Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on [DATE] with diagnoses which included spondylosis without myelopathy or radiculopathy, lumbosacral region, type 2 diabetes mellitus, morbid obesity, bipolar disorder, major depressive disorder, suicidal ideation's, auditory hallucinations, generalized anxiety disorder and manic episode. On 11/3/24 at 4:01 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that resident 57 initially resided on the locked memory unit with her mother, resident 45. RN 5 stated that resident 45 was placed on hospice services and was bed bound, and was subsequently moved off the locked memory unit. RN 5 stated that resident 45 passed away a week ago. RN 5 stated that resident 57 was currently in the hospital. RN 5 stated that resident 57 was admitted to the hopital for a Tylenol overdose. RN 5 stated that resident 57 had Tylenol at the bedside and no one was aware that she had it. RN 5 stated that resident 57 overdosed last Friday (11/1/24) and they found the bottle of medication at the bedside. RN 5 stated that resident 57 was alert and oriented and was on depression monitoring. RN 5 stated that she was not aware of resident 57 having a history of suicidal ideation (SI). On 11/3/24 at 5:34 PM, a follow-up interview was conducted with RN 5. RN 5 stated that if a resident had a history of suicidal ideation it should be documented in their medical record. RN 5 stated that if a resident had made statements of self harm then they would be placed on every 2 hour visual checks. RN 5 stated that she was not sure where to locate documentation of a past history of suicidal ideation for resident 57. RN 5 stated that any history of SI should be past on in report especially if that was something that they were monitoring for. RN 5 stated that staff were monitoring resident 57 for her mood throughout the shift and every resident with a history of depression was on 2 hour visual checks. RN 5 stated that both the licensed nurse and the Certified Nurse Assistant (CNA) were to conduct visual checks on the resident. RN 5 stated that the CNAs charted on a paper copy and the licensed nurse charted in the Treatment Administration Record (TAR). RN 5 stated that any behavior monitoring should be a part of the resident care plan. RN 5 stated that if they noted an increase in depressive statements they would chart in an alert charting progress note. RN 5 stated that they conducted a facility wide inspection of all patient rooms, and cleared out all supplies that were shipped and not provided by the facility. RN 5 stated that a lot of residents had items shipped from outside retailers and if it included over the counter (OTC) medication the facility would not have known about it. On 11/3/24 at 6:01 PM, an interview was conducted with the Administrator (ADMIN) and the Minimum Data Set (MDS) Coordinator. The ADMIN stated that resident 57 had taken too many Tylenol. The ADMIN stated that after resident 57's incident they conducted a room sweep of all residents. The ADMIN stated that they consulted with the Ombudsman prior to the room sweep. The ADMIN stated that the intention of the room sweep was to ensure that no other residents had any medications at the bedside that they should not have access to. The ADMIN stated that the facility notified the State Survey Agency of the incident with resident 57 on Saturday for the event that occurred on Friday. The MDS Coordinator stated that he was in charge of the room sweep. The MDS Coordinator stated that they identified two other residents that had medication at the bedside. The MDS Coordinator stated that the staff who participated in the room sweep were himself, the CNA Coordinator, Admissions staff, Housekeeping Supervisor, and Medical Records staff. The ADMIN stated that CNA 10 found resident 57 confused and vomiting blue stained emesis. The ADMIN stated that RN 6 assessed that resident 57's pupil was nonreactive to light and sent them out to the hospital for evaluation. The ADMIN stated that RN 6 observed 5 empty bottles of Tylenol at resident 57's bedside. The ADMIN stated that that they thought resident 57 used the Walmart order delivery and that was how she obtained the medication. The ADMIN stated that they were still in the process of their investigation as the incident had just occurred on Friday. The ADMIN stated that resident 57 had a history of SI that was documented in the PreAdmission Screening and Resident Review (PASRR) Level II. The ADMIN stated that resident 57's mother passed away about a week before her suicide attempt. The ADMIN stated that since the incident they had created a protocol to make sure that a resident's care plan needs addressed SI. The ADMIN stated that they provided staff education on Friday on recognition of the signs and symptoms of SI and depression. The ADMIN stated that the education included the Centers for Disease Control and Prevention (CDC) Guidelines for Preventing Suicide, Guiding Others Through Grief, and National Institute of Health (NIH) Depression training. The ADMIN stated that he had began working at the facility 3 months ago and prior to last Friday's education he had not provided education for the identification of risk factors for SI. The ADMIN stated that staff were providing frequent checks of resident 57, the activities coordinator was visiting daily and the resident's religious services had also visited. The ADMIN stated that he was in the process of obtaining staff attestations that demonstrated documentation of the frequent monitoring that was being conducted of resident 57. The ADMIN stated that if staff noted an increase in depressive statements by a resident they should notify the Director of Nursing (DON) and the ADMIN and then document the observations in the electronic medical records. The ADMIN stated that staff did not notify him of any increase in depressive statements made by resident 57 prior to the suicide attempt. Resident 57's medical record was reviewed 11/3/24 through 11/13/24. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated resident 57 was cognitively intact. A mood interview with resident 57 revealed she had thoughts that she would be better off dead or of hurting herself in some way about half or more days. A quarterly MDS dated [DATE] was not completed for the question above. A Suicide Lethality form dated 4/24/24 revealed Rt [resident] responded 'the details of how I would kill myself was supposed to happen on April 8th' 'I don't think about those things anymore.' When RA [Resident Advocate] prompted RT for more info - why don't you think about them anymore? Resident replied, 'I forgot about my obligation' 'My obligation to my mom, I did code, but I was told to come back and take care of my mom.' RA asked RT what would happen if your mom does pass away? RT replies she wants to live because that is what her mom wants, 'Mom wants me to live, and Mom will want me to keep living.'. A Preadmission Screening Resident Review (PASRR) Level II signed 8/26/24 by the evaluator revealed Patient was referred for level 2 evaluation due to diagnoses of bipolar, mood disorder due to medical condition, manic episode, major depression, generalized anxiety, auditory hallucinations, and suicidal ideation's. She did not report all the criteria for GAD [generalized anxiety disorder] and she disagreed that she was psychotic during her mania. She denied hearing a command hallucination to kill herself. She said it was her own thought. On 4/3/24 patient was admitted to [name removed] Psychiatric Hospital due to a threat to suicide via overdose. The SI was precipitated by the fact that she was being evicted from her apartment. During that stay she presented with symptoms of bipolar disorder with psychosis. She was grandiose and reported auditory hallucinations commanding her to overdose. Prior to this episode she had not been taking her medications. Bipolar and schizophrenia run in the family. She scored 21 on the PHQ-9 this week indicating significant depression and continued thoughts of suicide. At the age of 15 she had her first depression following grandmother's death. Her father [sic] dad was very depressed and expressed SI and attempted suicide. She said, 'I Turned to drinking.' She also said her mom's side of the family also has depression. At age 18 she started having SI. This SI was precipitated by job loss and money troubles. She felt worthless and attempted to cut her wrist but stopped because it hurt too much. In regards to mania she said, 'I have had manic episodes before, but didn't realize it now'. She said, 'I battle SI every day. But I try to remember that I'm here for a reason.' She said she feels safe and indicated she has no imminent plan to take her life. She said one of the biggest reasons for her current thoughts of wanting to be dead is her back. 'The pain in my back is so bad that I can't take care of myself.' The PASRR further revealed Patient suffers from a severe mental illness (bipolar) which has gone untreated for most of her life. Medication is helping. She will also need psychotherapy and possibly case management to remain safe and stable. Lastly, she would benefit from recreation therapy to address social isolation related to her depression. The recommendations for Specialized Services for mental illness treatment revealed, Please refer for psychotherapy. May also need a psychiatric consultation as she reports agitation just before her next dose of medication. Please refer for recreational therapy to address social isolation related to her depression. A PASRR Letter of Determination dated 8/26/24 revealed that Recommendations for specialized services are available on the PASRR evaluation which may be obtained through the Nursing Facility. Please consider behavioral health services to ensure present medications and other therapy services are best for your care. The right medications at the correct dosing, paired with appropriate and directed therapy services can be helpful with your overall mental health. A care plan dated 4/23/24 revealed Resident has mental health diagnoses of Mood disorder, hx [history of] of SI, bipolar disorder, anxiety, MDD [major depressive disorder], mania, auditory command hallucinations and requires the use of antidepressant and anti-psychotic medication. The goal was Resident will have no adverse side effects r/t [related to] use of psychotropic medication through the review date. Interventions included Resident will have no s/s [signs or symptoms] of unmanaged mental health symptoms daily through the review date; Administer medication per physician order. Monitor for side effects and notify MD [medical doctor] of any adverse or consistent side effects that occur r/t psychotropic drug use; Document target symptoms Q [every] shift. Notify MD of any new/worsened symptoms of mental illness that are not effectively managed with current pharmacological and nonpharmacological interventions; Follow PASRR [Preadmission Screening Resident Review] level II recommendations: SI, bipolar disorder, anxiety, MDD, mania, auditory command hallucinations; If resident's mental health symptoms become unmanageable in-house or a mental health crisis occurs, call the crisis line or notify the MD to obtain transfer orders for a psychiatric evaluation in the hospital setting; Obtain informed consent for use of psychotropic medication. Medication regimen including black box warnings will be reviewed in each care conference meeting; Psychotropic committee will review medication regimen, target symptoms and side effects at least quarterly and make recommendations as indicated; PASRR II: Has a Level II PASRR due to their diagnosis of General Anxiety Disorder, Bi-Polar Disorder, Major Depressive Disorder; Psychosocial, mental and physical needs will be met through the next review date; Administer medications as ordered and monitor for adverse effects and notify physician as needed; Follow PASRR II plan of care; Psychology consult as needed/recommended; Staff will utilize facility resources to meet the needs of the resident and; Updates will be made to PASRR and appropriate agencies notified as necessary. Progress notes revealed the following: a. On 4/24/24 at 9:45 PM, .Resident recently admitted to facility, shares room with her mother. Reports having a rough couple of days, but states things are improving . b. On 7/18/24 at 6:15 AM, a Psych [psychiatric] Evaluation revealed .She usually shares a room with her mother who is on hospice. She has a significant history of depression with one past suicide attempt with hospitalization . c. On 8/15/24 at 7:30 AM, a Psych Follow Up note revealed .has returned to her regular room that she shares with her mother. This has improved her mood and anxiety . d. On 11/1/24 at 3:14 PM, Psychosocial Note: Asked the resident if she would like to move rooms. She stated she wanted to stay in her room, but didn't want another roommate. She was worried about someone else coming in the space her mom used to be in. She stated that she didn't want anything taken out of the room. Asked if there was anything we can do for her at [sic] during this difficult time. She denied any needs. e. On 11/1/24 at 9:30 AM and was created on 11/2/24 at 12:12 PM by the Director of Nursing (DON), IDT Late Entry: Data: Resident was found throwing up blue vomit by CNA. She was observed to have dilated pupils that was unreactive to the light. 5 empty bottles of Tylenol pm in Pts electric wheelchair. Action: IDT [interdisciplinary team] team met to discuss resident including: Admin, DON, regional nurse, activities director, MDS, CNA coordinator, medical records. Response: Resident was taken to the hospital immediately after nurse was notified of incident. f. On 11/1/24 at 3:27 AM, Discharge Progress Note Date/time of discharge/transfer:: 11/1/2024 0327 [3:27 AM] Discharge/transfer location:: [name of facility] room [ROOM NUMBER] Mode at transportation at time of discharge/transfer:: [local ambulance company] ambulance on stretcher Reason for Transfer/Discharge: Pt [patient] was found throwing up blue vomit by PN [?]. Pt was observed to have dilated pupils that was unreactive to the light. Pt thought she was at [local hospital] and stated [sic] to throw away her fathers ashes. PN found 5 empty bottles of Tylenol pm in Pts electric wheel chair. Discharge teaching/instructions completed during discharge/transfer process:: discharge teaching to [local ambulance company] Discharge paperwork released with resident at time of discharge/transfer:: paperwork realized [sic] to [local ambulance company] Resident's response to discharge/transfer process:: Resident confused and unaware of situation. How were resident's personal effects stored/handled at time of discharge/transfer?:: Pt was not sent with personal effects. Name of individual to whom report was provided at new location:: [local ambulance company]dispatch Name of resident representative notified (if resident is not self-responsible):: [name removed] Name of Physician notified:: [name removed]. It should be noted there was no information about resident 57's mother passing away in the progress notes. The October 2024 TAR revealed the following: a. Behavior monitoring: # of anxious statements every shift. There were no documented episodes until 10/31/23 when there were 6 episodes during the night shift. b. Behavior monitoring: # of episodes of agitation every shift. There were no episodes until 10/31/23 when there were 8 episodes during the night shift. c. Behavior monitoring: # of episodes of expressions of hopelessness every shift. There were no episodes until 10/28/24 with 1 on day shift and then 2 on the night shift on 10/31/24. On 11/6/24 at 9:08 PM, an interview was conducted with the RA. The RA stated The Director of Acquisitions and Risk Management was not a Social Service Worker (SSW) but was extremely knowledgeable with the federal regulations and the PASRR. The RA stated that the Director of Acquisitions and Risk Management coordinated facility monthly calls for all RA's. The RA stated the monthly calls included RA duties. The RA stated there was another SSW that was willing to sit down with him but was not willing to supervise him. The RA stated for the first 6 months he did not have anyone who was willing to help train him. The RA stated the SSW came by the facility for about an hour a couple times a month and then he took her advise. The RA stated the Business Office Manager at a sister facility, helped with assessments and PASRR level II's. The RA stated the PASRR evaluator was also very helpful. The RA stated the previous RA showed him a lot of what he did. The RA stated he was a mental health case manager prior to working at the facility. The RA stated the previous RA showed him how to track things, priorities and things like that. The RA stated it took a lot of time for him to learn the position. The RA stated that care planning was a big deal and hard for him to understand. The RA stated there was no Licensed Clinical Social Worker (LCSW) to provide guidance. The RA stated if a resident was having behaviors, nurses notified the DON and RA. The RA stated then behaviors were discussed with the clinical team and MD. The RA stated the clinical team included the DON and Administrator. The RA stated the facility had psychiatrist with a local behavioral health facility who came weekly to visit residents. The RA stated the psychiatrist met with resident 57 weekly and notes were in the progress notes of the residents medical record. The RA stated resident 57 was immediately set up with services because of her level II. The RA stated the the PASRR was straight forward with her needing psychiatric services. The RA stated resident 57 was seen on 10/22/24. The RA stated resident 57 shared a room with her mom and resident 57 was upset since her mother passed away. The RA stated if he was at the facility full time, he would have met with the resident 57 the day after her mother had passed away, checked on her, had staff monitor her, and would have set up a psychiatric appointment. The RA stated he had been notified that resident 57's mother passed away through a manager group chat. The RA stated he planned to talk with resident 57 on 11/2/24 when he was planning to work at the facility. The RA stated he worked a few hours on Saturday and Sundays. The RA stated resident 57 had tried to commit suicide, ordered Tylenol through a mobile application and had it delivered to the facility. The RA stated she took the Tylenol and resident 57 was rushed to the hospital. The RA stated that resident 57 had not had suicidal ideation's. The RA stated upon admission he completed a Suicidal Lethality form. The RA stated based on the form, with the answers resident 57 provided, he would complete a safety plan. It should be noted there was no safety plan located in resident 57's medical record. On 11/7/24 at 4:17 PM, a follow-up interview was conducted with the DON and Administrator (ADMIN). The ADMIN stated if someone was admitted with a history of suicidal ideation, facility staff needed to create a care plan based on their PASRR. The ADMIN stated the IDT team which included the RA, ADMIN, Activities Director (AD), DON and MDS coordinator, met to discuss the residents needs. The ADMIN stated while there was not a full time RA, the AD and Medical Records Director helped with RA duties. The ADMIN stated the Regional Nurse Consultant was involved and there was a consultant LCSW that provided oversight to the RA. The ADMIN stated staff were trying to make sure care plans were up-to-date, PASRR's and level II's were done. The ADMIN stated resident 57 ordered a bunch of stuff from a local store and had it delivered. The ADMIN stated the Tylenol was in delivery and he was not sure when the resident took it. The ADMIN stated when a CNA was doing rounds about 3:00 to 3:30 AM, resident 57 had vomited and it was blue. The ADMIN stated resident 57 was confused, eyes were not reacting to light, the nurse sent her to hospital, and then noticed there were 5 empty Tylenol bottles on the ground. The ADMIN stated nurse called the ADMIN, when they found the bottles. The ADMIN stated it was reported to the State Survey Agency and an investigation was being completed. The ADMIN stated that the hospital reported resident 57's Acetaminophen level was 135. The ADMIN stated a sweep of residents rooms was completed to make sure no other residents had medications in their room. The ADMIN stated education was provided to staff on depression, medication labeling and storage, coping with grief, and another one. The ADMIN stated once resident 57's mother passed away the AD made sure that relief society came to visit, the AD checked in on her daily. The ADMIN stated that resident 57 was sad about her mother passing but nothing triggering. The ADMIN stated that during the investigation he obtained statements from staff that had interacted with her, including the housekeeping staff. The ADMIN stated CNA's and nurses reached out to resident 57, when nurses were doing medication pass they were making sure resident 57 was okay. The ADMIN stated he was able to get statements after, but the AD had daily notes. It should be noted there were no progress notes from the AD. On 11/12/24 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not currently have a full time RA, Social Service Worker or LCSW. The DON stated any behavioral concerns would be referred to behavioral health services who was in contact with the facility. The DON stated if a resident was in a crisis, facility staff would send the resident to the hospital or call the crisis hotline. The DON stated the AD was able to do trauma informed training, but the DON was not sure what the AD's training was. The DON stated the AD could do RA duties if she was trained but not sure who or what she had been trained on. The DON stated there was a mental health screening and a Suicidal Legality assessment done with the RA upon admission. The DON stated resident 57's mental health triggers would be assessed in those assessments. The DON stated the death of resident 57's mother would be a trigger for her. The DON stated staff were checking in on resident 57 and there were statements provided by staff after the resident went to the hospital. The DON stated resident 57 was experiencing escalating episodes of behaviors, there needed to be more training on documenting alert charting, monitoring and letting management know. The DON stated resident 57 needed a safety plan and suicide monitoring. The DON stated there was extra monitoring of resident 57 but there was no documentation of the monitoring. The DON stated when a resident had behaviors, staff were educated on de-escalation and management of trauma. The DON stated the care plan was how staff knew de-escalation techniques, but the DON did not know how CNA's were able to access the care plans. The DON stated she was not sure if the CNA's had access to the Kardex system that was triggered from the care plans. The DON stated nurses should be aware of residents with a history of suicidal ideation by the care plan or diagnoses. The DON stated there would be physician's orders for monitoring of behaviors. The DON stated the number of episodes were documented by nurses in the TAR. The DON stated if nurses noted an increase in episodes of behaviors, the nurses should notify the DON or RA. The DON stated medication adjustments might be needed. On 11/13/24 at 9:03 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated she was on shift when resident 57's mom passed away. LPN 3 stated resident 57 was sad and called her family for comfort. LPN 3 stated it seamed like resident 57 was coping well with her mom passing away. LPN 3 stated that she did not know if the psychologist was contacted after her mom passed away. LPN 3 stated the DON asked a few weeks ago, if resident 57 could call the DON if she was in a crisis. LPN 3 stated she just wanted to listen to resident 57 and let administration know if there were any indications that she had SI. LPN 3 stated staff could let the RA know and behavioral health services know if the resident needed help. LPN 3 stated she was provided company training on a computer for Post Traumatic Stress Disorder and how to deal with traumatic events. On 11/13/24 at 12:43 PM, an interview was conducted with Regional Nurse Consultant (RNC) 2. RNC 2 stated the facility hired an RA but then they took another position at the last minute. RNC 2 stated the facility currently did not have a full time RA. 38031

Based on observation, interview and record review it was determined, for 17 of 65 sampled residents, that the facility did not employ sufficient staff with the appropriate competencies and skills set to carry out the function of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, meals were observed to be served over an hour later than the posted meal times, a resident was observed to be yelling he was hungry, residents were in the hallways waiting for food, residents were upset in the dining room waiting for meals and residents council minutes revealed complaints of late meals. Resident 16 will be cited at a harm level. Resident identifiers: 9, 13, 14, 16, 22, 24, 26, 27, 30, 32, 36, 38, 44, 50, 52, 55 and 120. Findings included: Posted facility meal time were as follows: Breakfast: 7:30 - 8:30 Lunch: 12:30 - 1:30 Dinner: .L5:30 [sic] - 6:30 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of left middle cerebral artery, cognitive communication deficit, diabetes mellitus and major depressive disorder. On [DATE] at 9:19 AM, an observation was made of resident 16. Resident 16 was observed at the kitchen door yelling I'm [expletive removed] hungry, man! Resident 16 was observed to tell the Maintenance Director he needed to talk to the kitchen staff. The Maintenance Supervisor was observed to tell resident 16 that he needed to talk to the nurse and could not come through any door he wanted. Resident 16 was observed to tell the kitchen staff he was [Expletive removed] hungry and he had not received breakfast. The Dietary Manager (DM) was observed to intervene between resident 16 and the Maintenance Supervisor. The DM asked resident 16 what he would like to eat for breakfast. Resident 16 was observed to tell the DM what he wanted for breakfast. Resident 16 was observed to use his wheelchair to motorize through the hallway to his room. On [DATE] at 9:23 AM, an interview was conducted with resident 16. Resident 16 stated he was a [Expletive removed] Chef and it was 9:30 AM. Resident 16 stated he needed food before 9:30 AM. Resident 16 stated he asked staff about his food and staff say I don't know or they were not sure. Resident 16 stated that he was really trying to be patient but breakfast was always late. Resident 16 stated he was okay if his breakfast came before 9:00 AM, but the food never came that early. Resident 16 stated the food was either loved or hated. Resident 16 stated the portions were too small. Resident 16 stated he should be getting double portions but never got that much. Resident 16 stated I'm hungry. Resident 16 stated he had a stroke 7 years ago and that was why he was at the facility. Resident 16 stated he had been hungry for about a year and a half. Resident 16 stated he was not getting snacks and staff told him that corporate did not allow for snacks. Resident 16 stated that he had to go to the kitchen to get food because if he asked any other staff they tell him he had to wait a minute and then he would not get anything to eat. Resident 16 stated once he yelled about food, then he was able to get food. Resident 16 stated he loved the kitchen staff but they were so slow and delayed. Resident 16 stated the kitchen staff he received dinner the night before at almost 8:00 PM and he did not get enough food. Resident 16 stated he was not offered a snack last night. Resident 16's room was observed to have 3 cans of Campbell's chicken noodle soup, a bag with uncooked rice, bag of small candy and spicy nacho chips. Resident 16 stated his sister had to bring him snacks. On [DATE] at 9:45 AM, an interview was conducted with Housekeeping Supervisor (HS) who was passing meal trays in the 300 hallway. The HS stated resident 16's meal tray should have been on the 300 hallway cart but she did not know where it was. On [DATE] at 9:47 AM, an observation was made of resident 16's tray leaving the kitchen. An interview was conducted with the DM. The DM stated resident 16's tray went to the dining room and that was why resident 16 did not have a tray delivered to his room. The DM stated resident 16 should have asked to have his tray sent to his room. The DM stated if a resident wanted to go to the dining room, then their tray was served there. The DM stated staff did not monitor which food trays were not eaten in the dining room. On [DATE] at 1:13 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 16 was friendly with her, as long as everyone respected him and they allowed him time to communicate. CNA 1 stated resident 16 cussed at times which seamed aggressive. CNA 1 stated resident 16 sometimes slept in and often missed breakfast. CNA 1 stated resident 16 tried to store food in his room to eat later. CNA 1 stated resident 16 usually communicated with the kitchen staff regarding his meals. CNA 1 stated if he felt like he was not being heard or listen to, then he would get upset, yell and cuss. Resident 16's progress note revealed the following on [DATE] at 11:37 PM, Order - Administration Note: BEHAVIOR MONITORING: # OF ANGRY OUTBURSTS Q [every] SHIFT. every shift for Behavior monitoring pt [patient] was upset that supper was late. On [DATE] at 9:47 AM, an interview was conducted with the Administrator (ADMIN) and Assistant Dietary Manager (ADM). The ADM stated if a resident requested to eat in dining room, then dietary staff put their tray in the dining room. The ADM stated staff were not aware resident 16 wanted to eat in his room. The ADM stated after a meal was left out for longer 5 minutes, then staff needed to find out why the resident was not in the dining room and they needed to take the meal to their room. The ADM stated normally the CNA's put the trays out in the dining room. The ADM also stated the dietary staff put the trays on the table. The ADM stated the dietary staff should be checking in the dining room. On [DATE] at 1:07 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated when resident 16 did not get what he needed he became angry and yelled. LPN 5 stated if they did not bring food on time or the food was cold then resident 16 yelled. LPN 5 stated resident 16 was easy to get along with and was able to verbalize his needs. LPN 5 stated if resident 16 received small portions he yelled. LPN 5 stated there were new staff in the kitchen that had not been educated, so they did not send the right food to residents. 2. Observations: a. On [DATE] at 1:15 PM, an initial walk-through of the kitchen was conducted. The ADM and a cook were present in the kitchen at the time and 1 dietary aide. The DM arrived at approximately 1:30 PM. On [DATE] at 1:15 PM, an interview was conducted with the ADM who stated she had been working 18 hour days and was glad the kitchen was fully staffed. On [DATE] at 1:30 PM, an interview was conducted with the DM who stated there was a cook and a dietary aid for the morning shift and the afternoon shift, and the DM or the ADM. The DM stated that on some days there was a prep aide that would come in to help. The DM stated meal service took between 1 hour and 1 ,d+[DATE] hours. The DM stated meal trays went out to the hallways first and the dining room was served last, which was about an hour after the first hall cart left the kitchen. The DM stated for the breakfast meal, the first cart would leave the kitchen at 6:30 AM, for the lunch meal, the first cart was out by 12:30 PM, and for the dinner meal, the first cart left the kitchen at 6:30 PM. b. On [DATE] at 1:30 PM, an observation was made of Certified Nursing Aide (CNA) 2 delivering lunch trays to the 300 hallway. CNA 2 stated that the tray delivery had just begun. CNA 11 stated that lunch usually started on the 300 hallway at around 1:00 PM. CNA 11 stated that approximately 10 residents ate in the main dining room and the majority of residents ate in their room. CNA 2 stated that room [ROOM NUMBER], 214, 303 and 317 B needed assistance with dining. c. On [DATE] at 1:35 PM, an observation was made of the lunch meal tray for room [ROOM NUMBER] A. The tray contained one chicken leg, mashed sweet potatoes, green beans, a roll, and a pie dessert with the chocolate topping melted. The dessert appeared to be a pudding that was no longer solid. d. On [DATE] at 6:10 PM, an observation was made of the 100 hallway meal cart being delivered. e. On [DATE] at 6:12 PM, the food cart was observed to arrive on the 100 hallway. At 6:16 PM, LPN 1 arrived to check meal tickets and food. At 6:16 PM, the first meal tray was delivered in the 100 hallway by CNA 7. At 6:21 PM, the last meal tray was delivered in the 100 hallway. f. On [DATE] at 8:06 PM, an observation was made of the dining room. Residents were observed to be seated in the dining room and the dinner meal had not been delivered. g. On [DATE] at 8:49 AM, the breakfast meal trays arrived on the memory unit (300 hallway), and the last tray was delivered by 9:00 AM. h. On [DATE] at 9:00 AM, an observation was made of the 2nd 300 hallway meal cart being delivered to the 300 hallway. At 9:02 AM, an observation was made of resident 14. Resident 14 was observed to wheel himself in his wheelchair to the meal cart. CNA 5 was observed to tell resident 14 that he needed to be patient and wait for the nurse. Resident 14 was observed to put his head down and wheel toward his room. At 9:05 AM, resident 14 was observed pacing the hallway in his wheelchair between his room and the meal cart. A CNA was observed to get resident 14's tray and stated this was his meal. Resident 14 was observed to say YAY!. i. On [DATE] at 9:03 AM, an observation was made of the facility kitchen. [NAME] 1 was observed to be plating the breakfast meal for the 300 hallway cart. j. On [DATE] at 12:45 PM, an observation was made of 100 hallway. The lunch meal cart was delivered. k. On [DATE] at 1:24 PM, an observation was made of resident 30. Resident 30 stated that she was hungry and she was going to see if they had some lunch for her. On [DATE] at 1:41 PM, resident 30 again stated that she was hungry. LPN 3 stated that she could give her some water until her lunch arrived. Resident 30 was observed pacing the hallway. l. On [DATE] at 1:45 PM, the lunch meal trays were delivered to the memory care unit and the first tray was delivered to room [ROOM NUMBER]. On [DATE] at 1:49 PM, all trays were delivered to the residents on the unit. m. On [DATE] at 6:17 PM, the meal cart was delivered to the unit and was parked outside of room [ROOM NUMBER]. On [DATE] at 6:19 PM, the first meal tray was delivered to room [ROOM NUMBER]. n. On [DATE] at 8:43 AM, an observation was made of the 300 hallway meal cart was delivered to the hallway. The first tray was served at 8:46 AM. 3. Resident Interviews: a. On [DATE] at 2:05 PM, an interview was conducted with resident 50 who stated she had just received her lunch. Resident 50 stated that because of low staffing, they were bringing a big cart to the dining room, but they had a hard time finding a staff member who could pass the trays in the dining room. Resident 50 stated the kitchen decided to bring individual trays out and did not bring the trays until the residents came to the dining room, and the residents do not know when they were going to be served. b. On [DATE] at 2:37 PM, an interview was conducted with resident 120. Resident 120 stated that meals have never been on time since she was admitted to the facility in September. Resident 120 stated that meals have gotten later in the past few weeks and staff have not told her why when she had asked. Resident 120 stated that her meals arrive barely warm. c. On [DATE] at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that the newest cook served meals an hour or more later than what they should be. Resident 26 stated that she had to wait more than two hours for meals to be delivered to her room. d. On [DATE] at 5:32 PM, the resident residing in room [ROOM NUMBER] was heard stating to a CNA What is up with the kitchen? Last week dinner was served at 3:30 PM. They are so damn inconsistent. The CNA informed the resident that the dinner was scheduled for 6:00 PM. The resident stated that this place sucked. e. On [DATE] at 5:33 PM, an interview was conducted with resident 9 who stated the food was cold 90 percent of the time. Resident 9 stated dinner arrived to the residents somewhere between ,d+[DATE] PM or whenever. Resident 9 stated that breakfast usually did not arrive until about 9:00 AM. f. On [DATE] at 5:45 PM, an interview was conducted with resident 24. Resident 24 stated the dinner meal was served anywhere from 3:00 PM to 6:00 PM. Resident 24 stated the food was very inconsistent and sometimes it was served at 7:00 PM which was Damn late. At 6:44 PM, an interview was conducted with resident 24. Resident 24 stated he normally got dinner around 3 and 4 PM. Resident 24 had not been served dinner. g. On [DATE] at 6:14 PM, an observation and interview was made of the dining room. Resident 44 was observed to be sitting in the dining room. Resident 44 stated he was waiting for dinner since 3:00 PM with no snacks offered. Resident 44 stated dinner was usually served about 6:30 PM. At 8:00 PM, resident 44 had not received his dinner meal. h. On [DATE] at 7:12 PM, resident 50 was sitting in the hallway outside of her room and had not been served dinner. Resident 50 was observed commenting about the late dinner to residents and staff walking by. i. On [DATE] at 8:09 AM, an interview was conducted with resident 22. Resident 22 stated the meals were always late. Resident 22 stated she should be served at 5:30 PM for dinner but did not usually get her meal till after 7:30 PM. Resident 22 stated breakfast should be served at 7:30 AM and she was not served till after 9:00 AM. j. On [DATE] at 8:14 AM, an interview was conducted with resident 27. Resident 27 stated that she was tired of complaining about the meals and never knew when she was going to get her food. k. On [DATE] at 8:22 AM, an interview was conducted with resident 32. Resident 32 stated that meals were always late. Resident 32 stated that breakfast should be at 7:30 AM but was not served until 9:00 AM. Resident 32 stated when he was admitted the meals were at 7:00 AM, 12:00 PM and 5:00 PM. Resident 32 stated he was not sure when he had received a meal on time. Resident 32 stated his dinner the night before was served at 8:15 PM. Resident 32 stated he was diabetic and had not had problems with low blood sugars. l. On [DATE] at 8:43 AM, an interview was conducted with resident 26. Resident 26 stated that meals were sporadic and came at unknown times. Resident 26 stated she has had to miss therapy and activities because meals have come late. m. On [DATE] at 8:51 AM, an interview was conducted with resident 55. Resident 55 stated he had not received breakfast yet. n. On [DATE] at 8:51 AM, an interview was conducted with resident 52 who stated she was still waiting for breakfast. Resident 52 stated she received dinner the night before at 7:30 PM. o. On [DATE] at 9:23 AM, an interview was conducted with resident 36. Resident 36 stated the meals were late and he was not sure why the meals were so late. p. On [DATE] at 11:07 AM, an interview was conducted with resident 13 who stated the food was always served late. q. On [DATE] at 12:38 PM, an interview was conducted with resident 38 who stated meals were being delivered 2 - 2 ,d+[DATE] hours late. Resident 38 stated he had to remind staff that he needed to eat. Resident 38 stated breakfast in the morning was 2 hours late and then his tray was not picked up. r. On [DATE] at 1:07 PM, an interview was conducted with resident 24. Resident 24 stated he did not get dinner until 7:45 PM on Sunday night. s. On [DATE] at 10:25 AM, a follow up interview was conducted with resident 55. Resident 55 stated meals were still served late. 4. Staff interviews: On [DATE] at 2:46 PM, an interview was conducted with staff member 1 who stated the kitchen was not doing what they were supposed to. Staff member 1 stated the dinner meal had been served as late as 9:00 PM, food was not properly covered. Staff member 1 stated residents should have regularly scheduled meals so their medications can be provided appropriately. Staff member 1 stated residents were not getting meals that were according to their meal tickets. On [DATE] at 10:24 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that residents complained of late meals. RN 4 stated she was not sure why meals were late most of the time. On [DATE] at 1:32 PM, an interview was conducted with CNA 5. CNA 5 stated that breakfast was served around 9:00 AM and lunch around 1:00 PM. On [DATE] at 5:54 PM, an interview was conducted with the ADMIN. The ADMIN stated the meals would be late because a surveyor was in the kitchen talking to kitchen staff. The ADMIN stated there were 3 staff members in the kitchen and if 1 person was asked a question it delayed the meals. The ADMIN stated the dinner meal was to be served between 5:30 PM and 6:30 PM. The ADMIN stated the meals were served in the order of 100 hallway, 200 hallway, 300 hallway, 400 hallway and then the dining room. On [DATE] at 5:48 PM, the DM stated that his Dietary Aide had walked out. The DM was at the steam table serving the dinner meal. The HS was observed in the kitchen and making quesadillas and preparing salad in a bowl. The morning cook, cook 2, was plating the food. At 6:45 PM, all of the hall carts had not been brought out and the kitchen staff were still cooking food because there had not been enough food prepared. On [DATE] at 8:39 AM, an interview was conducted with the ADM who stated usual kitchen staffing had been 1 [NAME] and 1 Dietary Aide in the morning at 5 AM leaving at 1 PM, and a Prep Aide between ,d+[DATE] AM. The ADM stated the afternoon/evening cook arrived at noon until 8 PM or when the shift ended. On [DATE] at 11:03 AM, an interview was conducted with the Registered Dietitian (RD) who stated the kitchen was a disaster. The RD stated she had been employed by the facility since [DATE]. The RD stated she learned quickly that the kitchen staff were doing their best to get the food out to the residents. The RD stated she had recommended the DM to the facility. The RD stated that meal delivery had been off and she brought it to their attention 2 weeks ago. The RD stated it was a struggle to get dinner and breakfast meals out and she did not know if they had enough support. The RD stated that would be a good questions for the DM. The RD stated she was not aware that residents had expressed concerns that meals were being served late. The DM stated under the last dietary manager food items were not ordered and not being delivered. The RD stated kitchen staff were having to run to the store all the time. The RD stated she did not think that should be happening now. The RD stated her contract was for ,d+[DATE] hours per week. The RD stated with a census of 75 residents she would need at least 20 hours per week just to do the resident assessments and did not include kitchen duties. On [DATE] at 3:47 PM, an interview was conducted with the ADMIN. The ADMIN stated the meal times were Breakfast 7:30 AM to 8:30 AM, Lunch 12:30 PM to 1:30 PM and Dinner 5:30 PM to 6:30 PM. The ADMIN stated the meal times recently changed because kitchen staff were not getting meals out on time so the new schedule worked better. The ADMIN stated the change was communicated to the residents by talking to all residents and posting updated meal times at the nurses station. The ADMIN stated the meals were served to 100 hallway, 200 hallway, 300 hallway, 400 hallway and then the dining room. The ADMIN stated the dining room was served last because that was how it was when he started at the facility. The ADMIN stated he had not seen residents request their meal in their room because it was served to the rooms before the dining room. The ADMIN stated the dietary department needed to get the process down for residents to get their meals in a timely manor. The ADMIN stated if meals were late, staff should call managers to help pass the trays as quickly as possible. The ADMIN stated there were all kinds of impacts to residents if meals were served late like blood sugars for diabetics and increase behaviors and moods. The ADMIN stated there was a Performance Improvement Plan (PIP) started on [DATE]. On [DATE] at 4:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated serving meals on time was a work in progress. The DON stated there was a PIP going on for the last month. The DON stated the DM had health concerns which had delayed the correction. The DON stated some residents were frustrated with meal times not being consistent. The DON stated she had not heard about resident 16 being upset about breakfast being late. The DON stated if a resident was not in the dining room for a meal, then a CNA should take the meal tray to the residents room. The DON stated meals being late could cause blood sugar management problems like feeling dizzy, cranky, light headed, and overall not feeling good. The DON stated if a resident received insulin without food their blood sugar could drop. 50200 The Facility assessment dated [DATE] revealed the average census each month was between 56 and 72 residents. Resident Support and Care Needs section revealed specific care and practices for nutrition included individualized dietary requirements, liberal diets, specialized diets, nutrition, tube feeding, cultural or ethic dietary needs, assistive devices, fluid monitoring or restrictions. The Facility Resources Needed to Provide Competent Support and Care for our Residents Population Every Day and During Emergencies revealed for Food and Nutrition Services needed a Dietitian, Dietary Manager and [NAME] Support Staff. The Staffing Plan was to have a contracted Registered Dietitian approximately ,d+[DATE] hours per week and a Dietary Manger who completed the Certified Dietary Manager (CDM) course. The Food and Nutrition services needed a full time CDM, ,d+[DATE] total dietary personnel working 6:00 AM through clean-up of the evening meal. A review of resident council meeting minutes revealed the following: a. [DATE]: .timing inconsistent with serving meals . b. [DATE]: .There were multiple complaints with meals. Nursing staff reported that the scheduled mealtimes are approx. [approximately] 7:40am, 11:45am, and 4:30pm. Multiple residents reported that their meals were arriving late, usually. Several residents commented that the meals are often missing condiments and that their plates do not match their preferences. Some residents indicated that they thought some of their food was expired. Some residents stated that they have noted improvements with some meals. The drinks also do not match some residents' expectations . c. [DATE]: .Several residents reported that food is cold. [Activities Director] shared that maintenance is in the process of replacing a heating element necessary to keep the trays warmer and those are actively being replaced. Some residents regularly receive clamshells instead of trays and asked why, as they get cold faster. It was reported that sometimes dishes are in short supply . d. [DATE]: .Residents reiterated that food is arriving after 2PM [sic] for lunch, most days (breakfast usually arrives by 9AM [sic] and dinner around 7PM [sic]) . On [DATE] at 3:00 PM, the facility resident council was attended. It was reported by many residents that meal times were not consistent and varied day to day. Many residents voiced concerns over the delay in receiving meals. 38031 43212 48709

Based on observation, interview, and record review it was determined, for 30 of 65 sampled residents, that the facility did not provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, meals were served late, menus were not meeting nutritional needs, portion sizes were not appropriate, food was not palatable, resident food allergies and preferences were not honored, beverages were not offered between meals, therapeutic diets were not followed, snacks were not provided, adaptive equipment was not provided, and the kitchen was not sanitary. In addition, weights and nutritional assessments were not being completed. Resident identifiers: 1, 3, 5, 4, 9, 10, 12, 13, 14, 15, 16, 22, 24, 26, 27, 28, 29, 30, 32, 36, 38, 44, 49, 50, 52, 53, 55, 60, 65 and 120. Findings include: 1. Based on observation, interview and record review it was determined, for 17 of 65 sampled residents, that the facility did not employ sufficient staff with the appropriate competencies and skills set to carry out the function of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, meals were observed to be served over an hour later than the posted meal times, a resident was observed to be yelling he was hungry, residents were in the hallways waiting for food, residents were upset in the dining room waiting for meals and residents council minutes revealed complaints of late meals. Resident 16 will be cited at a harm level. Resident identifiers: 9, 13, 14, 22, 24, 26, 27, 30, 32, 36, 38, 44, 50, 52, 55 and 120. (Cross refer F802) 2. Based on observation, interview and record review it was determined, for 3 of 65 sampled residents, that the facility did not have menus that met the nutrition needs of residents in accordance with established nutritional guidelines. Specifically, menus were not followed and correct portion sizes were not provided to residents. Resident identifiers: 15, 16 and 55. (Cross refer to F803) 3. Based on observation, interview and record review it was determined, for 11 out of 65 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of food, there were multiple resident council complaints about the flavor of food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 9, 12, 16, 22, 26, 27, 28, 32, 50, 55, and 120. (Cross Refer to F804) 4. Based on observation, interview and record review it was determined, for 6 of 65 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, residents with food allergies and intolerances were served food containing identified allergens, and one resident who was admitted on [DATE] had not been questioned about food allergies until 11/5/24. Resident identifiers: 1, 10, 16, 26, 28, and 38. (Cross Refer to F806) 5. Based on observation, interview and record review for 4 of 65 sampled residents, the facility did not ensure each resident received drinks, including water and other liquids, consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, water was not being provided to residents between meals, residents had to seek out staff to obtain fresh water and resident water mugs were not being cleaned regularly. Resident identifiers: 26, 27, 55 and 120. (Cross Refer to 807) 6. Based on observation, interview and record review, it was determined for 1 of 65 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, a resident with a physician's order for thickened liquids was observed to have thin water at the bedside. Resident identifier: 60. (Cross Refer to 808) 7. Based on observation, interview and record review it was determined, for 12 of 65 sampled residents, the facility failed to provide each resident with 3 meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Additionally, snacks were not provided to residents who wanted to eat at non-traditional times or outside of the scheduled meal service times and consistent with the resident plan of care. Specifically, meals were not served according to meal times, meal times were changed without resident input, snacks were not being provided regularly. Resident identifiers: 9,13, 16, 26, 27, 29, 32, 49, 53, 55, 60, and 120. (Cross Refer to 809) 8. Based on observation, interview, and record review, it was determined for 1 of 65 sampled residents, that the facility failed to provide special eating equipment and utensils for residents who needed them to ensure that the resident could use the assistive devices when consuming meals and snacks. Specifically, one resident was not provided with a lipped plate when identified as needing one. Resident identifier: 5. (Cross Refer to 810) 9. Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the kitchen was dirty with spills and dried food down near the burners, the large mixer had a white substance on the arms that hold the bowl and under the mixer, the oven floor was caked with spilled food on the bottom, food items in the walk-in freezer were open to air, food items in the reach in refrigerator were not labeled, and food items in the dry storage room were open to air. Additionally, staff with facial hair were not wearing a beard cover, personal phones were in the food preparation area, there was damage to several areas of the wall, tiles missing around the baseboard, and there was crumbs and food particles under the dish machine, stove and oven. (Cross Refer to 812) 10. Based on observation, interview and record review, for 4 of 65 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, residents meal portion sizes were not adequate, residents weights were not obtained and residents nutrition assessments were not being completed. Resident identifiers: 3, 4, 55, 60, and 65. (Cross Refer to 692) On 11/3/24 at 1:15 PM, an interview was conducted with the Dietary Manager (DM). The Dietary Manager (DM) who stated he was trying to find the old cleaning schedules so that he could create new ones. The DM stated, This place looks like a mess right now, but it is far better than when I came. On 11/5/24 at 11:03 AM, an interview was conducted with the Registered Dietitian (RD)who stated she had worked at the facility since September and had started making suggestions in the kitchen. The RD stated she learned quickly that the staff were doing their best to get the food out to the residents, but the kitchen was a disaster. The interview also revealed: a. The RD stated the current Dietary Manager (DM) had only been at the facility for a short time. The RD stated the Assistant Dietary Manager (ADM) was acting as the DM prior to bringing on a new DM. The RD stated the current DM had a lot of experience, was very knowledgeable and had been through a survey many times in the past. The RD stated the DM was working on putting things in the facilities QAPI (Quality and Performance Improvement) program. The RD stated the DM was working on cleanliness in the kitchen, labeling and dating food items, menus, and staffing. The RD stated a lot of areas needed work. b. The RD stated she was only doing resident assessments when the residents were admitted . The RD stated the facility medical software was not populating quarterly assessments. The RD acknowledged that she needed to start doing the quarterly assessments that had not been done by the previous dietitian. The RD stated the facility did not even have an annual assessment form for documenting. The RD stated when she did admission assessments, if there were recommendations they would be on the bottom of the assessment and she would notify the Director of Nursing (DON) of her recommendations. The RD stated she met with residents when they were admitted . The RD stated if a resident had a special request, she would meet with them. The RD stated resident goals were communicated to the staff verbally through the DON. c. The RD stated kitchen audits should be completed once a month, but she had not completed one since the beginning of her employment. The RD stated the information from a kitchen audit should be given to the DM or the administrator. The RD stated during a kitchen audit the refrigerators and freezers should be checked for food being labeled and dated, cleanliness and proper temperatures. The RD stated during a kitchen audit an overall observation should be done of the kitchen for cleanliness, proper food temperatures, that the dish machine is functioning properly to sanitize the dishes, and that staff were following proper food handling techniques including wearing hair nets and wearing clean aprons. The RD stated she had not done any audits because she did not have anyone to address the problems with before the new DM was hired. The RD stated she did not know if the ADM had any training. The RD stated she did not know who should be providing education to the dietary staff. The RD stated if she identified something that needed to be fixed she would tell the administrator about it, but she did not provide the education. The RD stated the process for fixing problems in the kitchen should be that she would tell the DM and then the administrator. The RD stated she reviewed some things with the current DM and his response to her was that he was working on it. The RD stated a week ago she went through the kitchen with a corporate nurse and identified problems with the cleanliness in the kitchen, that the shelving in the store rooms were not 6 inches off the floor and when stock was delivered it was left sitting on the floor of the refrigerator or freezer. The RD stated she was making sure all staff were wearing hair nets. The RD stated she did not know if there was a cleaning schedule for the kitchen. The RD stated she has not been monitoring the temperature logs for the dish machine, refrigerator, freezer, or trayline. d. The RD stated she had not completed a tray audit since she was hired. The RD stated the process to complete a tray audit was to ask for a test tray, take the temperature of the food, taste the food and evaluate the presentation and if it was following the menu and was meeting the nutritional needs of the residents. The RD stated if a substitution needed to be made to the menu she had the ability to go into the dietary software and substitute food items in and out of the menu. The RD stated if substitutions were being made they should be posted. The RD stated there should also be a record kept of the substitutions and the record should be kept for a year. The RD stated the DM did not have to contact her if he wanted to make a substitution to the menu. The RD stated the software would make suggestions for alternations to the menu. The RD stated she sort of knew that the kitchen was not following the posted menu. The RD stated depending on what came on the delivery truck, a substitution could be necessary. The RD stated she did not know who trained the DM on the kitchen software and she was not sure if that was part of her role. The RD stated she was new to using that particular software herself. The RD stated she thought the DM should be self-monitoring what is going on in the kitchen. The RD stated when looking at the substitutions, she would look for adequate protein, vegetables, if the menu was meeting the 5 a day guidelines and requirements for vitamin A for the week. The RD stated she had not looked at the menu for that particular week. The RD stated there should be a seasonal rotation being used. e. The RD stated she did not know if there was a schedule for providing snacks or how the residents would receive a snack. The RD stated the DM could call or text her any time and that they have worked together for a long time. The RD stated the DM did not have a problem asking questions. The RD stated the DM should be assessing residents for their food preferences and that the preferences should be updated once a year. The RD stated the residents should also be assessed again after coming back from a hospital stay. f. The RD stated food allergies should be addressed when a resident was admitted and that the information should be communicated to the kitchen to be put on the resident's meal ticket. The RD stated she had not heard of any residents having a problem with food allergies or had any resident complaints. The RD stated she had not seen resident 16, who had a food allergy. The RD stated in a perfect world she would assess the residents every 90 days. The RD stated she needed to set up a schedule so the resident assessments would be getting done. The RD stated she had observed meal service at the facility. The RD stated not many residents were eating in the dining room. The RD stated the benefits of eating in the dining room were that the resident could get out of their room, a different food item could be obtained right away if needed, dietary staff could be communicated with more easily and the meal service would go faster. The RD stated the meal service had been off and it was brought to her attention 2 weeks ago. The RD stated it was a struggle to get dinner and breakfast out in a timely manner. The RD stated she did not know if there was enough dietary support in the kitchen and that it would be a good question for the DM. The RD stated she was not aware that residents had expressed concerns that meals were being delivered late. g. The RD stated under the previous dietary manager kitchen supplies were not being ordered, things were not coming in and the staff were doing a lot of running to the store for supplies. The RD stated she did not know if there were enough pellets to keep meals hot. The RD stated she did not know why residents were receiving food in Styrofoam bowls, or if kitchen staff were using those to cut down on the time it takes to do the dishes. h. The RD stated her contract was for 8-12 hours per week, and that was the number of hours she was currently working at the facility. The RD stated when she was hired the census was significantly lower. The RD stated with a higher census she would need at least 20 hours per week to complete resident visits and get the quarterly assessments up and going. The RD stated that would not include kitchen duties. 30563

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the kitchen was dirty with spills and dried food down near the burners, the large mixer had a white substance on the arms that hold the bowl and under the mixer, the oven floor was caked with spilled food on the bottom, food items in the walk-in freezer were open to air, food items in the reach in refrigerator were not labeled, and food items in the dry storage room were open to air. Additionally, staff with facial hair were not wearing a beard cover, personal phones were in the food preparation area, there was damage to several areas of the wall, tiles missing around the baseboard, and there was crumbs and food particles under the dish machine, stove and oven. Findings included: 1. On 11/3/24 at 1:15 PM, an initial walk-through of the kitchen was conducted. In the reach in refrigerator, hash brown patties were in a pan and were covered, but not labeled. There was no thermometer in the reach in refrigerator, and no temperature log on the outside. The walk in freezer had a temperature of -4 degrees Fahrenheit on the outside, but no thermometer could be found inside. A box of frozen dinner roll dough was open to air and a box of sausage patties was open to air. In the dry storage room, a bag of granulated sugar was open to air, and a container of graham cracker crumbs was open to air. In the food service area, there were 2 bags of cold cereal on top of a tray rack that were open to air. The large mixer had a white substance on the arms that hold the bowl and on the floor underneath. The burner plates on the stove were dirty, and crumbs were down around the burners. There was a large amount of crumbs and spills on the floor of the oven. There was rust around the drain behind the ice machine. Tiles were missing around the baseboard outside the freezer, and there was a loose tile along the wall behind the meal carts. The wall behind where the meal carts were stored was damaged and there was a white substance on the floor beneath the carts. On 11/3/24 at 1:20 PM, an observation was made of the cook and dietary aid serving the lunch meal. A cell phone was sitting above the steam table playing music. The cook, who had facial hair, was not wearing a beard cover. On 11/3/24 at 5:49 PM, an observation was made of the kitchen during the time the dinner meal was being plated. The large mixer had a white substance on the arms that hold the bowl, and there was a white substance on the floor beneath the large mixer. A tray on the tray cart had a brown substance on it and a piece of plastic wrap. The burner plates on the stove were dirty with crumbs down around the burners. There was food splatter on the front of the griddle and stove. On 11/5/24 at 6:02 PM, an observation was made of the kitchen during dinner meal service. The large mixer had a white substance on the arms that hold the bowl and below the mixer. Inside the large bowl was some dough that was covered with plastic wrap. The plastic wrap was labeled S.D. 11/5. There were apple slices on the floor, and a white substance that looked like dough on the floor that had been stepped on. A personal cell phone was above the steam table playing music. There was food crumbs and spills on the floor of the oven. On 11/7/24 at 1:35 PM, an observation was made of the kitchen during lunch service. A personal cell phone was above the steam table playing music while food was being plated. The cell phone was observed to fall into the macaroni and cheese below it. The Assistant Dietary Manager (ADM) who was serving the food removed the phone and continued to serve the meals. On 11/8/24 at 10:06 AM, an additional walk-through the kitchen was conducted. The large mixer was observed to have a white substance on the arms that hold the bowl and under the mixer. The stove and griddle had dried food splatter on them, the splash panel behind the griddle and stove was not clean. Temperature logs were observed outside of the walk in refrigerator and freezer, and the reach in refrigerator. The logs had been filled out through the beginning of November. In the reach in refrigerator, a bag of cheese and a bag of meat were observed to not be labeled, there was a container of red onions that were not labeled or dated. There were 12 Styrofoam bowl with what appeared to be dry cereal in them that were not labeled or dated, and a bag of lettuce that was not dated. In the dry storage room, a large bag of oats was not sealed or covered, sea salt caramel toffee sauce was not dated, and canned roasted red pepper strips were not labeled. In the walk in refrigerator, a bucket of chicken base was not dated. There was a leaking pipe that was dripping on a bottle of sea salt caramel toffee syrup that was not labeled and on the top shelf. There were bowls of what appeared to be pudding that were covered but not dated. A package of provolone cheese was observed to be open to air on the shelf and was not dated. A bag of cheddar cheese was not dated. There was chicken on the bottom shelf that was not dated. A box of raw bacon was open to air, and 2 bags of chives were not dated. In the walk in freezer, two boxes of frozen hash browns were open to air, a package of tater tots was not dated. Two boxes of frozen cookie dough were open to air, a box of whole frozen strawberries was open to air, a box of turkey franks was open to air, pork sausage links were open to air, a package of what appeared to be large sausage franks was open to air. There was ice on top of the back shelf, and icicles hanging from a hose in the freezer. The wall near the hand washing sink was damaged and the dry wall was exposed. The wall behind the mixer was damaged with the dry wall exposed. The drain behind the dish machine was rusty and dirty. There was a white substance on the wall behind the ice machine. The drain under the 3 sink area had rust around it and the drain under the defrost sink was rusty. Boxes of butter packets, jelly packets, sweetener, moist towelettes and a silverware holder with spoons and a paring knife was observed to be on the floor. The wall was dirty behind the coffee machine On 11/3/24 at 1:15 PM, an interview was conducted with the ADM who stated she was checking the dish machine temperatures after she finished all the dishes for the meal. The ADM stated if the temperature did not meet appropriate levels, she would report it to the Dietary Manager (DM). The ADM stated the dish machine was a low temperature machine. The ADM stated she was not positive as to what the appropriate temperature should be while running the dish machine, but had been going by 100 degrees Fahrenheit. The ADM was unable to find strips to check the chemical sanitizer level and stated the staff had not been checking it. The ADM stated they had not been keeping a log of the dish machine. On 11/8/24 at 10:37 AM, an interview was conducted with the ADM. The ADM stated she knew the dishes were being sanitized because the sanitizer, soap and rinse aid were visible dropping into the machine. The ADM stated she did not know what the required temperature should be for the dish machine. The ADM stated if the temperatures were not meeting requirements there was no way to verify that the dishes were being sanitized. The temperatures observed after several cycles of the dish machine were 74 degrees for the wash cycle, and 90 degrees for the rinse cycle. The ADM stated she did not know where the strips were to check the sanitizer in the dish machine. The ADM stated when the company who serviced the machine came last, the chemicals were adjusted and checked but the staff had not been checking since then. After the additional walk-through of the kitchen, the DM was not available for an interview. 50200 2. Resident 26 was admitted to the facility on [DATE] with diagnoses which include, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that the kitchen used to clean the mugs that residents used on a daily basis. Resident 26 stated that mugs were not getting clean and she began to wash the mugs she received with hand soap prior to using them. Resident 26 stated that washing the mugs in her bathroom sink was difficult due to size and that she purchased her own smaller mugs to use. Resident 26 stated that she purchased dish soap and washed the mugs in her bathroom sink because clean mugs were not provided to her.

Based on observation, interview and record review it was determined, for 2 of 65 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff not performing hand hygiene during meal service and medication pass, food was delivered to resident rooms uncovered, and the facility did not have a Legionella prevention and monitoring plan in their water management program. Resident identifiers: 20, 46. Findings included: 1. DINING OBSERVATIONS On 11/03/24 at 1:35 PM, an observation was made of the lunch meal service. Certified Nurse Assistant (CNA) 2 was observed to deliver a lunch tray to room [ROOM NUMBER] A. The tray contained one chicken leg, mashed sweet potatoes, green beans, a roll, and a pie dessert with the chocolate topping melted. The dessert was not covered and was walked from the nurse's station down the hallway to the end of the hall for delivery. On 11/05/24 at 6:17 PM, an observation was made of CNA 12 during meal service. At 6:19 PM, CNA 12 delivered the dinner tray to room [ROOM NUMBER]. CNA 12 did not perform hand hygiene and was wearing gloves. At 6:19 PM, CNA 12 delivered the dinner tray to room [ROOM NUMBER] A. CNA 12 was observed wearing gloves and touched their face. No hand hygiene was performed. On 11/12/24 at 1:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that her expectation with hand hygiene during meal service was that staff should perform hand hygiene after exiting a resident room and in between passing food trays. 2. On 11/13/24 at 10:24 AM, an interview was conducted with the Maintenance Supervisor (MS). A copy of the facility Legionella prevention and monitoring plan was requested. The MS stated that he was not in charge of the Legionella system, had not heard anything about it and did not know what it was. The MS stated that he was not aware of the facility water maintenance plan to prevent contaminants or measures to reduce the risk of Legionella. The MS stated that the facility had an emergency water agreement with a supplier but could not recall who that supplier was. The MS stated that they did not have a water management plan and he had not seen one in all the documentation left from the previous Maintenance Supervisor. It should be noted that the MS was newly hired and had only been on the job for approximately two weeks. No additional information was provided by the facility about the water management program. Review of the facility Water-borne Contaminants policy documented, The maintenance director or designee is responsible to identify the facility's risk for water-borne contaminants, including Legionella growth and spread, using a designated risk assessment tool approved and to implement appropriate prevention measures, including Legionella testing as indicated based on the risk assessment outcome. The policy was adopted on 12/16/19. 48709 3. On 11/6/24 at 7:54 AM, a medication pass was observed with Registered Nurse (RN) 2. RN 2 was observed to come out of room [ROOM NUMBER] with a food tray, placed it in the meal cart, and then went to the medication cart and poured medication into a cup. No hand hygiene was performed. RN 2 prepared the rest of resident 20's medications and then went into room [ROOM NUMBER]. No hand hygiene was performed. RN 2 poured resident 20's water into the cup with the liquid medication. Resident 20 took all the liquid medication and other oral medications. RN 2 proceeded to instill eyedrops into both of resident 20's eyes. No hand hygiene was performed. On 11/6/24 at 8:21 AM, a medication pass was observed with RN 2. RN 2 went into resident 46's room and turned off her call light. RN 2 left the room and went to the medication cart. No hand hygiene was performed. RN 2 proceeded to pull out resident 46's medications and put them into a medication cup. RN 2 was observed to open and close different medication drawers, used keys to open a locked drawer, and use the computer keyboard. RN 2 went into room [ROOM NUMBER] and handed the resident her medications in the medication cup. Resident 46 took the medications. RN 2 left room and went back to the medication cart, no hand hygiene was performed. RN 2 pulled out a requested pain medication from the cart and placed it in a medication cup. RN 2 was observed to rub her nose. No hand hygiene was observed. RN 2 went back into room [ROOM NUMBER] and handed resident 46 the medication cup and a cup of water. No hand hygiene was performed. Resident 46 took the medication and RN 2 left the resident's room. On 11/6/24 at 1:47 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated hand sanitizer should be used before and after going in each resident's room. LPN 4 stated hand hygiene should be performed at every interaction with a resident even if you do not touch anything. On 11/6/24 at 2:06 PM, an interview was conducted with RN 2. RN 2 stated you should hand sanitize between each resident and wash your hands after using hand sanitizer three times. On 11/7/24 at 4:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was to perform hand hygiene in between each resident during medication pass, before entering a room, and before preparing medications.

Based on interview and record review it was determined for 5 out of 65 sampled residents, that the facility did not develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, facility staff did not conduct capacity to consent to sexual relationships for residents prior to residents engaging in sexual relationships. Resident identifiers: 6, 49, 54, 121 and 319. Findings include: The facility's Abuse Policy revised on 6/11/24, was reviewed and revealed the following: Definitions .3. Sexual abuse: Non-consensual sexual contact of any type with a resident . Abuse Prevention .4. This facility honors a resident's right to engage in consensual sexual relationships. a. A licensed nurse or social worker shall complete the facility's designated assessment in the resident's medical record to determine whether the resident has the capacity to consent upon becoming aware that a resident wishes to engage in a consensual sexual relationship with another individual. b. The facility will re-evaluate a resident's capacity to consent as needed based on changes in the individual resident's physical, mental and psychosocial needs. c. If a resident has a legal or other designated representative to make decisions on his or her behalf, it is important for the resident, resident representative and facility staff to understand the types and scope of decision-making authority of the representative . 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. On 4/23/24 a Brief Interview for Mental Status (BIMS) assessment was conducted on resident 54. Resident 54 scored a 12. A score of 8-12 indicated moderately impaired cognition. A review of resident 54's care plan revealed, Focus: Resident has mental health diagnoses of TBI [traumatic brain injury] and adjustment disorder with aggression and depression as well as impulsive sexual behaviors. He uses of [sic] anti-depressant, anti-anxiety, anti-psychotic medications. Date initiated: 3/28/24 Revision on 5/16/24 Interventions included the following: a. Administer medication per physician order. Monitor for side effects and notify MD [medical doctor] of any adverse or consistent side effects that occur r/t [related to] psychotropic drug use. Date initiated: 3/28/24 b. Document target symptoms Q [every] shift. Notify MD of any new/worsened symptoms of mental illness that are not effectively managed with current pharmacological and non-pharmacological interventions. Date initiated: 3/28/24 c. If resident's mental health symptoms become unmanageable in-house or a mental health crisis occurs, call the crisis line or notify the MD to obtain transfer orders for a psychiatric evaluation in the hospital setting. Date initiated: 3/28/24 d. MD will perform a medication review and make adjustments to medication regimen as indicated to target impulsive sexual behaviors that have not responded to non-pharmacological approaches. Date initiated: 5/15/24 e. Obtain informed consent for use of psychotropic medication. Medication regimen including black box warnings will be reviewed in each care conference meeting. Date initiated: 3/28/24 f. Psychotropic committee will review the medication regimen, target symptoms and side effects at least quarterly and make recommendations as indicated. Date initiated: 3/28/24 g. Staff should use the following non-pharmacological interventions to help manage resident's behavioral symptoms: 1) Provide opportunities for socialization 2) Provide encouragement, support and active listening 3) Provide reminders about appropriate interactions with others. Set boundaries and reminder [sic] resident about boundaries for interactions with others as needed. 4) Due to religious beliefs, resident's RP [responsible party] prefers that resident not have materials provided to him to be able to self-express sexual needs. 5) Involve resident's family in care. Family to take resident out of facility on outings as able. Resident's dad identified that working out is a helpful outlet for sexual frustration. Date initiated: 5/16/24 Revision on 5/16/24 A review of resident 54's progress notes revealed the following: a. On 4/24/24 at 4.46 PM, a social service note documented, Note Text: RA [resident advocate] met with RT [resident] and RT father to discuss RT being physical with one of facilities NA [nursing aides]. RT apologized for this and promised to not do it again. RT would like to apologize to NA and RA will facilitate this meeting. RT father explained to RT in office that this is not allowed and also apologized to facility for this happening. RA spoke with RT about sexual health and keeping it private. Father said that he is going to start taking RT to the gym more to help provide an outlet for RT. Pend [sic] b. On 5/6/24 at 9:49 AM, a social service note documented, Late Entry: Note Text: RA interviewed [resident 54] separately and asked what happened? [resident 54] stated he hugged [resident 319] and then grabbed her breast. RA asked resident why he would grab a woman's breast without consent? [resident 54] replied 'because I am a guy.' RA explained that just because he is a guy he cannot grab another woman's body without consent. [resident 54] stated 'I see a tit I grab one.' RA explained that the victim of this could press charges and call the police for assault, [resident 54] then reminded RA that his father is a retired police man. Resident then told RA that he was sorry. c. On 5/22/24 at 11:23 AM, an alert charting note documented, Note Text: Helped get resident some water and medications for the morning. Ensured that call light was in reach and asked if there was anything else I could get him. He asked 'can I see your tits?' I told him no and that it was not an appropriate thing to ask. d. On 5/23/24 at 5:27 PM, an alert charting note documented, Note Text: Resident asked CNA [Certified Nurses Aide] who was helping him to shower 'it is not fair that I have to be naked' and you are not. 'You should also get naked'. Also tried to spray CNA with the shower hose. When to talked to Resident and explained that it is not appropriate this type of comments and that it is also not appropriate to try to get CNA wet with the shower hose . It is becoming hard for female CNA to provide care for this resident who continue to be have inappropriate behavior. e. On 5/23/24 at 11:45 PM, a general progress note documented, Note Text: Resident continuously tried to convince aide to go out on a date with him. Aide continued to tell him no. Educated resident that this behavior is inappropriate. Resident apologized and went to his room. f. On 5/24/24 at 1:00 AM, a provider encounter note documented, .Patient seen today for behaviors. Nurses report patient has been having low moods and inappropriate sexual behaviors . g. On 5/31/24 at 6:02 PM, an alert charting note documented, Note Text: Resident is fixated on a female CNA. She reported that he is following her in the Facility. When confronted by CNA to stop this behavior, resident just continue [sic] following her. Resident has to be re- directed several times according to CNA by managementsand [sic] nurses but resident continue to pursed [sic] her unwanted attention. h. On 6/1/24 at 1:15 AM, a general progress note documented, Note Text: Aide reported to nurse that she and other aides have previously experienced inappropriate behaviors from resident while assisting with showers. Aide stated that when giving the resident a shower, resident began to inappropriately touch himself, aide told resident that it was inappropriate and resident stated 'he was almost finished', aide said she would return when he was ready to get out of shower. Aide did not report this until hearing of his continued behavior because she was scared she would get in trouble for leaving resident alone. i. On 6/1/24 at 6:13 PM, an alert charting note documented, Note Text: During lunch in Dinning [sic] room A CNA dropped something on the floor. When she bend down to pick it up resident make [sic] a comment 'Nice ass'. This unsolicited comment made the female CNA very uncomfortable. CNA told resident that those type of comments are very inappropriate. I also when to talk to resident privately about this comment and explain again that his actions and comments are very inappropriate towards females. j. On 6/1/24 at 11:07 PM, an alert charting note documented, .Pt [patient] kept staring at a female cna this evening. Pt kept asking female cna about her boyfriend. Made female cna feel uncomfortable . k. On 6/3/24 at 1:00 AM, a provider encounter documented, .Today I was also informed by the staff that patient has been displaying inappropriate sexual behaviors toward female staff at the facility, such as groping an underage CNA. When speaking to patient about this she [sic] denies doing anything wrong. At this point after discussion with the facility management we will arrange a care coordination meeting with the patient's power of attorney to help decide on the best course of action. This could possibly include additional medications to help suppress his behavior, or a possible referral to the behavioral health unit . l. On 6/4/24 at 5:32 PM, an alert charting note documented, Note Text: Resident is to be male only when preforming [sic] cares due to hypersexual behaviors. Must have 2 females present if female staff is preforming [sic] cares. m. On 6/28/24 at 9:00 PM, an alert charting note documented, Note Text: Resident had call light on. When CNA entered room and asked what he wanted he said 'your number.'CNA asked if he actually needed anything and resident started to use his urinal in front of her. CNA told resident to call when he was done and left the room. n. On 11/7/24 at 10:40 AM, a communication with resident note documented, Resident [resident 54] was observed kissing resident [resident 121] in his room. Administration met separately with [resident 54] to discuss his relationship with [resident 121]. [Resident 54] stated that they are just friends and confirmed that that both she and [resident 54] consented to the kiss. A review of resident 54's Monitoring Record revealed the following number of episodes of inappropriate sexual comments every shift: a. On 5/23/24 PM shift- 2 b. On 5/25/24 PM shift- 2 c. On 5/26/24 AM shift- 2 d. On 6/14/24 AM shift- 1 e. On 6/21/24 AM shift- 4 f. On 6/28/24 PM shift- 1 g. On 9/1/24 AM shift- 2 h. On 9/1/24 PM shift- 2 i. On 9/7/24 PM shift- 1 j. On 9/9/24 AM shift- 1 k. On 9/10/24 AM shift- 2 l. On 9/16/24 AM shift- 2 m. On 9/16/24 PM shift- 2 n. On 9/17/24 AM shift- 1 o. On 9/22/24 AM shift- 2 p. On 9/23/24 AM shift- 2 q. On 9/24/24 AM shift- 1 r. On 9/29/24 AM shift- 2 s. On 9/30/24 AM shift- 1 t. On 10/1/24 AM shift- 1 u. On 10/1/24 PM shift- 1 v. On 10/5/24 AM shift- 2 w. On 10/6/24 AM shift- 2 x. On 10/7/24 AM shift- 2 y. On 10/13/24 AM shift- 1 z. On 10/14/24 AM shift- 1 aa. On 10/15/24 AM shift- 1 bb. On 10/20/24 AM shift- 2 cc. On 10/21/24 AM shift- 2 dd. On 10/22/24 AM shift- 2 ee. On 10/26/24 AM shift- 2 ff. On 10/27/24 AM shift- 2 gg. On10/28/24 AM shift- 1 hh. On 11/3/24 AM shift- 2 ii. On 11/4/24 AM shift- 2 jj. On 11/4/24 PM shift- 2 kk. On 11/5/24 AM shift- 2 2. Resident 121 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, type 2 diabetes mellitus with hypoglycemia, acute respiratory failure with hypoxia, iron deficiency anemia, other seizures, unspecified dementia, restlessness and agitation, and mild neurocognitive disorder due to known physiological condition with behavioral symptoms. Resident 121's medical record was reviewed. On 9/30/24 a BIMS assessment was conducted on resident 121. Resident 121 scored a 10. A score of 8-12 would indicate moderately impaired cognition. A review of resident 121's care plan revealed, Focus: The resident has a behavior problem of angry outburst, wandering, hallucinations and delusions at times Date initiated: 10/25/24 Revision on: 11/5/24 Interventions included teh following: a. Anticipate and meet The resident's needs. Date initiated: 10/25/24 b. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date initiated: 10/25/24 c. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date initiated: 10/25/24 d. Praise any indication of The resident's progress/improvement in behavior. Date initiated: 10/25/24 e. Provide a program of activities that is of interest and accommodates residents status. Date initiated: 10/25/24 Another care plan revealed, Focus: The resident has an alteration in neurological status r/t disease process MILD NEUROCOGNITIVE DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH BEHAVIORAL DISTURBANCE Date initiated: 11/4/24 Revision on 11/4/24 Interventions included the following: a. Allow the resident a rest period when she is upset. Date initiated: 11/4/24 b. Cueing, reorientation as needed. Date initiated: 11/4/24 c. Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Date initiated: 11/4/24 d. Give medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 11/4/24 e. Provide emotional support when the resident appears agitated. Date initiated: 11/4/24 f. Special attention provided when the resident has contact with her mother. Date initiated: 11/4/24 A review of resident 121's progress notes revealed the following: a. On 9/25/24 at 3:35 AM, an admission progress note documented, 9/25/2024 03:35 (3:35 AM) Admission Progress Note admitted /Time:: 9/24/2024 1930 (7:30 PM) admitted from/Transported by:: [Hospital Name] transported by mother Primary diagnosis for admission:: Pneumonitis Secondary diagnoses:: DM2 [diabetes mellitus type 2], Acute Respiratory Failure with hypoxia Hx [history] of methamphetamine abuse Vital signs upon admission:: 150/93 bp [blood pressure] 96 pulse 24 rr [respiratory rate] 97.5 t [temperature] 96 o2 [oxygen] 61 inches tall 148.5 lbs Pain level/interventions administered as applicable:: na [not applicable] Mental status upon admission:: Resident was very anxious and hysterically crying. Resident stated she was angry her mom left her here. Mother brought a few belongings in, and told the staff good luck and left facility. Pt very stressed and pacing in the halls. CNA showered resident andpt [sic] calmed down. During assessment patient was oriented and answered questions appropriately, but gets distracted and confused easily. Mobility status/mobility devices:: patient ambulates independently. States she used a walker in the hospital and is requesting a walker to use.Special devices used:: na Oriented to facility. b. On 9/25/24 at 11:45 AM, a skilled charting note documented, Late Entry: Note Text: Resident is A/A/O [sic] [alert and oriented] x 2 with intermittent confusion with auditory and visual hallucinations noted. c. On 9/26/24 at 12:28 AM, an alert charting note documented, Note Text: Pt very anxious at beginning of shift. Returned from an outing with her mother and was very upset and crying. pt stated her mom doesn't care about her and only wants to visit her so she can lecture her about using drugs. Nurse took pt to her room and talked to her for a few minutes while giving her, her medications. Pt took medications and stated she needed to go walk the halls because she continued to be so upset with her mom. After pacing the halls for 20 minutes patient returned to room to watch tv [television]. d. On 9/30/24 at 11:15 PM, a skilled charting note documented, Note Text: Resident alert and oriented to self. no resp [respiratory] distress noted, lungs clear. Denies pain at this time. Requires frequent redirection. talks to self and wanders up and down the hallways, yelling at self and staff and other residents. Neighbor reports she was kicking at the walls in the middle of the night last night. pt skin turgor supple, intact. continent of bowel and bladder. good appetite, eats rapidly. takes fluids well. e. On 10/1/24 at 8:00 AM, a psychological provider note documented, [resident 121] exhibits poor cognition throughout interview including poor attention, distractibility, poor memory, poor social understanding or decreased complex attention. She is unable to explain how she became homeless or how she took care of herself prior to or during homelessness. She is unable to verbalize a plan after discharge. [Resident 121] has persistent abnormal movements including rubbing at her face, neck and arms. She is unable to remain still. Subjective interview and objective assessment of MOCA [Montreal Cognitive Assessment] scoring 14 indicate Major Neurocognitive Disorder, most likely drug induced from many years of alcohol and methamphetamine abuse . f. On 10/1/24 at 9:19 AM, a skilled charting note documented, Note Text: pt had overdose on meth [methamphetamine] use. pt currently on augmentin for s/s [signs and symptoms] of resp [respiratory] infection. no resp distress noted. lungs clear. room air sats [saturations] at 97. Denies pain this am. needs redirected often. talks to self and wanders up and down the hallways, yelling at self and other staff and residents. pt educated to stop slamming doors and raising her voice at others. pt skin turgor supple, intact. continent of bowel and bladder. good appetite, eats rapidly. takes fluids well. Today pt reported by management that pt is going to be staying long term. g. On 10/6/24 at 9:27 AM, a skilled charting note documented, Note Text: pt wandering up and down hallways, talking loudly to self and arguing with staff and other residents. unable to redirect pt. h. On 10/7/24 at 1:34 AM, a skilled charting note documented, Late Entry: Note Text: Pt returned to facility from outing with mom and granddaughter. Pt very agitated and crying stating her mother makes her super upset. Pt states she does not want mother or granddaughter into the facility. Pt very upset and pacing the halls yelling at her self for 30 min [minutes]. i. On 10/18/24 at 11:21 PM, a skilled charting note documented, Note Text: Resident is alert and oriented x 2-3. Often confused, not oriented to situation. Pleasant with staff. Wanders hallways often. Good appetite. Compliant with BS [blood sugar] checks and insulin administration. Takes pills whole. Denies pain. Has not slept well the past two nights. j. On 10/27/24 at 3:36 PM, an alert charting note documented, Note Text: Corporate nurse found pt walking by street in front of facility this afternoon, nurse was able to direct pt back into the facility. notified DON [Director of Nursing] k. On 10/29/24 at 1:57 PM, a skilled charting note documented, Note Text: Resident is alert and oriented x 2 self, situation. Resident has episodes of confusion. Resident shows signs of anxiety and sadness. Resident is found often pacing the hallways and talking to self. Resident was redirected and invited to multiple activities during the day. Resident has redness under pannus. Resident is a limited assistance with dressing ADL [activities of daily living] and toileting. WCTM [will continue to monitor]. l. On 10/31/24 at 4:00 PM, a skilled nursing note documented, Late Entry: Note Text:. No changes in LOC [level of consciousness]. Resident did have multiple verbal outburst. Resident was upset because mother would not take her trick or treating. Resident was given time to calm down and verbalize why she was upset. Resident calmed and went to socialize with other residents in theactivity [sic] room. WCTM. m. On 11/8/24 at 8:49 AM a COMMUNICATION - with Resident note documented, Note Text: Resident [121] was observed kissing resident [54] in his room. Administration met separately with [resident 121] to discuss her relationship with [resident 54]. [Resident 121] stated that they are just friends and confirmed that both she and [resident 54] consented to the kiss. 3. Resident 319 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on [DATE] with diagnoses which included metabolic encephalopathy, hypothyroidism, bipolar II disorder, anxiety, disease of blood and blood-forming organs, hypertension, and traumatic brain injury. Resident 319's medical record was reviewed 11/3/24 through 11/13/24. A quaterly MDS dated [DATE] revealed resident 319's BIMS score was 13 which indicated congitively intact. A social services note dated 5/6/24 at 9:45 AM revealed a late entry RA met with [resident 121] to inquire about report that [resident 54] grabbed her breast. [Resident 121] stated that she was coming down 200 hall towards the gym area and stopped to give [resident 54] a hug and as he hugged her he moved his hand down her body and grabbed her breast, [resident 121 stated that she immediately told [resident 54] no and he said he was sorry and continued moving away from her towards 300 hall and she went outside. That was the end of it. A social services note dated 5/6/24 at 9:47 AM was a late entry created on 5/14/24. The note revealed, RA met with RT again and asked if RT would like to press charges against RT for what she reported? RT stated 'No, I don't want to cause trouble for anyone.' RA asked RT if she was sure, and maybe wanted to think about it longer? RT replied 'I am sure, I don't want to press charges, period.' Potiential for Harm 4. Resident 6 was admitted to the facility on [DATE] with diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, other abnormalities of gait and mobility, aphasia, dysphagia following cerebral infarction, epilepsy, cognitive communication deficit, and major depressive disorder. On 11/3/24 at 6:14 PM, an observation was made of resident 49 pushing resident 6 in her wheelchair in the 100 hallway. On 11/3/24 at 6:45 PM, an interview was conducted with resident 49. Resident 49 was sitting in the dining room when resident 6 entered the dining room in a wheelchair. Resident 6 was observed to sit at resident 49's table. Resident 49 pointed to resident 6 and stated that was his girlfriend. Resident 6 was observed to move her head in a yes motion and smiled. On 11/6/24 at 3:37 PM, an observation was made of resident 49 and resident 6 in the activity room. Resident 6 and resident 49 were sitting on a sofa. Resident 6 was observed to have her head on resident 49's chest and resident 49 had his arm around resident 6. Both residents were observed with their eyes closed. Resident 6's medical record was reviewed. On 2/6/24 a BIMS assessment was completed on resident 6. Resident 6 scored a 9. A score of 8-12 would indicate moderately impaired cognition. A review of resident 6's sexual activity capacity for consent dated 2/21/24 revealed: a. Describe resident's stated choice: She stated, 'I love him' she said and likes to cuddle with him, but does not want a sexual relationship. She does not want any sexual touching. A review of resident 6's care plan revealed Focus: MOOD & BEHAVIOR: [Resident 6] has potential for mood and coping issues due to desire to have a romantic relationship with another resident. [Resident 6's] outside medical provider [name redacted] has been consulted and confirmed [resident 6] has capacity to make her own decisions and provide consent. Date initiated: 5/29/24 Revision on 6/26/24 Interventions included the following: a. Assess [resident 6's] capacity to give consent for romantic relations with another resident. Date initiated: 5/29/24 Revision on: 5/29/24 b. If any other resident requests romantic encounter with [resident 6], staff will verify if [resident 6] also wants encounter and if she doesn't, staff will make sure her rights are protected. Staff will make sure other resident respects [resident 6's] wishes. Date initiated: 5/29/24 c. Offer psychosocial support as needed Date initiated: 5/29/24 Revision on: 5/29/24 d. Whenever [resident 6] elects to spend time with other resident, staff will ask and verify that spending time is what she wants and that there is no coercion involved. Reinforce that any kind of romantic and/or sexual expression is her choice. Date initiated: 5/29/24 Revision on: 5/29/24 Another care plan revealed Focus: [Resident 6] has an on again off again relationship with another consenting resident. Date initiated: 6/26/24 An intervention included [Resident 6] will only have romantic companionship with other consenting residents. Staff will verify that 321B is interested in a romantic encounter with [resident 6] PRN [as needed]. [Resident 6] and 321B will confine their romantic relations to a location that is appropriate and separate from other residents. [Resident 6] and 321B will be respectful of other resident's and their rights. Date initiated: 6/26/24 A review of resident 6's progress notes revealed the following: a. On 3/4/24 at 11:22 AM, a social service note documented, RA met with resident and confirmed resident no longer wants to associate with [resident 49] after the incident at church yesterday. RA asked if resident has attempted to talk with resident since, and resident stated no. RA asked resident to notify staff if she feels unsafe. RA will meet with [resident 49] and talk with him about no contact with [resident 6]. b. On 3/4/24 at 1:27 PM, a social service note documented, RA received call from responsible party who is upset about learning of incident yesterday from her brother rather than us calling her directly. RA was able to ascertain that resident called her son and informed him of incident with [resident name redacted] through facetime [sic] with the help of her aid [sic] at her request. RA contacted responsible party back and explained situation. Responsible party stated she spoke with residents nurse and was able to learn the fact of the situation and it has put her mind to rest. RA assuredresponsible [sic] party that staff is aware of the interactions and will keep an eye on residents moving forward. c. On 3/6/24 at 1:21 PM, a social service note documented, RA was informed buy [sic] nurse aide that resident was seen exiting [resident 49's] room. Aide spoke with resident who told her everything was okay. RA visited with resident and asked why resident was in [resident 49's] room? Resident nodded smiling informing RA that it had to do with a blanket being returned. AR [sic] explained that since Sunday's incident, resident should not be visiting with resident in his room. If resident wants to visit with [resident 49] in his room it must be accompanied by a nurse or nurse aid [sic] otherwise visits should be kept to public areas. Resident stated that she agreed to this requirement going forward. RA explained that it is very confusing for staff when resident decides no contact last Sunday and then we see her visiting with resident alone in his room and we are told everything is ok. Resident replied with telling RA that 'they are friends'. RA explained that I will add notes to her chart. d. On 3/9/24 at 11:12 PM, an alert charting note documented, Pt [patient] was allowing resident [resident 49] to push her around in her w/c [wheelchair]. Pt. was sitting next to [resident 49] in the activity room. When pt was asked if she wanted to be with him, pt shook her head yes. c. On 4/1/24 at 4:44 PM, a social service noted documented, RA met with rt to discuss 'friendship' with [resident 49], and staff concerns for her safety. Rt states they are just friends, nothing more. RA explained that due to observed behavior from [resident 49], rt should not request to be pushed in her wheelchair anywhere by [resident 49] and she is not allowed in his room alone and vice versa. Rt agreed. d. On 4/9/24 at 11:26 AM, a social service note documented, Rt asked RA to follow her into activities room and transfer her to couch. She asked RA to grab [resident 49] from his room to come too. After both rt and [resident 49] were seated, Rt was able to say, No sex to [resident 49] 3 different times, and then stated she is catholic and then pointed at [resident 49]. When I addressed [resident 49] and asked him what Rt means with these statements, [resident 49] stated she is upset about her children and that this is why she is visibly crying. RA informed [resident 49] in frontof [sic] Rt that it seems to me Rt is making is clear, 'No Sex' to [resident 49] in front of me for a reason. RA explained [resident 49] that he is not allowed to push Rt in her wheelchair, and not allowed to transfer Rt at any time. RA also reiterated that [resident 49] is not allowed in Rt bedroom and she is not allowed in his. RA explained safety of all rt's is top priority. Rt and [resident 49] can be friends, but in public areas only. Both Rt said they agreed. e. On 9/26/24 at 9:49 AM, a communication with resident note documented, Admin [Administrator] and (Resident Advocate) spoke with resident. She stated that she no longer wants to marry another resident at BT [resident 49]. They had a disagreement and she realized getting married would not work. RA and admin were told by resident that she feels safe and would just like to not marry [resident 49]. 5. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, paroxysmal atrial fibrillation, heart failure, morbid obesity due to excess calories, cognitive communication deficit. Resident 49's medical record was reviewed. A BIMS score dated 5/3/24 revealed resident had a BIMS of 15 which indicated resident was cognitively intact. A care plan dated 5/16/24 Resident has history of sexually inappropriate behaviors directed towards others. The goal Resident will have no s/s of unmanaged sexually inappropriate behaviors directed towards others daily through the review date. Interventions include If resident has sexually inappropriate behaviors that become unmanageable inhouse or a crime occurs, call the local police for legal assistance; Resident declines to be referred for mental health services through the local mental health authority: [name of behavioral health service]. Facility staff will refer resident for these services again in the future if resident expresses interest; Resident has history of a sexual crime and must register as a sex offender. Due to resident denial, resident requires staff assistance to remember to register as legally required every 6 months based on date of birth; RESOLVED: Resident is a 1:1 while in facility due to being sexually inappropriate with residents. Date Initiated: 05/30/2024 Revision on: 06/26/2024 Resolved Date: 06/26/2024; Staff should use the following non-pharmacological interventions to help manage resident's behavioral symptoms if observed: 1) Provide appropriate outlets for meeting resident's sexual needs, including providing private space as needed 2) Provide reminders as needed about appropriate boundaries with others 3) Conduct Sexual Capacity for Consent Assessments as indicated to determine if resident and any other applicable parties have capacity to consent to any desired sexual relationships and honor resident's rights if it is determined he and the other party hav [TRUNCATED]

Based on observation, interview, and record review it was determined, for 13 out of 65 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, residents complained of cold temperatures in their rooms, resident rooms were not cleaned, resident toilets leaked and a toilet seat was loose, a resident sink leaked water, resident showers flooded rooms, holes were found in a residents door, a brown substance was observed on a resident's wall, and resident personal belongings were lost. Resident identifiers: 3, 13, 20, 22, 26, 27, 29, 30, 32, 51, 53, 55, and 120. Findings Included: 1. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, osteomyelitis of vertebra, anxiety disorder, type 1 diabetes mellitus with hyperglycemia, unspecified protein-calorie malnutrition, sepsis, psoas muscle abscess, alcohol abuse, and major depressive disorder. On [DATE] at 2:08 PM, the following observations were made of resident 53's room: a. Towels were wrapped around the base of the toilet and water was leaking out of the bottom of the toilet. b. Toilet seat was loose and covered in brown stains. On [DATE] at 2:08 PM, an interview was conducted with resident 53. Resident 53 stated that her toilet was not getting clean by the facility, the toilet was leaking water on to the floor, and the toilet seat was loose. On [DATE] at 1:26 PM, a follow up interview was conducted with resident 53. Resident 53 stated that the leak for the toilet was fixed, but the toilet lid was still loose and covered in brown stains. 2. Resident 20 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, displaced intertrochanteric fracture of right femur, mild protein-calorie malnutrition, muscle weakness, rheumatoid arthritis, hypothyroidism, essential hypertension, and unsteadiness on feet. On [DATE] at 4:21 PM, an observation was made of resident 20 in bed covered with multiple blankets around her body and two blankets wrapped around her head. On [DATE] at 4:23 PM, an interview was conducted with resident 20. Resident 20 stated that her room was cold and the air conditioner always felt like it was on. Resident 20 stated that she had asked staff to make her a shawl out of blankets to keep warm. Resident 20 stated that a few months ago the maintenance man placed a plastic device near the vent to divert the cold air, but that did not help her room from being cold. 3. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On [DATE] at 8:14 AM, the following observations were made of resident 27's room: a. There was no screen on the window. b. There were scrapes on the door. c. There were holes in the bathroom door. d. There was a large basin under the sink collecting leaking water. On [DATE] at 8:14 AM, an interview was conducted with resident 27. Resident 27 stated that she could not leave her window open because she did not have a screen on and was worried someone would get in. Resident 27 stated that when she turned on her sink it would leak and there was a container that collected the water. Resident 27 stated that her bathroom door had holes in it. 4. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On [DATE] at 3:20 PM, the following observations were made of resident 26' room: a. The shower floor had a black colored stain. b. The ceiling air vent was blowing cold air. c. The bathroom sink would only dispense a small trickle of water. On [DATE] at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that her bathroom sink would only dispense a trickle of water. On [DATE] at 8:43 AM, a follow up interview was conducted with resident 26. Resident 26 stated that heat was not coming on in her room at all. Resident 26 stated that she told maintenance and Certified Nursing Aides (CNA's) multiple times that her room was cold, there was no heat coming from the vent, and the vent would blow cold air every once in a while. Resident 26 stated that her shower would flood when taking a shower and the CNA's had to put towels around the floor to create a barrier to prevent the water from going into her room. 5. Resident 120 was admitted to the facility on [DATE] with diagnoses which included, but not limited to lymphedema, superficial mycosis, cellulitis of right lower limb, activated protein c resistance, cellulitis of left lower limb, and morbid (severe) obesity due to excess calories. On [DATE] at 2:18 PM, an interview was conducted with resident 120. Resident 120 stated that her room had not gotten cleaned and the garbage had not been taken out. Resident 120 stated that this happened on a daily basis. On [DATE] at 8:45 AM, an interview was conducted with the housekeeping supervisor (HS). The HS stated resident rooms got cleaned daily. The HS stated that cleaning a resident room entailed sweeping and mopping the floor, wiping down side tables, nightstands and dressers, and dusting pictures. The HS stated that cleaning the bathroom entailed cleaning the toilet, mirrors and checking the tissue and toilet paper. The HS stated that all garbage should be removed from the resident's rooms. The HS stated that expectations for the housekeeping staff were for the resident rooms to be cleaned daily. On [DATE] at 10:24 AM, an interview was conducted with the Maintenance Supervisor (MS). The MS stated that for all maintenance issues, it should be written down in the maintenance log book unless it was an emergency and then he would expect a text or verbal request. The MS stated that the maintenance logs were checked daily, Monday through Friday. The MS stated that he would write in the log and initial when a request was completed. The MS stated that there were thermostats all over the facility and he was still learning where they were located. The MS stated that in the hallway where residents 20, 26, 27, and 53 were located, he had heard some complaints about the temperature and rooms being cold, but had since remedied the situation. The MS stated that all the windows in the facility should have screens. The MS stated he had not heard about any residents with leaking sinks or toilets. The MS stated that he had not heard about showers in the facility flooding and would assume that it would be reported to him because it might have been ignored in the past. 38031 6. ODORS On [DATE] at 3:44 PM, a strong odor of urine was noted in the memory unit immediately upon entrance past the locked double doors. On [DATE] at 1:44 PM, a strong odor of urine was noted on the memory unit outside of room [ROOM NUMBER]. Resident 30 was pacing the hallway and smelled of urine. On [DATE] at 9:13 AM, a strong odor of urine was noted in the 300 hallway outside of room [ROOM NUMBER]. On [DATE] at 10:25 AM, an observation was made of CNA 5 spraying air freshener multiple times in room [ROOM NUMBER] and 321. 7. On [DATE] at 5:27 PM, an observation was made in the main dining area. A coffee cart was located against the wall towards the main door/corridor. The cart contained a large carafe that was not warm to the touch, a tray of coffee cups, creamer and sweetener. The coffee cart was observed dirty with spilled coffee noted on the shelf. Two empty and used coffee cups were observed in the window sill. On [DATE] at 9:40 AM, an observation was made of the dining room located in the locked memory unit. The floor was observed to be scuffed and dirty. The walls were also scuffed and spackled. The table nearest to the courtyard door had a soiled table cloth on it, and the table near the sink had a soiled table cloth on it. On [DATE] at 9:56 AM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that she was assigned to the memory unit and the 400 hallway and worked on Wednesday, Thursday, and Saturday. HK 1 stated that she cleaned all the resident rooms and the dining room. HK 1 stated that the resident room cleaning process included cleaning the bathroom sink, toilet, sweeping and mopping the floors, cleaning the bedside tables, wiping off the door handles and light switches, and restocking the toilet paper and paper towels. HK 1 stated that there were usually 4 to 5 housekeeping staff in the building at a time, but lately it had been 4 staff because they were short staffed. HK 1 stated that due to the short staff situation she was helping out in other areas once her area was completed. HK 1 stated that there had been occasions that she was not able to complete her area assigned tasks because resident rooms were extra dirty. HK 1 stated that sometimes she was not able to clean all her assigned rooms and when that happened it would be passed off to the next shift. Review of a housekeeping checklist revealed a line for each resident room. Next to the resident room were columns with sections for check marks in which the housekeeper could document that the following was cleaned: surfaces, sink, toilet, mirror, toilet paper/paper towel, sweep, mop, and trash. There was a column for the housekeeper to document the date and time that the cleaning started and the time finished for that room, and if the resident refused the cleaning. On [DATE] at 2:08 PM, an interview was conducted with the HS. The HS stated that she had just started this week and had begun the scheduling for the housekeeping department. The HS stated that scheduling for housekeepers was to have four staff on the floor, one per hallway, seven days a week during the daytime. The HS stated that she had two laundry staff that were separate from housekeeping staff and one staff was scheduled seven days a week during the daytime. The HS stated that there were new sheets and towels in the laundry room that were ordered last week, and she just ordered 4 dozen towels, 4 dozen flat sheets, and 4 dozen fitted sheets. 8. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included drug induced secondary Parkinsonism, adult failure to thrive, dementia, bipolar disorder, anxiety disorder, drug induced akathisia, suicidal ideation, post-traumatic stress disorder, nephrogenic diabetes insipidus, hyperparathyroidism, chronic kidney disease, schizoaffective disorder, hyperlipidemia, Meniere's disease, non-ST elevation (NSTEMI) myocardial infarction, obstructive sleep apnea, cognitive communication deficit, insomnia, hypertension, and chronic pain. On [DATE] at 2:26 PM, an interview was conducted with resident 29. Resident 29 stated that she had clothes go to laundry that had not been returned. Resident 29 stated that she had two t-shirts and two pairs of shorts go missing in the last 6 months. Resident 29 stated that she informed staff but had never had a resolution to the missing items. Resident 29 stated that she had never had her missing items returned or replaced and had to buy more clothing items herself. Resident 29 stated that her room was cold for about a month now and that she had complained about it to the staff. Resident 29's medical records were reviewed. On [DATE], resident 29's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10, which would indicate that the resident had a moderate cognitive impairment. On [DATE], resident 29's New Admit Belonging Inventory documented the following: one sweater, one pant, one black iPhone, one charging cord. No documentation could be found of an updated and current resident inventory list. The grievances were reviewed from [DATE] through [DATE] and no documentation could be found for resident 29's missing personal property. On [DATE] at 1:56 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 29 was alert and oriented times 4 to person, place, time, and situation. LPN 3 stated that resident 29 use to have intermittent confusion but had been more stable in the last 5 months since some medication adjustments. On [DATE] at 1:59 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 had not reported any missing property. CNA 3 stated that the process for locating any missing property was to look in the laundry room for any missing clothing and if she could not find it she would report it to the laundry staff to keep an eye out for it. CNA 3 stated that she would then report the missing item to the CNA Coordinator who would then put it on the group chat. On [DATE] at 10:58 AM, an interview was conducted with Laundry Staff (LS) 1. LS 1 stated that the previous process for labeling resident clothing was that the aides were to bag the clothing and tag it so that it could be labeled in the laundry room. LS 1 stated that the aides had not been following that process. LS 1 stated that on Fridays she would take any unlabeled clothing out and ask the residents and staff if they knew who it belonged to. LS 1 stated that if no one claimed the clothing they were previously stored in a big room but does not know where the clothing was located now. LS 1 stated that if a resident was missing clothing the aides would come and look for it in the laundry room. LS 1 stated that she had not had any aides ask about missing clothing for quite some time. 9. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On [DATE] at 2:34 PM, an interview was conducted with resident 51. Resident 51 stated that she had multiple items of missing clothing. Resident 51 stated that she had informed the Resident Advocate (RA) of the missing items but that he was no longer at the facility. Resident 51 stated she was missing jackets, a pink hamper, pajamas, sweat pants, and t-shirts. Resident 51 was unable to state the quantity of the missing clothing items. Resident 51 stated that she had never had her missing items returned or replaced. Resident 51 also stated that she was missing her bottom dentures and that they had been gone since she changed rooms. Resident 51 stated that her room was cold and that she had informed management but they had not done anything about it. Resident 51 stated that the vents were still blowing cold air into the room and it was worst at night. Resident 51's bathroom was observed with the toilet seat soiled with stool. Resident 51 stated that the remote control for her television did not allow her to select anything and the volume did not work. Resident 51 stated that she could only turn the television on and off. Resident 51 stated that the previous Maintenance Director left last week and no one had fixed her thermostat or television. Resident 51 stated that during incontinence care, CNA 5 threw a soiled chuck pad towards the wall and it smeared stool on the wall. The area pointed out by resident 51 was observed with a dried brown mark consistent with stool. Resident 51's medical records were reviewed. On [DATE], resident 51's MDS Assessment documented a BIMS score of 14, which would indicate that the resident was cognitively intact. The assessment documented that resident 51 did not have any hallucinations or delusions and did not have any physical or verbal behavioral symptoms. On [DATE], resident 51's New Admit Belonging Inventory documented the following: 7 t-shirts, 1 coat, 9 sweats, 1 short, 3 bras, 6 underwear, 6 pairs of socks, a cell phone and a charger. The grievances were reviewed from [DATE] through [DATE] and no documentation could be found for resident 51's missing personal property. On [DATE] at 12:53 PM, an interview was conducted with CNA 6. CNA 6 stated that if a resident reported missing property they would inform the nurse and the nurse would inform the Administrator (ADMIN). CNA 6 stated that they would then attempt to find the missing item. CNA 6 stated that upon admission they obtained an inventory of all the resident's belongings. CNA 6 stated that it was difficult to keep track of any additional personal items that were brought to the facility and he did not know if they updated the resident inventory sheet. CNA 6 stated that resident 51 had reported missing clothing but they had found them. On [DATE] at 9:39 AM, an interview was conducted with LPN 3. LPN 3 stated that resident 51 was alert and oriented times 4 to person, place, time and situation and had no memory deficits. LPN 3 stated that resident 51 did not have any missing personal items. LPN 3 stated that missing money was reported to the ADMIN. LPN 3 stated that if the missing items were clothing she would wait for laundry to check and search in the resident room then if the items could not be located she would notify the ADMIN. LPN 3 stated that sometimes the laundry staff misplaced a clothing item and she would inform them first in an attempt to locate the missing item. LPN 3 stated that resident 5 wore dentures and to her knowledge she did not have any missing dentures. LPN 3 stated that approximately 4 months ago resident 51 resided in a different room. LPN 3 stated that if a resident was missing dentures she would notify the kitchen in case they were left on a meal tray. LPN 3 stated that no one brought missing teeth to her attention and those were expensive so they needed to follow up on that. On [DATE] at 1:59 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 51 had not reported any missing property. CNA 3 stated that resident 51 had reported she could not find an article of clothing but it was located inside the room. On [DATE] at 2:58 PM, an interview was conducted with the HS. The HS stated that for missing property they would leave a rack with unlabeled clothing in the activity room for residents to claim. The HS stated that they asked the residents to come down hall by hall to see if any of the items were theirs. The HS stated that when they were notified of missing items they kept track of them on a sheet of paper. A resident roster with room numbers was observed on the wall. The HS stated that she would write any missing items next to the resident's name. The HS stated that she was not aware of any missing items for resident 29 or resident 51. The HS stated that as the supervisor the missing item log was supposed to go to her, but she had not received any of those logs yet. The HS stated that there were no clothes in laundry that were not labeled and unaccounted for. On [DATE] at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the grievance form was located on the Resident Advocate (RA) door. The DON stated that staff were to fill out the form, place it under the RA's door and he would determine which department would investigate the grievance. The DON stated that the resident, ADMIN and RA signs the form. The DON stated that missing personal property would go to the ADMIN and RA and the RA would determine if a grievance needed to be filled out for the missing property. The DON stated that if a grievance was escalated to her it would be investigated. The DON stated that when she investigated a grievance she would ask the resident when was the last time they saw the item, the timeframe of it being missed, ask staff if they noticed the item was missing, review camera footage, and then replace the property as needed. The DON stated that staff should report missing property to the RA or ADMIN. The DON stated that if a missing item was located in the resident room then they would not fill out a grievance form. The DON stated that staff should just know to inform the DON, ADMIN or RA of any missing property. On [DATE] at 9:08 PM, an interview was conducted with the RA. The RA stated he was in charge of the grievances. The RA stated the process was that when a complaint came in, the facility had 5 days to investigate the complaint. The RA stated there was a form that was filled out by the resident, staff or family members. The RA stated that staff looked for missing items and if they were unable to find the item then they would talk to the resident about what they wanted to happen. The RA stated they replaced clothing items. The RA stated that when the investigation was completed he went over it with the resident and the ADMIN signed the form. On [DATE] at 9:40 AM, a follow-up interview was conducted with the RA. The RA stated that resident 29 had not informed him of any missing personal property. The RA stated that typically, if something was missing, they would take the resident to the lost and found to locate the item. The RA stated if the resident was still unable to locate the missing item they would let the ADMIN know so that the item could be replaced. The RA stated that if a resident was missing dentures, they would first look to see if they were thrown away by mistake. The RA stated that if the dentures could not be located, he would make an appointment with the dental provider to obtain a replacement. The RA stated that resident 51 would state that clothing items were missing but it was determined that those items were never brought into the facility. The RA stated that the resident's inventory sheet did not contain the extensive list of items that resident 51 had said was missing. The RA stated that the resident inventory list should be updated anytime they brought new items into the facility. The residents should notify the CNA's so they could update the inventory. The RA stated that if a CNA noticed that the resident had new items they should inventory those new items right away. The RA stated that items came and went from the facility and if something was delivered to the facility for a resident and staff was aware then it should be added to the inventory list. The RA stated that resident 51 never mentioned to him that she was missing her dentures. The RA stated that resident 51 had a habit of leaving her dentures out. The RA stated that if resident 51 was stating that her dentures were missing then they needed to locate them or obtain new ones. On [DATE] at 9:55 AM, an observation was made of the facility thermostats. The ,d+[DATE] hallway had two thermostats, one with a #4 written in sharpie on it and a second unlabeled one next to it. The #4 thermostat read 64 degrees and was set at 74 degrees Fahrenheit. The second unlabeled thermostat read 66 degrees and was set to 74 degrees. The 300 hallway across from the nurse's station read 70 degrees and was set at 72 degrees. The memory unit thermostat located at the nurse's station read 69 degrees and was set to 82 degrees. The door to the outside patio was observed propped open in the dining room. On [DATE] at 1:46 PM, a follow-up interview was conducted with the DON. The DON stated that dental appointments were now being scheduled by her, but previously it was the RA's responsibility. The DON stated that missing personal property was investigated through the grievance process by the ADMIN and DON now. The DON stated that the staff should help the resident fill out the form. The DON stated that for missing items, such as clothing, staff should contact the HS and see if the item could be located in laundry, then they should look in the resident room. The DON stated that if the item was not found they would replace the item as needed. The DON stated that the CNA's should update the resident inventory list and fill out a new sheet every time there are new items brought into the facility. The DON stated that the grievance notice needed to be updated. The DON stated that new dentures would be obtained for resident 51 and she would make the appointment now. On [DATE] at 10:24 AM, an interview was conducted with the MS. The MS stated that he started at the facility approximately 2 weeks ago. The MS stated that the process for maintenance requests or repairs was that staff would text him in an emergency situation and if it was not an emergency, staff would write it in the daily maintenance log. The MS stated that he checked the log daily, Monday through Friday. The MS stated that he documented in the log any issues that were resolved or passed off to another department. The MS stated that the facility temperature was regulated by ambient air by the thermostats. The MS stated that a few rooms on the 100 and 200 hallway had the thermostat located inside the room and another thermostat in the hallway. The MS stated the when he was hired he had no training and nothing was passed off to him. The MS stated that the previous supervisor was gone when he started. The MS stated that he had complaints of residents being cold and resident 51 was one of those residents to complain. The MS stated that he had taken care of the cold temperature complaints. The MS stated that one of the rooms was on a different thermostat and he changed it from cold to heat. The MS stated that the thermostat in the ,d+[DATE] hallway was turned off. The MS stated that if the thermostat was reading a lower temperature than it was set to, it was set to cool. The MS stated that when he arrived the thermostats had not been set to heat yet. The MS stated that he was not sure of any records prior to his start date. The MS stated that the televisions not in working condition would be replaced. The MS stated that he had provided resident 51 with a new television remote when he first started. 43212 10. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On [DATE] at 4:40 PM, an interview was conducted with resident 3 who stated one of her blankets had gone missing and was never found. Resident 3 stated that she notified one of the laundry staff members, but they were unable to find the blanket. Resident 3's medical records were reviewed between [DATE] and [DATE]. Resident 3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated a normal cognition. On [DATE] at 3:30 PM, medical records revealed there was no documentation of resident 3's belongings when she was admitted to the facility. 11. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On [DATE] at 4:04 PM, an interview was conducted with resident 13 who stated she had several items of clothing that were missing. Resident 13 stated tops, bottoms, and some of her temple garments were missing. Resident 13 stated a new bag of garments had been thrown away. Resident 13 stated when clothing items went missing the staff would search for them. Resident 13 stated staff have been able to find most, but not all of her clothing. Resident 13's medical records were reviewed between [DATE] and [DATE]. On [DATE], an admission MDS assessment dated [DATE] revealed resident 13 had a BIMS score of 13, which indicated a normal cognition. On [DATE] at 3:34 PM, a review of resident 13's medical records revealed an inventory sheet from [DATE]. The inventory form included 4 t-shirts, 1 sweater, 4 pairs of pants, 2 pajama tops, 2 pajama bottoms, 6 garment tops, 6 garment bottoms, 1 pair shoes, 1 pair sandals, 4 pairs socks, 6 rings, 20 pairs earrings, 2 pair glasses, 1 black cell phone, 1 cell phone charger, 2 headphone sets, 1 black radio with CD player and cassette player, 1 gray HP laptop, 1 black water filter pitcher, DVD rack with DVDs, CDs and videos, 1 power chair, 1 power amp, craft supplies, 3 book cases with books, 1 nebulizer, 1 CPAP. No updated inventory sheets were found. Grievances were reviewed between [DATE] and [DATE]. No documentation was found regarding resident 3's missing blanket or resident 13's missing clothing items. On [DATE] at 4:06 PM, an interview was conducted with CNA 4 and CNA 5 who stated if a resident's clothing went missing, they would first go to the laundry to see if the item was there. CNA 4 stated she would report the missing item to the nurse and to the Human Resource (HR) manager. CNA 4 stated the nurse would document missing items. CNA 5 stated mostly the CNA's looked in the resident's room, but would also look in the activities room or the kitchen. On [DATE] at 10:58 AM, an interview was conducted with LS 1 who stated the process for missing clothing was that the CNA's were supposed to put new resident's clothing in a bag and put a tag on the bag so the clothing and other items could be labeled. LS 1 stated that process had not been happening for 3 to 4 years. LS 1 stated she had been taking unlabeled laundry out every Friday and asking residents to identify items that belonged to them. LS 1 stated if clothing items were not claimed, they used to be taken to a room where they were stored, but she did not know if that was being done now. LS 1 stated there was a label machine in the laundry room, but had not labeled the laundry for quite some time since resident clothing was being brought to the laundry room in large laundry barrels with clothing of several residents inside. LS 1 stated laundry was done every day so there should not be a long wait for laundry to return to the resident. LS 1 stated CNA's had not come to look for laundry in quite some time. LS 1 stated she was aware of resident 3's missing blanket, but was unable to find it. On [DATE] at 3:15 PM, an interview was conducted with the DON who stated the RA was taking care of grievances, and was responsible for missing personal property. The DON stated she and the ADMIN would follow up on those grievances. The DON stated residents could use a grievance form to let staff know about missing personal items, or could tell them directly. The DON stated all residents should know how to fill out a grievance form. The DON stated she was not sure if there was a posting to let residents know who they could contact for a grievance form. The DON stated depending on the type of clothing that was missing, the HS would be contacted. The DON stated staff could help the resident look through their room to locate the missing item. The DON stated there were mesh bags that were sent to the laundry with resident clothing when the resident was admitted so clothing could be labeled. The DON stated that CNA's should fill out a new inventory sheet upon admission and when new clothing items came to the facility. 30563 12. On [DATE] at 10:16 AM, an observation was made of room [ROOM NUMBER]B. The privacy curtain had a red substance on it and there was a brown splatter on the wall. Resident 32 resided in room [ROOM NUMBER]B and was interviewed. Resident 32 stated it had been a while since his room and privacy curtain was cleaned. Resident 32 stated, This isn't the greatest place to be at this time in life. 13. On [DATE] at 4:09 PM, an observation was made of room [ROOM NUMBER]A. There was a brown stain on Resident 55's sheet by his elbow. The bathroom had a strong urine odor. Resi [TRUNCATED]

Based on observation, interview, and record review it was determined, for 2 out of 65 sampled residents, that the facility did not make prompt efforts to resolve grievances. Specifically, residents expressed grievances about missing personal property to staff and there was no resolution to the grievances. Resident identifiers: 29, 51. Findings included: 38031 1. Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included drug induced secondary Parkinsonism, adult failure to thrive, dementia, bipolar disorder, anxiety disorder, drug induced akathisia, suicidal ideation, post-traumatic stress disorder, nephrogenic diabetes insipidus, hyperparathyroidism, chronic kidney disease, schizoaffective disorder, hyperlipidemia, Meniere's disease, non-ST elevation (NSTEMI) myocardial infarction, obstructive sleep apnea, cognitive communication deficit, insomnia, hypertension, and chronic pain. On 11/03/24 at 2:26 PM, an interview was conducted with resident 29. Resident 29 stated that she had clothes go to laundry that had not been returned. Resident 29 stated that she had two t-shirts and two pairs of shorts go missing in the last 6 months. Resident 29 stated that she informed staff but had never had a resolution to the missing items. Resident 29 stated that she had never had her missing items returned or replaced and had to buy more clothing items herself. Resident 29's medical records were reviewed. On 9/29/24, resident 29's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10, which would indicate that the resident had a moderate cognitive impairment. On 12/13/21, resident 29's New Admit Belonging Inventory documented the following: one sweater, one pant, one black iPhone, one charging cord. No documentation could be found of an updated and current resident inventory list. The grievances were reviewed from January 2024 through October 2024 and no documentation could be found for resident 29's missing personal property. On 11/06/24 at 1:56 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 29 was alert and oriented times 4 to person, place, time, and situation. LPN 3 stated that resident 29 use to have intermittent confusion but had been more stable in the last 5 months since some medication adjustments. On 11/06/24 at 1:59 PM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that resident 29 had not reported any missing property. CNA 3 stated that the process for locating any missing property was to look in the laundry room for any missing clothing and if she could not find it she would report it to the laundry staff to keep an eye out for it. CNA 3 stated that she would then report the missing item to the CNA Coordinator who would then put it on the group chat. 2. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 11/03/24 at 2:34 PM, an interview was conducted with resident 51. Resident 51 stated that she had multiple items of missing clothing. Resident 51 stated that she had informed the Resident Advocate (RA) of the missing items but that he was no longer at the facility. Resident 51 stated she was missing jackets, a pink hamper, pajamas, sweat pants, and t-shirts. Resident 51 was unable to state the quantity of the missing clothing items. Resident 51 stated that she had never had her missing items returned or replaced. Resident 51 also stated that she was missing her bottom dentures and that they had been gone since she changed rooms. Resident 51's medical records were reviewed. On 10/9/24, resident 51's MDS Assessment documented a BIMS score of 14, which would indicate that the resident was cognitively intact. The assessment documented that resident 51 did not have any hallucinations or delusions and did not have any physical or verbal behavioral symptoms. On 1/11/24, resident 51's New Admit Belonging Inventory documented the following: 7 t-shirts, 1 coat, 9 sweats, 1 short, 3 bras, 6 underwear, 6 pairs of socks, a cell phone and a charger. The grievances were reviewed from January 2024 through October 2024 and no documentation could be found for resident 51's missing personal property. On 11/05/24 at 12:53 PM, an interview was conducted with CNA 6. CNA 6 stated that if a resident reported missing property they would inform the nurse and the nurse would inform the Administrator (ADMIN). CNA 6 stated that they would then attempt to find the missing item. CNA 6 stated that upon admission they obtained an inventory of all the resident's belongings. CNA 6 stated that it was difficult to keep track of any additional personal items that were brought to the facility and he did not know if they updated the resident inventory sheet. CNA 6 stated that resident 51 had reported missing clothing but they had found them. On 11/06/24 at 9:39 AM, an interview was conducted with LPN 3. LPN 3 stated that resident 51 was alert and oriented times 4 to person, place, time and situation and had no memory deficits. LPN 3 stated that resident 51 did not have any missing personal items. LPN 3 stated that missing money was reported to the ADMIN. LPN 3 stated that if the missing items were clothing she would wait for laundry to check and search in the resident room, then if the items could not be located she would notify the ADMIN. LPN 3 stated that sometimes the laundry staff misplaced a clothing item and she would inform them first in an attempt to locate the missing item. LPN 3 stated that resident 5 wore dentures and to her knowledge she did not have any missing dentures. LPN 3 stated that approximately 4 months ago, resident 51 resided in a different room. LPN 3 stated that if a resident was missing dentures, she would notify the kitchen in case they were left on a meal tray. LPN 3 stated that no one brought missing teeth to her attention and those were expensive so they needed to follow up on that. On 11/06/24 at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the grievance form was located on the RA door. The DON stated that staff were to fill out the form, place it under the RA's door and he would determine which department would investigate the grievance. The DON stated that the resident, ADMIN and RA signs the form. The DON stated that missing personal property would go to the ADMIN and RA and the RA would determine if a grievance needed to be filled out for the missing property. The DON stated that if a grievance was escalated to her it would be investigated. The DON stated that when she investigated a grievance she would ask the resident when was the last time they saw the item, the timeframe of it being missed, ask staff if they noticed the item was missing, review camera footage, and then replace the property as needed. The DON stated that staff should report missing property to the RA or ADMIN. The DON stated that if a missing item was located in the resident room then they would not fill out a grievance form. The DON stated that staff should just know to inform the DON, ADMIN or RA of any missing property. On 11/6/24 at 9:08 PM, an interview was conducted with the RA. The RA stated he was in charge of the grievances. The RA stated the process was that when a complaint came in, the facility had 5 days to investigate the complaint. The RA stated there was a form that was filled out by the resident, staff or family members. The RA stated that staff looked for missing items and if they were unable to find the item then they would talk to the resident about what they wanted to happen. The RA stated they replaced clothing items. The RA stated that when the investigation was completed he went over it with the resident and the ADMIN signed the form. On 11/07/24 at 9:40 AM, a follow-up interview was conducted with the RA. The RA stated that resident 29 had not informed him of any missing personal property. The RA stated that typically if something was missing they would take the resident to the lost and found to locate the item. The RA stated if the resident was still unable to locate the missing item they would let the ADMIN know so that the item could be replaced. The RA stated that if a resident was missing dentures, they would first look to see if they were thrown away by mistake. The RA stated that if the dentures could not be located he would make an appointment with the dental provider to obtain a replacement. The RA stated that resident 51 would state that clothing items were missing but it was determined that those items were never brought into the facility. The RA stated that the resident's inventory sheet did not contain the extensive list of items that resident 51 had said was missing. The RA stated that the resident inventory list should be updated anytime they brought new items into the facility. The residents should notify the CNA's so they could update the inventory. The RA stated that if a CNA were to notice that the resident had new items they should inventory those new items right away. The RA stated that items came and went from the facility and if something was delivered to the facility for a resident and staff was aware then it should be added to the inventory list. The RA stated that resident 51 never mentioned to him that she was missing her dentures. The RA stated that resident 51 had a habit of leaving her dentures out. The RA stated that if resident 51 was stating that her dentures were missing, they needed to locate them or obtain new ones. On 11/12/24 at 1:46 PM, a follow-up interview was conducted with the DON. The DON stated that dental appointments were now being scheduled by her, but previously it was the RA's responsibility. The DON stated that missing personal property was investigated through the grievance process by the ADMIN and DON now. The DON stated that the staff should help the resident fill out the form. The DON stated that for missing items such as clothing staff should contact the HS and see if the item could be located in laundry, then they should look in the resident room. The DON stated that if the item was not found they would replace the item as needed. The DON stated that the CNA's should update the resident inventory list and fill out a new sheet every time there are new items brought into the facility. The DON stated that the grievance notice needed to be updated. The DON stated that new dentures would be obtained for resident 51 and she would make the appointment now. 3. A review of the facility's resident council meeting minutes revealed: a. April 2024: .resident concerned that his non-labeled clothes are disappearing. Another resident commented that she had the same issue with a pair of pants that were not labeled not coming back through laundry .lost & found 'laundry day' for residents to search through unmarked clothing to find their missing property .proposed system changes for noting missing clothes, labeling clothes properly, or repairing/replacing damaged clothing .asked for grievances for all damaged/missing clothing, to be followed-up on, after the lost-&-found event, if still missing . b. July 2024: .Various interventions being taken, including process being implemented for labeling and bagging new clothing, a large clothing reclamation event being held, a weekly unlabeled laundry lost and found rack, a staff meeting in-service on process, and regular training for implementing consistent labeling procedure . c. August 2024: .Laundry Missing PIP [performance improvement plan] in process, to address . d. September 2024: .Laundry Missing Incidents were individually investigated and resolved . On 11/6/24 at 3:00 PM, the facility's resident council meeting was attended. Multiple residents stated that they did not know how to file a grievance and to whom the grievance should be filed with. On 11/7/24 at 10:07 AM, an observation was made of the facility's posted grievance procedure with an outdated resident advocate's name listed as the grievance official. On 11/7/24 at 12:04 PM, an interview was conducted with the ADMIN. The ADMIN stated that he had attended the resident council meeting on 11/6/24. The ADMIN stated that he did not know that some residents did not how to fill out a grievance form and that he learned that in the resident council meeting. The ADMIN stated that he would discuss grievances with the management staff and how to notify residents about the grievance process. [Cross-refer F584]

Based on interview and record review, it was determined for 6 out of 65 sampled residents, that in response to an allegation of abuse, neglect, exploitation, or mistreatment, the facility failed to report immediately, but not later than 2 hours to the other officials including the State Survey Agency (SSA). Specifically, sexual abuse, a fall with a major injury, a fall from a hoyer lift, exploitation of a resident, involuntary seclusion, and an elopment were not reported to the SSA. Resident Identifiers: 5,13, 46, 54, 121, 419 Findings Include: The facility's Abuse Policy and Procedures were reviewed. The following was documented in the policy: .The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property is reported immediately but no later than 2 hours, after the allegation is made . 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. 2. Resident 121 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, type 2 diabetes mellitus with hypoglycemia, acute respiratory failure with hypoxia, iron deficiency anemia, other seizures, unspecified dementia, restlessness and agitation, and mild neurocognitive disorder due to known physiological condition with behavioral symptoms. On 11/7/24 at 10:40 AM, a communication note documented, Note Text: Resident [54] was observed kissing resident [121] in his room. Administration met separately with [resident 54] to discuss his relationship with [resident 121]. [Resident 54] stated that they are just friends and confirmed that both she and [resident 54] consented to the kiss. On 11/7/24 at 1:41 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN was asked for a copy of the 358 that was submitted to the state in reference of the incident that occurred with resident 54 and 121. The ADMIN asked the state surveyor if the incident was a reportable one and that he did not report the incident to the state. On 11/7/24 at 1:45 PM, a follow up interview was conducted with the ADMIN. The ADMIN stated that his definition of sexual abuse was exploiting or taking advantage of someone especially if they can't consent. The ADMIN stated he had contacted the Ombudsman and was told that as long as the residents were consenting then it was fine. The ADMIN stated that the residents 121 and 54 had their own right to kiss, he made a note in their medical records about it and thought everything was fine. On 11/7/24 at 3:38 PM, an interview was conducted with the ADMIN. The ADMIN stated that he had submitted the reportable 358 to the state. 43212 3. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On 11/3/24 at 4:04 PM, an interview was conducted with resident 13 who stated she had sustained several falls in the facility over the past year. Resident 13 stated earlier in the year, one of her falls resulted in a shoulder fracture. Resident 13's medical record was reviewed between 11/3/24 through 11/13/24. On 6/11/24, an Minimum Data Set (MDS) admission assessment revealed resident 13 had a Brief Interview for Mental Status (BIMS) score of 13 indicating normal cognition. Progress notes: On 5/27/24 at 4:45 PM, an alert charting progress note revealed, Found pt [patient] laying on her bed with a hematoma on her forehead. Pt with a laceration on her nose. Severe pain to her right shoulder and pain and bruising to her left knee. Pt states that her pant leg got caught on her electric w/c [wheelchair] and she fell forward. Pt got herself up into her bed and then called for assistance. Pt requested to go to ER [emergency room ] for evaluation of her right shoulder. Non-emergent ambulance called. Notified physician on call and pt's [family member]. Pt sent out at this time. On 5/27/24 at 4:48 AM, a discharge progress note revealed, Date/time of discharge/transfer: 5-27-24 at 4:35 AM. Discharge/transfer location: [Hospital name]. Mode at transportation at time of discharge/transfer: non-emergency ambulance. Reason for transfer/discharge: severe pain to right shoulder- possible fracture. Discharge teaching/instructions completed during discharge/transfer: [blank]. Discharge paperwork released with resident at time of discharge/transfer: Transfer/discharge record, order summary, face sheet. Resident's response to discharge/transfer process: Pt wanting to go to the ER. How were the resident's personal effects stored/handled at time of discharge/transfer?: Personal items left in her room. Pt took her phone and phone charger with her. Name of individual to whom report was provided at new location: [blank]. Name of resident representative notified (if resident is not self-responsible): [family member]. Name of physician notified [name redacted] on call for [physician name]. On 6/4/24 at 6:46 PM, a progress note alert charting revealed, Pt readmitted to facility via facility transport. A/O [alert and oriented] x 4. Able to verbalize needs. Continent of bowel and bladder. Resident using sling to R [right] shoulder. Has bruises to: forehead, L [left] knee, Rt [right] shoulder, LFA [left femoral artery], L elbow, 2 small bruises on bilat [bilateral] ankle, RFA [right femoral artery]. She has small scan on bridge of nose. Incision to R chest area intact, no s/s [signs and symptoms] of infection. Uses motorized w/c for mobility. Last BM [bowel movement] 6/3/24. C/O [complains of] pain to R shoulder Oriented to facility. Call light is within reach. On 8/6/24 at 7:53 AM, a social service progress note revealed, RA [Resident Advocate] met with RT [resident] to discuss help with setting up crypto account. RA quickly determined RT is victim of scam. Perpetrator is stating they are '[celebrity]' the singer and they are going to marry RT. RT is excited about this relationship and '[celebrity]' coming to St. [NAME] while touring in Las Vegas to meet RT. RA made it very clear that any requests for money, or crypto, loans is a scam and RT could fall victim to identity and financial theft. RA contacted [bank] after learning RT has provided log in information for her online banking. [Bank] closed down the accounts and froze the fraudulent deposit. RA facilitated RT visiting the DLD [Drivers License Division] to renew her license, this was first step for RT to visit the branch in person to have new accounts created. RA offered support to RT and explained feelings of grief are normal and expected when any relationship ends. RA made it clear that RT should no longer speak with this person and block any further communications. On 8/13/24 at 7:58 AM, a social service progress note revealed, RA has communicated with RT therapist [name], [Local Behavioral Health Center]. Therapist confirmed RT has continued online relationship, and is having difficulty accepting that relationship was a scam. RA has learned that RT was upset about account being closed, and was not happy RA intervened to help RT not fall victim to scam. RT has communicated with nursing staff that she is attempting to repair online relationship and that '[celebrity]'son is now speaking with her about repairing damage to the relationship by asking RT to qualify for a loan to make it up to him. RA has communicated with RT therapist, and [name] RT APRN [Advanced Practice Registered Nurse]. All treatment providers agree it is best to allow RT to make her own decisions and respect her autonomy. RT has been warned about scam, and is being offered support regardless of her choices. RT has been determined to be capable of making her own decisions. RA met with RT and offered support, RA also apologized for quickly acting on scam and having RT account closed, even with RT consent and being present for the calls to [bank]. RA explained this was done in an effort to help RT avoid suffering and that RT wishes are important and RA wants to honor them. RT stated she understood and appreciated the talk. On 8/22/24 at 3:39 PM, a social service progress note revealed, RA contacted APS [adult protective services] to file report about online relationship-RA explained the situation and APS provided case [number redacted]. Resident 13's care plan revealed: a. Risk for falls r/t [related to] neuropathy, gout, dependence on supplemental oxygen, impaired mobility with use of assistive device, hx [history] of falls. Date initiated: 7/18/22, Revision on 6/26/23. The goal was, The resident will be free of falls with injury through the review date. Date initiated: 7/18/22, Revision on: 4/12/24, Target Date: 2/7/25. Interventions included, .5/27/24- unwitnessed fall, risk management done, resident educated. Date initiated: 5/28/24 .Follow facility fall protocol if a fall occurs. Date initiated: 7/18/22 . b. The resident has had an actual fall. Poor balance, poor safety awareness. 10/12/24. Date initiated: 8/30/24, Revision on 10/21/24. The goal was, Resident will not have a fall with major injury. Date initiated: 8/30/24, Target date: 2/7/25. Interventions included, .Encourage resident to participate in fall prevention. Date initiated: 8/30/24 .Monitor/document/report PRN [as needed] x 72 h [hours] to MD [medical doctor] for s/sx [signs and symptoms]: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Date initiated: 8/30/24, Revision on 8/30/24 . c. Mood & Behavior: [resident 13] has potential for coping and adjustment issues, related to a desire for an online relationship and potential for online exploitation. Depression. Due to this desire, [resident 13] has had a capacity to consent evaluation done and has been found to have the ability to consent to a relationship. Date initiated: 8/14/24, Revision on 11/8/24. The goal was, Dignity will be preserved and quality of life improved by allowing [resident 13] to make her own informed decisions. Date initiated 8/14/24, Revision on 8/14/24, Target date: 2/7/25. Interventions included, .Provide information to [resident 13] regarding potential financial and emotional exploitation. Assist PRN with banking issues if [resident 13] requests. Follow mandatory reporting policies if needed. Date initiated: 8/14/24. d. The resident has a psychosocial well-being problem r/t sexual activity capacity. 11/8/24: Resident does not have capacity for sexual activity consent: Date initiated: 11/8/24, Revision on: 11/8/24. The goal was, The resident will have on indications of psychosocial well being problem by/through review date. Date initiated: 11/8/24, Target date: 2/7/25. Interventions included, Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears when conducting sexual activity capacity for consent assessment. Date initiated: 11/8/24; .Provide opportunities for the resident and family to participate in care. Date initiated: 11/8/24; The resident needs assistance/encouragement/support to identify causative and contributing factors. Date initiated: 11/8/24; The resident needs assistance/encouragement/support with identification of potential solutions to present problems. Date initiated: 11/8/24 On 11/7/24 at 11:59 AM, an interview was conducted with the MDS coordinator who stated the incident on 5/27/24 was a result of resident 13's pant leg getting caught on her wheelchair. The MDS stated resident 13 was given verbal education about wheelchair safety on the day of the fall. The MDS stated resident falls were reviewed in morning stand up meeting and then the IDT (interdisciplinary team) meeting. It should be noted that no IDT meeting progress note could be found for resident 13's fall on 5/27/24. The Resident Advocate could not be reached for an interview. On 11/13/24 at 8:59 AM, an interview was conducted with the Director of Nursing (DON) who stated resident 13 believed she was in a relationship with a celebrity. APS and the ombudsman were involved. The DON stated she would have to check with the RA about the situation. The DON stated the police should have been notified about the exploitation. The DON stated the RA helped resident 13 with her bank account. The DON stated resident 13 had to get a new bank account to protect her information. The DON stated resident 13 was trying to cash a check that was fraudulent. The DON stated she would provide more information after speaking with the RA. It should be noted that no additional information was provided regarding exploitation of resident 13. It should also be noted that this injury of unknown origin event was not reported to the SSA within the required 2 hours of becoming aware, and the resident's exploitation was not reported to the SSA until 11/13/24. [cross-refer 689] [cross-refer 602] 46232 4. Resident 419 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of metabolic encephalopathy, schizophrenia, psychological and behavioral factors, and polydipsia. Resident 419's medical record was reviewed on 11/13/24. A hospital history and physical dated from 2/6/24 to 3/20/24 documented resident 419 was unable to care for themselves nor make medical decisions and lacked self-awareness. The physician documented resident 419 needed to be placed into a care facility with 24-hour supervision. On 3/7/24, an inpatient psychiatric (psych) evaluation was conducted on resident 419 and the psychiatrist deemed resident 419 decisionally incompetent and unable to reliably care for themselves. The psych note stated, Patient would be best suited for admission to long-term skilled nursing facility. Due to patient's current cognitive impairment and condition, she is unsafe to be discharged home as she is unable to safely take care of herself. On capacity testing again she remains unable to exhibit the four generally accepted decision-making abilities that constitute capacity, understanding, expressing a choice, appreciation, and reasoning. On 3/15/24 at 10:51 AM, an emergency court ordered appointed guardian was granted to resident 419, who was declared to be an incapacitated adult. The document stated the emergency guardian had the authority to make medical, financial, placement, and end-of-life decisions. The temporary guardianship was to be effective for 30 days. An admission wander/elopement risk evaluation completed on 3/20/24 stated resident 419 was a high wander/elopement risk. Resident 419 was documented to have the following risk factors: History of wandering, cognitive impairment, impaired decision-making skills, memory impairments, and previous elopement attempts. A care plan focus area initiated on 3/20/24 stated resident 419 wanted to discharge back into the community. Listed interventions included encouraging resident 419 to discuss feelings and concerns related to discharge and staff were to monitor and address sources of anxiety, fear, or distress in order to promote a calm and orderly discharge. Another intervention stated the resident advocate was to make a referral to the local contact agency when indicated to help facilitate resident 419's discharge plan. A care plan focus area initiated and revised on 4/12/24 stated resident 419 had impaired cognitive function/impaired through processes related to a BIMS of 6, and impaired safety awareness. [Note: It should be noted this was initiated 18 days after the resident left the facility against medical advice (AMA) and was charged with criminal trespassing and sent to jail.] An Admission MDS completed on 3/25/24 documented resident 419 had a BIMS score of 6 which indicated severe cognitive impairment. A care conference documented resident 419 wanted to look into housing and an evaluation was being set up with local housing for a possible housing transition. On 3/25/24, a social service note created at 12:52 PM, stated resident 419 had walked out of the facility AMA. Resident 419 stated they were fine on their own and had packed their belongings in a plastic bag and were heading to a local homeless center where they could live by themselves. The RA stated resident 419 had not given a reason to their change of mind and left the faciity on foot. The RA contacted resident 419's guardian and the local police. The RA contacted Adult Protective Services at 12:59 PM and filed a report due to resident 419 leaving the facility AMA. A discharge progress note created at 1:03 PM, stated resident 419 had left the facility AMA at 12:30 PM and was going to a local homeless center on foot. It was documented the case manager had called the local homeless center and was informed residents 419 was above their level of care. The homeless center was provided resident 419's guardian name and phone number by the RA. [Note: It should be noted this incident was not reported to the state survey agency. Resident 419 was appointed a guardian due to being unable to make medical decisions for themselves. Resident 419 did not have the cognitive capacity to sign out AMA and the facility did not notify the guardian about resident 419's desire to leave AMA before they left the facility.] On 11/13/24 at 11:07 AM, an interview was conducted with the ADMIN. The ADMIN stated an elopement was considered when staff lost sight of a resident who left the facility property. The ADMIN stated if a resident did not have the capacity to sign out AMA and they left the facility, they would consider it an elopement. The ADMIN stated resident 419's AMA occurred before they were the Administrator. A follow up interview was conducted with the ADMIN at 11:53 AM. The ADMIN stated they were working on submitting a report for resident 419's elopement. On 11/13/24 at 12:06 PM, an interview was conducted with the [NAME] President of Clinicals (VPC). The VPC stated a resident was appointed a guardian depending on their situation. The VPC stated a guardian was appointed to look out for the resident and their best interest. The VPC stated resident 419's discharge was not reported to the state agency because they believed the resident had left AMA and had not eloped. 48709 5. Resident 46 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, aphasia, cognitive communication deficit, chronic obstructive pulmonary disease with acute exacerbation, lack of coordination, acute kidney failure, major depressive disorder, and anxiety. On 11/7/24 at 11:38 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that resident 46 was moved into the memory care unit on 10/2/24 and moved back out on 10/17/24. On 11/7/24 at 1:17 PM, an interview was conducted with the ADMIN. The ADMIN stated resident 46 was put into the memory care unit because she was noncompliant with smoking. The ADMIN stated she should be able to understand the smoking policy. The ADMIN stated she was moved out of the memory care unit because her daughter was upset that the doors were locked and wanted her moved out. Said surveyor reported the act of involuntary seclusion for resident 46 to the ADMIN during interview. On 11/13/24 at 11:07 AM, a follow-up interview was conducted with the ADMIN. The ADMIN stated that he had not reported the involuntary seclusion allegation for resident 46 to the SSA and that he should have reported it already. 6. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, paralysis of vocal cords and larynx, congestive heart failure, and major depressive disorder. Resident 5's medical record was reviewed 11/3/24 through 11/13/24. An Alert Charting note, dated 11/8/2024 at 2:55 AM, indicated, Resident was being lifted up in the hoyer sling x2 [times two] CNAs [certified nursing assistant] from wheelchair to bed placed in bed to go to sleep. CNA's Stated that sling snapped and Pt [patient] slid onto floor. Pt was assessed by nurse and took Pt vitals were WNL [within normal limits] BP [blood pressure]= 133/80, P [pulse]=73, O2 [oxygen saturation]= 93, R [respirations]=20. Pt got skin tear to Left arm. no other injury appeared at this time. dressing applied by nurse. no other issues were noted at this time. On 11/13/24 at 11:53, an interview was conducted with the ADMIN. The ADMIN stated he should have reported the hoyer lift fall because the staff used the sling and it could have been neglect. The ADMIN stated he did look at the sling when it happened and saw that the sling was frayed. The ADMIN stated that he was still working on the report for resident 5's hoyer lift fall and that he should have reported it to the SSA last week when it happened. 30563

Based on interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 32 sampled residents, a resident that had uncontrolled anxiety and agitation for two months had a fall that resulted in a fracture. This resulted in a finding of harm. In addition, a resident had four falls, did not have preventative interventions in place, and/or adequate supervision to prevent falls. The falls resulted in the resident hitting their head and causing lacerations. Resident identifiers: 47 and 164. Findings included: HARM 1. Resident 164 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease, insomnia, vascular dementia, and osteoporosis without current pathological fracture. Resident 164's medical record was reviewed on 6/26/23. A care plan Focus initiated on 12/27/22, documented Risk for falls r/t [related to] severe cognitive impairment, impaired balance, and noncompliance with fall precautions. A care plan Goal documented The resident will be free of falls with injury through the review date. Interventions were initiated on 12/27/22, and included: a. Anticipate and meet the resident's needs. Keep frequently used items within reach. b. Educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing. c. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. d. Follow facility fall protocol if a fall occurs. e. Orient resident to call light. Keep the resident's call light within reach and encourage the resident to use it for assistance as needed. f. Refer to therapy for evaluation and treatment as indicated to address fall risk. g. Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: even floors free from spills and/or clutter; adequate, glarefree light; handrails on walls in the hallway. On 12/21/22 at 5:33 PM, a Health Status Note documented Note Text: Hospice nurse, [name removed] in to see resident at time of admit. Reconciled medications. Resident placed on mechanical soft diet d/t [due to] no teeth but is able to eat things such as PB&J [peanut butter and jelly] sandwiches. Resident is very anxious about being in a new place and is very worried about the fact that she will forget most of what she is told at least at first. Changed call light to a pressure button d/t resident with contractures to both hands and is really only able to use thumb and index finger on both hands. On 12/22/22 at 3:40 AM, a Health Status Note documented Note Text: Resident is oriented to self only, frequently forgets and confuses where she is and when it is. Shows many signs of anxiety and fearfulness r/t new facility and new living situation. Is weight bearing. Vital signs WNL [within normal limits]. Will continue to be monitored and looked after closely as she transitions to staying here. On 12/22/22 at 5:49 PM, a Health Status Note documented Note Text: Resident is alert and oriented to self only. Requires frequent re-direction and re-assuring. High anxiety and paranoia. Wandered into another resident's room and urinated on the floor shortly after a staff member had taken her to the restroom. Enjoyed time in activities today and enjoyed eating meals in the dining room. On 12/23/22 at 5:55 PM, a Health Status Note documented Note Text: Resident continues to be restless and paranoid. Needs frequent re-direction. Needs fed unless finger foods. Must be prompted to use the restroom. Does not like to be alone at any time. Spoke with her daughter for at least an hour this morning. Only oriented to self. Enters other resident's rooms. On 12/24/22 at 3:58 PM, a Health Status Note documented Note Text: Resident is alert and oriented x1 [oriented to person] self only. Takes pills whole. Continent b/b [bowel and bladder] as long as she is prompted to use the restroom. Requires assistance eating, toileting and transferring. Very restless and anxious. Does like to participate in activities and go to the dining room to eat. On 12/29/22 at 2:56 PM, a Health Status Note documented Note Text: Resident alert and oriented to self only. Continues have high anxiety. Really does not like to be in her room alone, prefers to be around other people and having someone to talk to. Does not understand or remember how to use call light, instead calls out for help frequently. Resident able to walk with a shuffling gait and does wander into other resident's rooms at times. Continent of b/b. Resident able to feed self if food is able to be eaten with hands, otherwise needs to be fed as she cannot use silverware. Eats lunch and dinner in the dining room, participates in activities. On 1/3/23 at 8:55 AM, a Hospice Nursing Clinical Note documented . Pt [Patient] is more confused which is adding agitation. Pt is very emotionally unstable today. On 1/6/23 at 11:25 AM, a Hospice Nursing Clinical Note documented . Pt very anxious today but cooperative. On 1/6/23 at 11:36 AM, a Social Service Note documented Note Text: Called and notified resident's POA [Power of Attorney] regarding her move, to room [ROOM NUMBER] so she can be closer to the nurse's station. Received verbal consent. On 1/11/23 at 1:15 PM, a Hospice Nursing Clinical Note documented . Pt continues to have episodes of anxiety and repetitive behavior and questions. On 1/14/23 at 1:15 PM, a Hospice Nursing Clinical Note documented . Pt was in wheel chair by nurses station asking to go to her room upon sn [skilled nursing] arrival. pt was agitated and anxious. On 1/19/23 at 7:30 AM, a Health Status Note documented Note Text: Resident had stuck her hands in her brief and got BM [bowel movement] on them and licked her fingers before CNA [Certified Nursing Assistant] could stop her. Assisted resident to wash hands and brush teeth. On 1/19/23 at 10:31 AM, a Health Status Note documented Note Text: Resident reporting to BOM [Business Office Manager] that a young man had come in her room and threw her to the ground. No one has been witnessed in resident room and resident unable to get self off floor. Administrator notified of resident's statements. Resident's baseline is oriented to self only. On 1/19/23 at 3:25 PM, a Health Status Note documented Note Text: Resident's hospice nurse in to see her today. Reports that today is the calmest and happiest she has ever seen resident in all the time she has taken care of her. On 1/27/23 at 3:36 PM, a Health Status Note documented Note Text: Resident very anxious today. Constant supervision required. Report that resident was wandering into other resident rooms during the night. Repetitive statements. On 2/19/23 at 6:30 PM, a Health Status Note documented Note Text: Pt with constant hollering out, unable to redirect pt. pt upsetting other residents, wandering into other residents rooms. other residents using foul language due to her increased behaviors. unable to spend 1:1 [one on one] with resident. unable to redirect. pt urinating on floors and having episodes of defecating on the floor in her room and or the hallway. notified pt hospice nurse [name removed] of pt uncontrollable hollering and behaviors. Nurse reports she will reach out to the sister again and notified the hospice physician regarding behaviors. notified management of pt condition. On 2/20/23 at 1:26 PM, a Health Status Note documented Note Text: Pt has multiple anxious episodes, which are evident by her repeated calling out, wondering when not answered and increase in agitation. Pt has now started to scream loud and become angry when extremely anxious. On 2/20/23 at 6:00 PM, a physician's order documented LORazepam Intensol Oral Concentrate 2 MG/ML [milligrams per milliliters] (Lorazepam) Give 1 ml [milliliter] by mouth at bedtime for anxiety. The order was discontinued on 2/23/23 at 1:24 PM. On 2/20/23 at 6:30 PM, a physician's order dated LORazepam Intensol Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed [PRN] for anxiety/anxious behaviors. The February 2023 Medication Administration Record was reviewed. Resident 164 received PRN lorazepam on 2/21/23 at 11:34 AM, 2/23/23 at 1:55 AM, 2/24/23 at 3:35 AM, 2/24/23 at 8:02 PM, 2/25/23 at 4:03 AM, and 2/25/23 at 10:59 PM. [Note: Resident 164 had documented anxiety and agitation since admission on 12/21/22. The lorazepam for anxiety and anxious behaviors was initiated two months after resident 164's admission.] On 2/21/23 at 6:27 PM, a Health Status Note documented Note Text: pt was taken from dining room and placed at nurses station in her wheelchair due to increased anxiety. nurse visiting with pt and trying to calm resident. pt requiring 1:1 attention. unable to calm pt, yelling at staff, other residents. pt given her hs [take at bedtime] medications at this time. pt sitting at nurses station so staff could watch her due to impulsive behavior. pt attempts to ambulate without assist [assistance]. pt has unsteady gait. asked pt to sit at station and visit with other residents at this time. visitors in facility and had a dog and family let [resident 164] pet and visit with the dog. seemed to calm pt for a little while. nurse went to another pt room to assist with cares. pt in w/c [wheelchair] at nurses station visiting with other residents and dog in the building. On 2/21/23 at 7:00 PM, a Health Status Note documented Note Text: pt still at nurses station in her w/c. continues with agitation. staff visiting with [resident 164] to try to calm her. pt given hs snack, cheezits. pt happy with her snack. On 2/21/23 at 7:30 PM, a Health Status Note documented Note Text: CNA found nurse in another pt room and reported [resident 164] is laying on the floor by the nurses station. Pt was laying on her back with rt [right] leg extended in front other and her left leg bent at the knee in front of her. Her w/c was behind her. pt baseline is confused and disoriented due to diagnosis of severe dementia. Pt was hollering loudly that she was in pain. Pt unable to describe what happened. Residents at nurses station reports she stood and fell . pt continued to yell and cry out in pain. pt pupils reactive to light, no red or raised areas noted to head. body assessment performed by nurse. pt able to extend her right leg, no rotation of leg or hip noted. pt unable to extend rt leg, kept in bent position. no rotation of hip noted. no other [sic] red or raised areas noted to other body parts. pt logged roll with assist times 3 using blanket into her bed. pt continues to scream out in pain. vitals [vital signs] [blood pressure] 112/69, [pulse] 84, [respirations] 18, [temperature] 97.2, oxygen sats [saturations] at 95 room air. noresp [nonrespiratory] distress noted. mental status appears at baseline. pt always confused and disoriented. Notified [name of hospice removed] of pt fall and screaming in pain. asked [name removed] hospice nurse if nurse needed to call pt daughter, [name removed] reported no she would call her. Asked [name removed] protocol for fall while pt on hospice services. Explained to hospice nurse that felt pt had a broken left hip and or leg. [Name removed] reports to nurse that no they do not send the pt to the hospital and that she would be out to facility to assess, evaluate pt at this time. pt was give prn morphine as ordered through hospice for extreme pain to left hip area. tol [tolerated] well. pt calm after receiving prn morphine. vital signs after morphine [blood pressure] 110/64, [pulse] 71, [respirations] 16, [temperature] 97.6, room air sats at 96. pt continues to guard left hip area. pt able to relax left leg after receiving prn morphine. [Note: Resident 164 received one PRN dose of lorazepam on 2/21/23 at 11:34 AM. Resident 164 had documented anxiety and agitation throughout the day on 2/21/23, prior to the fall.] On 2/21/23 at 7:46 PM, a Health Status Note documented Note Text: Received call back from Hospice nurse [name removed] reporting she notified pt daughter [name removed] and that the daughter was very upset that nurse had given her mother morphine for pain. Hospice nurse reports that she would not be out to assess the pt as the daughter was very upset and was on her way to take the pt, her mother to the ER [emergency room ] herself. explained to the hospice nurse that the daughter should not take her in a car to the ER if pt has suspected injuries or broken hip. Nurse at [name of Long Term Care (LTC) Facility removed] notified the DON [Director of Nursing] of [name of Hospice removed] of situation and nurse was instructed to send the pt to the ER via [name of Ambulance company removed] if injury suspected and not to allow daughter to take the pt to the hospital. Explained to DON of hospice company that daughter is very upset and unable to calm her daughter and explained pt was in severe pain and gave morphine under pt prn orders. DON told [name of LTC Facility removed] he would reach out to the daughter and his hospice nurse regarding the situation. Nurse at [name of LTC Facility removed] notified pt daughter [name removed] that we would be sending the pt via [name of Ambulance company removed] to [name of hospital removed] for eval [evaluation] and treatment. daughter yelling at nurse on phone so loudly that other staff could hear her, daughter upset that none of the staff here would be accompanying her mother in the ambulance to the hospital. explained we dont do that and that she would be with the EMTs [emergency medical technicians] and that the daughter could meet her at the hospital. daughter continued to raise her voice at nurse at [name of LTC Facility removed] demanding to know why her mother fell . explained to daughter that we can not provide constant 1:1 services and that [resident 164] does require a lot of supervised attention and care and cant be redirected and is a fall risk. daughter continued to be upset over prn morphine. educated daughter that pt pain non-controllable and was not going to let her suffer and cry out in pain and morphine was ordered by her hospice physician and that pt was calm after giving to her and that her vitals stable after getting this medication. daughter allowed nurse to hang up at this time as nurse needed to notify [name of Ambulance company removed] for transport to hospital. On 2/21/23 at 11:30 PM, a Health Status Note documented Note Text: Nurse called ER to check on status of pt. [Name removed] RN [Registered Nurse] reported to nurse that pt had a fractured pelvis and that they were going to finish xray to left shoulder because pt with complaints of pain to left shoulder. On 2/21/23, an Emergency Department (ED) note documented ED COURSE: Patient seen and evaluated has history of Parkinson's and also dementia by report is approximately baseline patient received morphine before coming in seems the pain at this point is controlled. CT [computed tomography] head and cervical spine were obtained which shows no acute injury she does have old compression fractures of T1 [thoracic vertebra] with T3-5 age-indeterminate but no acute abnormality of the cervical spine CT head is unremarkable x-ray of the hip obtained which shows a superior and inferior inferior [sic] pubic rami fracture but no acute hip fractures. X-ray of the shoulder is negative for any acute injury there is degenerative changes. Ortho [Orthopedics] recommends weight-bear as tolerating and follow-up with them in clinic. Patient is in a nursing home already and is already on hospice given that she is in a SNF [Skilled Nursing Facility] I think she is okay for discharge . On 2/21/23 at 11:35 PM, a Health Status Note documented Note Text: Daughter called facility and reported that left shoulder not broken and that [resident 164] was ready to be transported back to facility at this time. On 3/4/23 at 11:35 PM, a Change of Condition documented Note Text: Resident passed peacefully with dignity and respect. On 6/27/23 at 1:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident was admitted to the facility on hospice services the hospice company would bring the medications to the facility for the resident. LPN 1 stated if patients were close to death and only receiving comfort medications the facility staff would administer lorazepam for anxiety and morphine for pain. LPN 1 stated that if the resident was on other medications they would be scheduled. LPN 1 stated that she would contact the hospice company if the resident did not already have something in place for agitation and the hospice company would prescribe something. LPN 1 stated that if a resident was wandering the protocol would be to take the resident back to their room, deescalate the situation, and LPN 1 would give the PRN medication if needed. LPN 1 stated it was usually on the MAR to observe for the behaviors for medications. On 6/27/23 at 1:35 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 164 was confused a lot and always yelled help me. CNA 1 stated that resident 164 could walk with help and the walker. CNA 1 stated the other CNAs would say that resident 164 could not walk. CNA 1 stated if you asked resident 164 questions she was coherent enough to answer. CNA 1 stated that resident 164 was really anxious but pleasant and if you went in to calm resident 164 down she would be fine. CNA 1 stated that she would put resident 164 in the recliner and put a lap blanket on resident 164's lap because it made resident 164 feel safe. CNA 1 stated that resident 164's daughter always had snacks for resident 164. CNA 1 stated that resident 164 did not have medications for anxiety and resident 164's daughter did not want resident 164 on anything. CNA 1 stated it took a lot of talking to calm resident 164 down and it was all about your approach with resident 164. CNA 1 stated that she was not on shift when resident 164 fell . CNA 1 stated that she felt bad after resident 164 fell because it hurt her so bad to change her. On 6/27/23 at 1:52 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 164 was legally blind or mostly blind. The ADON stated that resident 164 was a very anxious resident and had a hard time tracking faces but recognized voices and shadows. The ADON stated that resident 164 was very impulsive and had very poor safety awareness. The ADON stated that resident 164 spent a lot of time at the nurses station so staff could keep an eye on her. The ADON stated that the night of the fall resident 164 had an impulsive event where she got up and fell . The ADON was asked about treating resident 164's anxiety and agitation. The ADON stated that in this environment they could not chemically restrain residents. The ADON stated that resident 164 was a constant challenge. On 6/28/23 at 8:43 AM, an interview was conducted with the DON. The DON stated that resident 164 admitted to the facility on hospice services and was really anxious. The DON stated that the staff tried not to sedate resident 164. The DON stated that resident 164 was moved to a room closer up the hall near the nurses station and staff would keep resident 164 parked by the water fountain. The DON stated that another resident would sit with resident 164 so staff could come and go. The DON stated that resident 164 would ask for PB&J sandwiches often. The DON stated that resident 164 was always in a wheelchair and would try to and ambulate on her own with a blanket. The DON stated that resident 164 would also try and ambulate with the wheelchair as a walker. The DON stated that the night of the fall resident 164 was alone at the nurses station. The DON stated that a resident was not with resident 164 and the nurse had just left the station to pass a medication when resident 164 had gotten up and fallen. The DON stated that resident 164 was unsupervised for two to three minutes. The DON stated that resident 164's daughter was the POA and did not want hospice to give any Ativan or morphine until the end. The DON stated that usually when a resident was on hospice services Ativan and morphine were medications that were the usual regimen. The DON stated that resident 164 had melatonin and valerian root at night that the daughter gave resident 164 for anxiety. The DON stated that she was told on admission that the daughter did not want those medications from the hospice provider. The DON stated that resident 164 did not have pain prior to the fall. The DON stated other distractions for anxiety that the facility implemented for resident 164 included a digital picture frame and television shows that resident 164 liked to watch. The DON stated that once those ran the course they would bring resident 164 out to sit with staff. The DON stated that resident 164 ate in the dining room. The DON stated that nonpharmalogical interventions were used for resident 164 and the staff could be better at documenting those interventions. The DON further stated that resident 164 did not want to be isolated in her room and resident 164 had a hard time seeing. POTENTIAL FOR HARM 2. Resident 47 was admitted to the facility on [DATE] with diagnoses which include, but were not limited to, pneumonitis due to inhalation of food and vomit, abnormalities of gait and mobility, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cognitive communication deficit, low back pain, essential hypertension, repeated falls, pain in right shoulder, and esophageal obstruction. Resident 47's medical record was reviewed on 6/26/23. On 4/5/23 at 3:53 PM, a Baseline Care was opened in resident 47's medical record but never completed. On 4/5/23 at 3:53 PM, a Morse Fall Scale documented that resident 47 was a moderate risk for falling. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 47 required supervision of one person for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, and dressing. Resident 47 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated that resident 47 was intact cognitively. The Care Area Assessments and Care Planning section documented that falls was a triggered care area and falls were addressed in the care plan. [Note: A care plan for resident 47 was not developed until 5/30/23.] On 4/14/23 at 5:40 AM, a Health Status Note documented Note Text: Resident pressed his call light and was found in bed alert and oriented. He stated he fell in the bathroom when he was trying to urinate and hit the left side of his head on the bathroom floor. There is a small laceration on the left side of his head, that has coagulated blood there, no active bleeding. Assessed resident for other injuries, none noted. No c/o [complaints of] pain at this time. Neuro [Neurological] checks done, B/p [blood pressure] 108/61, HR [heart rate] 69, temp [temperature] 97.6, resp [respirations] 18. Will continue to monitor. [Note: A care plan was not developed and no new interventions were implemented.] On 4/14/23 at 5:40 AM, an Incident Report documented . Xray of right shoulder and clavicle ordered on 4/17 [23], completed on 4/18/23. No fractures of clavicle or shoulder, both normal. On 4/15/23 at 7:43 PM, a Health Status Note documented Note Text: Post fall note form 4/14 [23]: continues to c/o pain in R [right] shoulder/clavical [sic] area, R rib/back area and R hip from fall. No further bruising or bumps noted. AAOx4 [Awake, alert, and oriented to person, place, time. and event]. Uses call light more often as requested. Falls asleep in odd positions. Many boxes and plastic containers with belongings scattered around the room. Resident walks around these obstacles and is in danger of recurring falls and injury. Continue to monitor. On 4/16/23 at 12:11 PM, a Health Status Note documented Note Text: Patient was reaching for something at the side of his bed and fell on to his left side out of bed as per patient. Patient states that he did not hit his head. This nurse found patient on floor attempting to get up. Assisted patient back to bed. This nurse assessed patient, no apparent injuries. Vitals taken, BP: 117/68 HR: 78 O2% [oxygen saturation percentage]: 97 RR [respiratory rate]: 14. MD [Medical Director], DON, ADON and Administrator notified. [Note: A care plan was not developed and no new interventions were implemented.] On 4/28/23 at 10:54 PM, a Health Status Note documented Note Text: Pt had pressed his call light and was found sitting on his bed with blood on his floor. Pt had blood in his hair on the left side of his head. When asked what happened, Pt stated that he was trying to stand up and walk to his chair when his feet got caught in his blankets and he tripped over them and hit his head. Pt stated he then got back up and sat in bed and pressed his call light to let us know. HR: 74 BP: 134/72 Temp: 98.4 RR: 18 O2 [oxygen]: 98 head injury assessed and cleansed. Vitals taken and neuros assessed with no signs of concussion or other trauma. MD notified and DON notified, pt stated no one needed to be contacted for him. [Note: A care plan was not developed and no new interventions were implemented.] On 5/4/23 at 6:32 PM, an Incident Note documented Note Text: Heard resident calling out, entered room, resident observed laying on the floor on L eft [sic] in fetal position, small amount of [NAME] blood noted to head and on floor. Resident awake and able to converse with staff. Sat resident up, denied serious pain, nausea, or dizziness. assisted to stand with 2 person assist and to get in bed. Resident denies pain in legs, hips, knees with standing. Laceration noted to L [left] eyebrow, cleansed with wound cleanser, 2 steri-strips applied, superficial abrasion to outer R ankle, tender to touch, no swelling. Initially stated he didn't know how he ended up on the floor, then stated he stood up and his L leg just gave out. Neuros initiated. VS [vital signs]: [blood pressure] 134/80, HR 74, RR 16, [temperature] 97.4, [oxygen] 93% on room air. [Name of MD removed] notified. Resident states no one needs notified on his behalf. Resident tearful and repeatedly apologizing. Re-assured resident that staff is here to help him. [Note: A new intervention was developed but not initiated until 5/30/23, when the care plan was developed.] On 5/18/23 at 9:49 PM, a Morse Fall Scale documented that resident 47 was a high risk for falling. A care plan Focus initiated on 5/30/23, documented The resident is at risk for falls r/t difficulty maintaining sitting balance, impaired balance during transitions, use of psychotropic and opioid medications, anemia, visual and hearing impairment, cognitive impairment and pain. A care plan goal documented The resident will not sustain serious injury through the review date. Interventions were initiated on 5/30/23, and included: a. 5/4/23, Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: Declutter room. b. Anticipate and meet the resident's needs. Keep frequently used items within reach. c. Educate and encourage the resident to wear appropriate footwear, such as nonskid socks or shoes, when ambulating/mobilizing. d. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. e. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. [Note: Resident 47 had four falls prior to a care plan with safety measures being implemented. Three of the falls resulted in resident 47 hitting his head and causing lacerations.] On 6/28/23 at 11:15 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 47 required minimal cares and resident 47 did a lot on his own. CNA 2 stated that resident 47 had good and bad days. CNA 2 stated that resident 47 was able to toilet himself. CNA 2 stated that he had never known resident 47 to have fallen here at the facility. CNA 2 stated that resident 47 was very knowledgeable and required reassurance with the call light. CNA 2 stated that resident 47 would fall asleep with food in his mouth and the nurses were adjusting medications. CNA 2 stated that resident 47 would go from using the walker to not using the walker but resident 47 was not a risk taker. On 6/28/23 at 11:19 AM, an interview was conducted with LPN 2. LPN 2 stated that resident 47 was very independent. LPN 2 stated that the floor nurses did the baseline care plans. On 6/28/23 at 11:35 AM, an interview was conducted with the DON. The DON stated that the nurses on admission would open the baseline care plan and start them. The DON stated the MDS coordinator would finish the baseline care plans. The DON stated that resident 47's baseline care plan had been opened but not completed. The DON stated that the baseline care plan should be closed within 72 hours. The DON stated a care plan should be completed within two weeks of admission. The DON stated if a resident had a fall a risk assessment would be completed and the interdisciplinary team would meet. The DON stated that she would update the care plan for falls and nutrition at risk. The DON stated the ADON would update the care plan for wounds and the MDS coordinator would update all other areas of the care plan. The DON stated that the safety interventions in place for resident 47 included straightening up his room and encouraging him to use his call light. The DON stated that when resident 47 was admitted he did not want to be a [NAME] on staff and the staff have had to encourage resident 47. The DON stated that resident 47 understood that now and would use his call light.

Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility did not ensure that the resident was free from abuse, neglect, and misappropriation of property. Specifically, a Certified Nurse Assistant (CNA) was witnessed to hit a resident three times and shoved incontinence wipes inside the resident's mouth during toileting cares. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (MS), systemic lupus erythematosus, paraplegia, type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease, cognitive communication deficit, pain in right hip, urge incontinence, major depressive disorder, anxiety disorder, insomnia, hypothyroidism, and polyosteoarthritis. The facility abuse investigation report documented the description of the incident as, On ,d+[DATE] C.N.A [name of CNA 1 omitted] reported that C.N.A [name of CNA 3 omitted] had asked her to help change [resident 1's name omitted] brief. It was reported that [resident 1] became combative and scratched the arm of C.N.A [CNA 3], it is reported that [CNA 3] then hit the resident 3 times. The resident then tried to bite [CNA 3], at this time it is alleged that [CNA 3] shoved wipes into her mouth and said, 'bite these'. The report documented that CNA 3 was interviewed and denied hitting resident 1 or stuffing any wipes in her mouth. CNA 3 reported that resident 1 was combative and was resisting cares and that she was inappropriate with how she spoke to the resident. The report then documented that resident 1 was interviewed and stated that she did not like CNA 3 and had stated that morning CNA 3 had grabbed her arm and hurt it. The report documented that resident 1 did not say anything about being hit or having wipes shoved in her mouth. The report documented that another CNA, not identified, had heard a commotion, and entered resident 1's room. The unidentified CNA stated that CNA 3 was inappropriate with how she was speaking to the resident but did not see her hit the resident and did not see any wipes in or around the resident's mouth. The facility determination of the investigation findings was to substantiate the allegation of abuse and CNA 3 was terminated. On [DATE] resident 1's medical records were reviewed. Review of resident 1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] documented that resident 1's Brief Interview for Mental Status (BIMS) score was a 12, which would indicate moderately cognitively impaired. The assessment documented that resident 1 had hallucinations with physical and verbal displays of the behavior occurring daily. The assessment documented that resident 1 was a two-person extensive assist for bed mobility, transfers, toileting and personal hygiene; a limited 2 person assist for dressing; and a limited 1 person assist for eating. On [DATE] at 2:47 PM, resident 1's progress note documented, Per CNA, pt [patient] is combative today. CNA reports scratching and biting type behavior. Pt has also refused to have adult brief changed. Full linen change of bed required. Bed linens soaked roughly 90% of entire fitted sheets. No documentation could be found of a skin assessment of resident 1 after the allegation of abuse was reported. On [DATE] at 8:44 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the witness to the alleged incident was CNA 1 and CNA 2. The ADM stated that CNA 2 entered resident 1's room upon hearing a commotion from the hallway. The ADM stated that CNA 2 had not witnessed anything but overheard loud noises. The ADM stated that he did not recall any exact statements that were reported or what CNA 2 had heard from the hallway. On [DATE] at 8:50 AM, an interview was conducted with the resident 1. Resident 1 stated that she had resided at the facility forever. Resident 1 asked what city they were in and when told the name of the city replied, Oh good, its where I'm supposed to be. Resident 1 stated that the staff were attentive to her needs when they finished assisting with her roommate. Resident 1 stated that her roommate thought she ruled the place and the staff would assist her after they took care of the roommate. Resident 1 was asked if any staff were mean to her or had hurt her and resident 1 replied that was when they sent me to another country. Resident 1 stated that staff assisted with brief changes, dressing, and bathing. Resident 1 stated only one hand worked and demonstrated by moving the left hand. Resident 1 stated she could not move her legs and could only move the fingers on the right hand. Resident 1 stated that she did not recall having any problems or concern with any of the aides last year. Resident 1 stated she did not recall any aides being mean to her or hurting her last year, I don't think so. Resident 1 was observed to close her eyes and did not respond to any further questions. On [DATE] at 10:31 AM, a follow-up interview was conducted with the ADM. The ADM stated that at the time he was the only person who conducted the abuse investigation, but the Director of Nursing sat in on the interviews with CNA 1 and CNA 3. The ADM stated that no other staff conducted interviews for the investigation. The ADM stated that CNA 1 reported that CNA 3 asked for help in providing incontinence care to resident 1. CNA 1 reported that during that care resident 1 scratched CNA 3's arm and CNA 3 responded by hitting the resident 3 times, on the arm and shoulder area. The ADM stated that it was described as 3 fast hits. The ADM stated that CNA 1 then reported that resident 1 had tried to bite CNA 3 and CNA 3 responded by shoving incontinence wipes inside resident 1's mouth. The ADM stated that CNA 1 reported that CNA 2 then walked into the room, and together CNA 1 and CNA 2 persuaded CNA 3 to leave the room. The ADM stated that CNA 1 did not say if the wipes were still in the mouth, but CNA 2 reported that there were no wipes in or around resident 1's mouth. The ADM stated he did not know who removed the wipes from resident 1's mouth. The ADM stated that CNA 1 reported the incident to her sister the CNA Supervisor, and together they came and reported the incident. The ADM stated that CNA 1 and CNA 2 convinced CNA 3 to leave the room and they provided the care to resident 1. The ADM stated that he then interviewed CNA 3. The ADM stated that CNA 3 confirmed that resident 1 had scratched her arm. The ADM stated that CNA 3 denied hitting resident 1 or stuffing wipes in her mouth but admitted that she may have been too bold or forward in her approach to get resident 1 to cooperate with her cares. The ADM could not say what bold or forward meant nor what was said exactly by CNA 3. The ADM stated that CNA 3 had said she was concerned about resident 1 refusing cares and had gone in with the attitude of we are going to get you cleaned up. The ADM stated that CNA 3 did not say, and he did not ask, what was said to resident 1. The ADM stated that CNA 3's demeanor and descriptions were that resident 1 needed this done and they were going to get it done. The ADM stated that CNA 3 was worried about resident 1, as she could be combative and refused cares. The ADM stated that he discussed the resident's rights to refusal with CNA 3 and if they did refuse care to report it to the nurse, and to reapproach later. The ADM stated that he did not recall what was said exactly and did not recall any other information provided in the interview. The ADM stated that he told CNA 3 that she was suspended pending the investigation and she needed to leave immediately. The ADM stated that he followed CNA 3 out the door. The ADM stated that he then interviewed CNA 2. The ADM stated that CNA 2 reported hearing loud voices from the hall, but he did not recall if she heard what was said. The ADM stated that CNA 2 went into resident 1's room and she and CNA 1 convinced CNA 3 to leave the room. The ADM stated that CNA 2 reported that she could tell that there was tension in the room. The ADM stated that CNA 2 was close with CNA 3 and liked to work with her. The ADM stated that when he interviewed CNA 3 she admitted in the altercation that she was bold and sometimes upset the residents. The ADM stated that he did not recall if he asked CNA 3 how her behavior upset residents. I'm sure I asked how it upset the resident, but I don't recall. The ADM stated that the discussion was more about CNA 3's approach. The ADM stated that he did not have any other documentation of the staff interviews other than the abuse investigation report. The ADM stated that he then interviewed resident 1. The ADM stated that initially resident 1 had reported no concerns or problems with staff, but when asked directly about CNA 3 resident 1 had said she did not like CNA 3. The ADM stated he asked resident 1 why she did not like CNA 3 and the resident replied that CNA 3 had grabbed her arm forcefully. The ADM stated that resident 1 did not report anything about getting hit or having incontinence wipes shoved in her mouth. The ADM stated he did not recall if anyone assessed resident 1 after the incident, but if they did it would be documented in the resident's electronic medical record. The ADM stated that it was part of their practice to have a nursing evaluation on any residents with allegations of abuse. On [DATE] at 11:22 AM, the Director of Nursing (DON) entered the interview with the ADM. The DON stated that Registered Nurse (RN) 1 was assigned to resident 1 on the day of the incident. The DON stated that at the time of the incident resident 1 had a roommate, but that resident was deceased now. The DON stated that the roommate was not interviewable and was not cognitively intact. The DON stated that resident 1 had advanced MS and refused cares and medications. The DON stated that resident 1 had hallucinations that people were outside of her window such as family members or her doctor or her late husband. The DON stated that resident 1 was alert and oriented times 2 to self and place. The DON stated that resident 1 was not oriented to time. The DON stated that resident 1's long term memory was intact, but she had short term memory deficits. The DON stated she did not interview resident 1 after the incident, nor did she conduct any assessments or evaluations of resident 1 after the incident. The DON stated that a weekly skin check might have been done. The DON stated that she did not instruct RN 1 to perform a skin evaluation. The DON stated that she believed that RN 1 was aware of the incident. The DON stated that the process for investigating allegations of physical abuse was that staff should inform the ADM and DON; find the responsible person and conduct interviews; take that person off the floor away from the situation; make sure there's no physical harm to either party; make sure the resident did not have any injuries; and make notifications to the state, police, and the physician. The DON stated that she did not recall if resident 1 was evaluated for any injuries. The DON stated that documentation of the evaluation for injuries would be in the resident's progress note or risk management. The DON stated that she was present for the interview with CNA 1. The DON stated that CNA 1 reported that she was helping CNA 3 with a brief change and resident 1 was yelling. The DON stated that CNA 1 reported that CNA 3 slapped resident 1 on the arm, told her to stop yelling, put peri wipes in her mouth, and told her to bite down on the wipes. The DON stated that CNA 1 observed the incident, was on the opposite side of the bed because resident 1 was a two person assist for all cares. The DON stated that there was no reason to believe that CNA 1's recollections of the incident were not accurate. The DON stated that CNA 1 had reported that CNA 2 walked in because she heard the yelling and commotion for the hall. The DON stated that CNA 2 had CNA 3 leave the resident room and then assisted with finishing the brief changed. The DON stated that she had to tell CNA 1 to compose herself, she was crying and was hysterical. The DON stated that CNA 1 had recently had a family member die in hospice care, and to witness that kind of care struck a nerve with her. The DON stated that CNA 1 was stunned and had stated that this was the first time that she had seen this. The DON stated that it surprised CNA 1 and shocked her, she did not know what to do. The DON stated she was present when CNA 3 was interviewed, and she denied everything. The DON stated that CNA 3 was asked what happened in resident 1's room and she had a flippant attitude. The DON stated that they asked CNA 3 if she slapped resident 1 on the arm or put wipes in her mouth and she denied all those actions. The DON stated that resident 1 was yelling and could be combative at times. The DON stated that resident 1 had behaviors of scratching, punching, but this was the first time biting. The DON stated that resident 1 could only use her left arm and she would throw items at the staff. The DON stated that resident 1 was indiscriminate with whom she demonstrated these behaviors with. The DON stated that staff should document behaviors in the progress notes. The DON was observed to review resident 1's skin assessments and progress notes and stated that there was no documentation of the incident. The DON stated that there were no incident reports or risk management notes that were initiated for the allegation. The DON stated that there was not an assessment of resident 1 for injuries after the incident. The DON stated that she would have been the person who notified the MD of the incident through the facility messaging app but did not have documentation of the notification. The DON stated she recalled notifying the physician shortly after the incident was reported, and the physician ordered to monitor the resident. The DON stated that they would have monitored for any injuries to the arms or any adverse reaction to the wipes being inside the mouth. The DON stated that documentation of the monitoring should be on alert charting, but they did not do any alert charting. The DON stated that she does not recall if she informed the staff of the physician's orders to monitor resident 1. The DON stated that the incident occurred when RN 1 was new and this was one of his first shifts working on his own. The ADM stated that he informed the police department, and they came out to the facility the same day. On [DATE] at 11:04 AM, a telephone interview was conducted with RN 1. RN 1 stated that he was not present for the incident between resident 1 and CNA 3 but was informed within an hour after it had occurred. RN 1 stated that it was his understanding that there was some fighting or combative behavior by resident 1 during a brief change and CNA 3 had negative words towards the resident. RN 1 stated that one of the other aides reported the incident to him, but that he did not recall who that person was as he had just started working at the facility. RN 1 stated that he did not do anything at that time, because he had heard that it was reported to leadership or the CNA Supervisor. RN 1 stated he recalled thinking someone is going to take care of it and I don't know what to do. RN 1 was read the progress note on [DATE] at 2:47 PM that was authored by him and stated that vaguely rang a bell with him. RN 1 stated that was when the negative words were reported to him but does not recall what was said only that it was harsh words. RN 1 stated that what was reported was harsh in the tone and the words used. RN 1 stated that he did not have any concerns with abuse at the time and understood the frustration. RN 1 stated that now with more experience he would characterize the report as abuse and would require leadership involvement. RN 1 stated that the process for reporting allegation of abuse was to file a grievance and give it to the grievance officer, and then notify the DON and ADM. RN 1 stated that after the incident was reported he did not immediately assess resident 1. RN 1 stated that he checked on resident 1 later, and she was still combative. RN 1 stated that resident 1 was holding her stuffed animal and did not want to be assessed or talked to. RN 1 stated that he did not perform a physical assessment of the resident, because she would not allow it. RN 1 stated that resident 1 was alert and oriented to person, sometimes place, sometimes time of day, but situation was impaired. RN 1 stated that resident 1's memory was poor, and she had short- and long-term deficits. RN 1 stated that resident 1 had behaviors of yelling, scratching, combative verbally, and throwing items. RN 1 stated that resident 1 had delusions and would say that certain medication was not ordered by her doctor, and we needed to contact a different doctor. RN 1 stated that he had seen hallucinations documented for resident 1 but had not experienced it directly. RN 1 stated that no one in administration had talked to him about the incident, but he thought he may have spoken to the CNA Supervisor about it. On [DATE] at 2:34 PM, an interview was conducted with CNA 1. CNA 1 stated that on [DATE] CNA 3 had asked for assistance with a brief change. CNA 1 stated that resident 1 required 2 staff for assistance. CNA 1 stated that resident 1 sometimes refused cares and could be combative. CNA 1 stated resident 1 refused cares frequently, and she became combative 95% of the time with cares. CNA 1 stated that resident 1 would hit the staff. CNA 1 stated that resident 1 and CNA 3 were having issues with each other that day, and for whatever reason resident 1 did not want CNA 3 to take care of her. CNA 1 stated that resident 1 was already being aggressive and cranky and that was why CNA 3 asked for help. CNA 1 stated that when they walked into resident 1's room, CNA 3 told the resident they needed to change the bedding. CNA 1 stated that CNA 3 was not exactly nice when speaking to the resident. CNA 1 stated that CNA 3 had said we have to change your brief and recalled CNA 3 was ornery with the resident. CNA 1 stated that resident 1 responded to this by saying no, that she did not need to be changed, and that she was not wet. CNA 1 stated that they knew she was wet and could smell her. CNA 1 stated that resident 1 was agitated and did not want them in there. CNA 1 stated that she was not sure if resident 1 truly did not know if she was wet or if she was just refusing care. CNA 1 stated that when resident 1 told CNA 3 no to the incontinence care, CNA 3 responded by telling resident 1 she did not have a choice and it needed to be done. CNA 1 stated that resident 1 kept saying no and it became a verbal confrontation between the resident and CNA 3. CNA 1 stated she tried to intervene and said that she could do the brief change alone and told CNA 3 twice that she could leave. CNA 1 stated at this point CNA 3 became short tempered with resident 1 and hit her 3 or 4 times. CNA 1 stated that CNA 2 heard the commotion, entered the room, and they told CNA 3 multiple times that they would finish with resident 1's care. CNA 1 stated that CNA 3 hit resident 1 on the upper arm near the biceps. CNA 1 stated that resident 1 was already positioned on her right side and CNA 3 hit resident 1's left arm. CNA 1 stated that resident 1 scratched CNA 3 a couple of times after she was hit in an attempt to protect herself. CNA 1 stated that while resident 1 was still on her side she attempted to bite CNA 3. CNA 1 stated that CNA 3 responded by shoving incontinence wipes in resident 1's mouth and said, bite on this. CNA 1 stated that she was on the left side of the bed behind the resident and CNA 3 was on the right side in front of resident 1. CNA 1 stated that resident 1 was yelling out to leave her alone and not touch her when she was hit, and then resident 1 tried to fight back. CNA 1 stated that on a scale of one to ten with one being a light tap and ten being full force, the hits would be a 7. CNA 1 stated that the hits left red marks on resident 1 but did not recall if it bruised. CNA 1 stated that resident 1 did not actually make contact with the bite, and afterwards the resident pulled the wipes out of her mouth. CNA 1 stated that was when she and CNA 2 told CNA 3 to leave the room. CNA 1 stated that CNA 3 kept saying that she was not going to leave and that resident 1 was her assigned resident. CNA 1 stated that they were insistent that CNA 3 leave the room. CNA 1 stated that afterwards she and CNA 3 finished the brief and linen change they tried to console resident 1. CNA 1 stated that resident 1 was upset, half crying and half whining about what just happened. CNA 1 stated that she believed that CNA 2 witnessed one of the hits and was present when CNA 3 put the wipes in resident 1's mouth. CNA 1 stated that she had never heard of or witnessed any incidents with CNA 3 before, and that she had previously assisted CNA 3 with resident 1's care. CNA 1 stated that prior to the incident the working relationship with CNA 3 was good, and she thought she was a really good aide. CNA 1 stated that at the time of the incident she had only been working at the facility for ,d+[DATE] weeks. CNA 1 stated that after the incident she reported it to the CNA Supervisor. CNA 1 stated that initially she went to the bathroom and cried. I was so dumbfounded that it happened. CNA 1 stated that it was no more than 15 to 20 minutes after the incident occurred that she reported it to her supervisor, and she went to her supervisor first because she was her sister. CNA 1 stated that the CNA Supervisor went to the ADM and DON to report the incident. CNA 1 stated that she did not report anything to the nurse, but only spoke to the CNA Supervisor, ADM and DON regarding the incident. On [DATE] at 4:01 PM, a telephone interview was conducted with CNA 2. CNA 2 stated that she heard CNA 3 yelling from the nurse's station and that was what prompted her to go into resident 1's room. CNA 2 stated she could not hear what was said, just heard loud noises and automatically reacted. CNA 2 stated that when she entered the room, she saw CNA 1 and CNA 3 trying to get resident 1 changed. CNA 2 stated that she helped CNA 1 finish resident 1's brief change. CNA 2 stated that resident 1 was upset, and that was all that she could remember. CNA 2 stated that resident 1's body language was tense, but she was not crying. CNA 2 stated that CNA 3 was upset so her focus was getting CNA 3 removed from the situation. CNA 2 stated that CNA 3 was agitated. CNA 2 stated that resident 1 had been hard to change, and it was not a new problem. CNA 2 stated that resident 1 would hit, throws things, was verbally combative, and throws food trays. CNA 2 stated that when resident 1 behaved this way they were to respond by approaching again later. CNA 2 stated that the process for assisting combative residents who were refusing cares was to approach again later and then notify the nurse so they can document the refusal of care. CNA 2 stated that she did not recall if CNA 3 said anything, but that she knew that she was frustrated. CNA 2 stated that she could not recall if CNA 3 touched resident 1, and not that I know of did the resident have wipes in her mouth. CNA 2 stated that after she left resident 1's room she did not report the incident to anyone, because she did not know what was going on. CNA 2 stated she had heard loud noises, knew that CNA 3 was agitated and frustrated, and they needed to get her out of the room. CNA 2 stated she talked to the ADM and DON about the incident on the same day after it occurred. CNA 2 stated that with any possible situation of abuse they were to report it to the ADM or DON. On [DATE] at 10:39 AM, a telephone interview was conducted with the CNA Supervisor. The CNA Supervisor stated that she was notified of the incident by CNA 1. The CNA Supervisor stated she was off the clock and had already gone home at the time of the notification. The CNA Supervisor stated that CNA 1 had asked her to return to the facility, and when she arrived CNA 1 was outside crying and was devastated. The CNA Supervisor stated that CNA 1 had reported that she and CNA 3 had gone to change resident 1's brief, and the resident started getting upset which was common for her. The CNA Supervisor stated that CNA 1 had said that resident 1 had hit CNA 3 and CNA 3 retaliated by hitting the resident back and had stuffed wipes in the resident's mouth to get her to shut up. The CNA Supervisor stated that it was her understanding that CNA 3 had hit resident 1 three separate times, but she was not sure if it was on the arm or head. The CNA Supervisor stated that at this point she told CNA 1 that the ADM and DON needed to be informed and that she accompanied CNA 1 with the notification. The CNA Supervisor stated that she had no other involvement with the facility investigation. The CNA Supervisor stated that she assisted resident 1 a couple of days after the incident and the resident was pretty shaken up. The CNA Supervisor stated that resident 1 was selective about which aide she would allow to provide care to her. The CNA Supervisor stated that 2 days later she had asked resident 1 if she could change her, and resident 1 responded by asking if she was going to hurt her. The CNA Supervisor stated that this was a new behavior for resident 1. The CNA Supervisor stated that she responded by telling resident 1 that she was not going to hurt her and that she was just going to change her brief. The CNA Supervisor stated that resident 1 was particular about who she allowed to assist her with cares. The CNA Supervisor stated that resident 1 did not want the other aide to assist with the care that day, so they got another aide to help. The CNA Supervisor stated that resident 1 was then fine with the incontinence care. The CNA Supervisor stated that resident 1 was particular with taking it slow, asked what we were going to do to her, wanted a step-by-step account of what was going to happen, and if it was going to hurt. The CNA Supervisor stated that with resident 1 they always had to tell her what they were going to do, but the question of are you going to hurt me or will this hurt was a new behavior. Review of the facility Abuse Policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish or deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. The policy documented that all occurrences of resident abuse, suspected abuse, neglect and injuries of unknown source shall be promptly reported to the facility abuse coordinator for investigation. The policy stated that should an incident of resident abuse be reported, the Administrator, shall conduct an investigation of the alleged incident, and if abuse happened the nurse shall assess and treat the victim. The policy was last revised on ,d+[DATE].

Based on observation, interview and record review it was determined, for 2 of 52 sample residents, that the facility did not ensure that a resident who displayed or was diagnosed with a mental disorder or a psychosocial adjustment difficulty, or who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, one resident with severe depression was not provided behavioral care and services to meet her emotional or physical needs. This was cited at a Harm level. Another resident did not receive counseling services. Resident identifiers: 11 and 13. Findings include: HARM 1. Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During resident 13's stay, additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/13/21 at 3:17 PM, resident 13 was interviewed. Resident 13 stated that she had been severely depressed while at the facility. Resident 13 stated that she had refused some cares from staff. Resident 13 stated that it would be nice to have staff to talk to her in the afternoon some time. Resident 13 stated The other day one helped me hang some clothes up. On 9/13/21 at 3:17 PM, resident 13's room smelled strongly of urine. On 9/16/21 at 2:47 PM, resident 13's room smelled strongly of urine. On 9/16/21, resident 13's medical record was reviewed. Resident 13's care plan included the following: a. Focus: Refusal of cares or assistance with cares was initiated on 2/5/21. Targeted behaviors monitored daily a) withdrawal from activities b) tearfulness/crying c) verbalization of sadness, and refusal of cares(personal hygiene, etc ). This intervention was initiated on 2/17/21. b. Focus: The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) mental illness, refusal of or delayed self care, poor motivation to participate in self care, initiated on 8/25/21. Interventions included .Encourage the resident to discuss feelings about self-care deficit . c. Focus: Self care deficit related to: decreased motivation, energy deficit, environmental barriers. Resident will participate as able in ADL's and have all basic self care needs met at all times through next 90 day review. Initiated on 2/17/21. Interventions included assist patient in accepting necessary amount of dependence, encourage resident to do as much self care as possible, encourage use of commode or toilet as soon as possible .maintain regular toileting at set intervals and/or continence programs .support the resident to come to his or her own conclusions and offer alternatives to interventions that the resident insist he or she will not comply with. Negotiate autonomy and decision making. Adapt the plan as needed. d. Activities/Recreation Therapy: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, initiated on 2/6/21. Interventions included .The resident needs assistance/escort to activity functions. Provide 1:1 visits prn (as needed). e. Focus: Resident has mental health Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: .Document target symptoms Q (every) shift. Notify MD (Medical Doctor) of any new/worsened symptoms of mental illness that are not effectively managed with current pharmacological and non-pharmacological interventions. Follow PASRR (Preadmission Screening and Resident Review) level II recommendations .Staff should use the following non-pharmacological interventions to help manage resident's behavioral symptoms. Interventions: 1) Provide opportunities for socialization 2) Provide encouragement, support and active listening 3) Encourage resident to follow her self-identified approaches on her safety plan 4) Resident likes to have a sense of control over care. Honor resident's preferences for care provision to the extend possible. If she refuses care, return and offer care again later. The (date) Treatment Administration Record (TAR) for resident 13 revealed that tracked behavior was Number of expressions of hopelessness. No tracking of withdrawing from activities, tearfulness/crying, verbalization of sadness were tracked. Refusal of cares was tracked under specific tasks. Resident 13 had a PASRR II level 2 for a serious mental health illness completed on 6/25/2020. The anticipated stay in the facility was less than 30 days, so a PASRR II was not to be completed at that time. On 2/3/21, after a change in condition that required hospitalization , the PASRR II was completed. The PASRR II revealed that resident 13 was too medically complex for two behavioral health units. Resident 13 has been refusing to complete toiletry. She is capable of toileting on her own, but she is depressed and has stated that toileting is what she feels she 'has control over'. The control she chooses to exercise is to not toilet and sit in her urine and feces for days. The odor is extreme and makes it difficult for staff to care for her; it rises to the level of making them physically ill and burning their eyes when they go into the room. [Resident 13] also now has skin breakdown from sitting in this and has wounds from her thighs to her upper back. The PASRR II recommended including family in cares and fostering positive relationships with a former activities director (who is no longer working at the facility) and a night nurse. The PASRR II stated that Applicant/Resident requires at least substantial physical assistance with activities of daily living about the level of verbal promptings, supervising, or setting up; . Resident 13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 5/12/21, resident 13 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: Resident 13 received the consultation on 7/23/21.] b. On 8/13/21, Wound Care: Bilateral buttocks, Coccyx, right thigh rear and left thigh rear : Apply Chamosyn Ointment every shift. On 9/16/21, a weekly skin assessment revealed, Pt. (patient) and CNA (Certified Nursing Assistant) state red open area's (sic) on bil (bilateral) Buttox cheeks, refused assessment of buttox (sic). Ointment was to be applied with brief changes and as needed. A skin assessment on 9/2/21 revealed that the wounds were caused by moisture associated skin damage (MASD). A monthly assessment completed on 8/14/21, revealed that resident 13 required assistance for transfers, that her emotional state was withdrawn and interferes with care. The skin condition was dry and fragile and resident 13 regularly declines to permit skin assessment or skin care/treatment . CNA tasks for resident 13 revealed the following: a. Brief changes for the past 30 days revealed that CNAs assisted resident 13 with brief changes 20 times. b. CNAs provided assistance with toilet use 13 times in the past 30 days. c. Resident 13 refused cares 7 times in the past 30 days. A safety plan for resident 13, printed on 1/28/21, included the following warning signs: 1. Isolating, 2. Not wanting to get out of bed, 3. Annoyed. The plan further revealed activities to help resident 13 take her mind off problems included craft stores, crochet, lunch with friends, going for drives and reading. Nursing notes were reviewed. Additional mental health concerns were noted before May. However, for brevity, notes beginning in May, 2021 were included and revealed the following: a. On 5/3/21 at 3:43 AM, Resident still has not gotten OOB (out of bed). Room has strong foul odor, urine saturating clothing and bedding and running on to floor. b. On 5/4/21 at 4:15 PM, CSW (Certified Social Worker) in resident room to complete MDS (Minimum Data Set), The room had a foul odor. Resident was in bed and there were about five flies moving around her body. CSW asked when she's showered last and she reported last Tuesday. CSW let her know that it was time to shower again. CSW opened the window to air the room out. Education provided on hygiene and health concerns. Resident said she can shower herself and would get it done tonight. CSW told her I would f/u (follow up) in the morning . c. On 5/5/2021 at 6:16 PM, Resident did not get up during the whole shift. The odor was so strong the urine was seeping through the bed. Unable to do wound treatment. Will continue to encourage resident to comply with wound care and personal hygiene. d. On 5/8/21 at 5:37 PM, Resident, again, did not get OOB this entire shift despite several promises to get up and shower. Resident has refused all attempts by several staff members to assist her with hygiene cares. Bedding is severely soiled all around resident. Linens had to be placed at foot of residents bed to stop urine from running across floor. Multiple flies are in room. Odor from room is so severe a resident across the hall had to change rooms d/t (due to) odor causing nausea. Resident's window is opened in effort to air out room. e. On 5/14/21 at 4:46 PM, a skin/wound note revealed that resident 13's last wound assessment was on 3/18/21. f. On 6/2/21 at 5:59 PM, Resident has refused all attempts by staff to assist her with hygiene cares. Has refused to get OOB this entire shift to use the bathroom or to clean herself. Bed is noticeably soiled . g. On 6/3/21 at 2:43 PM, Resident has yet to get OOB and shower despite promises . Nurse with resident that she appears to be [NAME] like she usually does and resident stated, 'I know and I'm just disgusted with myself but I can't help it.' Resident then began crying and asked to be left alone . h. On 6/4/21 at 5:28 PM, Resident got out of bed today. She had dripping feces coming out of her [pant] leg. Feces in the bed and on the floor. We got her to the bath room and showered her off. Had to wash over her body 3 or 4 times to get the feces off her skin. She has skin break down all over her body . i. On 6/4/21 at 5:42 PM, Wash her heel look at the heel some skin loss due to sitting in feces . j. On 6/5/21 at 2:42 PM, .She has sore[s] all over due to sitting in her feces . k. On 6/6/21 at 9:44 AM, resident complaining of pain due to pressure ulcers all over her body.she is at risk for [CONDITION(S)] due to sitting in her feces and refusing to get changed for over three weeks . l. On 6/6/21 at 2:33 PM, Open sores on both hips, down the back of both legs, on her bottom and between her thighs. m. On 6/25/21 at 8:21 PM, resident 13 had MASD on thigh. Completed an application for psych evaluation. n. On 6/30/21 at 5:14 PM, resident 13 refused to get up. The mal odor is coming from resident room can be smelled in the hallways and the nursing station . o. On 7/4/21 at 5:41 PM, Resident did not get up from her chair during the whole shift. There is urine dripping from resident chair to the floor. The mal odor is coming from resident room can be smelled in the hallways and the nursing station . p. On 7/8/21 at 12:48 PM, Patient remains sitting in recliner soiled with urine and feces. Wound doctor here, patient refused wound cares. q. On 7/9/21 at 1:22 PM, .Resident had crying bouts for 1/2 hour about how she is scared to get up and how she worries all the time . r. On 7/10/21 at 12:35 PM, Resident cried a little, said it is really hard to get up everyday she feels anxious all the time and has down days where she just wants to sleep all day . s. On 7/16/21 at 4:52 PM, Resident got up after sitting in her feces for 4 days refusing any changing and refusing to get up and get showers. She has sores running down her bottom . t. On 7/18/21 at 5:14 PM, Resident refused wound treatment during this shift. She did not get out of her chair during this shift . u. On 7/19/21 resident 13 had a mental health counselor screening appointment. v. On 7/23/21 resident 13 had a mental health counseling appointment. w. On 7/24/21 at 5:21 PM, Resident decided to get out of bed and take a shower. Her bed was soaking with urine and BM. residents clothes were also soaked. She has refused every shift for 4 days . A skin and wound note from 7/24 revealed .She feels down and doesn't feel good enough to get up. Resident has not been up or changed in over 4 days. Resident just sits in her feces and refuses to get up. Resident stated that she had called her behavior med counselor and tried to cancel it because she was not out of bed. counselor came anyways. Resident stated she wanted to get up after lunch . x. On 8/1/21 at 5:43 PM, Resident did not get out of her chair during this shift. Was unable to do wound care . y. On 8/3/21 at 4:08 PM, Resident got out of chair Chair is saturated with feces and urine. Administration knows about the chair. Covered with clean blankets and pads. Resident has wounds on bottom due to sitting in her feces She was feeling down and didn't want to get up. Resident stated she was not feeling well mentally and physically. After resident got cleaned up she felt better z. On 8/6/21 at 5:07 PM, resident refused to get up . Resident was feeling down and anxious today. Resident was feeling overwhelmed and tired. She has been sitting in her chair for three days. She is sitting in her feces and urine. The odor is strong and other residents are complaining about the smell . aa. On 8/7/21 at 7:00 PM, . Resident has been sitting in her feces and urine for 4 days. odor was strong. Chair resident sits in is soak[ed] with urine and feces. Management is aware of the situation with the chair. Her wounds have reopened up and are bleeding . bb. On 8/12/21 at 4:20 PM, .Resident did not get OOB to shower and has not been out of recliner since early yesterday morning . cc. On 8/13/21 at 5:36 PM, Resident was sitting in her urine and feces for three days. She refused to get up. Resident stated she wasn't doing well mentally and couldn't take care of her self. So decided to just sit in her urine . She has sores all up and down her legs and in between her bottom. resident refused to see the wound doctor yesterday .Resident had an appt. with councilor (sic) today. It went well resident stated. she feels better mentally and physically today . dd. On 8/15/21 at 4:55 PM, Resident refused treatment she did not get out of her chair during this shift. ee. On 8/19/21 at 2:29 PM, Resident refused scheduled appointment with wound specialist today resident has refused to get OOB so far today to allow cares. ff. On 8/26/21 at 6:56 PM, Resident continues to refuse to allow wound MD to reassess wounds. gg. On 9/2/21 at 6:24 PM, Wound MD attempted to reassess resident's wounds but she continues to refuse all care by him. hh. On 9/3/21 at 12:09 PM, the wound specialist dismissed resident 13 from services due to refusal of assessments. ii. On 9/5/21 at 5:52 PM, Resident did not get [out] of her chair during this shift. She stated that she was going to get up during this shift but it did not happen. Unable [to] do wound treatment. jj. On 9/7/21 at 5:44 PM, Resident did not get [out] of her chair during this shift. Unable [to] do wound treatment. kk. On 9/12/21 at 5:27 PM, Resident did not get out of her chair during this shift . Un able to do wound treatment . ll. On 9/14/21 at 8:33 AM, Resident refused to allow staff to assist her to get cleaned up. On 9/16/21 at 8:51 AM, Certified Nursing Assistant (CNA) 9 was interviewed. CNA 9 stated that resident 13 did not ask for help, and therefore CNA 9 did not see her very often. CNA 9 stated that she did not really know resident 13 well. On 9/16/21 at 9:01 AM, CNA 6 was interviewed. CNA 6 stated that she did not assist resident 13 with many tasks. CNA 6 stated that she took resident 13 her breakfast and lunch but did not assist resident 13 with any other tasks. On 9/16/21 at 9:07 AM, CNA 2 was interviewed. CNA 2 stated that resident 13 had depression, so the CNAs tried to get her out of her room. CNA 2 stated that resident 13 did not push her call light very often. CNA 2 stated that if resident 13 did not press her call light, the CNAs would let resident 13 do tasks on her own, and just took her meals. CNA 2 stated that the Resident Advocate (RA) and activities staff did more with resident 13. On 9/16/21 at 10:54 AM, the Activities Director (AD) was interviewed. The AD stated that resident 13 colored in her room and staff assisted her with her mail. The AD stated that resident 13 was invited to activities, but if resident 13 was depressed, she stayed in her room. The AD stated that she had only seen resident 13 out of her room [ROOM NUMBER] or 4 times. The AD stated that resident 13 had one-on-one activities in her room that were to happen weekly, but the AD could not always get to resident 13 every week, so activities happened every other week. On 9/16/21 at 11:40 AM, the Resident Advocate (RA) was interviewed. The RA stated that she was recently hired, and had been working to resolve old grievances, and finding missing items, helping with PASRRs, discharge planning, care conferences, and anything that popped up. The RA stated that she was familiar with a select group of residents for which she was the guardian, and was not familiar with all the residents in the facility. The RA stated that resident 13 was one of her residents, but the RA was not familiar with her. The RA stated that resident 13 had not had any needs that she's made known to the RA. The RA stated that she was not informed about any of resident 13's issues. On 9/16/21 at 12:04 PM, the Regional Nurse Consultant (RNC) was interviewed. The RNC stated that she was aware resident 13 had counseling, but during the pandemic, the counselors were not coming to the facility very often. The RNC stated that the previous social worker had not created progress notes for residents, so staff was unaware if anything was being done. The RNC stated that they wished resident 13 would have been able to go to a psychiatric unit, but resident 13 had medical issues that did not allow her to be admitted to the psychiatric unit. The RNC stated that resident 13 just wanted to be left alone. The RNC stated that resident 13 refused treatments and services because she just doesn't care. The RNC stated that when resident 13 met with a counselor and it really helped. POTENTIAL FOR HARM 2. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/14/21 at 10:42 AM, an interview was conducted with resident 11. Resident 11 stated that he had depression and wanted to see a counselor. Resident 11 stated he had not seen a counselor for a few years. Resident 11's medical record was reviewed on 9/16/21. A quarterly MDS dated [DATE] revealed that resident 11 scored 9 on the Patient Health Questionnaire-9 (PHQ-9). The score revealed that resident 11 had mild depression. A care plan dated 9/30/19 revealed MOOD/DEPRESSION- [Resident 11's] PHQ severity score was 11/27. Depression causal factors include: Anxiety and MDD (major depressive disorder) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident presents with symptoms of depression during the PHQ interview including: Feeling depressed; trouble sleeping - as a result feeling tired; and trouble concentrating when too much stimulus present. A goal developed was [Resident 11] will engage in mental health treatment and work on improving mood state and outlook, through next review. An intervention developed on 9/30/19 and revised on 8/14/2020 revealed [Resident 11] is currently participating in counseling services; encourage resident to continue to engage in therapy services. A Preadmission Screening Resident Review (PASRR) level II dated 2/13/19 revealed recommendations for Specialized Services for mental health treatment was Please refer to psychotherapy and psychiatric consultation. Resident 11's progress notes revealed the following entries: a. On 4/27/21 at 11:07 AM, CSW (Clinical Social Worker) met with [resident 11] to complete the quarterly MDS & discharge summary. [resident 11] is oriented and verbally responsive. BIM (sic) (Brief Interview of Mental Status) Score is 10. Resident appears to be frustrated with his level of care, he lists many complaints and unresolved concerns. PHQ 9 score is 9. [Resident 11] has a PASRR L2 LTC (level 2 Long Term Care) letter of determination. He is diagnosed with Anxiety & Depression. b. On 6/23/21 at 10:07 AM, Received and order to refer to counselor/social worker on regular basis. On 9/16/21 at 3:48 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that resident 11 was receiving services for therapy weekly until the pandemic hit. The RNC stated that the last time resident 11 received therapy was in March 2020. The RNC stated that she called a behavioral health company and the staff member was out of the office for a week. The RNC stated that facility staff would continue to work on getting resident 11 services. The RNC stated she did not know why resident 11 was not receiving therapy services.

Based on interview and record review, it was determined the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, 1 of 6 sample residents sustained a significant injury following an improper transfer utilizing a hoyer lift. Resident identifier: 1 Based on corrective measures taken by the facility, the non-compliance was determined to be past non-compliance. Corrective measures were implemented by 4/20/19. Corrective measures included: Staff training immediately following the incident and termination of the employee responsible for the incident. (Note: During the facility's recertification survey on 10/24/18, no deficient practice was identified related to accidents involving residents. During the abbreviated complaint survey on 6/25/19, no deficient practice was identified related to accidents involving residents.) Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's progress notes documented the following entries: a. Discharge Summary note dated 4/20/19 at 6:40 PM; Note Text: Pt (patient) transferred via EMS (emergency services) at approx. (approximately) 1840 (6:40 PM) for evaluation s/p (status [REDACTED]. awaiting pt status update. b. Incident Note dated 4/20/19 at 6:52 PM; . Incident Summary: Nurses were giving report at the end of shift, nurses at station B heard CNAs (certified nursing assistants) call for help, Resident was found lying on floor and on the hoarer (sic) lift, the aid attending to the resident was assisting alone while using the lift and the resident was dropped and fell forward onto the hoar (sic) lift, hitting her head and cut it open on the left side by her temple. There was a laceration the (sic) was 3in (inches) in size on the left side and skull was noticeable. pupils were equal and responsive to light. EMS was called and transferred resident to the emergency room . Hospice was called and notified and family members were notified, the resident did not express any pain or discomfort but is also non verbal. c. Incident Note dated 4/20/19 at 11:20 PM; . Incident Summary: Resident returned from ER (emergency room ) visit approx 23:10 (11:10 PM) Dressing to top of head CDI (clean, dry, intact). Resident assisted to bed using mechanical lift and two person assist. Resident guarding L (left) arm, facial grimacing noted. PRN (as needed) [MEDICATION NAME] administered for pain. Neuros (neurological assessments) WNL (within normal limits) for this resident. VSS (vital signs stable). Bed in lowest position with bilateral fall mats in place . d. Incident Note dated 4/21/19 at 12:11 AM; Incident Summary: New orders from ER include [MEDICATION NAME] antibiotic, leave current dressing in place for 24 hours, then daily dressing changes, f/u (follow up) with PCP (primary care physician) in 1 week for assessment for staple removal . Will clarify date of staple removal with (physician) or resident's hospice nurse once they have been able to assess the laceration. Resident 1's Minimum Data Set (MDS) assessment, dated 4/7/19, documented that she was totally dependent upon staff and required the physical assistance of at least two people while transferring. (Note: This assessment was completed prior to resident 1's improper transfer on 4/20/19 with physical assistance provided by one person.) Resident 1's Nursing - Daily Evaluation, dated 4/19/19, documented that she was totally dependent upon staff and required the physical assistance of at least two people while transferring. (Note: This assessment was completed prior to resident 1's improper transfer on 4/20/19 with physical assistance provided by one person.) On 6/25/19 at 2:35 PM, Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was trained by one of the more senior CNAs on how to properly use the hoyer lift and two people were always required while transferring a resident with the hoyer lift. CNA 1 further stated resident 1 required total assistance and staff had to do everything for her. In addition, CNA 1 stated resident 1 had required the hoyer lift for transfers for at least a year. On 6/25/19 at 2:42 PM, CNA 2 was interviewed. CNA 2 stated she knew the level of assistance each resident required based on the Kardex, which was a resource that contained detailed information related to the needs of each resident. CNA 2 stated when the hoyer lift was used to transfer a resident, two people were required at all times, and she was trained on how to use the hoyer lift by the CNA Coordinator and Director of Nursing (DON). In addition, CNA 2 stated there was an inservice approximately a month prior specifically related to transferring residents using the hoyer lift. CNA 2 further stated the Kardex specified that resident 1 required the hoyer lift for transfers and was totally dependent on staff for assistance. The facility Kardex was reviewed with CNA 2 related to resident 1's level of assistance with transferring. The Kardex documented the following information: Transfers . Hoyer lift with 2 person assist using sling. On 6/25/19 at 2:50 PM, CNA 3 was interviewed. CNA 3 stated she was trained by one of the more senior CNAs on how to properly use the hoyer lift and two people were required while transferring a resident with the hoyer lift. CNA 3 further stated resident 1 required the hoyer lift for transfers. On 6/25/19 at 3:00 PM, CNA 4 was interviewed. CNA 4 stated the CNA responsible for resident 1's improper transfer assisted resident 1 by himself. CNA 4 further stated the CNA responsible disconnected resident 1 from the hoyer lift, did not have her positioned correctly, and she fell forward out of her wheelchair and onto the lift. In addition, CNA 4 stated the CNA responsible had been terminated and the situation was taken very seriously. Immediate Inservice Hoyer Lifts documentation, dated 4/20/19, documented that staff were trained on the following information immediately following the incident involving resident 1: 1. All transfers involving a mechanical lift require 2 staff members, no exceptions. There is NOT any situation in which it would be okay to operate a mechanical lift alone. 2. Failure to adhear (sic) to this policy will be subject to disciplinary action up to and including termination. 3. This policy is imperative for the safety of our patients and our staff. (Note: The inservice documentation was signed and dated by nursing staff and CNAs on 4/20/19, 4/21/19, and 4/23/19.) On 6/25/19 at 3:33 PM, the DON was interviewed. The DON stated staff were trained on how to properly use the hoyer lift upon orientation, annually, and when any issue arises. The DON further stated the Kardex was utilized in order to communicate each resident's level of assistance and is generated based on a variety of assessments. In addition, the DON stated the CNA responsible for resident 1's improper transfer assisted resident 1 by himself, attempted to reposition her from behind while she was in the sling, she fell forward onto the leg of the hoyer lift, and sustained a laceration to the side of her forehead. The DON further stated other staff members were available at the time of the transfer and the CNA responsible did not request assistance from a second person. The DON further stated the CNA responsible provided a statement indicating that he was going off shift and was trying to complete the transfer quickly.

Based on interview, record review, and observation, the facility did not ensure that 5 of 51 sample residents received adequate supervision and assistance devices to prevent accidents. In addition, the facility did not ensure that the resident environment remained as free from accident hazards as possible. Specifically, residents 3 and 72 were injured while being assisted by staff. The deficient practice identified for these 2 residents will be cited at a harm level. In addition, one resident experienced a fall while being transferred in a Hoyer lift, and observations of staff indicated that current staff practices with regard to proper Hoyer lift use were unsafe. In addition, chemicals were left out in an area residents had direct access to. Resident identifiers: 3, 38, 69, 72, and 102. Findings include: HARM 1. Resident 72 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 7/11/17 at 7:40 AM, an interview was conducted with resident 72. When asked how her stay was at the facility, resident 72 stated that she was upset that facility staff had broken her ankle recently. When asked to elaborate, resident 72 stated that two therapists had come to her room to wheel her down to the therapy room. Resident 72 stated she was seated in the wheelchair, but was using her feet to help propel herself in the hallway. Resident 72 also stated that at some point during the transport from her room to the therapy room, one of the therapists gave me a shove and my right foot got caught under the wheelchair because there weren't any leg rests on it. then it (the resident's leg) was dragging. It got stuck under there (the wheelchair) twice . I can't forget it, it was too painful. At this point, resident 72 began to cry. Resident 72 then stated, The pain was so severe I get emotional . now it's six weeks extra that I have to stay here because they broke my ankle. On 7/12/17 at 12:00 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that on 6/12/17, which was a Monday, resident 72 was being wheeled into the therapy gym. UM 1 stated that resident 72 had her legs extended and elevated because therapy was attempting to strengthen the quadriceps muscles of resident 72's legs after her bilateral femur fractures. UM 1 stated that resident 72 dropped her foot at when the therapist entered the therapy room, and her foot was caught under the wheelchair, and the therapist picked her foot up. UM 1 stated that resident 72 began to complain of pain on Wednesday, two days later, so facility staff weren't sure when the fracture actually occurred. Progress notes for resident 72 were reviewed and revealed the following: a) 6/14/17 at 10:07 AM: Message left with (name of medical assistant), MA (medical assistant) for her to get a message to one of the Dr's (doctors) or PA's (Physician's Assistants) concerning the increase (sic) pain the resident is complaining of in her right leg. b) 6/14/17 at 2:57 PM: Administered Tylenol per pt (patient) request for pain. c) 6/14/17 at 4:06 PM: . The resident stated that it is her rig ht (sic) ankle that is hurting . (Note: No documentation could be located in the resident's progress notes to indicate that resident 72's foot had become lodged underneath the wheelchair during transport on 6/12/17, nor did the notes indicate that a nurse had assessed resident 72 at that time.) A radiology report dated 6/25/17 revealed that resident 72 had An acute fracture of the distal tibial with mild displacement. Resident 72's June 2017 Medication Administration Record (MAR) was reviewed. The MAR indicated that prior to the incident on 6/12/17, resident 72 had requested Tylenol for pain one time, on 6/3/17. After the incident, beginning 6/13/17 and ending 6/30/17, resident 72 requested Tylenol for pain 19 times. In addition, the MAR indicated that resident 72 had not requested Tramadol for pain during June 2017, until one occasion on 6/13/17, which was after the incident. On 7/12/17 at 2:30 PM, an interview was conducted with Physical Therapy Aide (PTA) 1. PTA 1 stated that he was functioning in the role of the Therapy Director at the facility. PTA 1 stated that resident 72 was alleging that Certified Occupational Therapy Assistant (COTA) 1 broke her foot on 6/12/17. PTA 1 stated that the resident did not complain of pain at that time. PTA 1 confirmed that resident 72's leg rests were not on the wheelchair at the time of the transport on 6/12/17 because therapy staff were trying to get the resident to use her legs. A report written by COTA 1 dated 6/26/17 was reviewed. COTA 1 documented the following: On 6/12/17, I was transporting pt (patient) (resident 72) from room to gym and informed pt we were using w/c (wheelchair) w/o (without) leg rests to (increase' BLE (bilateral lower extremity) strength/endurance. In gym, pt lowered BLE's on carpet while w/c still moving slowly, BLE's slipped under w/c to a stop. Pt c/o (complained of) some pain but appears to be fine. She continued (with) therapy and tolerated standing frame (with) 12 minutes no problem, also Nu-step (for) 10 minutes. It appears no damage done that day. On 6/14/17, pt c/o pain in (right) ankle as noted in my note. Pt has always c/o pain with therapy and is difficult to work with daily with mod/max (moderate to maximum) v/c (verbal cueing) to initiate and follow through on ADL (activity of daily living) task. Pt refused an x-ray at this time 6/14/17 when asked to do so. Also for the past 2 wks (weeks) since, pt gets on the Nu-Step and insists to do more than the 15 minutes (45 minutes) and we have had a hard time getting her off it. (Note: COTA 1's note did not indicate whether nursing staff evaluated resident 72's foot at that time.) On 7/12/17 at 5:30 PM, an interview was conducted with COTA 1. COTA 1 stated that on 6/12/17, he was transporting resident 72 from her room to the gym. COTA 1 stated that part of the therapy for resident 72 was to increase the strength in resident 72's quadriceps muscles, so therapy staff decided to transport resident 72 to the therapy gym in a wheelchair without leg rests. COTA 1 stated that he told resident 72 to lift her feet up and hold them there as he transported the resident. COTA 1 stated that as he was turning resident 72's wheelchair into the gym, he had to stop because there was a threshold there where the tile floor transitioned to carpeted floor. COTA 1 stated that he put resident 72's wheelchair wheels over the threshold and it jarred a little. COTA 1 stated that at that time her feet touched the carpet on the gym floor. COTA 1 then stated that I was pushing her through the doorway her feet came under her, as they always do with other patients. She (resident 72) said 'Stop! Stop! You hurt my leg!' I said 'I told you to lift your feet up' and she said 'let's get our therapy done.' COTA 1 stated that resident 72 participated in therapy that day both standing and on the Nu-Step. COTA 1 stated that the next day resident 72 was complaining of pain in her feet, at which time we talked to the nurse who said 'let's get an x-ray.' On 7/12/17, at 5:20 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that she was aware of the incident involving resident 72 on 6/12/17, and that she had subsequently conducted an inservice about notifying nursing staff immediately after an incident. The ADM did not indicate whether or not an inservice had been provided regarding proper foot placement/transport techniques to prevent injuries to residents. 2. Resident 3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on 7/13/17. A significant change Minimum Data Set (MDS) Assessment was completed by the facility staff on 12/29/16. The facility staff assessed resident 3 requiring extensive assistance of two or more people for transfers. Additionally, resident 3 was assessed as being unsteady. On 7/11/16 the facility staff developed a care plan for (Resident 3) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Limited ROM (range of motion), Fatigue, Musculoskeletal impairment (fx (fracture) RLE (right lower extremity)), Activity intolerance, Limited Mobility. The goal developed was The resident will remain free of complications related to immobility, including contracture, thrombus formation, skin-breakdown, fall related injury through the next review date. The interventions developed to achieve the goal included .TRANSFER: The resident has required 2 staff participation with transfers. On 2/24/17 at 9:03 AM, a facility nurse documented (at) 0705 (7:05 AM) CNA (certified nurse assistant) was transferring pt (patient) from bed to w/c (wheelchair). during transfer CNA stated that pt's R (right) leg twisted and bent. Pt c/o (complained of) pain to R leg. CNA notified Nurse. Nurse assessed R leg and swelling was noted below R knee. Pt was transferred back into bed with 2+ staff assist. Ice was applied below R knee. Hospice answering service was called at 0725 (7:25 AM). Sister was notified at 0745 (7:45 AM) Hospice notified again (at) 0800 (8:00 AM) that pt needed to be transferred to the ER (emergency room ) to be evaluated. (Ambulance service) notified and when EMTs (Emergency Medical Technicians) arrived they placed R leg in an immobilizer and pt was transferred to gurney. EMT's left facility with pt (at) 0830 (8:30 AM). Review of the hospital emergency room visit, the emergency room physician documented, CHIEF COMPLAINT/REASON FOR VISIT: Leg pain-swelling. HISTORY OF PRESENT ILLNESS: .female who presents the emergency department, via EMS (Emergency Medical Services), with a report of a right lower extremity injury. The patient is a long-term resident of Bella Terra care center and the CNA was transferring the patient and her leg got caught on a chair when being transferred to the bed. She has obvious swelling with a question of deformity to the right lower extremity just distal to the knee. The patient has had a stroke in the past and has some difficulty with communication. She has right-sided hemiparesis. She does withdraw from pain with any movement to the leg. In order to further evaluate the extent of the patient's injuries and (sic) x-ray was done and found to be positive for a comminuted and mildly displaced fracture of the proximal tibia with a fracture into the tibial plateau. There is also an impacted fracture of the proximal fibula. Diagnosis: [REDACTED]. Tibia/fibula fracture . On 2/27/17, the facility administrative staff conducted an investigation as to how resident 3 sustained a tibial plateau fracture and a tibia/fibula fracture. A written statement from CNA 5 documented, Transferred (resident 3) from bed into wheelchair. When transferred leg bent underneath her. I do not know how leg got tangled. She was transferred and had leg under her. Sheets moved, and had her give me a hug like normal to transfer. Do not know how it happened. The document was signed by CNA 5. An interview was conducted with CNA 5 on 7/13/17 at 10:00 AM via telephone. CNA 5 stated that she was transferring resident 3 from the bed to the wheelchair when resident 3's left leg bent. CNA 5 stated that she was not aware that resident 3's care plan documented that resident 3 was to be transferred by two people. CNA 5 stated that another person did not assist her when resident 3 was transferred. An interview was conducted with Licensed Practical Nurse (LPN) 4 on 7/13/17 at 10:07 AM. LPN 4 stated that resident 3 was supposed to have been transferred by 2 staff members. LPN 4 stated that only one person transferred resident 3 from the bed to the wheelchair when the fractures occurred. LPN 4 stated that resident 3 immediately complained of pain and had swelling to her right lower extremity. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/13/17 at 10:02 AM. The ADON stated two people were to assist resident 3 for all transfers in accordance to the care plan that was developed. The ADON stated that there was not a second person while resident 3 was being transferred from the bed to the wheelchair. POTENTIAL FOR HARM 3. MECHANICAL LIFT TRANSFERS a) Resident 102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/10/17, resident 102's medical record was reviewed. An Unusual Occurrence (sic) Report dated 11/17/16 for resident 102 was reviewed. The report indicated that 2 CNAs (Certified Nursing Assistants) were transferring resident in hoyer lift to wheelchair. when the hoyer lift tipped over sideways both CNAs tried to brace the lift so it would not tip, lift still went to the floor with resident in sling. fall was assisted by both CNAs. Upon going down, resident bumped her head on her wheelchair. There was a stat (immediate) call to the room. Examed (sic) the resident throughly (sic) no signs of bleeding or injury. resident did stated (sic) that she had a pain in the back of her head and was causing a headache. The Administrative Comments listed on the Report stated . Inservice to be done on using the lifts at CNA meeting on 11/25/16. A Nursing Post Fall assessment dated [DATE] for resident 102 was reviewed. The report indicated that an intervention to prevent further falls was keeping hoyer lift low, use larger lift. don't hurry, work together. On 7/12/17 at 5:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 confirmed that she had filled out the unusual occurrence report for resident 102's fall from the hoyer lift on 11/17/16. LPN 1 stated that she was called to resident 102's room after the hoyer lift had fallen over. LPN 1 stated that upon entering the room, the 2 CNAs were on the floor, and resident 102 was on top of the CNAs and her legs were under the lift. LPN 1 stated that she saw the legs of the lift were not extended appropriately, so she asked the CNAs about it. LPN 1 stated that the CNAs informed her that they had lifted up the resident using the hoyer lift, but when they moved the lift to the side, they had closed the legs of the lift, and that is when resident 102 tipped over in the hoyer lift. LPN 1 stated that she told the CNAs they need to keep the legs of the hoyer lift extended. LPN 1 also stated that the CNAs also should have used a larger hoyer lift, as resident 102 weighed more than 400 pounds. b) On 7/12/17, facility staff provided surveyors with a list of residents who currently required the assistance of a mechanical lift during transfers. There were 14 residents on the list. On 7/12/17 at 5:30 PM, an observation was made of CNA 18 and NA (Nurse Assistant) 1 transferring resident 38 from the bed to the geri-chair. NA 1 placed the legs of the hoyer lift under resident 38's bed. (Note: The legs of the hoyer lift were in the closed position). The third loop on resident 38's hoyer sling was attached to hanger bar hooks. Resident 38 was lifted off the bed by NA 1. NA 1 then removed the hoyer from under resident 38's bed with resident 38 suspended in the air. NA 1 moved the hoyer approximately 5 feet. NA 1 arranged the hoyer lift above the geri-chair so that one leg of the hoyer was underneath the geri-chair and the other leg was outside the geri-chair. The legs of the hoyer lift remained in the closed position and were not extended. Resident 38 was then lowered into the geri-chair. CNA 18 and NA 1 were immediately interviewed following the hoyer transfer. NA 1 stated that she had been trained on how to use the hoyer a couple of months ago and was instructed to keep the legs of the hoyer lift in the closed position. CNA 18 stated that she had been employed by the facility for approximately 7 years and had not received training on how to use the hoyer lift. CNA 18 and NA 1 stated they had no concerns related to transferring a resident in a hoyer lift with the legs of the hoyer remaining in the closed position. c) An interview was conducted with RN 4 on 7/12/17 at approximately 5:45 PM related to hoyer transfers and the positioning of the legs of the hoyer lift. RN 4 stated that the legs of the hoyer could not be in the open position when placed underneath a resident's bed because the leg would hit the wall. RN 4 stated that the legs of the hoyer lift should be extended when the resident was being raised. RN 4 further stated that the legs of the hoyer should be in the closed position when the resident had been raised and positioned above the bed, wheelchair or geri-chair. RN 4 stated the leg of the hoyer lift should be in the open position when then resident was lowered into the bed, wheelchair or geri-chair. d) On 7/12/17 at 6:40 AM, an observation was made of NA 1 and CNA 9 transferring resident 69 from the raised toilet chair to the bed. The hoyer lift was placed so that the legs of the hoyer lift straddled (in the open and locked position) the raised toilet chair. NA 1 and CNA 9 secured the third loop on the hoyer sling was attached to the hanger bar hooks. NA 1 raised resident 69 up off of the raised toilet chair. NA 1 closed the legs of the hoyer lift and positioned the legs of the hoyer lift underneath resident 69's bed. NA 1 then lowered resident 69 onto the bed. CNA 9 was immediately interviewed. CNA 9 stated that she was recently employed by the facility. CNA 9 stated that she had been trained on the use of the hoyer lift by other CNAs employed at the facility. e) On 7/12/17 at 3:20 PM, LPN 2 was interviewed. LPN 2 stated that he had been employed at the facility since 2014. LPN 2 stated that he had not received training on how to operate the hoyer lift. LPN 2 stated that he was not sure how to operate the hoyer lift. LPN 2 further stated that the legs at the base of the hoyer lift were to be in the opened position when the resident was in the sling. LPN 2 stated that the legs at the base of the hoyer were to be in the closed position only when the resident was no longer in the hoyer lift. f) On 7/12/17 at 7:00 PM, an interview was conducted with LPN 6. LPN 6 stated that she knew of the lift worked but had never used it. LPN 6 stated that when a resident needed to be transported by a lift she would get the aides to do it. LPN 6 would not comment on how she would transport a resident with a lift if she could not find aides to help. LPN 6 stated she had not be trained by the facility to operate a lift but had been trained at another facility a long time ago. LPN 6 stated to safely use the lift required 2 people. g) On 7/12/17 at 6:40 PM, RN 6 was interviewed regarding Hoyer lift usage, training, and safety. RN 6 stated that to use the Hoyer lift you needed 2 staff to complete the transfer, and the legs at the base of the Hoyer need to be in (straight and parallel with each other) during the transfer. RN 6 stated that she had not received training for the use of the Hoyer lift at the facility), but had been trained about a year ago by her previous employer. RN 6 could not give a rationale for why the legs at the base of the Hoyer would be positioned in. RN 6 stated she was not aware of any accidents or injuries involving the Hoyer lift that had occurred at the facility. h) On 7/12/17 at 5:57 PM, CNA 15 was interviewed regarding Hoyer lift usage, training, and safety. CNA 15 stated that the transfer required 2 staff, the appropriate sling need to be the used and secured, the legs at the base of the Hoyer lift needed to be opened for balance so the resident did not fall. CNA 15 stated that she had not been trained on the use of the Hoyer at the facility, however she had been trained about 5 years ago at a facility that she used to work at. CNA 15 stated that she recalled that resident 102 had an incident involving the Hoyer lift and she thought it was due to using the wrong Hoyer that did not support resident 102's weight. CNA 15 stated that she recalled that resident 102 hit her head; however the resident did not need outside treatment, and she was not aware of any other incidents involving the Hoyer lift. i) On 7/12/17, at approximately 6:15 PM the Assistant Director of Nursing (ADON) was interviewed regarding Hoyer lift usage, training, and safety. The ADON explained that the Hoyer needed to be operated by 2 staff, the appropriate sling needed to be used, hooks secured, and that the legs at the base of the Hoyer needed to be opened for balance and to prevent the tipping of the Hoyer. The ADON state that she was aware of resident 102 having a fall involving the Hoyer lift, and that staff had been in serviced on the use of the Hoyer. The ADON stated that she was not aware of any other incidents involving the Hoyer lift. The ADON stated that when staff were oriented there was a list of what they needed to be trained on, and the training for the use of Hoyer lifts should be part of the orientation. The ADON was interviewed regarding documentation regarding who had been trained; however she could not provide documentation for the use of the Hoyer lift or a list that documented the training of the Hoyer lift had occurred during orientation. j) The owner's manual for the hoyer lift was reviewed. The following was documented: .Lifting the patient WARNING When using an adjustable base lift, the legs MUST in in the maximum Opened/Locked position before lifting the patient. Operating the Patient Lift Closing/Opening the Legs of the Base Assembly .WARNING .The legs of the lift must be in the maximum open position and the shifter hand locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only for as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shift handle immediately. k) On 7/12/17, the facility's Policy and Procedure for Mechanical Lift Transfers was reviewed. The policy did not address appropriate extension of the lift legs to ensure stability during the transfers. The policy did say that staff were to Follow Manufacturer's guidelines on how to operate machine. 4. On 7/10/17 at 11:54 AM, a general tour of the facility was conducted. The door to the assisted dining area was open. There was a red sanitizer bucket with a sanitizing solution in the bucket on a table. There were two residents in the hallway immediately in front of the assisted dining room.

Based on observation, record review and interview it was determined that the facility did not ensure that 1 of 51 sample residents received care and services to promote pressure ulcer healing and to prevent new ulcers from developing. Specifically one resident's pressure ulcers deteriorated and the resident developed additional pressure sores. These findings were to have occurred at a harm level. Resident identifier: Resident 42. Findings include: Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/12/17, resident 42's medical record was reviewed. A Minimum Data Set ((MDS) dated [DATE], documented that resident 42 had a stage III pressure ulcer measuring 6.0 cm (cementers) in length, 3.0 cm in width, and 3.5 cm in depth. The MDS also indicated that resident 42 required extensive assistance and the support of two persons for physical assistance, bed mobility, transfers, and toileting. The Brief Interview for Mental Status (BIMS) on the MDS was 15/15, indicating that resident 42 was intact cognitively. The MDS also indicated that resident 42 was not exhibiting behavioral symptoms, such as rejection of care. A Pressure ulcer care plan dated 7/14/16, with a target date of 9/14/17 for resident 42 was reviewed. Review of the care plan revealed that resident 42 had a stage III pressure to his right ischium, and required protection for his left ischium, coccyx and bilateral heels related to his [DIAGNOSES REDACTED]. The care plan also revealed The resident will have no complications (related to) pressure injuries of the (right) Ischium and minimize risk of further skin injury to other at risk areas through the review date. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. Do not apply on any wounds. Monitor/document location, size and treatment of [REDACTED]. to (medical doctor). The resident needs an air overlay mattress with (left) Bed cane and podis boots to protect the skin while in bed. The resident needs assistance to apply protective garments: podis boots. A Skin risk care plan dated 7/15/16, with a target date of 9/14/17 for resident 42 was reviewed. Review of the care plan revealed Problem: Resident is assessed to be high risk for pressure sore development, based on BRADEN Score AND related to: ulcers present on admission, immobility, fragile skin, [MEDICAL CONDITION], worsened wound appearance upon return from (leave of absence). Currently the resident's skin status is: Impaired. Goal: The resident will have no complications skin injuries of the (right) ischium through the review date. Approaches: Apply incontinent barrier cream. Apply pressure relieving cushion to chair/wheelchair. Podis boots to (bilateral lower extremities) at all times. Apply Special mattress on bed (alternating air mattress, setting at 5). Check air mattress if functioning properly every shift and as needed (PRN) monitor for pressure ulcer potential, review profile quarterly (every three) months and PRN. Wound clinic consult as indicated. Nutritional interventions as ordered. Off-loading of bilateral heels when in bed every shift and reposition resident (every two) hours and PRN, extensive assist. Overhead trapeze to assist with bed mobility. A [MEDICAL TREATMENT] care plan dated 2/24/17, with a target date of 9/14/17 for resident 42 was reviewed. Review of the care plan revealed Problem: the resident needs [MEDICAL TREATMENT] [MEDICAL TREATMENT] (related to) [MEDICAL CONDITION]. Goal:The resident will have no (signs or symptoms) of complications from [MEDICAL TREATMENT] through the review date. Approaches: Check central catheter: Permacath for signs of bleeding. Contact (Name of [MEDICAL TREATMENT] center) if bleeding observed. Coordinate with [MEDICAL TREATMENT] center using communication sheet. Encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments. Resident receives [MEDICAL TREATMENT] at (Name of [MEDICAL TREATMENT] center) Mon, Wed, Fri. Monitor labs and report to doctor as needed. Monitor/document for [MEDICAL CONDITION]. Monitor/document report to MD (signs or symptoms) of depression. Obtain order for mental health consult if needed. Monitor/document/report to medical doctor (MD) as needed (PRN) any (signs or symptoms) of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for (signs or symptoms) of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations, and blood pressure (BP) immediately. Only [MEDICAL TREATMENT] center staff will change central catheter dressing at the [MEDICAL TREATMENT] center. Provide diet as prescribed by MD. Diet is Renal. Monitor intake and record every meal. Provide supplements if ordered. Resident's [MEDICAL TREATMENT] [MEDICAL TREATMENT] schedule is: Mon Wed Fri Resident to be ready for transport by: 11:30. Before [MEDICAL TREATMENT], resident needs bag/sack lunch with resident, if requested/needed. Work with resident to relieve discomfort for side effects of the disease and treatment. (Cramping, fatigue, headaches, itching, [MEDICAL CONDITION], bone demineralization, body image change and role disruption). On 7/12/17 an interview was conducted with a member of the Transportation Staff (TS). The TS stated that he typically transported resident 42 to [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays at 11:30 AM. On 7/10/17 an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that resident 42 received [MEDICAL TREATMENT] services on Mondays, Wednesdays and Fridays. RN 4 stated that resident 42 typically returned from [MEDICAL TREATMENT] at approximately 5:00 PM. (Note: Based on interviews and the care plan, resident 42 was receiving [MEDICAL TREATMENT] services on Mondays, Wednesdays and Fridays from approximately 11:30 AM to 5:00 PM.) On 7/12/17, at 9:15 AM, CNA 19 was interviewed regarding resident 42's plan of care. CNA 19 stated that resident 42 required full assistance with cares. CNA 19 stated that resident 42 had a wound to his buttock, but used an air mattress. CNA 19 also stated that resident 42 was incontinent of bowel and used a brief, but was able to tell staff when he had a bowel movement. CNA 19 stated that resident 42 was independent for upper body with use of the trapeze but required assistance with his lower extremities related to his paralysis. CNA 19 stated that resident 42 could not reposition himself without a trapeze or another assistive device. CNA 19 stated that depending on the day that the resident 42 required limited to extensive assistance and needed help with areas of his body he could not reach. Review of resident 42's nursing and wound clinic progress notes revealed the following: a) On 2/27/2017, a facility Skin/Wound Note: Assessed skin to bilateral buttocks, coccyx and bilateral feet. right ischium wound continues with STG 3 P/I (stage III pressure injury) measuring 1.7 cm (centimeter) x (by) 1.4 cm x 0.3 cm with small-moderate amount of serosanquineous (sic) drainage and no (signs or symptoms of infection). Wound appears pink with normal peri (surrounding) wound appearance. Resident with following interventions: [MEDICATION NAME], extra fluids with each meal, air mattress, bed cane, podis boots. Resident tolerated procedure well with no pain expressed. Resident has begun [MEDICAL TREATMENT] with fistula and permacath in place. b) On 3/28/17, a facility Skin/Wound Note: R (right) ischium continues with stable appearance with wound appearing pink with small amount of serous drainage, no s/s (signs and symptoms) of infection, wound measuring 2.4 cm x 1.8 cm x 0.1 cm. Trapeze used for bed mobility. (Note: [MEDICAL TREATMENT] was initiated on 2/27/17 and the wound to the right ischium is noted to be larger in size on 3/28/17.) c) On 3/30/17, a Wound clinic Note: Skin: base clean and granulated. Physician comments: Stage III Pressure Ulcer right ischium - Improved. [MEDICATION NAME] ag (silver) every other day. Offloading. The wound clinic described the wound to the right ischium as having a moderate amount of serous exudate with full thickness wound with exposed full thickness. Wound bed contains beefy red granulation tissue, and the peri wound is intact. Measurements listed 2 cm by 1.11 cm by 0.2 cm. d) On 4/20/17, a Wound clinic Note: Physician's comments: Stage III Pressure Ulcer right ischium - Stable. Off-loading. Skin: Base clean and granulated, some hypergranulation. Wound: minimum amount of serous exudate, tissue loss is full thickness wound with exposed subcutaneous, wound bed contains beefy red granulation tissue, contains with tissue and contains slough, and peri wound is intact and macerated. Measurements: 2 cm x 1.5 cm x 0.2 cm, stage III. Goals: Reduce pressure on wound. (Note: The wound on 4/20/17 now presented with slough and was macerated.) e) On 4/25/17,a Skin/Wound Note: Right ischium continues with slow improving pressure injury to area measuring 2 cm x 1.2 cm x 0.2 cm with wound appearing pink/red wound bed surrounded by macerated skin appearance with small amount of serous drainage, no signs or symptoms of infection. Trapeze for bed mobility. Resident with trip to Mexico planned with departure this Saturday (4/29/17). Provided education regarding wound care during trip. Will supply resident with materials to help with wound care during absence from facility. f) On 5/8/17, a Skin/Wound Note: Assessed skin to resident upon return from Mexico trip 5/7/2017. (Right) ischium with significantly worsening appearance with wound appearing larger with deep reddened area 2.5 x 3.3 x 0.1 cm. g) On 5/11/17, a Wound clinic Note: Right ischium skin: Base necrotic and bruised. All tissue firmly adhered. Wound to right ischium: moderate amount of serous exudate, tissue loss is full thickness wound with exposed subcutaneous, wound bed contains beefy red granulation tissue, contains necrotic tissue and contains yellow tissue. Peri wound is intact. Measurements: 8 cm x 5 cm x 2.2 cm, stage III. Physicians Progress note: 5/11/17 Ulcers deteriorated. Patient went to Mexico against medical advice. Goals: Reduce pressure on wound, to promote wound healing. (Note: The wound clinic documented the wound on resident 42's right ischium as being significantly larger than what facility staff documented three days prior, indicating that resident 42's right ischium worsened in three days, or that staff inaccurately measured resident 42's wound on 5/8/11.) h) On 5/17/17, a Skin/Wound Note: Right ischium appears with no significant improvement, measuring 6.7 cm x 3.5 cm x 2 cm with wound bed is beefy red, moderate serosanguineous drainage and no signs or symptoms of infection. Periwound appears to have skin intact. Resident continues with [MEDICAL TREATMENT] this week. i) On 5/18/17, a Weekly Skin interdisciplinary team (IDT) Meeting: Right ischium Stage 3 measuring 6.7 cm x 3.5 cm x 2.0 cm, wound nurse measurement, beefy red wound bed, no slough. Resident continues to wear podis boots. Air mattress and roho cushion in place. Receiving [MEDICAL TREATMENT] 3 times a week. Trapeze for mobility while in bed. j) On 5/22/17, a Skin/Wound Note: Right ischium continues with stage III injury measuring 5.5 cm x 3.8 cm x 2 cm with beefy red wound bed, moderate amount of serosanguineous drainage, yet no signs or symptoms of infection, peri wound intact. k) On 5/31/17, a Skin/Wound Note: Right Ischium appears to be improving as wound now measures 4.5 cm x 2.8 cm x 2 cm. Wound bed appears beefy red and appears to be darker as wound becomes deeper with pink edges and darkened edge to inferior portion of wound, with some gray coloration to superior portion, no signs or symptoms of infection at this time. Resident to be seen at wound clinic tomorrow. l) On 6/1/17, A Wound clinic note: Physician's comments: Resident 42 comes to the clinic for 2 week evaluation, doing well. Ulcers all improving. Skin: Multiple areas of pressure noted. All are healing. No evidence of infection. Left buttock now healed. Right buttock is with minimal fat necrosis, no evidence of infection, and good granulation. No odor. Wound to right ischium: moderate amount of serous exudate, tissue loss is full thickness wound with exposed subcutaneous, wound bed contains beefy red granulation tissue, and periwound is intact. Measurements: 3.5 cm x 3.5 cm x 2 cm, stage. Goals: promote wound healing. Reduce pressure on wound. m) On 6/5/17, a Nurse's note: Certified Nursing Assistant reported to nurse that resident 42 has a temperature of 102.0. Nurse called physician, who ordered resident be sent to emergency room for evaluation/treatment of [REDACTED]. n) On 6/6/17, a Social Services Note: Resident is doing well, is happy, joyful, and has no complaints at this time. (Note: No documentation with resident 42 not complying with medical treatment or plan of care.) o) On 6/6/17, a Skin/Wound Note: Right Ischium appears to be improving as wound bed appears beefy red and appears with darker tissue to entire wound with wound measuring 3.6 cm x 3.2 cm x 2 cm and no s/sx of infx no signs and symptoms of infection at this time. Left ischium is resolved with pink intact tissue. p) On 6/9/17, a Weekly Skin Interdisciplinary team (IDT) meeting: Right ischium Stage 3 measuring 3.6 cm x 3.0 cm x 2.0 cm, wound nurse measurement, beefy red wound bed, no slough. Resident continues to wear podis boots. Air mattress and roho cushion in place. Receiving [MEDICAL TREATMENT] 3 times a week. (Note: There was no documentation in the IDT note related to resident 42's urinary tract infection, intravenous antibiotic treatment at [MEDICAL TREATMENT] with probable increased time in chair, the root cause of the deterioration of the wound. In addition, there was no documentation for the potential requirement of additional interventions or treatments for resident 42's wound. Also, there was no documentation that the facility had been in contact with the wound clinic to discuss potential changes in treatment.) q) On 6/13/17, a Skin/Wound Note: Right ischium appears with a worsened appearance as wound bed appears less beefy red, some gray slough to wound bed sides and appears with a darkened tissue to superior portion of periwound measuring 4 cm x 3 cm and wound measuring 6 cm x 3 cm x 3.5 cm with no signs or symptoms of infection at this time. Will notify wound clinic of change in wound appearance. (NOTE: The worsening of the wound was identified approximately one month after the resident had been back from vacation.) r) On 6/15/17, a Wound clinic note: Skin: contains beefy red granulation tissue, undermines at margins and contains necrotic tissue. Wound to right ischium: moderate amount of serous and malodorous exudate, tissue loss is full thickness wound with exposed subcutaneous, and full thickness contains beefy red granulation tissue, undermines at margins and contains necrotic tissue, periwound is intact. Undermining: 5.2 cm centimeters from 11 to 1 o'clock Measurements: 10.5 cm x 6 cm x 3 cm, stage IV. Patient is to return to clinic in 3 weeks. Goals: promote wound healing. Reduce pressure on wound. s) On 6/19/17, a Nurses note: Patient returned from [MEDICAL TREATMENT] and infusion clinic with a 102.3 temp. [MEDICATION NAME] administered. Will continue to monitor. t) On 6/20/17, a Skin/Wound Note: Right Ischium continues with a worsened (sic). Resident sent to wound clinic last week related to worsened appearance with no new orders from wound clinic. Wound now appears less beefy red with some gray slough to wound bed sides and appears with a necrotic tissue to superior portion of periwound measuring 4 cm x 3 cm and wound measuring 6 cm x 3 cm x 3.5 cm with no signs or symptoms of infections at this time. Resident is receiving [MEDICATION NAME] and [MEDICATION NAME] at the [MEDICAL TREATMENT] clinic. (Note: The wound note did not address the extended time resident 42 would likely have required in his chair at the [MEDICAL TREATMENT] clinic related to the intravenous antibiotics. In addition, the facility's measurements are not consistent with the wound clinic measurements.) u) On 6/22/17, a Nurses note by Registered Nurse (RN) 5: Care Conference on 6/22/17. Spoke concerning resident's recent change with increased infection with antibiotic being administered. Also change in wound and overall lethargy. (Note: There was no documented change in plan of care related to lethargy or discussion related to [MEDICAL TREATMENT]. ) v) On 6/23/17, a Skin/Wound Note: Weekly Skin IDT Meeting: Right ischium Stage 3 measuring 9 cm x 3.2 cm x 2.7 cm, wound nurse measurement gray wound bed, black eschar to peri wound. Receiving [MEDICAL TREATMENT] 3 times a week. Trapeze for mobility while in bed. w) On 6/27/17, a Skin/Wound Note: Right ischium continues with large pressure sore measuring 9 cm x 4.5 cm x 3.4 cm with pink wound bed and area of eschar to superior portion that will soon detach. Wound was positive for foul odor being treated with Dakin's soaked packing twice a day. Resident stated he is eating more since changed diet to Regular foods. Resident continues with antibiotic [MEDICATION NAME] with [MEDICAL TREATMENT] 3 times a week. (Note: A review of the treatment administration record (TAR)for June 2017 revealed orders for resident 42's wound to be treated with Dakin's soaked gauze and a pad twice a day. Treatment was not documented as completed on the TAR on 6/5/17 day shift, 6/7/17 evening shift, 6/10/17 evening shift, 6/12 evening shift, and 6/28/17 on the day shift. Furthermore, there was no documentation of why these treatments were not signed as completed.) x) On 6/30/17, a Skin/Wound Note: Weekly Skin IDT Meeting: Right ischium Stage 3 measuring 9 x 4.5 x 3.4 cm, wound nurse measurement gray wound bed, black eschar to peri wound. Trapeze for mobility while in bed. (Note: There was no documentation in the IDT note related to resident 42's urinary tract infection, intravenous antibiotic treatment at [MEDICAL TREATMENT] with probable increased time in chair, the root cause of the deterioration of the wound. In addition, there was no documentation for the potential requirement of additional interventions or treatments for resident 42's wound besides the Dakins soaked gauze and abdominal pad covering. Also, there was no documentation that the facility had been in contact with the wound clinic to discuss potential changes in treatment.) y) On 7/6/17, a Wound clinic note: Physician's comments: Stage IV Pressure Ulcer right ischium - slightly improved. Continue Dakin's soaked gauze every day. Off-loading. Skin Based with more granulation but has necrotic subcutaneous tissue at base. Wound to right ischium: moderate amount of serous exudate, tissue loss is full thickness wound with exposed subcutaneous, wound bed contains beefy red granulation tissue, and contains slough, and periwound is intact. Measurements: 10 cm x 6 cm x 3 cm, stage IV. Post debridement measurements: 10 cm x 7 cm x 3 cm, stage IV. Physicians Progress note: Improved slightly but still have necrotic subcutaneous tissue at base. Bone palpable. Goals: reduce pressure on wound. (Note: Resident 42's wound continued to deteriorate, with palpable bone now present and is a stage IV pressure ulcer. It should be noted that this is two months after his return from Mexico.) z) On 7/7/17, a Weekly Skin IDT Meeting: Right ischium Stage 3 measuring 9 cm x 4.5 x 3.4 cm, wound nurse measurement gray wound bed, black eschar to peri wound. Resident continues to wear podis boots. Has air mattress and roho cushion in place. Patient is also receiving [MEDICAL TREATMENT] 3 times a week. Trapeze for mobility while in bed. (Note: The documentation from the IDT indicated that the wound was a stage 3, however the wound clinic had identified the wound as being a stage 4 on 7/6/17. There was no documentation in the IDT note related to resident 42's urinary tract infection, intravenous antibiotic treatment at [MEDICAL TREATMENT] with probable increased time in chair, the root cause of the deterioration of the wound. In addition, there was no documentation for the potential requirement of additional interventions or treatments for resident 42's wound besides the Dakins soaked gauze and abdominal pad covering. Also, there was no documentation that the facility had been in contact with the wound clinic to discuss potential changes in treatment.) On 7/12/17 at 11:00 AM, an observation was made of resident 42's wounds with RN 5 present. RN 5 stated that he had been wound care certified. Resident 42 was positioned on his left side on the bed for the dressing changes. RN 5 removed the dressing to resident 42's left ischium. RN 5 proceeded to clean the wound on resident 42's left ischium, and then applied the new dressing to resident 42's left Ischium. RN 5 did not change his gloves or wash his hands during this treatment and dressing change to resident 42's left ischium. RN 5 then proceeded to remove the dressing to resident 42's coccyx and right ischium, and at that time resident 42 had a small bowel movement. CNA 19, who was present in the room, then performed pericare for the resident. As CNA 19 was providing peri care for resident 42, RN 5 reached to his immediate left and picked up resident 42's garbage bin. RN 5 placed the garbage bin directly on resident 42's bed, and changed the liner of the garbage bin. RN 5 then left the room, and upon returning, applied hand sanitizer to his hands. RN 5 then measured the right ischium, however because resident 42 was laying on his left side, some of the skin from the resident's right buttock was covering part of the wound on the right ischium. RN 5 did not separate the resident's buttocks and surrounding skin in order to properly measure the size of the wound. RN 5 was asked during the observation what the stage of resident 42's wound on his right ischium was. RN 5 stated that the wound was a stage 3 because there was muscle involvement, but no bone involvement. (Note: On 7/6/17, the wound clinic assessed the wound as being a stage 4 because there was palpable bone.) RN 5 was asked by the surveyor if he was supposed to separate the buttocks in order to assess the entire wound. RN 5 stated that he did not do that typically. However, RN 5 then separated the resident's buttocks and surrounding skin which exposed an additional area on the upper medial aspect of the wound that was not initially assessed and measured by RN 5. The additional area was observed to have a dime sized area that was a dark purple color, that the RN described as the consistency of gel. RN 5 then measured the wound as 9 cm x 3.7 cm x 2.9 cm. After the second measurement was taken, RN 5 stated that he would classify resident 42's wound as unstageable because he could not see the base of the wound on the new area. On 7/12/17 at 11:30, RN 5 was interviewed regarding the observation of the wound treatment and dressing change of resident 42. RN stated he should have washed his hands and changed his gloves after removing the old dressing and before he applied the new dressing to resident 42's wounds. RN 5 also stated he should not have placed the garbage bin on the bed. Resident 42's [MEDICAL TREATMENT] communication documentation was reviewed. Review of a [MEDICAL TREATMENT] communication record dated 7/12/17 revealed, (residents name) has a pressure injury to (right) buttocks, IS (ischium). While (at) HD ([MEDICAL TREATMENT]) will you see that he is bumped off R (right) hip during [MEDICAL TREATMENT]? Thank you (RN 5). No other documentation could be located to indicate that facility staff communicated to the [MEDICAL TREATMENT] center that resident 42 currently had a pressure ulcer, or his need to off-load pressure to his right ischium prior to 7/12/17. On 7/12/17 at 12:15 PM, RN 5 was interviewed related to his documentation dated 7/12/17 on the communication form to the [MEDICAL TREATMENT] center. RN 5 confirmed this was his initial note to the [MEDICAL TREATMENT] center communicating that resident 42 needed to be repositioned related to his pressure ulcer on his right ischium. During the interview, RN 5 did not state that resident 42 had resistant behaviors which would have contributed to the worsening of resident 42's pressure ulcer. On 7/12/17 at 3:09 PM, the RN at the local contracted [MEDICAL TREATMENT] center, who had worked with resident 42 for the last three months while he was at the [MEDICAL TREATMENT] center, was interviewed regarding the care and services that were provided to resident 42 for offloading his pressure ulcer to his right ischium. The RN from the [MEDICAL TREATMENT] center stated that they had not been implementing any skin precautions, such as repositioning devices such as a trapeze, because the [MEDICAL TREATMENT] center staff were not aware that resident 42 had a pressure ulcer. The RN from the [MEDICAL TREATMENT] center stated that when resident 42 arrived at the [MEDICAL TREATMENT] center, he was typically transferred from his electric wheelchair to the [MEDICAL TREATMENT] chair for his [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] RN stated that resident 42 was then placed in a reclining position with pillows to his back. The RN from the [MEDICAL TREATMENT] center also stated that once residents 42's left arm was accessed for treatment for [REDACTED]. On 7/13/17 at 11:00 AM, the Assistant Director of Nursing (ADON) and RN 5 were interviewed, regarding residents 42's care plan and communication to the [MEDICAL TREATMENT] center. The ADON stated that the facility used the communication form to notify the [MEDICAL TREATMENT] center of concerns or needs for resident 42. The ADON confirmed that there was not any documentation regarding communication to the [MEDICAL TREATMENT] center prior to 7/12/17 regarding resident 42's pressure ulcer. The ADON did not state that resident 42 had resistant behaviors which would have contributed to the worsening of resident 42's pressure ulcer. The ADON also stated that she was in charge the infection control program, completing and updating the care plans, and was part of the IDT. RN 5 stated that resident 42's wound worsened due to his vacation to Mexico. (Note: Resident 42 returned from Mexico on 5/7/17, and the wound was still worsening approximately two months later.) (Cross refer to F441, and F500)

Based on observation, interview and record review it was determined that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 61 sample residents. Specifically, 4 residents had episodes of incontinence related to lack of staff response, and facility staff did not perform skin assessments for one resident resulting in skin breakdown . Resident identifiers 2, 11, 212 and 220. Findings include: 1. Resident 220 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/8/12 at 10:45 AM, an interview was conducted with resident 220. Resident 220 stated that the facility did not have enough staff to provide care in a timely manner. Resident 220 stated that a few weeks ago she had pushed her call light button to get assistance to go to the bathroom. Resident 220 stated that she waited over 45 minutes and ended up having an episode of bowel incontinence because she could not wait that long. Resident 220 stated "it was a horrible experience" and that "no one should have to go through that". On 5/9/12 resident 220's medical records were reviewed. The admission Minimum Data Set (MDS), dated [DATE], indicated that resident 220 was partially blind and needed extensive assistance with two person physical assistance with bed mobility, transfers and toileting. Further review revealed that resident 220 was occasionally incontinent of bladder with fewer than 7 episodes of incontinence since admission and was always continent of bowel. A review of resident 220's care plans revealed a plan of care for "Self Care Deficit related to activity intolerance status [REDACTED]. Interventions included "assist with ADLs (activities of daily living), assist with transferring, assist with repositions (sic), assist with grooming, call light within reach". On 5/10/12 at 12:55 PM, an interview was conducted with Certified Nursing Assistant (CNA) 9. CNA 9 stated that resident 220 was usually continent. CNA 9 further stated that if resident 220 had issues it usually happened at night when she could not get to the bathroom fast enough. CNA 9 stated that resident 220 was only incontinent of urine. On 5/10/12 at 1:00 PM, an interview was conducted with Registered Nurse (RN)1. RN 1 stated that resident 220 was continent every time RN 1 worked with the resident. On 5/10/12 at 1:05 PM, a follow-up interview was conducted with resident 220 regarding the incident she had previously described. Resident 220 stated that in that occasion, she needed to have a bowel movement and had pushed the call light button for assistance. Resident 220 stated that a CNA had answered her call light and stated that he would get someone to help and be right back. Resident 220 stated that the CNA never came back. Resident 220 stated that she was later told the CNA had forgotten and had gone home for the night. Resident 220 stated that because no one helped assist her to the bathroom she had an episode of bowel incontinence. Resident 220 stated that the event "was horrible and traumatizing" and that "no one should have to ever go through something like that". 2. Resident 212 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a) On 5/9/12 at 5:00 PM an interview was conducted with resident 212. Upon entrance to resident 212's room, a strong fecal odor was detected. Resident 212 stated that she needed to use the restroom and had pushed her call light to request staff assistance. On 5/9/12 at 5:01 PM CNA 3 was observed to enter resident 212's room. Resident 212 stated to CNA 3 that she needed help with toileting. CNA 3 stated that he would "be right back." Resident 212 was continuously observed until 5:58 PM, during which time resident 212 was repeatedly calling out for help. At 5:58 PM, CNA 3 entered resident 212's room to change resident 212's incontinence brief, at which time resident 212 stated "We should have done this 10 hours ago - 2 hours ago. It makes me mad when we don't do it when we should." On 5/9/12 at 5:58 PM, resident 212 was observed in her bed as cares were provided by CNA 3 and CNA 4. Resident 212 was observed to have a large amount of loose stool in her incontinence brief. CNA 4 stated that incontinence care was just provided for resident 212 at 2:00 PM, "and she was messy then too." Resident 212's medical record was reviewed on 5/7/12. The facility's Interdisciplinary Team (IDT) completed a Minimum Data Set (MDS) assessment, dated 4/18/12, for resident 212. The IDT determined resident 212 required extensive assistance of two staff for bed mobility, transfers, dressing, toileting and hygiene. A nursing note dated 4/2/12 indicated that resident 212 was "not incontinent of stool" and that the resident was "usually aware of toileting needs." Resident 212's falls care plan indicated that resident 212 required assistance with toileting. Resident 212's "Alteration in urinary elimination pattern" care plan documented that resident 212 required assistance with hygiene after urine elimination. Resident 212's "Alteration in Bowel Elimination" care plan indicated that resident 212 required assistance with cleansing her perianal area after bowel movements. Resident 212's skin integrity care plan indicated that resident 212's skin needed to be kept clean and dry. b) On 5/9/12 at 5:58 PM, resident 212 was observed in her bed as cares were provided by CNA 3 and CNA 4. The CNAs were queried regarding a concern with the resident's skin behind her left thigh, proximal of her knee. It was observed that resident 212 had two small areas with dry red scabs bordered by reddened skin. The CNAs stated they had not been aware of the wounds and the CNAs stated they were unaware of how the wounds had occurred. On 5/10/12 at approximately 7:30 AM, RN 3 was queried regarding resident skin checks. RN 3 stated nurses performed resident skin checks weekly. RN 3 stated between weekly checks, the CNAs performed daily checks. RN 3 provided a copy of a skin sheet that would be completed by the CNAs to report any new skin concerns. On 5/10/12 at approximately 8:10 AM, CNA 13 was queried regarding resident skin checks. CNA 13 stated whenever he observed a new bruise, skin tear, abrasion or any new concern, the information was documented on a skin sheet and referred to the nurse. On 5/10/12 at approximately 9:15 AM, CNA 1 was interviewed. CNA 1 stated that any resident's new skin issues should be reported to the nurse in charge as soon as they were observed. On 5/10/12 at 10:17 AM, RN 2 was interviewed. RN 2 stated nurses were inserviced in January 2012 on how to properly assess and describe wounds. RN 2 stated wounds were reported promptly to nurse management and discussed in daily stand-up meetings as well as in the Nutrition at Risk meetings. RN 2 stated that CNAs reported skin concerns as soon as they were observed to their nurse. RN 2 stated the reports were reviewed and verified by nursing and reported to the wound nurse. In addition, nursing was to perform and document weekly skin checks for each resident. On 5/10/12, the wound nurse was queried regarding resident 212's skin. The wound nurse was unaware of any skin concerns for resident 212. She stated she had not been advised by the CNAs who had worked with resident 212 on 5/9/12. The wound nurse then performed a skin check for resident 212, assessed and documented the wounds, and began an investigation regarding the origin of the new wounds. 3. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/8/012 at 9:00 AM an interview was conducted with resident 2. When asked about receiving the assistance she needed from facility staff, resident 2 stated that she did not feel her needs were being met. Resident 2 further stated "When I call and ask for help it takes them 5 to 10 minutes or 1 to 2 hours sometimes to get to me. . . One time last week they didn't get here in time to help me to the bathroom and I messed myself." Resident 2's medical record was reviewed on 5/7/12. Resident 2's self care deficit care plan dated 1/6/08 documented that resident 2 required the assistance of at least one aide with all of her activities of daily living. On 5/10/12 at 10:40 AM, an interview was conducted with CNA 10 regarding resident 2. CNA 15 stated that resident 2 sometimes was incontinent, but sometimes asked to be taken to the bathroom. On 5/10/12 at 10:00 AM, an interview was conducted with CNA 9 regarding resident 2. CNA 9 stated that resident 2 was continent "when she wants to get up." On 5/10/12 at 10:23 AM, an interview was conducted with CNA 15 regarding resident 2. CNA 15 stated that resident 2 was both continent and incontinent. CNA 15 further stated that resident 2 sometimes soiled her incontinence brief but that resident 2 "likes to go in the toilet if we get to her in time." 4. On 5/10/12 at 11:00 AM an interview was conducted with CNA 16. When asked about staffing at the facility, CNA 16 stated that there were not enough CNAs to perform all of the required duties. CNA 16 further stated that on one occasion resident 11, who was continent, requested help in to the bathroom. CNA 16 explained that because resident 11 required the assistance of 2 people to get to the bathroom, CNA 16 had to leave resident 11 to find another staff member. CNA 16 stated that by the time she found another staff member, and returned to assist resident 11, the resident had soiled her pants. On 5/10/12 at 2:15 PM an interview was conducted with resident 11. Resident 11 stated that she remembered the incident described by CNA 16, but that she was not upset. Resident 11 further stated that although she is continent, she sometimes has "accidents because they don't get to me in time." (Cross refer to F311 and F353)

Based on observation, record review and interview, the facility did not have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of 13 of 61 sample residents. Specifically, call lights were not answered timely, residents and staff voiced concern with the staffing levels, and residents were observed to wait for extended periods of time for staff assistance. Resident identifiers: 2, 7, 11, 28, 35, 41, 80, 142, 194, 212, 218, 220, and 222. Findings include: 1. On 5/8/12 the following call light observations were made: a) At 8:16 AM, the call light for room [ROOM NUMBER] was activated. The call light was still on at 8:23 AM when the observation concluded, after 7 minutes. b) At 8:30 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 8:39 AM, approximately 9 minutes later. c) At 8:30 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 8:43 AM, approximately 13 minutes later. d) At 9:07 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 9:21 AM, approximately 14 minutes later. e) At 9:12 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 9:21 AM, approximately 9 minutes later. f) At 9:13 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 9:20 AM, approximately 7 minutes later. g) At 9:13 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 9:21 AM, approximately 8 minutes later. h) At 10:22 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 10:34 AM, approximately 12 minutes later. i) At 3:54 PM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 4:01 PM, approximately 7 minutes later. 2. On 5/9/12 the following call light observations were made: a) At 9:18 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 9:25 AM, approximately 7 minutes later. b) At 12:41 PM, the call light for room [ROOM NUMBER] was observed to be on. The call light was still on when the observation concluded at 12:57 PM, after 16 minutes. 3. On 5/10/12 the following call light observations were made: a) At 8:29 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 8:46 AM, approximately 17 minutes later. b) At 8:37 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 8:52 AM, approximately 15 minutes later. c) At 8:41 AM, the call light for room [ROOM NUMBER] was oserved to be on. The call light was still on when the observation concluded at 8:57 AM, after 16 minutes. At 8:55 AM, two Certified Nursing Assistants (CNAs) were observed to pass the resident's room without stopping. d) At 9:20 AM, the call light for room [ROOM NUMBER] was activated. The call light was not answered until 9:30 AM, approximately 10 minutes later. e) At 10:22 AM, the call light for room [ROOM NUMBER] was observed to be on. The call light was not answered until 10:34 AM, approximately 12 minutes later. 4. On 5/9/12 at 5:00 PM an interview was conducted with resident 212. Upon entrance to resident 212's room, a strong fecal odor was detected. Resident 212 stated that she needed to use the restroom and had pushed her call light to request staff assistance. On 5/9/12 at 5:01 PM CNA 3 was observed to enter resident 212's room. Resident 212 stated to CNA 3 that she needed help with toileting. CNA 3 stated that he would "be right back." Resident 212 was continuously observed until 5:58 PM, during which time resident 212 was repeatedly calling out for help. At 5:58 PM, CNA 3 entered resident 212's room to change resident 212's incontinence brief. At 5:58 PM an observation was made of CNA 3 changing resident 212's incontinence brief. Resident 212 was observed to have a large amount of loose stool in her incontinence brief. 5. On 5/8/12 at 10:45 AM, an interview was conducted with resident 220. Resident 220 stated that the facility did not have enough staff to provide care in a timely manner. Resident 220 stated that a few weeks ago she had pushed her call light button to get assistance to go to the bathroom. Resident 220 stated that she waited over 45 minutes and ended up having an episode of bowel incontinence because she could not wait that long. Resident 220 stated that it "was a horrible experience" and that "no one should have to go through that." 6. On 5/10/12 between 10:15 AM and 11:15 AM, during a medication pass observation, five residents were observed to be given their medications after 10:00 AM and not at 8:00 AM as ordered by the physician. On 5/10/12 between 10:32 AM, Registered Nurse (RN) 8 stated she still had another resident to give morning medications to. RN 8 stated "It takes me a long time to do meds (medications). I need to get done by the next few minutes. I try to get done by 9 AM but I keep having interruptions. I had to do a wound dressing change before the resident showered, one resident had low oxygen, and I had to call the doctor, and I have to stop to give pain medications." At 11:00 AM RN 8 had not passed the morning medications to her last resident. On 5/10/12 at 11:00 AM, RN 4 was observed passing medications. RN 4 was asked how many residents she still had to administer medications to. RN 4 reported she still had to pass morning medications to two residents. RN 4 stated she had a lot of interruptions that morning and was late giving her morning medications. 7. On 5/9/12 at 8:00 AM, observations were made of the breakfast meal on the special needs unit. Eighteen residents were observed to be sitting in the dining room for the breakfast meal with two CNAs serving and assisting residents with their meals. Staff Member 8 stated that the facility staff needed more help. . . "It is impossible to assist the residents with meals and personal needs with only two CNAs". 8. Resident 218 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Interdisciplinary Team (IDT) completed a comprehensive Minimum Data Set (MDS) assessment, dated 4/24/12, for resident 218. The IDT conducted a Brief Interview for Mental Status (BIMS) with resident 218 to evaluate the resident's level of cognition level to include his attention, orientation and recall. Resident 218 scored 15 of 15 on the BIMS assessment, indicating no cognitive deficit. Resident 218's functional level was evaluated by the IDT. It had been determined that resident 218 required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, hygiene and bathing. The resident did not ambulate. Resident 218 ate independently after set up assistance. Resident 218 was interviewed on 5/8/12 at 2:00 PM. Resident 218 stated, "They (the CNAs) are pulled really thin." Resident 218 stated, "They have this call light system that times the lights, but then someone will answer it and say they will tell the nurse or have someone come back." Resident 218 then stated, "Then I wait up to an hour" for someone to help. Resident 218 stated that waiting for staff to come back to assist him was sometimes a problem. The resident stated he needed assistance with a straight catheter. Resident 218 stated that when his urine was not released timely it became "really uncomfortable". Resident 218 also stated he prefered to get up at 6:30 AM and eat with the other residents in the dining room. He stated staff usually had him eat in bed and got him up about 8:00 AM or 8:30 AM. Resident 218 stated, "I prefer to eat in the dining room". He stated, "I understand that I take a lot more time. I am quadriplegic and they need to use a hoyer lift. I am a big man . . ." The resident stated again, "I understand they are busy but I would like to get up earlier and eat in the dining room." On 5/9/12 at 9:10 AM, resident 218 was observed in bed and not dressed for the day. On 5/9/12 at 9:15 AM, CNA 2, who was providing care for resident 218 that day, was interviewed. CNA 2 stated sometimes the Occupational Therapist (OT) gets him up. CNA 2 stated, "I don't really know the schedule here yet." On 5/9/12 at 10:25 AM, OT 2 was interviewed. OT 2 stated that resident 218 "prefers to get up much earlier, but if the CNAs don't get him up, then we will. (We) usually try to get him up by 8:00 AM, but have not been able to get to him yet today." 9. On 5/9/12 at 9:12 AM, resident 194 was observed to be slumped down in bed to approximately eye level of his breakfast tray. The resident stated he had been waiting over half an hour for the CNAs to come pull him up in bed. When they delivered his breakfast, the resident stated that facility staff told him they would be back to scoot him up so he could see what was on his tray. Resident 194's food had become cold and dry while he waited. Resident 194 was residing on the 200 hall. On 5/9/12 at 9:15 AM, CNA 1 stated that one CNA from the 100 hall delivered hall trays and covered lights for the 100 and 200 halls during meal times. CNA 1 stated the other CNAs assisted in the dining room. 10. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/7/12 at 3:45 AM, resident 28 was interviewed. Resident 28 stated the facility was short staffed. The resident stated that was why she ate in the dining room. Resident 28 stated when she ate in the dining room it was easier to get what she wanted. 11. Resident 80 was admitted to the facility in 1997 and most recently readmitted [DATE] with [DIAGNOSES REDACTED]. On 5/7/12 at 4:05 PM, resident 80 was interviewed. Resident 80 stated, "They are short staffed a bit now. Some have quit and some have been fired. They have to work really hard." The resident stated call lights took too long to be answered, about 10 minutes. Resident 80 stated it took longer at meal times. 12. On 5/7/12 at 4:00 PM an interview was conducted with resident 7 regarding staffing levels. Resident 7 stated that the facility was "short on staff." Resident 7 further stated that she had to "wait a long time . . . about 15 minutes for someone to help me." 13. On 5/8/12 at 10:00 AM an interview was conducted with resident 222 regarding staffing levels. Resident 222 stated that facility staffing was not currently adequate. Resident 222 then stated that it took sometimes 10 minutes to have her call light answered. Resident 222 stated that "yesterday I thought I was going to mess my pants. I almost did but they got here in time." 14. On 5/8/12 at 9:00 AM an interview was conducted with resident 41 regarding staffing levels. resident 41 stated that the facility staff were "overworked" and the facility was "understaffed." Resident 41 further stated that he had to wait up to 30 minutes for his call light to be answered. Resident 41 also stated that his wife, who was also residing in the facility, has had to wait up to two hours to have her incontinence brief changed. 15. On 5/8/12 at 3:30 PM an interview was conducted with resident 142 regarding staffing levels. Resident 142 stated that there was not enough staff to meet his needs and that he had to "wait too long for help sometimes." 16. On 5/7/12 at 3:30 PM an interview was conducted with resident 35 regarding staffing levels. Resident 35 stated that she did not feel that there was enough staff at the facility. Resident 35 then stated that she had to wait 15 to 20 minutes for her call light to be answered. Resident 35 further voiced a concern that she had "gone up to 2 hours waiting for pain medication." 17. On 5/8/012 at 9:00 AM an interview was conducted with resident 2. When asked about receiving the assistance she needed from facility staff, resident 2 stated that she did not feel her needs were being met. Resident 2 further stated "When I call and ask for help it takes them 5 to 10 minutes or 1 to 2 hours sometimes to get to me . . . One time last week they didn't get here in time to help me to the bathroom and I messed myself." 18. On 5/10/12 an interview was conducted with Staff Member (SM) 1 regarding staffing levels. SM 1 stated that the facility was not fully staffed, despite multiple complaints to the corporation. SM 1 further stated that CNAs were assigned to care for 15 to 20 residents during their shift, which was too many residents per CNA. SM 1 then stated that several people had resigned at the facility due to feeling overworked, as recently as the week of the annual survey. 19. On 5/10/12 an interview was conducted with SM 2 regarding staffing levels. SM 2 that there was not enough staff to provide the care necessary to the residents. SM 2 further stated "I don't feel I can do everything how it's supposed to be done." SM 2 further stated that the facility was especially short staffed currently due to recent staff turnover. SM 2 stated that CNAs were usually assigned to 14 residents during a shift, which was too many residents to take care of appropriately. 20. On 5/10/12 an interview was conducted with SM 3 regarding staffing levels. SM 3 stated that residents "don't get good quality of care because we are short staffed." 21. On 5/10/12 an interview was conducted with SM 4 regarding staffing levels. SM 4 stated that the staffing level was "inadequate." SM 4 stated that CNAs were assigned to care for 15 to 22 residents during their shift. SM 4 then stated "It's crazy. We can't toilet them (the residents) as often so they become incontinent even though they are continent. We can't shower people either." SM 4 then stated that during dining times, only three CNAs were left to care for the residents in the facility who were eating in their rooms, which was "very bad." 22. On 5/10/12 an interview was conducted with SM 5 regarding staffing levels. SM 5 stated that the CNAs were assigned to care for 17 to 22 residents during their shift. SM 5 stated that residents were not getting showered because the facility was "shorthanded." SM 5 stated that sometimes when CNAs could not shower a resident, the CNAs "just do a quick wipe down." SM 5 stated that there was no one resident in particular who was not receiving showers, but that it seemed to be "across the board." SM 5 further stated that "I can't give good care because I feel rushed and a lot of pressure." SM 5 then stated that CNAs tried not let the residents see them rushed, but that "my residents seem to be concerned." SM 5 stated that some residents had commented on the fact that the CNAs were "hurrying." SM 5 stated that in one particular case, a resident was "upset" because SM 5 could not spend enough time assisting the resident. 23. On 5/10/12 an interview was conducted with SM 6 regarding staffing levels. SM 6 stated that CNAs were usually assigned to care for 11 to 18 residents during their shift. SM 6 stated that the facility did not have enough staff to provide the necessary cares to the residents. SM 6 stated that showers were not being performed "because they are time consuming." SM 6 further stated that on one occasion resident 11, who was continent, requested help in to the bathroom. SM 6 explained that because resident 11 required the assistance of 2 people to get to the bathroom, SM 6 had to leave resident 11 to find another staff member. SM 6 stated that by the time another staff member was located, and returned with SM 6 to assist resident 11, the resident had soiled her pants. 24. On 5/10/12 an interview was conducted with SM 7 regarding staffing levels. SM 7 stated that CNAs were usually assigned to care for 12 to 16 residents during their shift. SM 7 stated that there was not enough staff to provide cares for residents. SM 7 stated that showers were not being done. SM 7 then stated "we just get what we can done." On 5/10/12 an interview was conducted with the facility Director of Nursing (DON). The DON stated that she was unable to adjust the staffing ratios at the facility without specific corporate approval. The DON stated that the facility was low on staff due to "a lot of recent turnover." (Cross refer to F 242, F309, F311, F332)

Based on interview and record review, it was determined the facility did not ensure that each resident's drug regimen was free from unnecessary drugs without adequate monitoring for 2 of 61 sample residents. Specifically, one resident developed a [MEDICAL CONDITION] after receiving an excessive dose of [MEDICATION NAME] resulting in two high anticoagulant studies and one resident had duplicate unnecessary pain medications ordered. Resident identifiers: 60 and 188. Findings include: 1. Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 60 developed a [MEDICAL CONDITION] and was admitted to the hospital on [DATE] and readmitted on [DATE] to the facility. Resident 60 was again discharged to the hospital [MEDICAL CONDITION] on [DATE] where he expired. The admission Minimum Data Set (MDS), dated [DATE] did not indicate resident 60 was on anticoagulation therapy or a diuretic. A Care Plan for resident 60, dated [DATE] included: At risk for uncontrolled bleeding prone to bruise easily related to anticoagulant therapy. The goal was to have no uncontrolled bleeding and minimal bruising. The approaches included assess for coffee ground emesis, teach family and resident about risk of bleeding and assess any bleeding and report to physician. Also, coagulation studies were to be monitored as ordered. Report abnormal labs and administer coagulant as ordered. Physician Treatment Admit Orders for, dated [DATE], indicated resident 60 was to receive [MEDICATION NAME] dosing and [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) from the hospital anticoagulation clinic. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. [MEDICATION NAME] 10 mg (milligrams) every day. (Note: [MEDICATION NAME] is an antihypertensive medication.) b. [MEDICATION NAME] 10 mg every day. (Note: [MEDICATION NAME] is for inflammation and one of the side effects is gastrointestinal hemorrhage.) c. Aspirin 81 mg EC ([MEDICATION NAME] coated) every night. (Note: Side effects of aspirin include gastrointestinal distress and prolonged bleeding time.) On [DATE], resident 60 was placed on these medications: a. [MEDICATION NAME] 40 mg every day. (Note: [MEDICATION NAME] is a diuretic.) b. [MEDICATION NAME] was increased to 10 mg two times a day On [DATE] resident 60 was started on an antibiotic, Bactrum, two times a day for 14 days. The Pharmacy Managed [MEDICATION NAME] ([MEDICATION NAME]) Discharge Orders from the hospital, dated [DATE], were for resident 60 to have a PT/INR when ordered. In addition, resident 60 was to take [MEDICATION NAME] 5 mg by mouth once daily. The INR target range for resident 60 was 2.0 to 3.0. A physician order, dated [DATE], indicated the [MEDICATION NAME] dosing and PT/INR would be followed by the hospital anticoagulation clinic, AM shift and PM shift, until [DATE], then the [MEDICATION NAME] would be followed up with resident 60's physician. On [DATE], an INR result from a different laboratory than the hospital anticoagulation clinic was reported to the facility on [DATE] and indicated the INR for resident 60 was 3.1 which was a "higher-Intensity [MEDICATION NAME] Therapy". an order for [REDACTED]. On [DATE] a fax from the hospital anticoagulation clinic indicated the target range for resident 60's INR was 2XXX,[DATE].5 and that day's INR was 3.1 The instructions for the facility were to hold the [MEDICATION NAME] for one dose then decrease to 2.5 mg Saturday, Sunday, Tuesday and 5 mg Monday, Wednesday, Thursday and Friday. The order was to recheck the INR on [DATE]. Additional comments indicated there was a corrected fax indicating that the 5 mg [MEDICATION NAME] had already been given to resident 60 on [DATE] and the new order was that the facility was to hold the [MEDICATION NAME] dose on [DATE] then follow the same weekly orders. On [DATE] a fax from the hospital anticoagulation clinic indicated the facility had called them with an INR of 9.2. It indicated the facility had contacted resident 60's physician, but asked the clinic about the next step. The anticoagulation clinic suggested "if doc (doctor) wanted to (give) 2.5 mg vit (vitamin) K oral and (obtain the) next INR in the next day or 2. (Physician) called, they will follow. We (the clinic) are transferring the pt (patient) to (physician)." The lab result of the [DATE] INR was not in the medical record. However, the Director of Nursing (DON) provided a faxed summary list of PT/INR results for resident 60 from the hospital clinic that was dated [DATE]. The [DATE] INR was not listed. The [DATE] INR was listed at 9.9. It was unclear in the documentation if the INR was 9.9 or 9.2. The anticoagulation clinic listed both. By interview with the DON, it was unclear why the anticoagulation clinic did not know about the [DATE] INR. Nurses Notes included the following: a. [DATE] held [MEDICATION NAME] 5 mg due to orders b. [DATE]. . ." fax sent to attending MD (medical doctor) regarding change in condition per report son desired MD contacted re: pink tinged sputum on [DATE]. . ." Resident 60 showed signs of bleeding. c. [DATE] at 11:39 AM, "call placed to MD change of condition active rectal bleeding send to ER (emergency room ) for eval (evaluation)" . At 11:52 AM "during brief change noted dark red active rectal bleeding pooled in brief, MD notified." Physician orders, dated [DATE] indicated that a sputum culture and sensitivity was to be obtained on [DATE]. A Resident Chronology Report, dated [DATE], indicated resident 60 began antibiotic treatment for [REDACTED]. The pink sputum was not investigated. Nurses Notes also indicated resident 60 was presenting with low blood pressures. On [DATE] the nurses notes indicated resident 60's blood pressure was ,[DATE]. The note indicated the blood pressure was consistently low due to antihypertensives, diuretics, narcotics and 2 or more medications. The note indicated resident 60 was at high risk for [MEDICAL CONDITION] and the medications should be changed or discontinued. Other Nurses notes indicated resident 60's blood pressures were frequently low and [MEDICATION NAME] was held on [DATE], [DATE] and [DATE] for low blood pressures. Documentation that the physician was notified of the low blood pressures and that the [MEDICATION NAME] was held was not in the medical record. On [DATE] a telephone physician's orders [REDACTED]. Follow up was to be with resident 60's physician, not the hospital anticoagulation clinic. On [DATE] a telephone physician's orders [REDACTED]. Con't (continue) with order to hold [MEDICATION NAME] and recheck INR in 1 week." On [DATE] a telephone physician's orders [REDACTED]. On admit to the hospital on [DATE], the hospital nurse documented that resident 60's acuity was "emergent" and blood pressures were low at ,[DATE]. Two hours later resident 60's blood pressure had dropped to ,[DATE]. The history and physical hospital report for resident 60, dated [DATE], indicated: ". . . His [MEDICATION NAME] however, on Monday, [DATE], was INR of 9.9 and his [MEDICATION NAME] had to be stopped. Today, the patient was noted to have blood in the stool and his blood pressure was low . . . and an order was given to transfer to the emergency department, where he had further evaluation showing [MEDICAL CONDITION] with an INR of 3.9. . . hematocrit of 28.6.. . . He was resuscitated with IV (intravenous) fluids in the emergency department and blood [MEDICAL CONDITION] begun and he was transferred to the floor." The report listed as impression: "[MEDICAL CONDITION], suspect [MEDICAL CONDITION] (heart burn) secondary to [MEDICATION NAME] and aspirin, and excessive anticoagulation with [MEDICATION NAME]. . . " The plan included "Transfuse packed red cells to stabilize blood pressure and hematocrit at 28. (Normal for adult males is 42 to 54.) We will also use fresh frozen plasma to correct his [MEDICATION NAME] and he has been given vitamin K 5 mg in the emergency department. . . " On [DATE] three facility Registered Nurses (RNs) were interviewed and asked about the facility PT/INRs and [MEDICATION NAME] policy. The three RNs reported they did not know what the policy was. The three RNs stated that the INR results came from the laboratory and the MD was called for orders and they followed the orders. The three RNs were asked what they would do for a resident with an INR of 9.9. a) At 10: 28 AM, RN 8 stated she would hold the [MEDICATION NAME] and call the MD and do what was ordered. RN 8 was asked if the MD said to do another INR in one week, what would she say. RN 8 stated she would ask if the MD wanted to draw an INR sooner, she would not feel comfortable with waiting a week to draw another INR. b) At 12:47 PM, RN 6 was asked the same thing. RN 6 stated she would ask the MD if the order to draw the INR in a week was too long. RN 6 stated she would not be comfortable with the order to check the INR in one week if the INR was 9.9. c) At 1:46 PM, RN 1 stated, "I would tell the MD we need to check the INR sooner, like later that day or the next day." During the investigation of resident 60's [MEDICAL CONDITION] the DON was interviewed several times on [DATE]. a) At 10:15 AM, the DON stated that is was facility policy that if an INR was too high, the nurse would call the MD and follow orders. The DON was asked to provide a copy of the facility policies or programs concerning [MEDICATION NAME] administration and laboratory results. b) At 3:00 PM, the DON was asked why the faxed summary list from the hospital clinic of resident 60's INRs did not include the results of the [DATE] INR for resident 60. The DON stated she did not know. The DON stated "the diagnostic lab gives us the result of the INR and we report it to the hospital clinic." The DON stated that for resident 60, "the hospital clinic said that we would call the MD". The DON stated the vitamin K was given on [DATE] to resident 60. The DON stated she did not know why the vitamin K was given 2 days after the [DATE] INR of 9.2. The DON was informed that the hospital clinic had documented that the facility had informed the clinic of the 9.9 INR. The DON stated she would look into it. c) At 3:29 PM, the DON stated she had phoned the nurse on duty on [DATE] and the nurse had told her no vitamin K was given to resident 60. On [DATE] she had called the doctor to verify the order. d) At 5:00 PM, the DON provided the surveyor with the phone number to the hospital anticoagulant clinic and commented: "tell me how it works, I don't really know how the lab draws and INRs work (between the clinic and the MD). I need to find out about that." The DON reported she unable to find a facility policy or program concerning [MEDICATION NAME] administration and laboratory results. Note: At Medline Plus www.ahajournals.org, A Patient's Guide to Taking [MEDICATION NAME]/[MEDICATION NAME] From the Pharmacy Department and Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass., it states: "[MEDICATION NAME] (brand names [MEDICATION NAME] and Jantoven) is a prescription medication used to prevent harmful blood clots from forming or growing larger. . .[MEDICATION NAME] does not thin the blood but instead causes the blood to take longer to form a clot.. . . . [MEDICATION NAME] decreases the body's ability to form blood clots by blocking the formation of vitamin K-dependent clotting factors. Vitamin K is needed to make clotting factors and prevent bleeding. Therefore, by giving a medication that blocks the clotting factors, your body can stop harmful clots from forming and prevent clots from getting larger. The goal of [MEDICATION NAME] therapy is to decrease the clotting tendency of blood, not to prevent clotting completely. Therefore, the effect of [MEDICATION NAME] must be monitored carefully with blood testing. On the basis of the results of the blood test, your daily dose of [MEDICATION NAME] will be adjusted to keep your clotting time within a target range. The blood test used to measure the time it takes for blood to clot is referred to as a [MEDICATION NAME] time test, or [MEDICATION NAME] (PT). The PT is reported as the International Normalized Ratio (INR). The INR is a standardized way of expressing the PT value. The INR ensures that PT results obtained by different laboratories can be compared. It is important to monitor the INR (at least once a month and sometimes as often as twice weekly) to make sure that the level of [MEDICATION NAME] remains in the effective range. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding. This is why those who take [MEDICATION NAME] must have their blood tested so frequently. Unlike most medications that are administered as a fixed dose, [MEDICATION NAME] dosing is adjusted according to the INR blood test results; therefore, the dose usually changes over time. . . Many drugs, both prescription and nonprescription (OTC) over the counter, can affect the anticoagulant action of [MEDICATION NAME]. Some medications can enhance the action of [MEDICATION NAME] and cause excessive blood thinning and life-threatening bleeding. A few examples of such medications include aspirin and antibiotics." 2. Resident 188 was admitted to the facility on [DATE] with admit [DIAGNOSES REDACTED]. On [DATE] resident 188's medical records were reviewed. A review of resident 188's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The start date of the medication was dated [DATE]. A further review of the MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. A further review of the MAR indicated [REDACTED]. A notation on the MAR indicated [REDACTED]. On [DATE] at 8:53 AM, and interview was conducted with RN 1. RN 1 stated that she did not know why resident 188 still had an order for [REDACTED]. RN 1 further stated that she did not know why the resident still had the [MEDICATION NAME] and [MEDICATION NAME] medication orders. Resident 188 had not received these medications in a "long time". RN 1 stated that resident 188's family had requested Tylenol to be given first. RN 1 stated that Resident 188 only had pain when he moved and Tylenol seemed to control his pain. On [DATE] at 9:00 AM an interview was conducted with the DON. The DON stated that the nurses would come to her and ask that a medication be discontinued if the medication had not been used for a length of time, especially narcotics. The DON stated that the nurses did not like to continue to count the medications if residents were not using them. The DON stated that the pharmacy regimen review should have identified the medications to be discontinued. On [DATE] at 3:16 PM, an interview was conducted with the facility Pharmacist. The Pharmacist stated that if a medication had not been used in over a month then the medication should be discontinued.

Based on observation, interview and record review, it was determined that the facility did not ensure that 2 of 61 sample residents did not develop pressure sores. Resident identifiers: 9 and 194. Findings include: 1. Resident 9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/8/12 from 8:00 AM to 10:30 AM, a continuous observation was made of resident 9, sleeping in his gerichair with no off loading of pressure to his coccyx/sacrum/buttocks. On 5/9/12 resident 9's medical record was reviewed. Resident 9's Minimum Data Set ((MDS) dated [DATE], revealed that upon readmission to the facility, resident 9 was at risk of developing pressure sores. The MDS further revealed that resident 9 required extensive assistance with bed mobility and transfers. Resident 9's impairment of skin integrity care plan dated 1/28/12 revealed that resident 9 had "impairment of skin integrity, L (left) buttox (sic)" and identified "environmental factors, use of geri-chair (self inflicted friction/shearing r/t (related to) pt (patient) movement while in chair/bed), abrasion r/t friction." The approach was to "assess skin condition daily and note any changes, bandage as appropriate; Develop and monitor turning schedule, Keep clean and dry, Check placement of Geri chair pads while patient is up in Geri chair for prevention of shearing and friction and for comfort, Assist with hygiene and general skin care, Reposition every two hours, Follow turning schedule, Place Geri chair pad in geri chair before placing patient in chair, Regain skin integrity." No turning schedule could be found in resident 9's medical record. On 5/9/12 at 5:00 PM, an interview was conducted with Registered Nurse (RN) 7. RN 7 stated that the "Kardex system is the communication to the Certified Nursing Assistants (CNAs) informing them of the needs of each resident". RN 7 further stated that he was not aware of a turning and repositioning schedule for resident 9. On 5/9/12 at 5:05 PM, a review of resident 9's Kardex was conducted. Resident 9's Kardex revealed that resident 9 required assistance with bed mobility. An additional note on the Kardex dated 1/28/12 revealed, "T/R (turn and reposition), pressure relief to L (left) buttox (sic) frequently. Wnd (wound) tx (treatment) BID (two times daily)". CNA documentation revealed that between 2/1/12 and 5/10/12, resident 9 was turned and repositioned 22 times. It further revealed that resident 9 turned and repositioned himself independently 3 times. On 5/10/12 at 11:10 AM, an observation was made of RN 2 and another staff member as they transferred resident 9 to his bed. During the observation, resident 9 did not assist the staff members with the transfer. In addition, resident 9's skin was observed. The observation revealed that resident 9 had a large reddened area on his coccyx/sacral area approximately 14 centimeters (cm) x 10 cm that was barely blanchable with 3 open sores on his right buttocks, ranging from approximately 1 x 1 centimeter (cm) to 2 x 2 cm, and 7 reddened areas horizontally across his back. On 5/10/12 at 11:15 AM, an interview was conducted with RN 2 regarding resident 9. RN 2 stated, "Oh, he does spend a lot of time in that geri chair doesn't he?" RN 2 further stated that "the top wound was a pressure sore". On 5/10/12 at 9:25 AM, an interview was conducted with certified nursing assistant (CNA) 5. CNA 5 stated that he obtained his information regarding activities of daily living (ADLs) for each resident that he cared for from the nurses throughout the day and that he would also ask each resident what ADLs they were able to perform for themselves. CNA 5 stated that he could also obtain information from the care plans in the charts. CNA 5 then stated that he did not look at the care plans. On 5/10/12 from 1:00 PM to 4:00 PM, a continual observation of resident 9 was made. Resident 9 was sleeping in his geri-chair in the 400 hallway. At no time during the observation, did staff approach resident 9 or attempt to reposition him. On 5/10/12 at 4:00 PM, an interview was conducted with RN 4. RN 4 stated that she did not know that the "CNAs were not turning (resident 9) and I don't know why he was not turned today". She further stated that the CNAs were "supposed to be looking at the Kardex every day to know what the needs of the residents are". RN 4 stated that she had "not been made aware of the new pressure sores to (resident 9)'s right buttocks today". On 5/10/12 at 4:05 PM, an interview was conducted with RN 2. RN 2 stated that she had not been informed of the new pressure sores. RN 2, who was the wound nurse, stated that this was the first time that she had looked at the sores. On 5/10/12 at 4:10 PM, a telephone interview was conducted with CNA 10. CNA 10 stated that she had worked with resident 9 that day. CNA 10 stated that she knew what the needs of her residents are because of "common sense and because of my CNA class I guess". CNA 10 stated that she changed resident 9's brief that morning because he had been incontinent of bowel, and that she always monitored for changes with his coccyx/buttocks area. CNA 10 stated that she would report any change to the nurse. CNA 10 further stated that she did not notice anything on resident 9's buttocks that morning that needed to be reported to the nurse. CNA 10 stated that she did not reposition resident 9 that day and did not know why. On 5/10/12 at 5:30 PM, an interview was conducted with RN 4. RN 4 stated that a "turning and repositioning schedule" had now been started for resident 9. 2. Resident 194 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 194's medical record was reviewed on 5/7/12. Resident 194's admission MDS dated [DATE] documented that resident 194 did not have any pressure ulcers at that time, but that he was at risk for developing them. Resident 194's "Skilled Nursing Assessment" dated 3/3/12 documented that resident 194 required "extensive assistance" with bed mobility. Resident 194's nurses notes dated 5/8/12 documented that resident 194 "required physical assist of 2 or more persons to position extremeties (sic) and trunk with involved weight bearing, and little self-performance" for bed mobility. A nurse's note dated 5/10/12 documented that resident 194 had developed an "in house" unstageable pressure sore on his left medial knee. In addition, the note revealed that resident 194 had developed an "in house deep tissue injury", also on his left medial knee. A fax to resident 194's physician dated 5/10/12 revealed the following: "Two In house Pressure wounds found on 5/9/12 to patient's left medial knee. One is an unstageble (sic) r/t (related to) adhering yellow slough in wound bed. This wound measures 1.5 cm x 3.2 cm x unable to determine (depth). We are currently treating with Aghydrogel and Foam adhesive. Moderate serous drainage. No odor. Edges intack (sic). Periskin red and blanching. Second wound is also on left medial knee superior to first wound. It is a deep tissue injury. Dark purple, skin intact. Measures 2 cm x 2.2 cm x superficial. Could we please treat first wound with Santyl QD (every day) Topical to slough in wound bed with adhesive foam bandage and [MEDICATION NAME] to DTI (deep tissue injury)". No documentation could be located that indicated facility staff had identified any skin issues on resident 194's knee prior to 5/10/12. On 5/10/12 at 8:30 AM an interview was conducted with RN 2. RN 2 confirmed that resident 194 had developed a pressure sore on the inside of his knee. RN 2 stated that the sore was noticed the previous day, and it was most likely a stage III due to the slough that was present. On 5/10/12 at 4:15 PM an interview was conducted with CNA 2. CNA 2 stated that resident 194 was unable to reposition himself, and that staff were supposed to "go in and turn him every two hours." On 5/10/12 an interview was conducted with Staff Member (SM) 1. SM 1 stated that due to the low staffing levels, facility staff were not able to perform all necessary cares. When asked about resident 194, SM 1 stated that facility staff did not turn resident 194 at night as required, which resulted in the pressure sore. On 5/10/12 an interview was conducted with the facility DON. The DON confirmed that resident 194 had a pressure sore on the inside of his knee that had been identified the day before. On 5/10/12 at 5:15 PM an interview was conducted with resident 194. Resident 194 stated that he could not move independently in bed, and that the staff members were supposed to "come in to move me around in bed at night." A review of the facility's QA (Quality Assurance) Audit, defined "Pressure Ulcer" as "any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers." The QA Audit further defined a Stage II (2) pressure ulcer as a "partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." The facility policy and procedure for prevention of pressure ulcers, revealed that the purpose of the policy was "to prevent skin breakdown and development of pressure sores". The policy divided care for the residents into the following areas: A) Assessment guidelines: . . . B) Assessment of risk factors: . . .10. "Mobility status, including bed mobility" . . .11. "Limitation in range of motion and deformities" . . . 14. "History of pressure ulcers" C) Prevention: . . . D) Equipment: . . . E) Procedure: . . .5. "Use appropriate support surface in the resident's bed or chair" . . . 6. "Use pressure reducing or relieving devices as necessary" . . . 9. "Establish a turning and positioning schedule in bed and chair to meet the resident's needs" F) Documentation guidelines: . . . G) Care plan documentation guidelines: . . . . (Cross refer to F309, F311 and F353)