Every finding on record at Bethel Home

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R26 and R64) as well as staff, volunteers, visitors, and other individuals providing resident services. This practice had the potential to affect more than 4 of the 70 residents residing in the facility.The facility did not implement transmission-based precautions (TBP) for residents at the onset of respiratory symptoms to prevent the spread of contagious illness. R26 was not placed on droplet precautions at the onset of respiratory symptoms on 8/11/25. R26 was admitted to the hospital on [DATE] and diagnosed with sepsis due to pneumonia of right lower lobe due to infectious organism. In addition, R64 was diagnosed with pneumonia on 9/3/25 and was not placed on TBP. Findings include: The facility's Influenza-Like Illness Control and Surveillance policy, updated 1/2025, indicates: It is the facility's policy to implement infection control measures to identify, control, and notify the appropriate agencies of influenza–like illnesses .Isolation Precautions: Caregivers and visitors should adhere to the appropriate precautions in the presence of a resident with suspected or confirmed respiratory illness until the cause of an acute respiratory infection outbreak is determined. Both droplet and contact precautions should be initiated in addition to standard precautions. Droplet precautions: Illness with pathogens transmitted by respiratory droplets that are generated by a resident who is coughing, sneezing, or talking. Personal protective equipment (PPE) includes a mask and gloves. Working guidance and approval from the campus Medical Director, unless pneumonia is secondary to an infectious agent and conforms to already established Centers for Disease Control and Prevention (CDC) recommendations for common respiratory viruses, pneumonia will be addressed with standard precautions. The facility indicated they refer to CDC Appendix A, dated 2/7/25, for guidance on precautions. Appendix A contains the type and duration of precautions recommended for selected infections and conditions, including numerous pneumonia diagnoses. The facility also indicated they refer to the Department of Health Services (DHS) Transmission-Based Precautions Reference Guide for guidance on precautions which indicates: Transmission-Based Precautions in Health Care Settings: This reference guide may be used for common diseases to prevent transmission of infectious agents in healthcare settings. CDC Appendix A: Type and Duration Recommended for Selected Infections and Conditions. For a general list of clinical syndromes or conditions warranting empiric transmission-based precautions, refer to CDC Appendix A: Table 2. Standard Precautions: Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. Standard precautions apply at all times and in all locations of healthcare. Practice hand hygiene. Hand hygiene refers to cleaning your hands, either by washing with soap and water or by using alcohol-based hand rub (ABHR); Use PPE whenever there is an expectation of possible exposure to infectious material; Properly clean and disinfect resident-care equipment following products' manufacturer's instructions for use, including amount, dilution, and contact time; Promote respiratory hygiene or cough etiquette among staff and residents. Contact Precautions: Wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. [NAME] PPE upon room entry and discard before exiting the room to contain pathogens, especially those that have been implicated in transmission through environmental contamination; Use disposable or dedicated resident-care equipment (for example, blood pressure cuffs). If common use of equipment for multiple residents is unavoidable, clean and disinfect such equipment before use on another resident; The resident should perform hand hygiene and wear clean clothing when leaving the room; Limit movement of the resident outside their room to medically necessary purposes only. Transmission-Based Precautions: Transmission-based precautions are used in addition to standard precautions. They are used for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. There are three categories of transmission-based precautions including: contact precautions, droplet precautions, and airborne precautions. Wear a surgical or procedure mask for close contact with an infectious resident. The mask is generally donned upon room entry; Limit movement of the resident outside their room to medically necessary purposes only. Residents on droplet precautions who must be transported outside their room should wear a surgical or procedure mask if tolerated and practice respiratory hygiene and cough etiquette. 1.On 9/9/25, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to internal left knee prosthesis, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. R26's Minimum Data Set (MDS) assessment, dated 8/11/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R26 had intact cognition. R26 had an activated Power of Attorney for Healthcare (POAHC) to assist with medical decision making. R26's medical record indicated R26 was on enhanced barrier precautions (EBP) since admission. A progress note, dated 8/11/25, indicated R26 felt cold, was hypotensive, had chattering teeth, and had a temperature of 100.4 degrees. R26 was admitted to the hospital on [DATE] and diagnosed with sepsis due to pneumonia of right lower lobe due to infectious organism. R26 was readmitted to the facility on [DATE]. On 9/8/25 at 2:00 PM, Surveyor interviewed Infection Preventionist (IP)-D who indicated the facility follows standard precautions for residents diagnosed with pneumonia and continues to follow standard precautions if there is an infectious agent associated with the resident's pneumonia. IP-D verified the facility follows CDC Appendix A as a reference for PPE protocol and indicated CDC Appendix A indicates to follow standard precautions for residents diagnosed with pneumonia. IP-D verified the facility does not obtain a sputum sample for residents with respiratory symptoms suspected of having pneumonia and indicated residents are placed on standard precautions when respiratory symptoms are present. IP-D indicated the facility does not have a TBP policy and follows the DHS Transmission-Based Precautions reference guide. On 9/8/25 at 3:28 PM, Surveyor interviewed Medical Director (MD)-H who recommended residents be placed on droplet precautions at the onset of respiratory symptoms to protect themselves and others. MD-H indicated staff should wear a mask, gown, and gloves while working with residents suspected to have pneumonia and stated it is important to use good hand hygiene. MD-H indicated a sputum culture is indicated when pneumonia is suspected and stated a resident should be contained to their room until fever free for 24 hours and on antibiotics for 24 hours if antibiotics are necessary to reduce transmission. MD-H indicated it is the facility's responsibility to contain respiratory illness by limiting residents' transport to medically necessary purposes. On 9/9/25 at 12:05 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R26 was not placed on TBP or droplet precautions at the onset of respiratory symptoms. DON-B indicated the facility follows standard precautions for residents who are suspected to have and diagnosed with pneumonia and does not culture residents for pneumonia. 2. From 9/8/25 to 9/10/25, Surveyor reviewed R64's medical record. R64 was admitted to the facility on [DATE] and had diagnoses including diabetes and chronic kidney disease. R64's MDS assessment, dated 7/2/25, had a BIMS score of 15 out of 15 which indicated R64 had intact cognition. R64 made R64's own healthcare decisions. R64's medical record indicated R64 was diagnosed with pneumonia on 9/3/25 per a chest X-ray. R64 did not have a sputum test which would have determined R64's type of pneumonia. R64 had an order for Augmentin (an antibiotic medication) oral tablet 875-125 milligrams (mg), give 1 tablet by mouth two times daily for pneumonia for 7 days (start date 9/3/25). On 9/8/25 at 2:32 PM, Surveyor noted there was not a TBP sign or PPE cart near R64's door that indicated staff should wear PPE while caring for R64 to prevent the transmission of infection. Surveyor interviewed R64 who indicated staff do not wear PPE during cares except for gloves. On 9/9/25 at 12:10 PM, Surveyor interviewed DON-B who indicated the facility's policy indicates standard precautions are used for pneumonia and droplet precautions are not required. On 9/9/25 at 12:55 PM, Surveyor interviewed IP-D who indicated R64 was not placed on TBP because R64 was not deemed to have an infectious disease after a COVID-19 test was negative. IP-D confirmed a sputum culture was not obtained and R64's pneumonia was diagnosed via X-ray. On 9/10/25 at 9:48 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who verified R64 was not on TBP.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R44 and R3) of 2 sampled residents were accurately assessed for self-administration of medication. Theraworks pain relief spray was observed at R44's bedside. R44's most recent Self-Administration of Medication assessment, dated 9/3/25, indicated R44 was unable to self-administer medication. Oral medication and eye drops were observed at R3's bedside. A Self-Administration of Medication assessment for R3 was not thoroughly completed. In addition, R3 signed consent to self-administer medication while incapacitated. Findings include: The facility's Self-Administration of Medications policy, dated January 2025, indicates: It is the policy of Bethel Home to support residents' rights to self-administer medication when it is safe and clinically appropriate. Self-administration of medication must be authorized by the provider, assessed by nursing staff, and consented to by the resident or their legal representative. Nursing staff remain responsible for ensuring resident safety, compliance with treatment, and regulatory requirements .Purpose: To promote resident independence and dignity while also ensuring medication safety and adherence .Eligibility requirements: .1. Assessment: A licensed nurse will complete and document an assessment of the resident's ability to self-administer medication safely .3. Consent: The resident (or legal representative) must sign a consent form acknowledging understanding and acceptance of the responsibilities. Nursing Staff Responsibilities: 1. Verify which residents are authorized for self-administration .2. Report any concerns or missed doses immediately to the charge nurse/supervisor. 3. Maintain ongoing evaluation of the resident's ability . 1.From 9/8/25 to 9/10/25, Surveyor reviewed R44's medical record. R44 had diagnoses including neurocognitive disorder with Lewy Body dementia, depression, and insomnia. R44's Minimum Data Set (MDS) assessment, dated 5/5/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R44 had severely impaired cognition. R44 had an activated Power of Attorney for Healthcare (POAHC). On 9/8/25 at 9:05 AM, Surveyor observed R44 in R44's room and noted there was a bottle of Theraworks pain relief spray on the cabinet next to R44's recliner. R44's medical record contained a Self-Administration of Medication assessment, dated 4/7/25, that indicated R44 was capable of self-administering topical medications. A Self-Administration of Medication assessment, dated 9/3/25, indicated R44 was not capable of administering any medications, including topical medications. On 9/9/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse House Manager (RNHM)-C. DON-B completed the initial assessment on 4/7/25 that indicated R44 was capable of self-administering topical medications and stated R44 has been self-administering topical medications since that time. RNHM-C stated RNHM-C filled out the assessment on 9/3/25 but did not complete an actual assessment because R44 resides on the dementia unit. DON-B indicated an additional assessment was completed on 9/9/25 and R44 was assessed as capable of self-administering topical medications and can keep them at the bedside. DON-B indicated the 9/3/25 Self-Administration of Medication assessment was not completed per policy and R44 was not accurately assessed at that time. 2. From 9/8/25 to 9/10/25, Surveyor reviewed R3's medical record. R3 had diagnoses including diabetes, atrial fibrillation, hypertension, anxiety, and depression. R3's MDS assessment, dated 7/5/25, had a BIMS score of 14 out of 15 which indicated R3 had intact cognition. R3 had an activated POAHC who assisted R3 with medical decisions. R3's medical record indicated R3 was deemed incapacitated on 7/7/22 but signed a Self-Administration of Medication form on 8/7/23. R3's medical record did not contain a Self-Administration of Medication form signed by R3's POAHC. R3's medical record contained a Self-Administration of Medication assessment that indicated R3 wished to self-administer medication per verbal request on 5/20/25. The bottom of the assessment indicated the Interdisciplinary Team (IDT) determined R3 was cognitively, physically, and visually able to self-administer medications and contained an illegible signature dated 5/20/25. An assessment completed on 5/21/25 indicated R3 was not capable of storing, opening, or closing medication containers, needed assistance with time for medication administration, and could not correctly state the proper dosage for medication. Correct dispensing of medication and medication by route were not assessed. The assessment indicated R3 was fully capable of accurately documenting self-administration of medication. On 9/8/25 at 9:43 AM, Surveyor observed 2 pills at R3's bedside and a bottle of eye drops in a labeled container. Surveyor interviewed R3 who thought the pills were Tylenol from the night before and stated R3 fell asleep before taking them. R3 stated R3 had to keep the eye drops at bedside but preferred staff administer the eye drops in the evening. On 9/8/25 at 10:00 AM, Surveyor interviewed RN-G who indicated R3 can keep the eye drops at bedside. RN-G indicated the pills at R3's bedside were from the previous night and could be acetaminophen and Gas-X. RN-G was not sure if acetaminophen should be at the bedside but thought Gas-X could be. On 9/8/25 at 10:06 AM, RN-G approached Surveyor and indicated R3 could have medications at the bedside. Surveyor reviewed R3's Medication Administration Record (MAR) which indicated R3's scheduled acetaminophen 1000 milligrams (mg) by mouth at bedtime (HS) was last administered on 9/7/25 at 7:09 PM. The order did not indicate the medication could be left at the bedside. R3's MAR contained an order for dry eyes ophthalmic solution 0.5% Povidone instill 1 drop in right eye three times a day unsupervised self-administration and indicated the eye drops could be kept at the bedside. R3's September 2025 MAR contained documentation 3 times per day from 9/1/25 to 9/8/25 that indicated the eye drops were administered unsupervised. On 9/9/25 at approximately 8:00 AM, Surveyor was provided a Self-Administration of Medication assessment for R3 that contained a new order (with a start date of 9/8/25 at 7:00 PM) for staff to check R3's room twice daily to ensure R3 had taken all self-administered medications. R3's care plan was updated on 9/8/25 to reflect the physician order for self-administration of medication; however, the description indicated to specify the medications and if they were administered supervised or unsupervised. The medications and type of supervision were not specified. The facility provided a copy of education that was being provided to nursing staff to ensure staff visually verify residents who self-administer medication take the medication. On 9/10/25 at 9:19 AM, Surveyor interviewed DON-B who completed R3's Self-Administration of Medication assessment and indicated R3 can have medication at the bedside after the medication is prepared by a nurse. DON-B indicated R3 fell asleep the night before without taking medications that were signed out by the nurse. DON-B stated nursing staff should verify residents take medications left at the bedside and should do so prior to documenting their administration on the MAR. On 9/10/25 at 12:53 PM, Surveyor interviewed DON-B who indicated consent for self-administration of medication is not re-done if a resident is later identified as incapacitated and requires assistance with medical decision making. DON-B was unsure if R3's POAHC knew that R3 self-administers medication but thought so since care plans are reviewed at care conferences. (Of note: self-administration of medication was not added to R3's care plan until 9/8/25.) On 9/10/25 at 12:59 PM, Surveyor interviewed R3's POAHC who did not recall being informed that R3 self-administers medication.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R26 and R39) of 5 sampled residents were provided pneumococcal vaccines.R26 was eligible to receive a pneumococcal vaccine. The facility did not obtain R26's consent or declination to receive the vaccine in a timely manner.R39 was eligible for and signed consent to receive a pneumococcal vaccine. The facility did not administer the vaccine in a timely manner.Findings Include: The facility's Infection Control-Immunizations policy, revised 1/2025, indicates: The facility will ensure each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or the resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization; and The resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal .Utilize the flow chart when offering pneumococcal immunizations.Pneumococcal vaccine schedule guidelines indicate if there is no history of a PCV13 or PPSV23 vaccine, a Prevnar 20 vaccine should be administered. 1.On 9/8/25, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to internal left knee prosthesis, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. R26's Minimum Data Set (MDS) assessment, dated 8/11/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R26 had intact cognition. R26 had an activated Power of Attorney for Healthcare (POAHC) to assist with medical decision making. R26's medical record indicated R26 was admitted to the hospital on [DATE] and diagnosed with sepsis due to pneumonia of right lower lobe due to infectious organism.R26's 8/20/25 MDS documentation for vaccines indicated R26's pneumococcal vaccine was up to date. A Vaccine Administration Record-Immunization Consent Form for R26 contained a signature line that indicated R26 gave consent to receive the pneumococcal vaccine when offered on 9/8/25. R26's medical record indicated R26 received the pneumococcal vaccine on 9/8/25. On 9/9/25 at 9:50 AM, Surveyor interviewed Infection Preventionist (IP)-D who indicated consent for vaccines is obtained upon admission and is part of the admission paperwork. IP-D indicated R26 should have been offered and administered the pneumococcal vaccine within one or two days of admission.2. On 9/8/25, Surveyor reviewed R39's medical record. R39 was admitted to the facility on [DATE] and had diagnoses including acute osteomyelitis, cellulitis of right upper limb, and type 2 diabetes. R39's MDS assessment, dated 8/7/25, had a BIMS score 15 out of 15 which indicated R39 had intact cognition. R39 was responsible for R39's medical decisions. R39's medical record indicated R39 was admitted to the hospital on [DATE] and diagnosed with cellulitis. R39 returned to the facility on 8/18/25.R39's 8/5/25 MDS documentation for vaccines indicated R39's pneumococcal vaccine was up to date. An Authorization and Release for Pneumococcal Vaccine, signed by R39 and dated 8/5/25, indicated R39 consented to receive the pneumococcal vaccine. R39's medical record indicated R39 received the pneumococcal vaccine on 9/8/25. On 9/9/25 at 9:50 AM, Surveyor interviewed IP-D who indicated R39's consent for the vaccine was signed at the time of admission. IP-D indicated R39 should have received the pneumococcal vaccine within one or 2 days after R39 returned from the hospital on 8/18/25.On 9/10/25 at 9:50 AM, Surveyor interviewed MDS Registered Nurse (MDSRN)-I who indicated MDSRN-I documented that R26 and R39's pneumococcal vaccines were up to date because MDSRN-I had reviewed R26 and R39's Wisconsin Immunization Registries in error.

Based on staff interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 5 sampled residents when staff used a mechanical lift without ensuring a safety latch was in place prior to transferring R1.On 7/30/25 at 11:00 AM, Certified Nursing Assistant (CNA)-C and CNA-D transferred R1 from bed to Broda chair via a Liko Golvo 7007ES full body lift. CNA-C and CNA-D positioned the sling under R1 and hooked all 4 sling loops onto 2 hooks on either end of the sling bar. During the transfer, a sling loop slid down the sling bar, which caused the bar to go vertical. A safety latch that should have been attached to the sling bar hook was missing which caused a sling loop to detach from the lift. CNA-C and CNA-D were aware the safety latch was missing prior to the transfer. R1 fell out of the sling upper body first and hit R1's head on the leg of the lift. CNA-C stayed with R1 while CNA-D notified the nurse. R1 was bleeding from the back of the head and was transferred to the hospital. A computed tomography (CT) scan indicated R1 had a large right-sided acute subdural hematoma, a right scalp laceration, a small scalp hematoma, and a fracture of the C7 spinous process. R1 was admitted to the hospital and passed away on 8/2/25.The failure to identify and correct a known hazard related to the use of a mechanical lift created a finding of immediate jeopardy that began on 7/30/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 8/11/25 at 3:18 PM. The immediate jeopardy was corrected and removed on 7/31/25. The immediate jeopardy is being cited at past non-compliance. Findings include:The facility's Fall Risk Assessment and Management policy, dated January 2025, indicates it is the policy of the facility to provide as safe of an environment for our residents as possible .High-risk fall prevention interventions .are designed to reduce the severity of injuries due to falls as well as prevent falls from reoccurring, supplementing standard fall prevention interventions, including .Make sure supportive devices are applied properly before leaving the room for any reason.The facility's Safe Resident Handling policy, dated January 2025, indicates: .1. Protect the health and safety of residents and staff; 2. Maintain a high level of resident dignity and a positive resident experience during transfers; 3. Improve quality of care; 4. Maintain the resident's right to be as independent as possible based on their physical and psychological abilities; .6. Standardize resident lifting procedures. The policy also indicates mechanical equipment will be re-evaluated annually to ensure the equipment is adequate to meet the needs of the resident population .Caregivers will do visual inspections of lifts prior to use to ensure they are properly functioning. If equipment is in need of repair, it will not be used and maintenance staff will be contacted. Maintenance staff will complete an inspection of equipment as necessary to ensure it is properly functioning.On 8/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, epilepsy, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 6/18/25, indicated R1 was rarely to never understood and R1's cognition was severely impaired. The MDS also indicated R1 was dependent on staff for mobility and transfers. R1 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 7/30/25, indicated at approximately 11:00 AM, a CNA approached the nurse and indicated R1 fell out of a full body lift during a transfer and hit the back of R1's head. The nurse assessed R1 and noted R1 was bleeding from the back of the head. The nurse also noted a safety latch on the lift may have been faulty. The nurse called 911 and R1 was transferred to the hospital. A Hospital History and Physical (H&P), dated 7/30/25, indicated R1's CT scan showed a large right-sided acute subdural hematoma up to 2.3 centimeters (cm) thick with localized mass effect and an approximate 7 millimeters (mm) midline shift, as well as a right posterior lateral scalp laceration and a small underlying scalp hematoma. The cervical CT showed a mild displaced acute fracture of the C7 spinous process. The H&P indicated R1's POAHC opted for Hospice services and comfort measures. A Hospital Discharge summary, dated [DATE], indicated R1 passed away on Hospice services on 8/2/25. The primary cause of death was listed as a subdural hematoma with contributing illness of severe dementia. On 8/11/25 at 10:17 AM, Surveyor interviewed Deputy Medical Examiner (DME)-F via phone who stated R1's death certificate indicated the cause of death was an accident resulting in a closed head injury as a result of a fall. On 8/11/25 at 11:12 AM, Surveyor interviewed Maintenance Technician (MT)-E who stated MT-E completes monthly equipment checks on safety latches and other features of the lifts. MT-E stated if there is a concern, the lift is removed from the floor until maintenance repairs it. MT-E stated MT-E checked the lift with the missing safety latch 2 weeks prior to the incident and the latch was in place. MT-E stated MT-E carries extra latches because MT-E has had to replace the latches on other full body lifts in the past. On 8/11/25 at 11:18 AM, Surveyor interviewed CNA-D via phone who confirmed CNA-D assisted with R1's transfer on 7/30/25. CNA-D confirmed a sling loop detached which caused R1 to fall out of the sling and hit R1's head on the lift. CNA-D stated the sling loop became loose because one of the safety latches for the hook was missing. CNA-D stated CNA-D was aware the latch was missing prior to the transfer on 7/30/25 but was unsure how long the latch was missing CNA-D confirmed CNA-D had used the lift to transfer R1 prior to 7/30/25 with a missing latch. CNA-D indicated CNA-D did not think about the risk prior to the transfers. On 8/11/25 at 1:03 PM, Surveyor interviewed CNA-C who confirmed CNA-C assisted with transferring R1 on 7/30/25. CNA-C indicated a safety latch was missing from the sling bar hook which resulted in R1's fall. CNA-C confirmed CNA-C was aware the latch was missing prior to the transfer but was unsure how long the latch was missing. CNA-C was unable to state for certain if CNA-C had transferred R1 or any other residents with the lift prior to R1's fall on 7/30/25. The Liko Golvo instruction guide for model number 7007ES states for safe operation, a few procedures should be performed every day the lift is used including checking that the latches work properly.Surveyor reviewed the facility's monthly lifting device inspection audits for the facility's 24 mechanical lifts which included the following: Inspect each lift monthly with attention to specific operating points according to manufacturer; Check for accuracy of scale using 50 (pound) weight as needed; Check brakes and wheels, clean and lubricate wheels; Check for loose parts, bolts and nuts; Lubricate lift; Check voltage of all lift batteries; Remove lift from service if repairs are needed.A monthly lift inspection, due date 8/4/25, indicated the Liko Golvo 7007ES full body lift (T013) was last inspected by MT-E on 7/14/25. Surveyor also reviewed lift inspections dating back to March 2025 and noted inspections were completed monthly for all 24 of the facility's mechanicals lifts, including the T013 lift.On 8/11/25 at 9:31 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed CNA-C and CNA-D transferred R1 knowing that a safety latch was missing from the lift. DON-B stated CNA-C and CNA-D were suspended immediately, completed in-person hands on education related to equipment safety as well as abuse and neglect, and completed retraining on appropriate and safe transfer techniques, including demonstrations, before they returned to work. DON-B verified the lift in question was immediately removed from the unit. A full inspection was completed and the safety latch was replaced before the lift was returned to the floor. DON-B stated all staff received equipment safety education, which was completed on 7/31/25, and indicated all staff who transfer residents attended one of two transfer safety workshops to demonstrate competency. DON-B acknowledged CNA-C and CNA-D should not have transferred R1 knowing that the latch was missing.The failure to keep R1 free from a fall by identifying and eliminating a known hazard for a mechanical lift created a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 7/31/25 when it had completed the following:Immediately removed the lift from resident use, completed a full maintenance inspection, and replaced the safety latch before the lift was returned to the floor. The facility also completed audits on all other mechanical lifts.Removed the staff from resident care pending the outcome of the investigation and hands-on education.Educated staff on equipment safety, gait belt, stand lift, and full body lift transfers, and abuse/neglect related to equipment safety. Randomly audited 8 lifts per month for 3 months to ensure there are no maintenance concerns with lifts and slings.Audited 10 lift transfers per month for 3 months to ensure proper transfer techniques as well as proper pre-lift review of the equipment to ensure there are no safety concerns.

Based on staff interview and record review, the facility did not ensure the plan of care was revised for 1 resident (R) (R1) of 3 sampled residents. R1's plan of care was not updated to include recommendations from an Advanced Practice Nurse Prescriber (APNP) regarding transfer speed and hydration related to orthostatic hypotension (a condition where blood pressure drops when standing or sitting up) and unresponsive episodes. Findings include: The facility's Comprehensive Care Plans policy, with a review date of August 2024, indicates the comprehensive care plan will describe at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. On 10/23/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for surgical aftercare following surgery on the nervous system, cervical spine issues, right clavicle fracture, unresponsive episodes, supraventricular tachycardia, and hypertension (high blood pressure). R1's Minimum Data Set (MDS) assessment, dated 9/4/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. On 9/4/24, R1 had an unresponsive/dizzy episode while being transferred in a sit-to-stand lift by therapy staff. The physician was notified and responded with no new orders. On 9/18/24, R1 saw an APNP. A note from the visit indicated R1 had orthostatic hypotension and staff should continue to monitor, assist with slow position changes, and ensure R1 consumed fluids for adequate hydration. A progress note, dated 9/19/24, indicated R1 complained of dizziness and not feeling well approximately one hour after R1 received R1's AM medications and 45 minutes after breakfast. R1's blood sugar level was 252 mg/dL (milligrams/deciliter) and R1's blood pressure was 91/45 mmHg (millimeters of mercury). R1 was encouraged to consume fluids which R1 took well. Prior to therapy, R1 continued to complain of dizziness. R1's blood pressure at rest was 79/58 mmHg. Therapy staff had R1 do exercises and R1's blood pressure rose to 97/60 mmHg. Medical Doctor (MD)-C was notified via fax and a medication list was sent. MD-C gave an order to decrease R1's metoprolol extended release (ER) (a medication used to treat high blood pressure) to 25 mg and decrease R1's linisopril (a medication used to treat high blood pressure) to 10 mg daily. A care plan, initiated on 9/20/24, indicated R1 had the potential to have unresponsive episodes due to a history of syncopal (fainting or passing out) and unresponsive episodes. The care plan indicated R1 displayed symptoms of increased confusion, disorientation, and not responding to staff when prompted. The care plan contained interventions to acknowledge and accept R1's feelings, help R1 find other ways to communicate, assess R1 for unmet needs (such as pain, toileting hunger, or thirst) and note how R1 communicates nonverbally, have Certified Nursing Assistants (CNAs) acknowledge that they understand R1, face R1 and speak clearly when talking to R1, tell R1's nurse about any pain R1 has, allow time for R1 to respond, and ask R1 questions that can be answered with yes or no. On 10/23/24 at 3:54 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A and asked them to review R1's plan of care related to unresponsive episodes. DON-B and NHA-A confirmed R1's care plan interventions did not include the APNP's recommendation on 9/18/24 to transfer R1 slowly and confirmed the care plan should include that recommendation. When NHA-A asked how staff would know what slow was because it was subjective, Surveyor indicated it could be a cue to nursing staff to take more caution.

Based on staff interview and record review, the facility did not ensure a physician saw and responded to radiological records for 1 resident (R) (R1) of 3 sampled residents. R1 had X-rays of the shoulder and clavicle completed on 10/9/24 after R1 passed out during a transfer and complained of right shoulder/clavicle pain. R1's shoulder X-ray showed normal findings. R1's clavicle X-ray indicated R1 had a fracture. The facility did not ensure a physician received the results of R1's clavicle X-ray. Findings include: On 10/23/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for surgical aftercare following surgery on the nervous system, cervical spine issues, right clavicle fracture, unresponsive episodes, osteopenia, supraventricular tachycardia, and hypertension. R1's Minimum Data Set (MDS) assessment, dated 9/4/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. R1's medical record indicated the following: ~ R1 was admitted to the facility for rehabilitation after surgery due to surgical spine issues. ~ On 9/17/24, therapy staff changed R1's transfer status from Hoyer lift to sit-to-stand lift with 1 assist. In the weeks leading up to the change in transfer status, therapy staff worked with R1 on using a sit-to-stand lift and trained staff to transfer R1 with a sit-to-stand lift. R1's care plan was updated on 9/19/24. ~On 9/20/24, a care plan was initiated related to unresponsive episodes. ~ A progress note, dated 10/8/24 at 12:50 PM, indicated R1 had an unresponsive episode in a stand up lift. R1 complained of severe right shoulder/clavicle pain with limited range of motion (ROM). Staff applied ice to the area and as needed (PRN) Norco (a combination of acetaminophen and hydrocodone) was administered per R1's request with minimal relief. Staff called the physician's office and were asked to fax an update which Medical Doctor (MD)-C would address as soon as MD-C returned. R1 and R1's spouse were aware. ~ A physician contact note, dated 10/8/24, indicated R1 had an unresponsive episode while in a stand up lift. R1 complained of severe pain in the right shoulder/clavicle which was slightly swollen. The physician ordered X-rays of the right shoulder and clavicle due to limited mobility. ~ On 10/9/24, the X-rays were completed. ~ On 10/9/24, the facility received the results for R1's shoulder X-ray via fax at 11:00 AM which indicated there was no acute fracture. A handwritten note on the X-ray results indicated the same. The results were signed by MD-C on 10/10/24. ~ On 10/9/24, the facility received the results for R1's right clavicle X-ray via fax at 11:11 AM. The results indicated R1 had an age-indeterminate fracture of the mid-right clavicle with mild displacement of the distal fragment that correlated with the timing of the transfer and pain. The X-ray results did not contain a handwritten note or MD-C's signature. ~ A progress note, written by Registered Nurse (RN)-E on 10/9/24 at 1:51 PM, indicated R1's right shoulder/scapula X-ray was negative for fracture. R1 was updated and a report was faxed to the physician. ~ An orthopedic appointment note, dated 10/15/24, indicated R1 had a closed non-displaced fracture of the right clavicle shaft, point tenderness over the clavicle, and right shoulder pain. R1 had a history and physical exam finding of an acute right clavicle fracture that occurred approximately one week ago. R1 was asked to work on ROM as tolerated and apply ice. The note indicated the physician would follow-up with R1 to determine if R1 needed a rehab program and repeat the X-ray in 1 month. On 10/23/24 at 11:45 AM, Surveyor interviewed RN-E who verified RN-E was working on R1's unit when R1's X-ray results were received. RN-E recalled faxing 2 pieces of paper to MD-C on 10/9/24. RN-E documented in R1's medical record that there were no findings for R1's shoulder X-ray and faxed the results to MD-C. RN-E did not recall receiving R1's clavicle X-ray results. On 10/23/24 at 12:10 PM, Surveyor interviewed MD-C who indicated MD-C must not have seen the results of R1's clavicle X-ray because MD-C did not sign or date the results. MD-C wasn't sure if the results were faxed or if MD-C missed them. MD-C indicated when MD-C reviews X-ray results, MD-C dates and signs the document and sends it back to the facility. MD-C indicated MD-C wouldn't have ordered anything different had MD-C seen R1's clavicle X-ray results. MD-C indicated the treatment for a clavicle fracture was rest, ice, and use as tolerated. There was no surgery or casting needed. MD-C indicated R1 was already taking pain medication which was strong and addictive. On 10/23/24 at 2:09 PM, Surveyor interviewed Occupational Therapist (OT)-D who saw R1 on 10/10/24 due to R1's complaint of shoulder pain. OT-D indicated when OT-D entered R1's room, R1 had an ice pack on R1's shoulder. OT-D was under the impression that R1's shoulder X-ray was negative and was not sure if the X-ray included R1's clavicle. Based on OT-D's assessment, OT-D recommended R1 see Orthopedics due to clavicle pain. OT-D indicated that R1 felt instability and popping when R1 moved R1's right arm. OT-D indicated if OT-D had known R1 had a clavicle fracture, OT-D would have recommended R1 not use the arm and use a sling if R1 was up. OT-D would have also recommended that staff use a Hoyer lift to transfer R1 (which staff were already using). OT-D indicated it was okay for R1 to use R1's elbow and hand when in bed. OT-D indicated the treatment for R1's type of fracture was rest and let it heal On 10/23/24 at 3:54 PM, Surveyor interviewed Director of Nursing (DON-B) who indicated DON-B had not seen the results of R1's 10/9/24 X-rays but heard that MD-C noted there was no fracture. DON-B became aware of R1's clavicle X-ray result on 10/15/24 when a nurse completed paperwork to send to R1's Orthopedics appointment and discovered the clavicle X-ray result which did not contain MD-C's signature. DON-B notified MD-C who was in the building at the time. MD-C indicated the clavicle X-ray showed a fracture, however, MD-C must not have seen the results prior because there was no signature. MD-C indicated MD-C would not have changed R1's treatment because R1 was already receiving rest and ice and would have referred R1 to Orthopedics. DON-B indicated Orthopedics obtained X-rays, noted the clavicle fracture, and did not order anything aside from a sling and ice. DON-B indicated R1 was capable of applying and removing the sling but didn't like the sling. DON-B indicated RN-E said it was not unusual to get duplicate copies of the same results and RN-E remembered faxing 2 pieces of paper to MD-C. RN-E recalled seeing there was no fracture and was surprised to see there was a clavicle fracture. DON-B indicated the facility started a new process to add a date and time stamp when results are faxed to the physician so there is a record of when the results were faxed. On 10/23/24 at 4:57 PM, Surveyor completed a follow-up interview with DON-B who indicated items are put in a blue folder on the desk after they are faxed to MD-C. DON-B verified MD-C responded to the X-ray that stated no fracture on 10/10/24 and indicated staff didn't know there was another X-ray result that MD-C hadn't responded to. DON-B indicated the facility was working on a system to ensure all faxes were addressed by having the night shift supervisor look at all faxes sent to MD-C to see what MD-C had and hadn't followed up on. DON-B confirmed the facility should have followed-up to ensure MD-C saw and responded to R1's clavicle X-ray result.

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R50, R65 and R27) of 4 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R50 was transferred to the hospital on 4/5/24, 6/5/24, and 7/28/24. Neither R50 or R50's emergency contact were provided with a written transfer notice for R50's hospital transfers. R65 was transferred to the hospital on 6/24/24. Neither R65 or R65's representative were provided with a written transfer notice for R65's hospital transfer. R27 was transferred to hospital on 6/24/24. Neither R27 or R27's representative were provided with a written transfer notice for R27's hospital transfer. Findings include: 1. Between 8/5/24 and 8/7/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses including follicular lymphoma, chronic congestive heart failure, and type 2 diabetes. R50's Minimum Data Set (MDS) assessment, dated 6/11/24, stated R50 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R50 had intact cognition. R50 was R50's own decision maker. R50's medical record indicated R50 was transferred to the hospital from 4/5/24 to 4/10/24, 6/5/24 to 6/7/24, and 7/28/24 to 7/31/24. R50's medical record did not indicate R50 or R50's emergency contact were provided with a written transfer notice. On 8/7/24 at 10:11 AM, Surveyor reviewed Bedhold for hospitalization and Therapeutic Leave forms for R50's 4/5/24 and 6/5/24 transfers. Surveyor noted the forms did not include the reason for transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not have a Bedhold for hospitalization and Therapeutic Leave form for R50's 7/28/24 transfer. 2. Between 8/5/24 and 8/7/24 Surveyor reviewed R65's medical record. R65 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, intraventricular, acute kidney failure, and type 2 diabetes. R65's MDS assessment, dated 7/4/24, stated R65 had a BIMS score of 11 out of 15 which indicated R65 had moderately impaired cognition. R65 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. R65's medical record indicated R65 was transferred to the hospital on 6/24/24 and returned to the facility on [DATE]. R65's medical record did not indicate R65 or R65's POAHC were provided with a written transfer notice. On 8/7/24 at 10:25 AM, Surveyor interviewed Director of Nursing (DON)-B who stated nursing staff are expected to issue Bedhold for hospitalization and Therapeutic Leave forms for all residents regardless of payer source, but because Medicaid residents are an automatic 15 day bed hold, staff do not always issue the forms for Medicaid residents. 3. Between 8/5/24 and 8/7/24, Surveyor reviewed R27's medical record. R27 was admitted to facility on 3/10/17 with diagnoses including dementia, coronary artery disease, and asthma. R27's MDS assessment, dated 2/25/24, indicated R27's BIMS score was 2 out of 15 which indicated R27 had severe cognitive impairment. R27 had an activated POAHC. R27's medical record indicated R27 was transferred to the hospital on 6/24/24 for pneumonia. R27's medical record did not indicate R27 or R27's POAHC were provided with a written transfer notice. On 8/7/24 at 12:12 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A was not aware of a another written transfer notice that was completed and provided to residents or their representatives at the time of transfer besides the Bedhold for hospitalization and Therapeutic Leave. In addition, NHA-A stated the facility did not consistently provide the form to Medicaid residents because they had an automatic 15 day bed hold. NHA-A acknowledged the form provided to residents at the time of transfer did not contain all of the necessary information.

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R50, R65, and R27) of 4 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R50 was transferred to the hospital on 4/5/24 and 7/28/24. The facility did not provide R50 or R50's emergency contact with a bed hold notification. R65 was transferred to the hospital on 6/24/24. The facility did not provide R65 or R65's legal representative with a bed hold notification. R27 was transferred to the hospital on 6/24/24. The facility did not provide R27 or R27's legal representative with a bed hold notification. Findings Include: 1. Between 8/5/24 and 8/7/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses including follicular lymphoma, chronic congestive heart failure, and type 2 diabetes. R50's Minimum Data Set (MDS) assessment, dated 6/11/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R50 had intact cognition. R50 was R50's own decision maker. R50's medical record indicated R50 was transferred to the hospital from 4/5/24 to 4/10/24 and 7/28/24 to 7/31/24. R50's medical record did not indicate R50 or R50's emergency contact were provided with a bed hold notification for either transfer. On 8/6/24, Surveyor reviewed a bed hold form, dated 6/5/24, for another of R50's hospital transfers. The bed hold form contained the reason for the transfer, the location of the transfer, and the date of the transfer with a printed date of 6/5/24 and R50's signature. On 8/7/24 at 10:11 AM, Surveyor reviewed a bed hold form for R50's 4/5/24 transfer. Surveyor noted the reason for the transfer, the location of the transfer, and the signature and printed date matched R50's 6/5/24 transfer bed hold form, however, the form was dated 4/5/24. On 8/7/24 at 10:25 AM, Surveyor interviewed Director of Nursing (DON)-B who stated Nurse Manager (NM)-F did some research that day and was under the impression the Social Worker spoke with R50's family regarding the transfer, but a bed hold notice was not completed. DON-B stated NM-F wrote the 4/5/24 date on the 6/5/24 form. On 8/7/24 at 10:56 AM, Surveyor interviewed NM-F who confirmed NM-F made a copy of the 6/5/24 bed hold form and wrote the 4/5/24 date based on when R50 was transferred to the hospital. NM-F confirmed a bed hold form was not completed at time of the transfer and R50 was not provided with a bed hold notification for the 4/5/24 transfer. On 8/7/24 at 12:06 PM, Surveyor interview Nursing Home Administrator (NHA)-A who stated the bed hold notification should have been completed at the time of the transfer and not backdated. 2. Between 8/5/24 and 8/7/24, Surveyor reviewed R65's medical record. R65 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, intraventricular, acute kidney failure, and type 2 diabetes. R65's MDS assessment, dated 7/4/24, had a BIMS score of 11 out of 15 which indicated R65 had moderately impaired cognition. R65 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. R65's medical record indicated R65 was transferred to the hospital on 6/24/24 and returned to the facility on [DATE]. R65's medical record did not indicate R65 or R65's POAHC were provided with a bed hold notification for the transfer. 3. From 8/5/24 to 8/7/24, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] with diagnoses including dementia, coronary artery disease, and asthma. R27's MDS assessment, dated 2/25/24, indicated R27's BIMS score was 2 out of 15 which indicated R27 had severe cognitive impairment. R27 had an activated POAHC. R27's medical record indicated R27 was transferred to the hospital on 6/24/24 for pneumonia. R27's medical record did not indicate R27 or R27's POAHC were provided with a bed hold notice for the transfer. On 8/7/24 at 10:42 AM, Surveyor interviewed DON-B who stated DON-B expects staff to provide a bed hold notification for all residents regardless of payer source. DON-B stated since Medicaid residents were an automatic bed hold, Medicaid residents did not always receive a bed hold notice. On 8/7/24 at 12:06 PM, Surveyor interviewed NHA-A who confirmed not all Medicaid residents received a bed hold notice because Medicaid residents were an automatic 15 day bed hold.

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R33) of 1 resident was transferred safely and according to their plan of care. R33 was transferred via mechanical lift without the use of the lower extremity safety strap and without therapy staff present. Findings include: The facility's Transferring Residents Safely education document contained the following information: Transfer requirements are outlined on a resident's care plan and caregivers are expected to follow the transfer guidelines. On 6/5/23, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] with a diagnosis of morbid obesity and received physical therapy. R33 required extensive assistance of staff for most activities of daily living (ADLs), was R33's own decision maker, and had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 6/5/23 at 11:17 AM, Surveyor observed Certified Nursing Assistant (CNA)-D transfer R33 with a mechanical sit-to-stand lift. CNA-D did not use the lower extremity safety strap during the transfer. On 6/5/23 at 11:26 AM, Surveyor interviewed CNA-D and asked if the leg strap should have been used during R33's transfer. CNA-D stated it was easier to transfer R33 without the strap. On 6/6/23 at 1:35 PM, Surveyor interviewed Licensed Practical nurse (LPN)-E who stated the leg strap should be used when transferring residents. On 6/6/23 at 2:35 PM, Surveyor interviewed Director of Therapy Services (DTS)-F who stated R33 was only to be transferred using the sit-to-stand lift with therapy staff present to ensure a safe transfer. Surveyor noted therapy staff were not present during the transfer. DTS-F stated R33 should be transferred using a total body lift at all other times. Surveyor was provided therapy's recommendation for a total body lift transfer document and R33's care plan which indicated R33 required a total body lift for transfers.

Based on observation, resident and staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R33) of 1 resident reviewed. R33's medications were left at the bedside for R33 to self-administer. R33 did not have a physician's order or a self-administration of medication assessment that indicated R33 could safely and accurately self-administer medication. Findings include: [NAME] Nursing Procedures (used as the facility's standard of practice), Ninth edition, 2023, under Oral Drug Administration, stated after administering medications, Stay with the patient until the drug has been swallowed. On 6/5/23, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] with a diagnosis of morbid obesity and received physical therapy. R33 required extensive assistance of staff for most activities of daily living (ADLs), was R33's own decision maker, and had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 6/5/23 at 11:33 AM, Surveyor observed a medication cup that contained 15 pills on R33's bedside table. When Surveyor asked if the medications were R33's, R33 stated, I forgot to take them. They are my morning meds. I have to take them right now. Record review indicated R33's scheduled AM medications included: furosemide (diuretic), apixaban (anticoagulant), diltiazem (antihypertensive), spironolactone (diuretic), vitamin D, cetirizine (antihistamine), famotidine (antihistamine/antacid), magnesium, bupropion (antidepressant), duloxetine (antidepressant), sucralfate (antacid), acetaminophen, losartan (antihypertensive) and acidophilus (probiotic). R33 also had PRN (as needed) medications. On 6/6/23 at 1:43 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated R33's medication could be left at the bedside because R33 had an order to leave medication at the bedside. Surveyor and LPN-E reviewed R33's physician orders. LPN-E verified R33 did not have a physician's order to self-administer medication. R33's medical record contained a Medication Self-Administration Assessment, dated 4/17/23, that stated R33 did not want to self-administer medication. On 6/6/23 at 2:33 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R33 did not have a physician's order or an assessment to self-administer medication and R33's medications should not have been left at the bedside.

Based on record review and staff interview, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessments for 14 Residents (R) (R8, R47, R61, R51, R17, R42, R12, R9, R37, R25, R66, R16, R31 and R15) of 72 residents. The facility did not timely transmit RAI/MDS assessments for R8, R47, R61, R51, R17, R42, R12, R9, R37, R25, R66, R16, R31 and R15. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, states all Medicare and/or Medicaid-certified nursing homes must transmit required MDS records to the Centers for Medicare and Medicaid Services' (CMS') Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records include Admission, Quarterly, annual, discharge assessments and entry tracking records. Transmitted means electronically transmitting to the QIES ASAP System an MDS record that passes CMS' standard edits and is accepted into the system within 14 days of the assessment reference date (ARD) (last day of the resident assessment period). The RAI/MDS assessments were not transmitted within the required 14 days of the ARD for R8, R47, R61, R51, R17, R42, R12, R9, R37, R25, R66, R16, R31 and R15 and were beyond the 120 day requirement for transmission. On 6/7/23 at 10:17 AM, Surveyor interviewed Director of Nursing (DON)-B who verified the RAI/MDS assessments were transmitted late for R8, R47, R61, R51, R17, R42, R12, R9, R37, R25, R66, R16, R31 and R15. DON-B stated a transition in staff and the failure to apply a software update were the underlying causes of the late transmittals.

Based on staff interview and record review, the facility did not update staff and revise the care plan when an intervention implemented for 1 Resident (R) (R2) of 1 resident was ineffective. On 4/11/23, R2 was placed on 15 minute checks after R2 was observed fondling R1's breast. On 4/23/23, R2 made sexual comments to R3 and was found in R3's room during a 15 minute check. Following the observations on 4/23/23, R2's care plan was not revised and staff were not informed R2 was found in R3's room. Findings include: R2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, schizophrenia, and dementia. R2's Minimum Data Set (MDS) assessment, dated 3/29/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 was not cognitively impaired. R2 had an activated Power of Attorney for Healthcare (APOAHC). In addition. R2 wore a wanderguard (a device placed on the resident's person or ambulation device that notifies staff if the resident attempts to leave the unit). R2 was assessed as being at risk for elopement and resided on a secure unit. R3 was admitted to the facility on [DATE] and had diagnoses of Alzheimer's disease and dementia. R3's MDS assessment, dated 1/17/23, contained a BIMS score of 3 out of 15 which indicated R3 was severely cognitively impaired. The facility's Abuse policy, dated January 2023, contained the following information: Investigative Process/Investigation: 1. Once a concern is identified, the facility shall take whatever steps are necessary to ensure all patients/elders are protected from subsequent episodes of misconduct while a determination on the matter is pending. On 4/11/23 at 1:40 PM, staff observed R2 fondling R1's breast in the common area. R1 and R2 were separated and 15 minute checks were initiated for R2. The facility added an alarm to R1's door to alert staff if someone entered the room. The facility also had behavioral health review R2's medication regimen and initiate changes in medication. The facility began an investigation and submitted a facility-reported incident (FRI) to the State Agency (SA). On 4/23/23 at 3:30 PM, a progress note written by Registered Nurse (RN)-C, indicated R2 displayed R2's usual behaviors of wandering the unit and exit seeking. R2 took notice of and made sexual comments to R3 which R3 reported to staff. RN-C observed R2 follow R3 around the unit. R3 was moved away from R2 when R2 was too close. On 4/24/23 at 10:26 AM, Surveyor interviewed RN-C who verified RN-C worked the AM shift (6:00 AM-2:30 PM) on 4/23/23. RN-C verified R2 made sexual comments to R3 and R3 informed staff. RN-C stated staff kept a close eye on R2 and R3. R2 kept wanting to talk with R3 and followed R3; however, staff tried to keep R2 and R3 separated. RN-C verified R2 was on 15 minute checks due to the incident on 4/11/23. RN-C stated staff record the checks on a board; however, R2 is difficult to keep track of in 15 minutes. RN-C stated R2, who is mobile and pedals a wheelchair with R2's feet, can be in 4 different places on the unit within 15 minutes. RN-C stated when staff are in a room doing cares, staff check R2's whereabouts when they exit the room prior to moving onto their next task. RN-C indicated R3 did not seem upset by R2's comments or by being followed by R2. On 4/23/23 at 8:20 PM, a progress note written by Licensed Practical Nurse (LPN)-D, indicated R2 was observed following R3 into R3's room and was removed from the room. R2 then aimlessly wandered the unit all shift. On 4/24/23 at 10:37 AM, Surveyor interviewed LPN-D who verified LPN-D worked the PM shift (2:00 PM- 10:00 PM) on 4/23/23. LPN-D stated LPN-D was told in report to keep an eye on R2 and R3 due to their earlier interactions. LPN-D informed the Certified Nursing Assistants (CNAs) as well. LPN-D stated the information charted regarding R2 being found in R3's room was reported to LPN-D by LPN-E (who worked as a CNA that shift). LPN-D did not observe the interaction or intervene and documented what LPN-E reported. LPN-D stated R3 did not seem upset by the attention from R2 and wondered why R2 and R3 could not be by each other. On 4/24/23 at 10:59 AM, Surveyor interviewed LPN-E who verified LPN-E worked as a CNA on the 4/23/23 PM shift. LPN-E stated LPN-E looked for R2 during a 15 minute check and found R2 in R3's room. LPN-E did not see R2 enter R3's room. LPN-E stated R2 and R3 were a distance apart in the room and it did not appear anything happened or was happening between them. LPN-E stated R3 seemed fine with R2 in the room and did not understand why R2 had to leave. LPN-E stated this was the first time LPN-E observed R2 speaking to R3. LPN-E was not aware there was a concern between R2 and R3 on the previous shift and was not informed during shift report. LPN-E knew about the prior incident between R2 and R1 and was told police were called. LPN-E stated 95% of the time staff check on R2 every 15 minutes; however, occasionally it might be longer if staff are doing cares, if there is a fall or emergency or if staff are assisting other residents. On 4/24/23 at 10:47 AM, Surveyor interviewed LPN-F who was working on R2's unit. LPN-F was not aware of an interaction between R2 and R3 the previous day. LPN-F stated nothing was reported during shift change and nothing was written on the 24 hour report board. Surveyor informed LPN-F that R2 made comments to R3 and was found in R3's room yesterday. LPN-F stated R2 is quick and in 5 minutes can go from the common area near the dining room to the door at the end of the hallway. LPN-F also stated R2 is fast and scoots with R2's feet. LPN-F stated an agency nurse worked last night which might be why the information was not reported during shift change. On 4/24/23 at 1:03 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated when incidents occur, the team looks further to prevent a reoccurrence and felt 15 minute checks were sufficient for R2. NHA-A stated NHA-A trusts staff and knows staff will check on R2 every 15 minutes. Surveyor informed NHA-A about documentation regarding interactions between R2 and R3 on 4/23/23. Surveyor also informed NHA-A about interviews with staff who stated R2 was fast and could be in several locations on the unit within 15 minutes. Surveyor also informed NHA-A the nurse currently on the unit was not aware of the interaction between R2 and R3 on 4/23/23. NHA-A stated NHA-A wants to be especially careful when incidents occur on the secure unit and reiterated staff on the unit are good about keeping an eye on residents.

Based on staff interview and record review, the facility did not ensure a thorough investigation was completed to rule out abuse for a major injury of unknown origin for 1 Resident (R) (R1) of 3 residents reviewed for abuse. R1 was diagnosed with a left arm fracture. The facility's investigation of the injury of unknown origin did not include interviews with other residents to rule out potential abuse. Findings include: The facility's Abuse policy, last updated in January 2023, contained the following information: Once a concern is identified, Bethel Home shall take whatever steps are necessary to ensure all patients/elders are protected from subsequent episodes of misconduct while a determination on the matter is pending .Often, additional patients/elders are interviewed . On 4/17/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, osteoporosis, osteoarthritis of the spine, and osteoarthritis of the shoulder. R1 was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs). R1 was diagnosed with a left humeral (arm) fracture and severe degenerative disease of the left shoulder per an X-ray obtained on 4/5/23. The X-ray was ordered on 4/5/23 after R1 complained to a family member of left arm pain and staff notified the provider. Staff were unsure how the fracture occurred. On 4/17/23, Surveyor reviewed the facility's investigation related to R1's injury of unknown origin and noted the investigation included staff interviews, family and provider notification, and a revised plan of care. Surveyor noted the investigation did not contain other resident interviews to assist in ruling out abuse as the cause of the injury. On 4/17/23 at 8:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who stated other residents were not interviewed during the investigation because the unit was a dementia unit and the residents could not respond to questions. Surveyor asked if residents on other units or family members of residents on the dementia unit were interviewed. NHA-A and DON-B stated R1's family members were interviewed; however, other residents and/or family members were not interviewed.

Based on record review and interviews, the facility did not ensure an allegation of mistreatment was investigated for 1 Resident (R) (R16) of 1 Resident reviewed for allegations of mistreatment. The facility did not investigate R16's allegation of mistreatment. Findings include: The facility document titled Abuse Policy stated, .Investigative Process; Identification; 1. All allegations of mistreatment including abuse, neglect, exploitation and misappropriation are thoroughly investigated. On 7/20/22, Surveyor reviewed R16's medical record which included a care conference note dated 8/26/21 at 4:23 PM by a social worker no longer employed by facility. The note stated, Overall resident and [spouse] have no major concerns. They do have some complaints. Mostly with a particular staff. Resident states [staff] is rough with [R16] and rude to [R16] at times. Writer did talk to this staff and nurse leader about the complaint. Staff states [staff] tries [staff's] best to be nice and feels resident does not like [staff] as a person. Writer asked resident if [R16] wanted to do a concern complaint stated no not at this time. [R16] does not want to complain but does not like when [staff] is too rough with [R16]. Writer will follow up with nurse leader and staff to see if there is a better way to resolve situation. Other than that resident doing well .Writer will continue to follow up with resident and [spouse] to see how things are going. On 7/20/22 at 11:58 AM, Surveyor interviewed DON-B regarding R16's allegation on 8/26/21 of an un-named staff member being rough and rude. DON-B read the note and stated the note revealed the un-named staff member was talked to and that R16 did not want to submit a formal grievance. DON-B stated DON-B did not recall an investigation being conducted related to R16's allegation. On 7/20/22 at 1:06 PM, Surveyor interviewed NHA-A who stated NHA-A did not recall the situation with R16 alleging a staff member was rough and rude. NHA-A state the social worker who wrote the note would have brought forward R16's allegation if social worker thought it needed to be reported. NHA-A state R16 would also freely talk with NHA-A if R16 had a concern. NHA-A stated if NHA-A would have been made aware of something like this now, NHA-A would have investigated, ensuring resident safety, then make the determination of next steps.

Based on record review and interview, the facility did not ensure one of one staff required to test for COVID-19 obtained testing in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Human Resource Assistant (HR)-F did not receive COVID-19 testing per facility policy and CDC guidelines in June and July 2022. Findings: Facility policy titled Facility Testing Requirements with a revision date of 3/10/22 indicated: Miravida Living will follow CMS's (Centers for Medicare/Medicaid Services) guidance published on 8/26/20 Interim Final Rule CMS-3402-IFC CMS Document QSO-20-38-NH Interim Final Rule CMS-3402-IFC . related to long-terrm care (LTC) facility testing requirements, published on 8/26/20 and updated 3/10/22 read as follows: Routine testing of staff, who are not up-to-date (with COVID-19 vaccination), should be based on the extent of the virus in the community. Staff, who are up-to date, do not have to be routinely tested . Facilities should use their community transmission level as the trigger for staff testing frequency. Table 2: Routine Testing Intervals by County COVID-19 Level of Community Transmission: Level of Community Transmission Minimum Test Frequency Staff (not up-to-date) Low (blue) Not recommended Moderate (yellow) Once a week Substantial (orange) Twice a week High (red) Twice a week *The guidance above represents the minimum testing expected. On 7/18/22, Surveyor interviewed IP-E who indicated the facility is currently testing staff who were not up-to date with COVID-19 vaccine twice weekly. On 7/18/22, Surveyor reviewed the staff matrix which indicated only one staff, HR-F, was not up-to-date with COVID-19 vaccination, for which the staff received a non-religious exemption for on 1/4/22. Surveyor reviewed the staff testing logs for June and July which revealed the below for HR-F. Week Of Test Date 7/10 to 7/16 tested ,d+[DATE] 7/3 to 7/9: No entry 6/26 to 7/2: tested ,d+[DATE] 6/19 to 6/25: tested ,d+[DATE] Surveyor reviewed the community transmission rate provided by the facility which indicated each of the above-noted weeks the community transmission rate was high (red), which per guidelines would require twice a week testing. On 7/19/22 at 8:26 AM, Surveyor interviewed IP-E who confirmed HR-F is a full-time employee at the facility but does work remotely at times. On 7/19/22 at 8:47 AM, Surveyor interviewed HR-F who indicated having 7/4 off but worked the rest of that week. HR-F confirmed missing COVID-19 testing stating, I must have gotten mixed up and it (testing) most have completely slipped my mind that week. HR-F then confirmed having worked at the facility (not remotely) that week of 7/4. With regards to the weeks HR-F only tested on ce vs twice, HR-F stated, I believe that week of 7/10 and a few other weeks recently, I did not test twice. Some of the days of the week I worked from home and I must have been mixed up those weeks as well and did not test twice. Or I was working from home and I did not come in to test, I was mixed up those weeks as well. Surveyor asked how often do you work from home? HR-F replied, It depends, if someone feels sick here (at work), I may not come or if I have something going on, my boss is very flexible with that (working remote). On 7/19/22 at 8:57 AM, Surveyor again interviewed IP-E who confirmed HR-F is the only staff at the facility who has to test twice a week due to being not up-to-date with vaccine. IP-E indicated that a different employee who works offsite from the facility tracks the testing for facility staff and enters the data into a spreadsheet. Regarding missed testing for HR-F, IP-E stated, We will have to watch (testing frequency) more closely. IP-E indicated having looked back at lab results and said prior to 6/19, HR-F was testing very routinely and that IP-E will work with HR-F to set up a system or calendar to ensure testing is more routinely done. IP-E indicated that staff do self-testing, there is a testing station where staff swab and the swab goes into a refrigerator and then lab picks the swab up. On 7/19/22 at 12:27 PM, IP-E provided HR-F's time card for the timeframe testing was missed. The time card indicated the week of 6/19/22 HR-F worked remotely Monday, Thursday and Friday and at the facility on Tuesday and Wednesday. The week of 6/26, HR-F worked remotely Monday and Thursday, at the facility on Tuesday and Wednesday and was off Friday. The week of 7/3, HR-F was off Monday, worked at the facility on Tuesday and remotely Wednesday, Thursday and Friday. The week of 7/10, HR-F worked at the facility Monday and Tuesday and remotely Wednesday, Thursday and Friday. IP-E confirmed the week of 7/3 employee did not test at all and should have due to coming into the facility. On 7/20/22 at 8:32 AM, Surveyor again interviewed HR-F who explained that HR-F went back and looked at emails and text messages with HR-F's boss to determine if HR-F worked remotely and it was more often than originally thought. HR-F confirmed having worked at the facility 7/5 and did not test that week at all. With regards to testing twice a week, HR-F said the expectation was to test twice a week despite working remote at times but there was no discussion (by supervisors) if HR-F should go somewhere else to test other than the facility on those dates. HR-F confirmed no one has ever contacted HR-F when missing a test other than way back when the testing requirement first started, then IP-E reminded me to test twice a week. HR-F indicated that facility staff come to the HR department (in the lower level of facility) to ask questions and/or with requests and HR-F sees approximately five staff per day and also holds an anniversary luncheon once a month in which approximately seven employees are present with HR-F. On 7/20/22 at 12:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the expectation for staff COVID-19 testing when not fully vaccinated is to follow the guidelines put fourth for testing (referring to the CMS memo).

Based on interview and record review, the facility did not ensure ongoing communication with the [CONDITION(S)] facility was consistent with professional standards of practice and care plan was not put in place for for 1 Resident (R18) of 1 resident receiving [CONDITION(S)] care and services. R18 did not have a care plan in place for [CONDITION(S)] and monitoring of R18's fistula and was missing communication sheets between the facility and [CONDITION(S)] center on the days R18 had [CONDITION(S)]. Findings include: On 7/20/22 at 12:30 PM, Director of Nursing (DON-B) indicated that the facility does not have a policy for [CONDITION(S)]. On 7/20/22, Surveyor reviewed the [CONDITION(S)] contract between the facility and R18's [CONDITION(S)] center. This indicated: Collaboration of care; Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [CONDITION(S)] ([CONDITION(S)]) [CONDITION(S)] unit. R18 was admitted to the facility on [DATE] and had related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 had Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 8:15 AM Arrival time return to facility time is around 12:15. R18 had the following care plans related to [CONDITION(S)] in place: Nutrition; Weight fluctuations related to [CONDITION(S)]; Activity Participation level; Activities of Daily Living (ADL) assistance; Fluid restriction; Skin integrity. Between 7/18/22 and 7/19/22, Surveyor reviewed R18's medical record and did not locate a care plan related to [CONDITION(S)] or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/19/22 at 3:00 PM, Director of Nursing (DON-B) indicated there was no care plan specific for [CONDITION(S)], but there were other care plans that discussed nutrition, [CONDITION(S)], and mentioned that R18 was on [CONDITION(S)]. On 7/20/22, Surveyor noted that on 7/19/22 at 4:25 PM, a care plan related to [CONDITION(S)] was added to R18's electronic health record. This care plan indicated: I have [CONDITION(S)] and I am at risk of issues with my fluid balance. I am dependent on hemodialysis and I have a fluid restriction in place. I have a history of loose stools. I need my nurses too, Monitor my fluid intake, provide and encourage fluids with my ordered restriction, observe me for changes in my mental status or behavior, monitor the effects of my medications, monitor my weight regularly as ordered, and notify my provider as needed. Assess me for [CONDITION(S)] and determine the severity as needed, review my lab values as ordered. Send me to [CONDITION(S)] as scheduled (Currently Tuesdays and Fridays). Communicate any status changes to the [CONDITION(S)] center. My fistula is currently in my right upper chest/shoulder area but is going to be moved to my left arm on 7/28. Monitor my fistula site and report any concerns to [CONDITION(S)]/my provider. I need my aides to: report any confusion or behaviors that may not be normal for me, to my nurse. Report any changes in my abilities to my nurse. Record/report my fluid intake to the nurse. Report my daily weights to the nurse. I need dietary staff to: review my diet and fluid needs, and modify them as needed or ordered. I need social services to: Confirm my advanced directives related to fluid and hydration with me and/or my family. I need everyone to: report any confusion or behaviors that may not be normal for me to my nurse. On 7/19/22 at 8:49 AM, Surveyor interviewed Unit Secretary (US-I) who informed surveyor that [CONDITION(S)] sheets should be scanned in to the residents Electronic Health Record. Between 7/18/22 and 7/20/22, Surveyor reviewed R18's [CONDITION(S)] communication sheets for the previous 3 months (24 communication sheets.) Surveyor found 1 sheet from 5/20 in R18's electronic health record. On 7/19/22 at 1:55 PM, the facility provided 11 out of 25 communication sheets between 4/25/22 and 7/11/22 : 5/9, 5/16, 5/20, 5/23, 6/7, 6/10, 6/24, 7/1, 7/5, 7/8, 7/11. At this time, Nursing Home Administrator (NHA-A) indicated there is a sheet in an envelope that goes with R18 to [CONDITION(S)]. As for the missing ones, NHA-A was unsure if there was anything to report, so maybe the facility did not send them back with R18. Though NHA-A was unsure why the [CONDITION(S)] facility would not fill out the pre/post [CONDITION(S)] weights as on the other sheets. NHA-A indicated that unit secretary prepares the form but the staff nurse signs or updates it. Once the facility nurse reviews the sheet, the nurse places the sheet in the unit secretary's mailbox to be scanned in. Surveyor requested other missing sheets. On 7/20/22 at 11:52 AM, Surveyor interviewed Director of Nursing (DON-B) who indicated that the remainder of the [CONDITION(S)] sheets were missing, the Unit Secretary had to leave and at this time was unable to locate them. DON-B also indicated that a care plan for [CONDITION(S)] had been put into place for R18 and this care plan did discuss R18's fistula site.

Based on observation, interview, and record review, the facility did not ensure the necessary care and treatment to promote healing or prevent pressure injuries from developing for 2 of 2 sampled Residents (R) (R75 and R8) who were reviewed for pressure injuries (PI). Observations were made for 2 survey days of R75 sitting in chair without a cushion. R8 had a moderate risk for pressure injury and was observed with a sling and extra layer of cloth over R8's wheelchair cushion, negating the function and purpose of the cushion. Findings include: Facility's Skin Policy dated January 2022 indicated: Objective: This Facility strives to ensure that- (i) Residents receive care, consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable. (ii) A resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. R75 was admitted to facility on 11/25/20 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's MDS (Minimum Data Set) assessment indicated that R75 required extensive assist for transfers and staff assistance for bed mobility, dressing, and eating. Surveyor reviewed R75's medical record which indicated that on 6/26/22 R75 acquired an open area on left buttock area that measured 5 cm (centimeters) around with surrounding tissue intact. Another nursing note dated 6/27/22, indicated wound in the left gluteal fold measured, .8 x 2.0 x .1 cm, linear in shape. Another small area below .3 x .4 x < .1 cm Both areas clean + surrounding skin intact. Wound appears friction vs pressure. The next nursing note on 7/6/22 indicated skin conditions none, then on 7/11/22 a nursing note indicated skin to right buttocks is intact; previous open area is healed. On 7/19/22 at 10:37 AM Surveyor observed wound on left buttock area. Area appeared to be circular and un-blanchable, over bony prominence. The circular area appeared to have a center point. On 7/18/22 at 10:45 AM Surveyor observed R75 sitting in a wheelchair on a thick pad covering cushion in chair. Surveyor observed R75 through the shift until 3:30 PM sitting in chair with thick pad over cushion in chair. On 07/19/22 08:40 AM Surveyor observed R75 sitting in a different style wheelchair with no cushion in chair and a thick pad under R75. On 07/19/22 02:16 PM Surveyor observed R75 sitting in chair, no cushion, with a thick pad under buttocks. On 07/20/22 07:47 AM Surveyor observed R75 in dayroom sitting in recliner with no cushion underneath. R75's wheelchair was next to recliner with no cushion in wheelchair and a thick pad over surface of seat. On 07/20/22 09:50 AM Surveyor observed R75 sitting in wheelchair with no cushion in chair, thick pad under R75 and a sling in chair. On 07/20/22 10:54 AM Surveyor observed R75 sitting in wheelchair with no cushion in chair and sitting on sling and thick pad. On 07/20/22 11:56 AM Surveyor observed R75 sitting in wheelchair with no cushion in chair and sitting on sling and thick pad. On 7/20/22 at 12:06 PM Surveyor interviewed LPN (Licensed Practical Nurse)-D. Surveyor and LPN-D looked at R75 sitting in wheelchair, LPN-D verified that R75 did not have a cushion under R75 and was sitting on a sling and thick pad. LPN-D indicated that R75 should be sitting on a cushion and they must have missed it. Surveyor and LPN-D then went to R75's room and found the gel cushion R75 should be utilizing in wheelchair and all seated surfaces. R8 was admitted to the facility on [DATE] with related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 does not have a history of open areas or pressure injuries but on R8's Minimum Data Set (MDS) (A comprehensive evaluation of residents completed at regular intervals or upon a significant change of condition) Quarterly assessment dated [DATE], Section M0150 indicated that R8 was at risk for developing Pressure Ulcers. Additionally, R8 had a skin care plan related to having diabetes and potential for fragile skin. This care plan had an approach that indicated reduce pressure and friction between myself and bed or chair. On 7/13/22 at 11:01 PM, A progress note for R8 indicated: Staff discovered a skin issue on the inside of the left thigh close to the brief line that looked like a shear from the lift sling that measures 6 long X 1/4 wide at the middle. Cleansed, applied no sting barrier film on the edges where the dressing bonds, and applied a [MEDICATION(S)] dressing. Put note in folder with the update. On 7/19/22 at 1:03 PM, Surveyor observed CNA-G and CNA-H completing a hoyer lift transfer from R8's wheelchair to bed. At this time, Surveyor observed the sling under R8 while sitting in the wheelchair. CNA-G indicated that physical therapy was working on transferring with R8 and sometimes the sling falls low in the chair. CNA-G asked R8 to lean forward and pulled the sling up enough so it could be connected to the hoyer lift. After the transfer was completed, Surveyor observed a square white cloth pad app 1/4 thick sitting over R8's wheelchair cushion. Surveyor asked CNA-G who indicated this pad is used for those residents that are incontinent and R8 is sometimes. On 7/20/22 at 7:52 AM, Surveyor observed R8 in R8's room sitting in wheelchair. The brown sling was under R8 and Surveyor could see the white pad sticking out as well. On 7/20/22 at 10:37 AM, Surveyor observed R8 to see if there were any sling marks, and no sling marks were present on R8's skin. Surveyor observed the sling and the white pad between the resident and the R8's wheelchair cushion. On 7/20/22 at 10:14 AM, Surveyor interviewed Director of Nursing (DON-B) who indicated that the facility does not have an assessment or risk / benefit for leaving the sling underneath a resident and staff try not to. As for the white pad layer, DON-B indicated the facility encourages as few layers as possible between the resident and the wheelchair cushion.

Based on interview and record review, the facility did not ensure 2 of 2 Residents (R8 and R18) had a Preadmission Screening and Resident Review (PASRR) Level II screening completed when the county 30 day exemption expired or the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 was marked as a 30 day exemption and did not have a PASRR Level II screen completed. Findings include: 1. R8 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Between [DATE] and [DATE], Surveyor reviewed R8's medical record and noted R8's PASRR Level 1 was completed on [DATE] and marked as having a serious mental illness and taking medications that included [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Surveyor could not find a Level 2 screen. 2. R18 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Between [DATE] and [DATE], Surveyor reviewed R18's medical record and noted R18's PASRR Level 1 was completed on [DATE] and was marked as having a 30 day exemption. Surveyor could not find a Level 2 screen. On [DATE] at 2:53 PM, Surveyor interviewed Social Worker (SW-C) who indicated that they have been revamping the process for PASRR. It was the responsibility of the old admission coordinator who left earlier in the year to ensure the PASRR Level 1 and Level 2's were completed. Since that individual left, the facility is revamping the process to have more than one department looking at the PASRR's to ensure they are completed. At the time of R8 and R18's admissions, the admission coordinator should have been ensuring the Level 2's were completed. SW-C indicated that now SW-C tracks 30 day exemptions on SW-C's calendar. SW-C indicated R8 and R18 must have been missed.

Based on interviews and record review, the facility did not ensure residents were invited to participate in quarterly care conferences for 2 Residents (R) (R16 and R35) of 22 sampled residents. The facility did not create an opportunity for R16 and R35 to be included in care planning meetings since August 2021. Findings include: R35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) R35's medical record included one care conference note dated 8/27/21 at 12:50 PM during the past twelve months. R35's Minimum Data Set (MDS) dates were 5/23/22 (quarterly), 2/25/22 (significant change in status), 11/27/21 (quarterly), and 8/29/21 (quarterly.) On 7/18/22 at 10:21 AM, Surveyor interviewed R35 who stated R35 had no idea what the care plan is and that care plan and care conference is not discussed. R16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's medical record included two care conference notes dated 5/16/21 at 4:07 PM and 8/26/21 at 4:23 PM during the past twelve months. R16's MDS dates were 4/20/22 (quarterly), 1/22/22 (quarterly), and 10/24/21 (significant change in status MDS.) No care conferences were performed following each of the listed MDS assessments. On 7/18/22 at 11:03 AM, Surveyor interviewed R16 who stated R16 was not invited or involved with R16's care planning or care conferences. On 7/19/22 at 1:25 PM, Surveyor interviewed Director of Nursing (DON)-B who stated care conference notes are the only place the social workers would document notes for care conferences within the resident's medical record. DON-B stated SW-C was a little behind in entering notes for care conferences in the medical records. DON-B stated SW-C cannot find documentation that a care conference was done since the last care conference notes for R16 and R35. DON-B was not aware that care conferences should occur quarterly in addition to annually. DON-B then stated social workers, nursing, and therapy are usually meeting quarterly or frequently with residents. On 7/20/22 at 10:59 AM, Surveyor interviewed DON-B who stated the facility did not have a policy and procedure for care conferences and that the intent was to follow the regulation. On 7/20/22 at 11:13 AM, Surveyor interviewed Social Worker (SW)-C regarding care conferences with residents and the frequency the facility performs care conferences. SW-C stated care conferences were performed upon admission and as needed. SW-C stated the facility was looking at conducting them quarterly so they coincide with MDS assessments. SW-C stated SW-C had reached out in the past to R16's spouse and spouse did not want a care conference at that time. SW-C stated if a resident or family member would decline a care conference it would be in a social service note. SW-C stated there were no notes declining R16's care conference. SW-C was unaware of the regulation and care conference timing.

Based on staff interview and record review, the facility did not notify the resident's representative when there was a significant change in the resident's (R) (R1) physical status. R1's Power of Attorney (POA)-C was not notified when R1's pressure injury worsened and became infected. Findings Include: The facility's policy titled Acute Change of Condition Guidelines, dated March 2022, states: Each resident change of condition is entered on the 24 hour report form that same shift as a priority, with appropriate intervention: The resident, doctor, #1 contact/resident representative .and legal representative are notified by phone. The facility's policy titled Healthy Skin dated January 2022, states: .If a resident is admitted with or there is a new development of a pressure injury .the following procedures may be implemented: .notify provider, resident, and/or resident representative. Explain to the resident/resident representative the severity of the condition and the possible consequences .Educate the resident/representative of the importance of pressure injury prevention and treatment. Develop individualized interventions with resident/resident representative input. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent Minimum Data Set (MDS) assessment, dated 4/28/22, indicates R1 had severe cognitive impairment and required extensive assistance by staff for all Activities of Daily Living (ADLs) including bed mobility, toileting, and hygiene. R1's MDS also indicates a a Stage IV pressure injury with interventions to include a pressure-reducing device in the bed and chair, nutritional interventions, and wound care treatments. R1's POAHC was activated in 2021. On 5/3/22, the Surveyor reviewed R1's medical record. R1's progress notes indicate the following POA-C updates: 1/14/22 - Purple non-blanchable area to right buttocks, area feels hard/firm to touch. 3.5 x 2.0 cm surrounding skin intact, area noted by hospice nurse. Notification left for [Nurse Practitioner (NP) - J]. Wound nurse notified. Message left for #1 contact [POAHC-C] to update on purple non-blanchable area. 2/8/22 - Worsening wound right buttock Request made to NP-J requesting different treatment. Awaiting response .Hospice Nurse .and wound nurse aware of change in wound .Hospice to notify #1 contact of change in wound. R1's medical record does not include any further information related to contacting R1's POAHC-C and providing updates to R1's significantly worsening pressure injury or when it became infected and required antibiotic treatment. On 5/3/22 at 1:58 P.M., the Surveyor interviewed POAHC-C, who verified that they were never notified of R1's pressure injury re-opening, worsening, or becoming infected. On 5/3/22 at 3:41 P.M., the Surveyor interviewed the Director of Nursing (DON) -B, who verified that a worsening and/or infected pressure injury is something that would require an update to resident representatives and that staff should be re-attempting contact if unable to get a hold of the representative.

Based on record review, staff and family interviews, the facility did not immediately consult with the resident's physician and notify the interested family member when there was a significant change in the resident's physical status and need to alter treatment for 1 (resident #1) of 4 sampled residents. Resident #1 developed un-stageable pressure ulcers of the buttocks. The pressure ulcers increased in size weekly. Although resident #1 was responsible for his own decisions, resident #1 frequently refused treatments to the pressure ulcers, despite staff educating the resident regarding the possibility of infections. The facility did not consult with resident #1's physician regarding the change in resident #1's pressure ulcers, which started with a grayish color drainage and a foul odor. The facility informed resident #1's interested family member regarding the resident's pressure ulcers and the deterioration of the pressure ulcers. The facility did not inform the interested family member of the severity of the pressure ulcers or that a foul odor was present, which may have be indicative of a possible infection. Resident #1 was transferred to another long term care facility as scheduled. This long term care facility immediately transferred resident #1 to the hospital for an assessment and treatment of [REDACTED]. Resident #1 was admitted to the hospital with [REDACTED]. Findings include: The facility's policy and procedure for "Prevention and treatment of [REDACTED]. Signs of wound infection, but not limited to: * new tissue breakdown * wound getting larger * friable granulation tissue * purulent or serous exudates, increase in exudates * discoloration of granulation tissue * delayed healing * abnormal or foul smell The policy and procedure directed staff to notify the physician if the ulcer has not shown progress and/or is deteriorating in 2 - 4 weeks. On 08/05/13, surveyor # reviewed resident #1's medical record. According to the face sheet, dated 07/29/13, resident #1 was responsible for making his own decisions. The July 2013 TAR (treatment administration record) indicated resident #1 frequently refused treatment to the pressure ulcers. The nurses' notes dated 07/02/13, indicated resident #1 developed an un-stageable pressure ulcer to the right and left buttocks and included the following documentation: Left buttock * 5.2 cm (centimeter) X 1.8 cm * 95% eschar and 5% granulation * no odor (refuses to lie down) Right buttock * 7.0 cm X 3.0 cm * 95% eschar and 5% granulation * no odor The nurses' note dated 07/13/13 documented the following: Left buttock * 8.2 cm X 3.6 cm * 75% eschar and 25% epithelization * small serosanguious drainage * no odor Right buttock * 11.6 cm X 4.1 cm * 75% eschar and 25% epithelization * small serosanguious drainage * no odor A fax to resident #1's physician dated 07/16/13, indicated the resident has decided he wanted no further treatment to his buttocks, wants no further aggressive treatment and is asking to be kept comfortable.... The nurses' note dated 07/20/13, indicated resident #1 refused to have areas to buttocks measured, however did allow clean dry dressings to be applied, refused creams. Area to buttocks is worse in appearance, is open, draining, and odor noted. MD (medical doctor) aware of resident's refusal of treatments and wanting to die...... Documentation indicated that resident #1 was transferred to another skilled nursing facility on 07/26/13 and after staff completed the initial assessment of resident #1's pressure ulcers, the resident was transferred to the hospital to receive treatment of [REDACTED]. The hospital's emergency room documentation dated 07/26/13, indicated that resident #1 was admitted to the hospital with [REDACTED]. Ulcers had a moderate surrounding [DIAGNOSES REDACTED]. Resident #1's WBC's (white blood count) on 07/26/13 were 22.2 (normal value is 4.5 - 10). Blood cultures were ordered. The hospital progress note dated 07/27/13, indicated resident #1 had positive blood cultures of gram positive cocci. Patient is on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics)..... Repeat blood cultures in the AM and most likely could be from decubitus source. The hospital progress notes indicated resident #1 had infected stage 4 decubitus ulcers. On 08/15/13 at 10:55 a.m. and 2:40 p.m., surveyor # interviewed RN/UM (Registered Nurse/Unit Manager)-A regarding the notification of resident #1's family member and physician to update them on the deteriorating condition of the resident's pressure ulcer, with the onset of a foul odor. RN-A stated she had observed resident #1's ulcers on 07/20/13, after the resident allowed a shower to be taken. RN-A indicated she thought resident #1's pressure ulcers were starting to debride and slough was coming off. RN-A stated the drainage was a moderate amount of grayish drainage with an odor of necrotic tissue. RN-A stated that this was new, as there had previously been no odor. RN-A indicated she had not reviewed the previous documentation contained in the medical record to assess if the pressure ulcers were deteriorating. RN-A stated she thought the pressure ulcers were improving and the odor was from the necrotic tissue. RN-A indicated if she thought the ulcers were deteriorating she would have consulted with the physician. RN-A stated she had spoken with the interested family member on a few occasions and had updated him regarding resident #1 developing pressure ulcers and that they had deteriorated. RN-A verified she had never updated the interested family member on the size of the pressure ulcers or the specific condition of the pressure ulcers. On 08/05/13 at 12:35 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-B regarding resident #1's pressure ulcers. CNA-B stated within the week prior to discharge, resident #1 had allowed staff to assist with cares (which was not always allowed). CNA-B indicated she had noticed a foul odor when the incontinent product was removed. CNA-B stated other staff commented of the foul smell when they entered the room. CNA-B indicated the ulcers looked "bad" and had drainage, but she could not recall specific information. On 08/05/13 at 12:45 p.m., surveyor # interviewed CNA-C regarding resident #1's pressure ulcers. CNA-C stated during the last week that resident #1 resided at the facility, she would walk into his room and a foul odor was present upon entrance. CNA-C stated the odor was like "meat going bad". CNA-C indicated the licensed staff were aware of the ulcers condition as they would come in and change the dressing when resident #1 would allow. On 08/05/13 at 1:10 p.m., surveyor # conducted a telephone interview with FM (Family member)-D regarding his knowledge of resident #1's pressure ulcers. FM-D stated he was told that resident #1 had bedsores and they had deteriorated. FM-D indicated he was never told of the size or the specific condition of the bedsores. FM-D stated the first time he had observed the pressure ulcers and became aware of the severity of the condition of the pressure ulcers was when resident #1 was admitted to the hospital. FM-D stated he couldn't believe the condition. On 08/05/13 at 2:00 p.m., surveyor # interviewed CNA-E regarding resident #1's pressure ulcers. CNA-E stated she had given resident #1 a shower on 07/20/13 and a large amount of black, red, creamy color tissue came sliding off the ulcers and down the drain. CNA-E stated the pressure ulcers had a foul odor that she described as a "rotting smell". "It was awful." CNA-E indicated there had not been a foul odor previously and after 07/20/13, the foul odor was present when staff entered the room. On 08/05/13 at 2:20 p.m., surveyor # interviewed RN WCC (Wound Care Certified)-F regarding resident #1's pressure ulcers. RN WCC-F stated she was only involved on 07/03/13 after the discovery of the pressure ulcers, and the other facility nurses completed weekly measurements and assessments. Surveyor # informed RN WCC-F of staff indication of a new foul odor that was noted on 07/20/13. RN WCC-F stated "if the odor was new, the physician should have been updated." RN WCC-F indicated the new foul odor could have been indicative of an infection. RN WCC-F stated the family should also have been updated of the condition of the ulcer, even though resident #1 had stated he wished no further treatment and requested to be kept comfortable. On 08/05/13 at 3:15 p.m., surveyor # interviewed RN-G regarding resident #1's pressure ulcers. RN-G verified resident #1 allowed the dressing to be changed on 07/23/13, the day shift. RN-G indicated the ulcers appeared to have deteriorated in condition. RN-G stated she thought there had been some tunneling at the 7 o'clock area of the left ulcer and also the left ulcer bed appeared to have been "spongy". RN-G indicated she hadn't done a complete assessment, as resident #1 was very adamant and yelled that he wanted to sit down. RN-G stated she hadn't thought it had appeared infected and indicated she wasn't aware of the foul odor, but indicated other staff had commented of the foul odor. RN-G indicated she had educated resident #1 regarding the possibility of infection and worsening condition of the ulcers when he doesn't allow treatments or lying down to relieve the pressure, but resident #1 indicated he didn't care. RN-G verified she had not updated the physician regarding the condition of the pressure ulcers. On 08/05/13 at 4:30 p.m., surveyor # conducted a telephone interview with night shift CNA-H regarding resident #1's pressure ulcers. CNA-H stated a few nights prior to resident #1's discharge from the facility, resident #1 had allowed cares while he stood in the stand lift. CNA-H stated there was a foul odor that he classified like "dead tissue" coming from the ulcers. CNA-H stated the ulcers "looked real bad". CNA-H indicated he went and got the charge nurse to assess the ulcers and stated he recalled the nurse looked at the ulcers and commented "these could possibly [MEDICAL CONDITION]." On 08/06/13 at 9:15 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-I regarding resident #1's pressure ulcers. LPN-I verified resident #1 allowed the dressing to be changed on the PM shift on 07/23/13. LPN-I stated 07/23/13 was the first time she had worked with resident #1. LPN-I stated the ulcers were very deep brown in color and the left buttock ulcer was larger than the right buttock ulcer. LPN-I indicated there had also been a tannish color drainage from the left ulcer. LPN-I indicated resident #1 had also been incontinent of bowel and after cleansing she noticed a pungent, necrotic odor. LPN-I indicated she was not aware if the odor was new. LPN-I verified she had not reviewed resident #1's medical record in an attempt to determine if the ulcer had deteriorated. LPN-I stated she had not requested an RN assessment because she knew resident #1 would not stand in the lift for an extended period of time, nor would he have returned to a standing position after the RN came to the room. LPN-I stated she spoke with resident #1 regarding the ulcers, and indicated they would improve if he would lie down, but he had adamantly refused. LPN-I indicated resident #1 wanted to defer to his family member. On 08/06/13 at 9:40 a.m., surveyor # conducted a telephone interview with RN-J regarding regarding resident #1's pressure ulcers and the documentation of 07/20/13. RN-J verified she had documented the condition of the pressure ulcer on 07/20/13, but indicated she had not updated the physician. RN-I stated that the physician had previously been updated regarding resident #1's ulcers. RN-J indicated resident #1 had previously been incontinent of stool and was not sure if the pungent odor was from the feces or from the ulcers. RN-J indicated resident #1's ulcers had contained necrotic areas. On 08/06/13 at 10:05 a.m., surveyor # conducted a telephone interview with MD (Medical Doctor)-K regarding resident #1's pressure ulcers. MD-K stated if she had been aware of the foul odor, she would have ordered a wound culture to be done and also would have started resident #1 on antibiotics.

Based on observations, record review and staff interviews, the facility had not ensured that each resident received adequate supervision to prevent accidents in 1 (resident #3) of 24 sampled residents reviewed for incident occurrence. Resident #3 who resided on the special care unit of the facility had displayed escalating physical and sexual behaviors beginning on [DATE]. The behaviors were mainly focusing on 2 female residents (resident #15 and resident #23) who also resided on the special care unit. Resident #3 had reoccurring incidences of striking resident #15 due to being agitated by her behaviors, had struck resident #26 and had inappropriate sexual contact with resident #23 on more than one documented occasion. These incidents occurred after a care plan intervention had been initiated for resident #3 that included keeping him away from other residents. Although the facility investigated each incident, appropriate and effective care plan interventions were not put into place to stop resident #3's further inappropriate contact towards his peers. Resident #3 did not receive adequate supervision to prevent further physical and sexual contact with other residents. Resident #3's, resident #23's and resident #15's current plan of care interventions that included keeping the residents separated had not been consistently implemented. Resident #23's plan of care was not reviewed and revised to include keeping the residents separated until 4 days after the incident occurred between resident #3 and resident #23 and after an incident involving resident #26. The immediate jeopardy started on [DATE], when resident #3 had inappropriate sexual contact with resident #23. The provider was informed on [DATE] and submitted an acceptable removal plan including revamping of appropriate policies and procedures that incorporated staff education and monitoring. The removal plan was implemented and accepted with removal on [DATE]. The deficiency continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by the following: Resident #3's admission face sheet dated ,[DATE] indicated the resident had [DIAGNOSES REDACTED]. The resident's height was documented as 72 inches and weight was documented as 180 pounds. Resident #3's admission MDS (minimum data set) dated [DATE] indicated the resident had scored a 9 out of 15 on the initial cognition screen (the higher the score, the more cognizant), and had indicators of behaviors not directed toward others 1 to 3 days during the assessment period. Physical symptoms included hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, and disruptive sounds which which were assessed not to impact others. Resident #3 also displayed wandering behaviors 1 to 3 days during the assessment period which also did not impact others. Resident #3's targeted behaviors as of [DATE] were documented as pacing/rummaging; refusing cares; poor appetite; fidgety/restless; and easily irritable. A significant change MDS completed for resident #3 dated [DATE] indicated the resident's cognition had not changed from the admission assessment, but now resident #3 displayed physical behaviors directed toward others such as hitting, kicking, pushing, scratching, grabbing and sexual behaviors 1 to 3 days during the assessment period and was wandering daily. These behaviors were assessed to intrude on the privacy of others and significantly disrupted the living environment. Resident #3's targeted behaviors as of [DATE] were listed as wandering; delusions; and paranoid statements. A significant change MDS completed for resident #3 dated [DATE] indicated the resident's cognition had declined as indicated by a score of 4 out of 15 on the cognition screen, and his behaviors had increased to include verbal behavioral symptoms directed toward others such as threatening others, screaming at others, and cursing at others 4 to 6 days during the assessment period; had displayed other behavioral symptoms not directed toward others daily; and had displayed physical behaviors directed toward others 1 to 3 days during the assessment period. Resident #3 continued to wander daily and the resident's behaviors were assessed to intrude on the privacy of others and significantly disrupted the living environment. Review of resident #3's medical record include nursing entries, faxed information to the primary care physician, investigations related to incidences involving resident #3, and the resident's care plan interventions indicate the following information: * On [DATE], "resident (#3) was yelling at resident #15 who was calling out. Stated, "Shut your mouth or I'll do it for you!" The resident was moved away from resident #15 to a quieter area in the lounge. Does not understand resident #15 is not calling out purposefully or to agitate him." * On [DATE], resident #3's Levothyroxine dose was changed. * On [DATE], resident #3's activity plan of care was revised to include "I need to have structured activities. I will engage in at least 5 group activities per week". Prior to [DATE], resident #3's activity plan of care dated [DATE] had included an intervention to attend activities of interest at least 2 times a week and will socialize with other. * On [DATE], "altercation with peer (resident #15). Back handed her on her right arm when she sat next to him and started yelling loudly. No injury. Resident removed from area and kept safe distance from involved resident. Resident #15's care plan updated. No new orders. Actions taken to resolve concern: Remove resident away from situations before they occur." * On [DATE], resident #3's plan of care interventions were changed to include, "I exhibited combative behaviors i.e.. slapping another resident. I was agitated by the noises that she was making. I need my medications administered. Document my mood and behaviors. Consult with my doctor as needed. Assist with keeping me safe and intervene as needed. 1:1 visits to develop rapport with me. Meet with my ITeam and wife to determine care plan approaches for behaviors as needed. Assist the staff with supervision and intervention when I am agitated. If residents or staff are disruptive, it may increase my agitation. Observe me for signs of increased agitation i.e.. facial expressions, body language or increased restlessness. I may be resistive to assistance from staff but may need time to collect and calm down to be redirected. Offer me supervision and light conversation as I tolerate. Intervene and assist me with redirection, activities or assist me to my room to reduce my agitation. Document my mood and behaviors. I need encouragement to become involved in activities". The goal of the plan of care was listed as, "I will have no combative episodes with residents or staff. I will not injure myself or others." * On [DATE], "resident (#3) was grabbing out for walkers and tables and throwing them over. Purposefully moving in wheel chair at fast speed when someone approaches and attempting to ram into them with his wheel chair. States, "they can get the hell away from me". As need Ativan (anxiolytic medication) offered and accepted." * On [DATE], the antipsychotic medication Seroquel, prescribed for resident #3's visual hallucinations and thinking staff are his employees was decreased from 25 mg (milligrams) to 12.5 mg. daily. * On [DATE] at 4:15 p.m., "resident (#3) propelled his wheel chair toward resident #15, who was seated in a recliner with behaviors of crying out loudly and slapped her on the left lateral upper forearm. Staff placed resident's away from each other but both are mobile. Staff will continue to monitor and intervene as soon as noted. Action taken to prevent further harm: staff will intervene when resident (#15) calls out and address as necessary. Staff will more closely monitor resident (#3) to keep a safe distance from other residents. Encourage him to read magazines and watch TV and redirect as necessary." Resident #3's plan of care intervention to remove the resident away before instances occur and to keep him at a safe distance from others had not been implemented consistently. * On [DATE] at 6:00 a.m., resident #3 "came behind resident (#15) who was sitting in the TV room making her usual noises and put his hands around her neck loosely. No injury. Moved resident (#3) to lounge where there were other staff to watch him. Action taken to prevent further harm: more closely monitor resident (#3) to keep away from other residents especially resident (#15)." Resident #3's physician did not change or add any new orders at this time. Resident #3's plan of care intervention to remove the resident away before instances occur and to keep him at a safe distance from others had not been implemented consistently. * On [DATE], resident #3's behavioral plan of care included, "I exhibited combative behavior i.e.. slapping another resident, touching neck with hands. I was agitated by the noises she was making. I prefer a quieter environment. The addition of interventions to the resident's plan of care included, "If another resident is upsetting to me, validate my feelings and provide distance for safety and supervision. Keep me away from resident (#15) as much as possible." * On [DATE], "resident (#3) tapped resident (#15) 2 to 3 times on the top of the head with his finger tips as he was wheeling by her." Resident #3's physician did not change or add any new orders at this time. Resident #3's plan of care intervention to keep him away from resident #15 as much as possible had not been consistently implemented. * A Social Services note dated [DATE] indicating, "Follow up contact with wife, resident (#3) touched another resident's neck with hands. Resident has exhibited frustration with her (#15) yells/screams/screeches. Action was to stop noise." * On [DATE], resident #3, "became very paranoid on the p.m. shift. He started to make comments to other residents such as "you are a prisoner here too. Don't take any of the poison they give you". He also approached writer and started to frisk writer and stated, "where is the gun you are hiding"? Writer attempted to redirect resident, but he continued to make paranoid states. He then accused another resident of stealing items and told writer to take care of it. He started to shake another resident's wheel chair but did not come in contact with the resident. Staff intervened immediately and redirected him. As needed anxiety med given. Writer also asked resident to work on project involving nuts and bolts and he did stay occupied with this for about 30 minutes. Behaviors have increased since medication reduction." * On [DATE], resident #3's antipsychotic medication Seroquel was increased to previous dose of 25 mg daily from 12.5 mg. * On [DATE], "resident (#3) became obsessed with resident (#23) this afternoon. He is having paranoid thoughts that resident (#23) had been beaten and whipped so he stated to staff that he was going to take her home and give her food and a good education. He was very gentle with the resident and very nurturing toward her, but he attempted to move her off the unit by pushing her wheel chair toward 1 East, and when staff intervened, he was very protective of her and he became hostile toward staff as if the staff were dangerous to her. Staff were able to separate them and redirect this resident back to the circle. He remained hostile toward staff and he was persistent about finding resident (#23) to "save her". Staff were able to keep the two separated for a while, but he did find her again and he continued to nurture her. Again staff had difficulty getting him away from her as she needed to be toileted." On [DATE], A fax was sent to resident #3's physician indicating "Increased behaviors. Cornering resident (#23). Thinks she needs his help. Hovering over her. Found almost putting his hands up her shirt and telling staff, "I just want to go around the track a few times if you know what I mean." * On [DATE], resident #3 "was agitated and yelling at peers. Has tipped chairs over. Propelling wheel chair into objects and peers. Swearing and continues to seek out resident (#23)." Nurse Practitioner order: "Start Sertraline 25 mg daily. Diagnosis: [REDACTED]. Will speak with Neurologist to determine when we will start it." * On [DATE], 6:12 a.m., resident #3 "was agitated. Yelling out at staff and peers. Has resident (#23) cornered and will not allow staff removal to safe area. Stated, "I can do what I want with her. Thinks resident is his wife and staff is taking her away from him." Statements made by resident, " That's my wife. I can do anything I want with her. I will call the police if you steal her away." Resident (#23) was placed next to staff to prevent resident from keeping her in an area against her wishes. Resident (#23) is crying and telling resident (#3) to "let her go." * On [DATE] at 7:23 a.m., resident #3 was "propelling self backwards in wheel chair running into anything and anyone in his path. Staff is moving objects and residents out of the way due to resident refusing to stop going backwards. Resident thinks he is vacuuming with his wheel chair." * On [DATE] at 7:33 a.m. resident #3 was "approaching another male resident yelling at him to "do what I say or be fired." Other male resident telling this resident to shut up and leave him alone. Now thinks he owns this building and that everyone is his staff. Unit Clerk took resident to spend one on one time with him in attempt to decrease agitation/behaviors." * On [DATE] at 9:06 a.m., resident #3 "came to the dining area to eat breakfast, left as soon as he was finished and is cornering resident (#23) he was doing this to earlier this a.m. (#23). Redirected away from that resident and is now throwing pillows, turning chairs over, yelling for everyone to get out of his house. Will now attempt to offer recliner for comfort. Agreed to sit in recliner after several attempts. Then trying to tip self over in the chair. Is now involved in group activity and more pleasant." * On [DATE], resident #3 was evaluated by his primary care provider NP (Nurse Practitioner)-F. The dictated note indicated, "We as staff tried to decrease his Seroquel from 25 to 12.5 mg daily; however, he began with more increased paranoid behaviors, and we did increase his Seroquel back to 25 mg daily. Nonetheless, he is still struggling with some behaviors. He is noted to have some hypersexual behaviors at times. At other times again he is paranoid and mistakes the staff as being his employees. He also talks about the war as well. We will speak with (Neurologist-G) regarding possibly initiation of Sertraline therapy due to resident's recent hypersexual behaviors versus perhaps increasing the Seroquel as he is having more visual hallucination or maybe both". * On [DATE], resident #3 was "wheeling about unit shouting at other residents to do jobs for him. Thinking he is back in the war and is worried about being bombed at times and other times saying he could hear the bombing. Redirection unsuccessful." * On [DATE], resident #3 was evaluated by Neurologist-G. The dictated physician note from that visit indicated, "(NP-F) called to report that resident #3 was acting out sexually to the females at the nursing home and also noted increased in hallucinations". Neurologist-G suggested to start resident #3 on intramuscular injections of Provera (a female hormone), every two weeks and increase the resident's Seroquel to 50 mg daily for a week then increase to twice a day dosing. The resident's Seroquel was increased as suggested, but the facility did not wish to initiate the intramuscular female hormone into the resident's medical regime. * On [DATE], resident #3's Levothyroxine dose was changed. Resident #3's potassium medication dose was increased. CBC (complete blood count) was ordered for a [DIAGNOSES REDACTED]. * On [DATE], the order for Sertraline for resident #3 was discontinued "for now". * On [DATE], resident #3 "put his hands up resident (#23's) shirt and grabbed her breast. Resident (#23) was crying but stopped crying once she was taken to another part of the unit. Action to prevent further harm: distance resident (#3) from resident (#23). Staff more closely monitor resident (#3) to keep a safe distance from other residents." Resident #23 did not have her written plan of care revised to include an intervention to ensure that resident #3 stayed a safe distance away from her until [DATE]. * On [DATE], resident #3's behavioral plan of care indicated, "I have dementia and have inappropriately touched a particular female resident. When I was asked about it, I didn't remember doing it. Don't let me get near resident (#23). Redirect me by asking for my help and give me the nuts and bolts board, or a wheel chair with a doll or something in it to push around, or walk with me, or put in a western movie to watch, magazines that I like are National Geographic, Auto Mechanic. You can also offer me snacks. Don't let me get near resident (#23), and I will not inappropriately touch resident (#23)." A Social Service note dated [DATE] indicated, "Resident (#23) will reach out and touch anything in her path. Both residents are confused. Staff to monitor whereabouts and keep separated when possible." * On [DATE], resident #3 "struck resident (#26) on the right ear. No injury. Moved resident's apart. When resident (#3) asked if he hit another resident stated, "yes I did". When asked why, resident( #3) stated, "well, he was mouthing off and I didn't like it so I hit him". Action taken to prevent further harm: "directed resident (#3) away from resident (#26). More closely monitor resident (#3) and (#26) and keep them safe distance from each other and intervene as necessary. Resident (#26's) behavior is usually appropriate according to special care unit manager". Resident #3's physician did not change or add any new orders at this time. Resident #3's care plan intervention in place prior to this incident that included an intervention to monitor the resident more closely and to keep a safe distance from his peers had not been consistently implemented. Additionally, a review of resident #26's care plan interventions indicated an updated intervention noting to keep resident #26 away from resident #3 had not been initiated until [DATE], 4 days after the incident had occurred. * On [DATE], resident #3's behavioral plan of care indicated, "I exhibited combative behavior i.e.. slapping/hitting another resident, touching neck with hands. I was agitated by the noises she was making. Revision of care plan interventions included, "Keep me away from resident (#15) and resident (#26) as much as possible." * On [DATE], "CNA (Certified Nursing Assistant) witnessed resident inappropriately touching resident (#23). Resident (#3) was in the general area after supper and when staff were walking another resident, the resident started pointing and saying "oh, oh. Look". Resident (#3) was seen touching resident (#23) who was asleep in her wheel chair. Resident (#3) had one of resident (#23's) breast exposed (pulled out of her shirt) and was rubbing her". Action taken to prevent further harm: "resident (#3) was removed from the area. Care plan updated." The care plan included to keep resident #3 away from resident #23, which had been an intervention that had been implemented prior to this incident. * On [DATE] at 7:12 a.m., resident #3 "was seeking out resident (#23). Next went after resident (#25)." * On [DATE] at 7:27 a.m., resident #3 "thinks he is at the race with his wheel chair. Moving about the unit at fast speed propelling self in wheel chair with legs. Has no regard to safety of others yelling at them to " get the hell off the track if you're not going to race". Staff, unsuccessful, bringing him to activity table with nuts and bolts, magazine and movie of sports show put on TV. Continues to move around the unit refusing to stay in any activity area." * On [DATE], resident #3's activity intervention plan of care indicated, "I will engage in at least 5 group activities per week. Goal was not met. Continue with current activity care plan." * On [DATE], resident #3 "became very agitated when approached for cares. Yelling at staff and residents about calling the police and getting out of here. Became more upset when staff and residents approached him. Writer attempted to give resident something hands on to work with, resident refused. Resident did eventually agree to take his medications and writer gave as needed anxiolytic medication." * On [DATE], resident #3 was "wandering into other resident's rooms, stating he is going to call the police because a robbery is taking place. Writer attempted to redirect resident by asking him to push and empty wheel chair or put some blocks together, resident continued to go into other rooms and attempt to go out onto the patio." As needed anxiolytic medication given. * On [DATE], resident #3 was "very agitated tonight. Trying to get out of his wheel chair, keeps saying that he wants to go home and not pleasant to anybody. Trying to touch other resident and was redirected but not effective." The resident was given as needed anxiolytic medication. * On [DATE], a fax regarding resident #3 sent to the primary care provider indicated, "resident on Seroquel 50 mg at night. Has been having increased behaviors in the morning. Can we change order to Seroquel 25 mg twice daily?" Resident #3's Seroquel was changed as requested. * On [DATE], resident #3's medication Aricept was discontinued and the addition of a daily Exelon patch was ordered. * On [DATE], resident #3 was "pushing other resident's wheel chairs, running into residents with his wheel chair. Redirected." * On [DATE], "Earlier this morning, resident (#3) propelling wheel chair into other wheel chairs, the wall and book case going backward without watching where is was going. Stated, "too bad" when explained danger of this action telling writer, "not my fault if they are too stupid to move." On [DATE] from 7:10 a.m. until 7:20 a.m., surveyor # observed resident #3 seated at the table in his wheel chair in an unsupervised dining room. Resident #15 was also seated in the dining room at a table 6 feet away from the resident #3. Resident #15 made occasional loud moaning noises. LPN- D was standing at a medication cart parked in the central lobby of the unit. Surveyor # stood next to staff and was able to visualize resident #15 and not visualize resident #3. Resident #3's and resident #15's plan of care interventions to try to keep the residents separated had been consistently implemented. At 7:20 a.m., staff removed resident #15 from the dining room. On [DATE] at 7:00 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-D regarding resident #3. LPN-D verified to the surveyor that resident #3 was independently mobile in his wheel chair. LPN-D stated, "He (#3) did seek out (resident #23) for some reason. She (resident #23) would approach him and others as well, not in a sexual way. I think he (#3) though she was giving him a green light because she showed affection to others like stroking their arms or putting her head on their shoulder. I would park (resident #23) by me or keep him (#3) busy with activities. The intervention of trying to keep them apart or keeping them away from one another didn't work. We have enough staff to care for the resident's on this unit, but don't have enough staff to do a 1 on 1 for resident (#3). It was constant for us to keep him (#3) away from her (#23). We have done 1 on 1's in the past for other residents to keep everyone on the unit safe. It wasn't realistically possible to keep eyes on him (#3) at all times. I keep my med cart in a certain central area so I can keep an eye on the lounge area, but a quarter of the time, I am in the nursing station doing paperwork. I did see him (#3) more than once approaching and reaching for her (#23). I stopped and redirected him. He (#3) was not willing to sit by staff. He wants to be going. He thinks he has to go to work." On [DATE] at 7:05 a.m., surveyor # interviewed CNA-E. CNA-E stated, "He (#3) is very fast with mobilizing himself in the wheel chair. He can still independently move in it. I think we tried to keep eyes on him whenever he was out in the lobby or with her (#23). We never did 1 on 1's with him when he was having increased behaviors and never did 5 minute checks on him. When he was involved in an incident with another resident, we would direct him with activities. I don't know why the incidents continued to occur, but I think it was due to his behaviors. His behaviors have improved now." On [DATE] at 8:40 a.m., surveyor # interviewed UM (Unit Manager)-C. UM-C oversees operations on the special care unit where resident #3 resides. UM-C stated, "I spoke with the Nurse Practitioner about his (#3) sexually inappropriate behaviors and increase in hallucinations. She talked with the resident's Neurologist and he suggested a female hormone that was to be given intramuscularly. We did not give that medication. We did increase his Seroquel and did thyroid medication adjustments thinking that may be part of the problem. We have done 1 on 1's with residents in the past. I'm not sure why we chose the behavioral interventions that we did for him (#3)." On [DATE] at 10:00 a.m., surveyor # interviewed NP-F via the telephone. NP-F stated, "His (#3) Neurologist recommended the intramuscular injections of Provera and to increase his Seroquel, but it was just a recommendation. We were trying to change several things with him at the time due to atypical chest pain and thyroid medications, so we discussed that we would just continue with the current plan. I suggested we add an antidepressant medication, but the Neurologist didn't seem to think that was appropriate and the resident's wife tends to want the Neurologist to manage his medications. We had a trail dose reduction of his Seroquel on [DATE] which didn't go well, so we increased it again on [DATE]." On [DATE] at 10:00 a.m., surveyor # interviewed DON (Director of Nursing)-A regarding resident #3. DON-A stated, "We don't have an operational definition of what separation of residents means. We don't have the amount of space defined." On [DATE] at 10:30 a.m., surveyor # interviewed UM-C while reviewing incident reports and nursing entries regarding resident #3's documented behaviors directed toward peers with UM-C. UM-C stated, "We were keeping them (resident #3, #15 and #23) away from each other as much as possible. We were trying to keep them apart as best we could and did use activities as an intervention. We updated staff so they were aware that he (#3) was to be away from other resident and to engage him in activities. The plan of care changes we initiated after each incident did not prevent further incidents from occurring. Resident #15 used to be ambulatory and was hard to redirect, and she would often sit next to resident #3. Now she is wheel chair bound. Resident #23 is no longer in the facility." Resident #23 medical record indicated that the resident had expired on [DATE]. On [DATE] at 11:10 a.m., surveyor # interviewed SW (Social Worker)-B regarding resident #3. SW-B stated, "we made changes in her (resident #15's) plan of care to decrease her behaviors. We involved the Ombudsman and her husband and had very specific care plan interventions to decrease her calling out behaviors. It is still in both of their (resident #3 and #15) plans of care to keep them distanced from one another. There is no qualifier of what keeping a distance between residents means." SW-B also verified to the surveyor that resident #23 would seek out resident #3, that resident #23 did not recognize it was okay to touch others, and changes to her plan of care to promote safety had been initiated at the time of the incidents between the two residents. On [DATE], the facility revised resident #3's plan of care by implementing the intervention of 15 minute checks. On [DATE], the facility revised resident #3's target behavior monitoring list to include "sexually abusive". On [DATE] at 8:10 a.m., surveyor # interviewed DON-A, SW-B and UM-C regarding resident #23's written plan of care. UM-C verified to the surveyor that resident #23's written plan of care had not been revised to include keeping her separated from resident #3 until [DATE], even though the incident of physical contact between resident #23 and resident #3 had occurred 4 days earlier. UM-C stated, "We did separate them immediately and talked to staff about the incident." SW-B stated "When we get concerns, we talk about it. We just didn't get the intervention (for resident #23 to be kept separated from resident #3) into the plan of care. I do go to the unit and talk to staff about it, but that isn't reflected in my notes. I also leave a note at the nurses station to see if staff have any ideas for changes in plans of care interventions, but I don't have documentation of that either." DON-A stated, "We do pass along information via taped report every shift and do have a written 24 hour log that resident to resident incidents get passed along from staff to staff on." Surveyor # had requested to review the facility's 24 hour log that DON-A had referred to, but as of the end of survey, the surveyor had not received the information from the facility. The facility did not provide adequate supervision to resident #3 to prevent physical and sexual contact with other residents and to provide a safe environment for residents. Resident plans of care were not timely reviewed and revised to include interventions that were progressive and effective in preventing these incidents from reoccurring after resident #3 had repeated physical contact with resident #15 and had repeated sexual contact with resident #23.