Every finding on record at Canyonland Care Center

Based on interview and record review, the facility failed to ensure the right to voice grievances to the facility without discrimination or reprisal. Specifically, for 3 out of 18 sampled residents the right to file grievances anonymously was not provided to the residents or representatives of the residents. Resident identifier: 29 [Note: Two resident identifiers were withheld to maintain anonymity.] Findings included: During the survey a confidential interview was conducted with a resident representative, Confidential Interviewee (CI) 1. CI 1 stated that the facility's management did not always address resident, family member, and nursing staff concerns, including the concerns brought up in resident council. CI 1 stated that it was normal for concerns to be briefly addressed before the situation returned to its prior condition. CI 1 stated that in order to report concerns they had to verbally inform facility management, and that they did not know how to address concerns about facility management because there was not a way to make anonymous concerns. During the survey a confidential interview was conducted with a resident, CI 2. CI 2 stated that they did not feel comfortable discussing their concerns with some staff members, including some of the facility management, because they were uncertain how the staff members would react. CI 2 stated that there was not a way to report anonymous concerns. During the survey a confidential interview was conducted with a staff member, CI 3. CI 3 stated that it was not possible for family members or residents to fill out a grievance form anonymously, because they did not have access to the forms without requesting one from staff members. CI 3 stated that resident concerns were usually given to the Social Services Director (SSD) verbally, but if the SSD was not available a note could be left in her box. CI 3 stated that family member and resident concerns were resolved approximately half of the time. Additionally, CI 3 stated that there needed to be a change in facility processes in order to ensure resident concerns were resolved. On 11/4/25 at 12:54 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when a resident had a grievance they assisted residents with filling out the grievance form and then gave the form to the SSD. CNA 1 stated that grievance forms were located in a filing cabinet located behind the nurses station. CNA 1 was unable to locate a grievance form in the filing cabinet at the time of the interview. On 11/4/25 at 1:02 PM, an interview was conducted with CNA 2. CNA 2 stated that grievance forms were located behind the front entry receptionist desk. CNA 2 stated that filled out grievance forms were given to the Director of Nursing. CNA 2 retrieved a form titled: Staff Concern Information Sheet. The form contained a process for staff members to document and report concerns to facility management. On 11/4/25 at 1:04 PM an additional interview was conducted with CNA 1. CNA 1 stated that they were able to locate a grievance form at the nurses station. This form was titled: Grievance/Complaint Report and stated This form shall be utilized to provide written documentation of any concern expressed by a resident or resident representative and to record the follow-up action taken and results thereof. On 11/4/25 at 1:06 PM an interview was conducted with the SSD. The SSD stated that resident and family member concerns were addressed in the resident council. The SSD stated that concerns discussed in resident council were documented in the resident council binder. The SSD stated residents or family members could also bring concerns to her, the Administrator (ADM), or the Director of Nursing (DON) at any time. The SSD stated that after being informed of concerns, she spoke to the resident or family member about the concern, discussed filing a formal grievance with them, and then began to work on resolving the concern immediately. The SSD stated that the facility did not require a grievance form to be completed for every concern a resident had. The SSD stated that while residents and family members were always offered the opportunity to file a formal grievance, most usually declined. The SSD stated that in order to ensure that concerns were resolved she would have a follow up discussion with the resident or family member. On 11/4/25, the facility grievance log was reviewed. One grievance was documented as being filed on 4/19/25; no other grievances were filed during the 2025 year. Only three grievances were documented as being filed during the 2024 calendar year. On 11/14/25 at 2:05 PM, an interview was conducted with RN 1, who stated that grievance forms are kept at the nurses desk. RN 1 stated if a resident had a grievance they would tell staff and staff would help them fill out the form. RN 1 stated that grievance forms were not available for family or residents to obtain without asking a staff member for one. RN 1 stated they were unsure how a resident or family member would fill out a grievance form anonymously since they needed to obtain the form directly from a staff member. On 11/4/25 at 2:26 PM, an interview was conducted with a resident 29. Resident 29 stated that to file a grievance they had to ask a nurse for the form and that the nurse would help fill out the form. On 11/5/25 at 2:22 PM, an additional interview was conducted with the SSD. The SSD stated that she was informed of resident and family member concerns verbally or with a note. The SSD stated that she would communicate concerns with the ADM and the DON verbally or through email. Additionally, the SSD stated that while there was a log for formally filed grievances, there was not a log to track concerns and resolutions. The SSD stated that grievance forms, though kept at the nurses' station or the reception desk, were not directly accessible to residents and family members and required a request from a staff member. The SSD stated that residents and family members were given a document titled Concerns and Complaints on admission to the facility, and that the document provided education on how to bring concerns and grievances to facility management. On 11/5/25, an undated facility admission document titled Concerns and Complaints was reviewed. The document stated You can file a grievance orally, in writing or anonymously to the Administrator, Social Worker, or Facility Grievance Officer. While the document listed contact information for facility management, it did not contain a process to file grievances anonymously. On 11/5/25, a facility policy revised on 1/15/14 and titled Resident Grievance Process was reviewed. The policy stated Residents have the right to voice complaints and make suggestions for change without the fear of reprisal, discrimination, coercion or unreasonable interruption of care, treatment and services. The policy did not address the resident right to file grievances anonymously or a process to file grievances anonymously.

Based on interview and record review it was determined, for 1 of 18 residents sampled, that the facility did not ensure residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, a resident was not provided showers. Resident identifier: 3. Findings included: On 11/5/25 resident 3 was interviewed and stated she received hospice care but her showers were provided by the facility. Resident 3 stated she used to receive 3 showers a week but now she had only been getting 2 showers a week. Resident 3 stated she would like to get 3 showers a week and she had told the staff about her concern but nothing had changed. Resident 3's medical record was reviewed 11/3/25 through 11/5/25. Resident 3 was admitted to the facility on [DATE] with diagnoses which included corticobasal degeneration, malignant neoplasm of lung, depression, dementia, chronic pain and palliative care.A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 3 required substantial/maximum assistance with showers. The Brief Interview of Mental Status (BIMS) score was 15 which indicated resident 3 was cognitively intact.The tasks section of resident 3's medical record revealed for the month of October, resident 3 was showered on 10/11/25, 10/18/25, and 10/25/25. Staff had not documented that resident 3 had refused to be showered. A care plan dated 9/23/24 and updated on 9/26/24 revealed [Resident 3] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Musculoskeletal personal hygiene and oral care. Some interventions included were [Resident 3] required limited assistance by 1 staff with personal hygiene and oral care. And [resident 3] required touch/hands on assistance with bathing 2 x [times] a week and as necessary.On 11/5/25 the Director of Nursing (DON) provided a shower sheet that documented that resident 3 had received a shower on 10/28/25 along with the same documentation from the task section of resident 3's medical record indicating that resident 3 had not received additional showers for the month of October. On 11/4/2025 at 2:41 PM an interview was conducted with CNA 3. CNA 3 stated they had 3 different places that showers and baths were charted. CNA 3 stated resident 3 was given baths twice weekly she thought but was unsure and that resident 3 usually did not refuse her baths. On 11/5/2025 at 9:45 AM, an interview was conducted with the DON who stated that the CNA who worked on Tuesdays had bathed the resident but had not charted the baths. The DON stated she had evidence that resident 3 had received 5 baths for the month of October. The DON stated resident 3 should have received more than 5 baths for the entire month.

Based on interview and record review, it was determined that for 1 of 18 sampled residents, that the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically, the facility did not maintain documentation that a resident's primary care provider had been notified of a resident's change in condition. Resident Identifier: 34 Findings Included: Resident 34 was admitted [DATE], and discharged [DATE] with diagnoses including other frontotemporal neurocognitive disorder, personal history of transient ischemic attack and cerebral infarction without residual deficits, other recurrent depressive disorders, atrioventricular block first degree, age-related osteoporosis without current pathological fracture, hypothyroidism unspecified, essential (primary) hypertension, and hypokalemia. Resident 34's medical record was reviewed from 11/3/25 through 11/5/25. A progress note dated 1/15/25 at 10:51 PM stated, CNA's [sic] reported that resident had a LG [large] bowel movement after dinner that was black, tarry and putrid smell [sic]. Resident drank evening ensure with evening meds, however, did not eat dinner. This note was documented by Licensed Practical Nurse (LPN) 1. A progress note dated 1/16/25 at 11:51 AM stated, [Resident 34] continues to have black tarry stools. She has remained in bed d/t (due to) increased weakness. She is infertile [sic] at this time. This noted was documented by LPN 2. There were no other progress notes regarding Resident 34's tarry, black stools. There were no progress notes or documentation that showed that Resident 34's primary care provider had been notified of her change in condition. On 11/5/25 at 11:09 AM, a voicemail was left for LPN 1. LPN 1 no longer worked at the facility. LPN 1 did not return the voicemail. On 11/5/25 at 1:54 PM, an interview was conducted with LPN 2. LPN 2 stated that she could not remember the incident with resident 34. LPN stated that if a resident had a change in condition, she would call the resident's physician to notify them and write a progress note in the resident's medical record. On 11/5/25 at 9:23 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when a resident had a change in condition, the facility would notify the resident's primary care provider and document that the provider was notified as a progress note in the resident's electronic medical record. RN 1 stated that this would not be documented anywhere else in the medical record. On 11/5/25 at 12:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident had a change in condition, the facility should notify the resident's family and the resident's primary care provider, update the resident's care plan, update the resident's alert charting, and assess the resident. The DON stated that if a resident had a change in condition, the nurse on shift should write a progress note in the resident's medical record. The DON stated that she was unsure why there was no documentation in resident 34's medical record that resident 34's primary care provider was not notified of her change in condition. The DON stated that a check box that stated Show on MD[Medical Doctor]/Nursing Communications Report on the two progress notes that mentioned resident 34's tarry, black stools should have been checked in the medical record, but the box was not checked on these two progress notes. The DON stated that if the check box had been checked, the progress notes would have been carried over to a report that is printed out for the facility's physician each morning.

Based on observation, interview, and record review, it was determined that for 1 of 18 sampled residents the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise. Specifically, 1 resident experienced significant weight loss with interventions not put into place timely. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included depression, dementia, osteomyelitis, muscle weakness, chronic congestive heart failure and atrial fibrillation. Resident 2's medical record was reviewed on 11/4/25. Resident 2 had a BIMS (Brief Interview for Mental Status) completed on 10/11/25 which was 5 out of 15 which indicated severe cognitive impairment. A social service note dated 10/10/25 revealed resident 2's physical capabilities were decreasing. Resident 2's weight was 225.5 pounds on 4/14/25 and 186.0 pounds on 10/2/25.(Note: this is a 39.3 pound weight loss in 6 months with no new interventions put into place.) On 7/11/25 a Nutrition/dietary note documented, [Resident 2's] weight has decreased 10 pounds in the past 2 months. He continues on a regular diet, with several requests programmed into his meal tickets. His IBW [ideal body weight] is 172 +/- 10% [percent]. He gained weight initially when he was admitted , but has been stable around 223 [pounds] for the past year. Continue current diet for now, will consider adding a supplement if weight loss continues. I will follow his care. [Resident 2] as having a 10 pound decrease in weight, on a regular diet. No changes. Resident 2's weight was documented as 201.8 pounds on 9/9/25, a weight loss of 23.7 pounds. No new interventions were noted. On 10/2/25, a Nutrition/dietary note documented, [Resident 2's] weight has decreased significantly over the past three months. He is now 186.2 pounds. He is on a regular diet. Recommend starting an Ensure supplement BID [twice daily]. On 10/21/25, a Nutrition/dietary note documented, [Resident 2's] weight has decreased significantly, 28 pounds over the past 3 months, however, he is within his IBW. He does not eat well (he is on a mechanical soft diet), he only has 3 teeth and will eat the very soft foods on this tray (puddings, etc.) but, refuses to change his diet to something easier to chew. He has significant wounds on his feet and needs to be eating a higher protein diet. The family is resistant to hospice care. He is currently getting protein shakes BID, and I have recently added pudding, muffins and ice cream to his trays daily to encourage a higher calorie intake. Muffins, pudding or ice cream were not observed to be on resident 2's meal trays for breakfast and lunch on 11/4/25. There was no documentation located in the medical record of additional food items added to resident 2's meal trays. Physician orders documented, Ensure two times a day for weight loss was initiated on 11/4/25. The November 2025 Medication Administration Record (MAR) documented Ensure was given for the first time on 11/4/25 at 8:00 PM. On 11/5/2025 at 11:42 AM, an interview was conducted with the Dietary Manager (DM) who stated she attended the interdisciplinary meetings monthly to go over the residents' dietary needs. The DM stated she did a full assessment on the residents yearly and a follow up every three months. The DM stated they discussed whatever resident was assigned for that quarter. The DM stated the nursing staff do the weights and would let her know if there was an issue. The DM stated resident 2 slowly gained weight when he came to the facility and then he started to decrease again. The DM stated there were not any interventions put into place when resident 2 lost the 10 pounds in July. The DM stated in October 2025 she recommended resident 2 start Ensure twice daily. The DM stated she would have expected the nursing staff to have started that sooner than a month after the request. The DM stated that resident 2 should be getting a muffin on his breakfast tray and chocolate pudding and protein shake on his lunch and dinner trays, per his meal ticket. The DM could not say as to why resident 2 was not receiving those. The DM stated that resident 2 was not on the high calorie or high protein diet but he could be and that may help with his weight loss and wound healing. On 11/5/25 at 12:44 PM, an interview was conducted with the Director of Nursing (DON) who stated herself, the Assistant Director of Nursing, and the dietary manager met quarterly and monthly if needed to go over the resident's weight loss. The DON stated the dietary manager put the notes in the medical record and she would follow-up on them immediately. The DON stated resident 2's dietary recommendation got missed and resident 2 had not been given the Ensure as recommended for his weight loss.

Based on observation and interview, it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, opened multi-dose pens of medications were not labeled with open dates. Findings included: On 11/5/25 at 10:25 AM, the Entrada Hall Medication Cart was inspected. The cart contained the following open medication pens; Novolog, with no open dateBasaglar, with no open date An interview was immediately conducted with Registered Nurse (RN) 2. RN 2 stated that the medication pens should have been labeled with open dates because the medications were only good for 28 days after they had been opened. On 11/5/25 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the medication pens should have been labeled with open dates. Additionally the DON stated that the medications were good for 28 days after opening. The DON stated that they had previously educated nursing staff about the importance of labeling medications with their open dates, and that she would reeducate the staff.

Based on interview and record review it was determined, for 1 out of 18 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, hospice visit notes were not kept in the residents medical record. Resident identifier: 3.Findings included: Resident 3 was admitted to the facility on [DATE] with diagnoses which included corticobasal degeneration, malignant neoplasm of lung, depression, dementia, chronic pain and palliative care.On 11/5/25 resident 3 was interviewed and stated she received hospice care but her showers were provided by the facility. Resident 3 stated the hospice company came once a week. Resident 3's medical record was reviewed and weekly hospice notes were not located in the medical record. On 11/05/2025 at 8:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated they had new management take over the hospice company recently and she was not sure if the notes were sent over. LPN 3 was observed to look in resident 3's medical record and stated the facility used to have the hospice notes in each chart but was unable to locate the hospice notes. On 11/5/2025 at 9:23 AM, an interview was conducted with the Administrator (ADM) who stated they did not know they needed to have hospice notes in the medical record. The ADM stated the hospice company was just next door and they would get the records into resident 3's medical record.

Based on observation, interview, and record review, it was determined that, for 3 of 9 sampled residents, the facility failed to keep residents free from abuse. Specifically, a registered nurse interacted with a resident with unzipped and open pants and touched the resident under the blankets in the abdominal/pelvic area. Additionally, two other residents came forward after the incident with allegations of inappropriate interactions involving the same nurse. Resident identifiers: 1, 2, and 4. It was determined the provider's non-compliance with the requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of J. However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance. The IJ began on March 31, 2025, when Registered Nurse (RN) 1 interacted with Resident 1 with unzipped and open pants and touched the resident under the blankets in the abdominal/pelvic area. RN 1 was subsequently arrested, and two other residents came forward and alleged inappropriate interactions by RN 1. The provider was officially notified verbally and in writing of this finding on May 5, 2025 at 1:00PM. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by April 7, 2025 included the following measures: Terminating the nurse involved, interviewing all current residents to identify any potential abuse victims, and conducting physical and psychosocial assessments of the three residents identified as victims. Furthermore, the facility provided mental health services to all residents and trained all staff on abuse prevention. Newly identified abuse allegations were also appropriately reported to the relevant authorities. The health facility investigations team verified that all these interventions were completed before the survey start date. Findings Include: 1. Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. A facility reported incident submitted on April 1, 2025 to the State Survey Agency (SSA) by the by the facility's Administrator, who was also the abuse coordinator, included the following information: On March 31, 2025 at 8:30 PM, a camera set up in Resident 1's room showed RN 1 standing at the bedside of the resident who was lying down. RN 1 was facing Resident 1, and RN 1's back was to the camera. RN 1 unzipped his pants and then zipped them back up. The incident report revealed that in another camera shot, RN 1 reached under Resident 1's covers in the lower abdominal region and did not explain what he was doing. RN 1 was suspended immediately, and the facility started an investigation. Resident 1 was assessed, and no physical injury or mental anguish was noted. The surveyor reviewed the facility's investigation report submitted to the SSA on April 6, 2025, by the facility's Administrator. The Administrator documented, sexual abuse of a vulnerable resident substantiated and verified by evidence collected during the investigation. Perpetrator suspended immediately upon learning of the allegations and terminated the same day after paperwork was completed. He is incarcerated and in his termination letter he was informed that he is not allowed on Canyonlands Care Center grounds again. We feel the current threat is alleviated for the victim and all residents. The facility's investigation report included a plan to prevent recurrence and keep the residents safe. The Administrator documented, We will continue to assess and interview all residents and ensure their safety. We will monitor the resident involved in this situation for any signs of stress, emotional, cognitive, physical injury, or distress, We will continue to work with the residents family to see if they notice any new moods or behaviors and work with them on approaches they want to implement to maintain highest level of cognitive, emotional and physical function. We will retrain our staff on the definitions of abuse, abuse recognition, abuse reporting. Continue with cameras in all common areas and monitor as needed. Encourage any families with nanny cams to report to Administration what they see. Follow regulatory protocols for alleged abuse. Keep residents and residents families involved in all resident careplanning with quarterly careplan meetings. Five 10-second video clips from the 3/31/2025 incident between RN 1 and Resident 1 were provided to the surveyor by the facility. In one video clip, RN 1 stood at Resident 1's bedside. Resident 1 was observed in bed on her back. RN 1's back was to the camera, he was facing the resident, his lower legs touched the mattress, and his hands were in front of him and not visible. RN 1 was then observed to step backward away from the bed. RN 1's pants were observed to be open. RN 1 then slightly pulled his pants up and buttoned them. During the clip, Resident 1 appears to lift her knees under the blanket and pull the blanket up towards her chest when RN 1 steps away from the bed. In another video clip, RN 1 was observed kneeling at Resident 1's bedside, with his ungloved hand and forearm under the blanket near the resident ' s abdomen/pelvis, while the blanket remained covering the resident. RN 1 proceeded to stand up with his hand still under the blanket and moving. During the clip, Resident 1 is observed raising her arm, sliding her hand down the back of RN 1's arm, and holding onto his forearm when he stands up. The surveyor could not interview Resident 1 due to Resident 1's severe cognitive impairment. Resident 1 had a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of 04, which indicates severe cognitive impairment. The surveyor conducted a telephone interview with Resident 1's daughter on April 9, 2025 at 2:52 PM. Resident 1's daughter stated that the video footage was disgusting and that she believed her mother was preyed on because she has no memory and is unable to remember or vocalize anything. On May 5, 2025 at 11:00 AM the surveyor attempted to interview RN 1. RN 1 stated that he did not want to answer any questions. The surveyor completed a review of Resident 1's medical record. No documented evidence was found to explain a care need that would have required RN 1 to have his hand near Resident 1's abdomen or pelvis as observed in the video footage from March 31, 2025. 2. While investigating the incident that occurred between RN 1 and Resident 1 on March 31, 2025, the facility staff interviewed Resident 2 on April 2, 2025. The Administrator documented in an incident report submitted to the SSA that Resident 2 reported that approximately two months before their interview, RN 1 rubbed her back and started getting lower and lower, and the resident told him to stop. Resident 2 further reported that RN 1's zipper was halfway down, and he had his hands in his pants. The surveyor interviewed resident 2 on April 10, 2025 at 9:31 AM. Resident 2 stated that on an unknown date and time, after completing an assessment or skin check, RN 1 dropped his pants to mid-thigh and started playing with himself. Resident 2 stated there was a sound outside of her room, and RN 1 covered himself, and it was over. Resident 2 stated, I didn't know what to do, and It freaked me out .I'm having trouble dealing with it. Resident 2 further stated, It hurts to go to BINGO now .I don't feel comfortable going to BINGO. 3. While investigating the incident that occurred between RN 1 and Resident 1 on March 31, 2025, the facility staff interviewed Resident 4 on April 3, 2025. The Administrator documented in an incident report submitted to the SSA that in their interview with Resident 4, she reported that she had an uncomfortable back and neck rub given by RN 1 and stated, To go clear to the nipple for a neck rub is going too far. The surveyor interviewed resident 4 on April 10, 2025 at 9:13 AM. Resident 4 stated that RN 1 would put a patch on her neck at night for neck pain, and that at the end of March 2025, he had a tube of cream that he applied and rubbed into her neck. Resident 4 stated she did not have an order for cream to be applied to her neck, and during the neck rub, his hands went down to her upper chest and then down further to her nipples. Resident 4 reported she told the nurse, that's enough, and he replied, ok. Resident 4 stated she did not report the incident because I thought I could handle it. Resident 4 stated she feels safe now, but I didn't like it and I was angry. The surveyor interviewed the Director of Nursing (DON) on April 29th, 2025 at 1:25 PM. The DON stated that resident 2 and resident 4 had some on and off memory issues, but were mostly alert and oriented. The DON stated that this was the first time either resident had made an allegation of sexual abuse. 4. The facility reported to the SAA in December 2024 that a resident reported an allegation of inappropriate physical touch by RN 1. The facility reported the incident to the SSA, Police, and Adult Protective Services. The facility completed an investigation and the incident was unable to be substantiated. The resident had a rash that required assessment and RN 1 documented an assessment was completed.

Based on interview and record review, the facility did not allow the resident the right to formulate an advance directive. Specifically, for 1 out of 15 sampled residents, a resident that did not have a Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive was documented as do not resuscitate (DNR) in their medical record. Resident identifier: 19. Findings included: Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with psychotic disturbance, bradycardia, history of falling, diastolic heart failure, atrial fibrillation, type 2 diabetes mellitus, major depressive disorder, and chronic kidney disease. Resident 19's medical record was reviewed on 7/10/24. A physician's order dated 3/26/24, documented Order Summary: DNR. Advanced Directive Status: Verified By Medical Record Only. Order Type: Advanced Directive. An Advanced Directive or POLST were unable to be located in the medical record. A care plan Focus dated 4/2/24, documented I am DNR and I don't have any known allergies. The goal documented I will be as comfortable as possible through the review date. The intervention initiated on 4/2/24, documented Please follow POLST when there is one, obtain Hospice referral when condition is appropriate, and Family and resident agree. On 4/4/24 at 1:46 PM, a Nursing Note documented Note Text: [Resident 19] went to her admit appointment with [name redacted] today. The doctor scheduled the Lasix and the prn [as needed] order will continue for 7 more days. A CMP [Comprehensive Metabolic Panel] will be drawn in one week. She also discontinued the mirtazapine. The social worker is working on getting a POLST form filled out. On 7/10/24 at 2:18 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that she had resident 19 complete a POLST because the SSW did not have one on file. The SSW stated that she would be sending the POLST to the doctor to sign. The SSW stated that upon admission she would complete the initial interview and get the resident to the facility. The SSW stated that she would complete all the admission paperwork with the resident and family. The SSW stated she would ask for a POLST and if the resident did not have a POLST she would ask the resident to take one to their doctor on their admission visit. The SSW stated that if needed she would help the resident fill out the POLST and the SSW would take the POLST to the resident's doctor to sign. The SSW stated she would try to get the POLST completed the first three to four days after admission. The SSW stated the facility tired to get the resident admission appointment within three to four days after their admission. The SSW stated if the resident was a local resident they would already have the admission appointment set up. The SSW stated that out of state residents would need to get established with a doctor and that might take a little longer. On 7/10/24 at 3:03 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a resident did not have a POLST the resident would be a full code. RN 1 stated that if a resident did not have a POLST or Advanced Directive she would look into it but it would default to full code. On 7/11/24 at 9:14 AM, an interview was conducted with the Administrator. The Administrator stated that a POLST would be initiated on admission. The Administrator stated the staff would ask the resident if they already had Advanced Directives and if not the staff would help the resident with that process. The Administrator stated that sometimes the delay was on the resident or the doctor. The Administrator stated if the staff know what they want with their code status the staff would help the resident and educate. The Administrator stated if the resident did not have a POLST the resident would default to a full code status.

Based on observation, interview, and record review, the facility did not ensure that all residents were free from abuse. Specifically, for 3 out of 15 sampled residents, allegations of abuse were not investigated to determine if abuse occurred when a staff member reported to management that a residents family member was observed to approach another resident and stand over a resident speaking loudly. In addition, another incident when residents yelled at each other and one resident threw a wet paper towel at another resident were not reported or investigated. Resident identifiers: 20, 22, 23, and 33. Findings included: On 7/10/24 at 9:41 AM, an observation was made of camera footage from the facility. The footage was from 4/22/24 at 10:57 AM. Resident 20 was observed standing next to resident 33 who was seated in a recliner with a family member sitting next to her. Resident 20 and 33 were observed to be talking but the audio was not clear to hear what they were talking about. Resident 20 was observed to pick up her stuffed animal from the bedside table that was in front of resident 33. Resident 20 was observed to throw the stuffed animal on the ground. Resident 33's family member was observed to stand up and walk over to resident 33. The family member was observed talking to resident 33 and standing over resident 33 with shoulders back and standing tall. The family member was observed to pick up the stuffed animal off the ground. Certified Nursing Assistant (CNA) 1 was observed to enter the area and re-directed resident 33 away from resident 20 and the family member. Resident 20 was observed to lean toward her family member and put her head on their shoulder. The family member was observed giving resident 33 a side hug. 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included dementia severity without behavioral disturbance, malignant, anxiety disorder, insomnia, tubulo-interstitial nephritis, and hypertension. Resident 20's medical record was reviewed on 7/8/24 through 7/11/24. Progress notes revealed on 4/22/24 at 5:51 PM, Behavior Note: Earlier today [resident 20] walked up to room [ROOM NUMBER] [resident 23] and picked up the cup she had in the living room. 214 preceded to yell at [resident 20], [resident 20] yelled back. This nurse heard from the hallway. Upon walking up it was observed that [resident 20] had thrown a wet paper towel at 214, [resident 23] redirected from the area. Both residents moved on within a few moments, neither appeared to having lingering upset feelings. It should be noted that there was no documentation regarding the incident viewed on the camera footage. 2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included dementia, type 2 diabetes mellitus, and hypertension. Resident 23's medical record was reviewed on 7/8/24 through 7/11/24. A behavior note dated 4/2/24 at 5:53 PM revealed, Earlier today room [ROOM NUMBER] [resident 20] heard yelling with [resident 23] in the living room after 218 had picked up her cup from the table. Upon entering the room this nurse noted that 218 had thrown a wet paper towel at [resident 23], they continued yelling at one another. 218 redirected away from the situation, both residents calmed within moments of the interaction. There was no follow-up alert charting. 3. Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness, and chronic kidney disease. Resident 33's medical record was reviewed on 7/8/24 through 7/11/24. There was no documentation of the incident with resident 20 on 4/22/24. On 7/9/24 at 1:21 PM, an interview was conducted with the Therapeutic Recreational Therapist (TRT). The TRT stated she was also a CNA. The TRT stated resident 20 wandered around the facility and stopped to talk with residents and staff. The TRT stated resident 20 was alert to person and family sometimes. The TRT stated resident 20 liked to walk with people and other times told people to go away. The TRT stated some residents had a difficult time with resident 20 because resident 20 had been known to yell at other resident. The TRT stated staff intervened as quickly as possible and re-directed her. The TRT stated resident 20 had verbal and physical altercations with other residents in the past but could not remember who or when. The TRT stated she reported any of those interactions to the nurse and the Administrator because she did not know if it could be an abuse concern. The TRT stated she would report any hitting, scratching, biting, or purposefully running into another resident. The TRT stated mental abuse was a fine line. The TRT stated she did not try to determine if situations were abuse or not and that was why she reported everything to Administration. On 7/9/24 at 2:00 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that resident 20's needs were anticipated by staff. The MDS coordinator stated resident 20's wandering patterns were tracked by the staff, for example when and where the resident was wandering. The MDS Coordinator stated that once in a while other residents were irritated by resident 20, for example when she walked up and stood close to them. The MDS Coordinator stated residents had been angry and asked resident 20 what she was doing and she sometimes yelled back at them. The MDS Coordinator stated staff needed to keep a close eye on resident 20 because staff knew she irritated other residents. The MDS Coordinator stated if there were raised voices, then staff always looked for resident 20 because she was probably irritating another resident. The MDS Coordinator stated some residents were more irritated by resident 20 than others. The MDS Coordinator stated the male residents usually did not understand why resident 20 stood close to them. The MDS Coordinator stated most of the male residents were in the 100 hallway and resident 20 resided in the 200 hallway. The MDS Coordinator stated resident 23 had raised her voice at resident 20 before and resident 20 threw something at resident 23. The MDS Coordinator stated that was something that would be investigated as potential abuse. The MDS Coordinator stated the Administrator and Director of Nursing (DON) conducted abuse investigations. The MDS Coordinator stated when conducting an abuse investigation the camera footage was reviewed. On 7/9/24 at 4:27 PM, an interview was conducted with the Administrator. The Administrator stated she was the abuse coordinator. The Administrator stated when an abuse allegation was reported to her and there were cameras throughout the facility so the camera footage was reviewed. The Administrator stated the camera footage was reviewed to see if it met the criteria of willful injury or if it was a stay out of my space type thing. The Administrator stated resident 20 was a sweetheart and would not hurt a fly. The Administrator stated some residents might yell back at her, like resident 23. The Administrator stated if the resident did not make physical contact with each other it was not abuse. The Administrator stated verbal abuse would be if residents used derogatory names toward each other. The Administrator stated abuse was the willful infliction of injury for physical abuse. The Administrator stated residents yelling at each other was not verbal abuse. The Administrator stated any verbal interaction would need to be looked at to determine if there was abuse or not. The Administrator stated she did not have any allegations of abuse since the previous survey to investigate. On 7/10/24 at 9:19 AM, a follow-up interview was conducted with the Administrator. The Administrator stated she reviewed the definitions of abuse and she looked for willful intent to harm when reviewing the camera footage. The Administrator stated residents that had dementia, could not help their actions but the interaction could still be willful. The Administrator stated there were no current residents that targeted each other. The Administrator stated she reviewed the camera footage from the incident between resident 20 and resident 23. The Administrator stated it looked like resident 20 had a napkin rolled up and she tossed it into resident 23 lap. The Administrator stated if staff observed the incident and there was no harm, then staff did not need to contact Administration. The Administrator stated if staff felt there was something questionable, that Administration needed to review then it was reviewed. The Administrator stated there would be a care plan for residents after an incident. The Administrator stated an incident report would be completed if the resident was super aggressive and then alert charting would be completed. The Administrator stated if staff felt it was an occasional argument with no harm of any sort then there would not be an incident report or alert charting. The Administrator stated alert charting was completed in the psychotropic's area, daily nursing notes, alert notes, or behavior charting. The Administrator stated resident 20 and resident 23 had so many good interactions but only the negative ones were documented. The Administrator stated the incident between resident 20 and resident 23 was ruled out to not be abuse within two hours. The Administrator stated she did not have documentation on how abuse was ruled out besides it was an interaction and there was no harm. On 7/10/24 at 9:41 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated on 4/22/24, she witnessed resident 20 cleaning up resident 23's spilled coffee on an over bed table. LPN 2 stated she heard resident 23 and resident 20 yelling at each other. LPN 2 stated she re-directed the residents away from each other and checked to make sure they were okay. LPN 2 stated she reported to the DON and Administrator to make sure no one was hurt and then put a behavior note in each residents medical record. LPN 2 stated if there had been an injury or abuse then she would have filled out an incident report, called the families, notified the physician's, and notified the Administrator and DON about the incident. LPN 2 stated she did not witness the incident between resident 33's family member and resident 20. LPN 2 stated the incident was reported to her and she assumed that the DON investigated it and took care of the notifications. On 7/10/24 at 9:45 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the Social Service Worker (SSW) showed resident 33's family member the camera footage because the family member was standing over resident 20. The MDS Coordinator stated the SSW, DON, and Administrator had a meeting with resident 33's family member. The MDS Coordinator stated there was an informal investigation into abuse and sometimes the abuse investigations were so smooth no one noticed they were completed. On 7/10/24 at 9:51 AM, an interview was conducted with the SSW. The SSW stated she watched camera footage of an incident on 4/22/24, between resident 33's family member and resident 20. The SSW stated she was notified of the incident the following morning during the morning meeting. The SSW stated a staff member that reported the incident was very concerned that resident 33's family member was out of control with one of the residents. The SSW stated she observed resident 20 standing by resident 33 and her family member. The SSW stated resident 33's family member was irritated by the way he physically carried himself. The SSW stated that resident 20 needed to be acknowledged and then she moved along. The SSW stated if resident 20 did not get attention then she became feisty. The SSW stated her impression of the camera footage was resident 20 was ignored and when resident 20 picked up the stuffed animal it was to get attention. The SSW stated resident 33's family member stood up out of the chair, said words to resident 20, then picked up the stuffed animal off the floor and yelled for staff to come get resident 20. The SSW stated she had a meeting with resident 33's family member and showed the camera footage and the family member stated it was an overreaction and humbly apologized. The SSW stated she monitored resident 20 after the incident and she did not seam to be upset about it. The SSW stated resident 20's reaction in he camera footage was observed closely because staff needed to make sure resident 20 was protected. The SSW stated resident 33 was not as upset after the incident. The SSW stated there was lots of alert charting completed, staff tried to provide resident 20 with one on one supervision because she wandered. The SSW stated the incident was not abuse because of how the receiving party felt about it. The SSW stated if there would have been any physical or verbal interaction, that could be construed as an attack. The SSW stated if resident 20 would have responded as being scared or threatened in any way that would have been abuse. The SSW stated resident 33's body language in the video, was not a change in how she usually was with her family member. The SSW stated resident 20 did not have the comprehension of what was going on and did not appear to be threatened or afraid. The SSW was observed to review resident 20's and resident 33's medical record and stated there was no documentation regarding the incident. The SSW stated the biggest thing was, resident 33's family member was not allowed back into the facility if there were anymore interactions like that with other residents. The SSW stated people did not understand resident 20 and would get frustrated with her. The SSW stated that resident 23 was a grumbler and was upset with others. The SSW stated the same day resident 20 knocked over things of resident 23 and resident 23 yelled at resident 20. The SSW stated resident 20 and resident 23 did not know what was going on the day they yelled at each other. On 7/10/24 at approximately 10:00 AM, an interview was conducted with LPN 2. LPN 2 stated there was no alert charting after the situation with resident 33's family member and resident 20. LPN 2 stated she communicated with staff that something happened and to be more aware of how resident 20 interacted with others. LPN 2 stated she reported the incident to administration and it was reported the following morning in the morning meeting. LPN 2 stated resident 20 did not realize the situation happened. LPN 2 stated that CNA 1 reported what happened to her that day with resident 20 and resident 33's family member. LPN 2 stated the same day resident 23 was yelling and resident 20 picked up a wet paper towel and threw it at resident 23. LPN 2 stated that resident 20 and resident 23 were both very reactive but easily re-directed. LPN 2 stated she reported the situation to administration because she was worried about the yelling. On 7/11/24 at 8:44 AM, an interview was conducted with CNA 1. CNA 1 stated abuse training had been provided through a computer based system, in-services, and pamphlets distributed from management. CNA 1 stated on 4/22/24, she was walking down the 100 hallway, saw resident 33's family member telling resident 20 to get away. CNA 1 stated she redirected resident 20 out of the area. CNA 1 stated she did not see what happened prior. CNA 1 stated resident 33's family member seamed a little aggressive because of his posture toward resident 20. CNA 1 stated she reported the incident to LPN 2 who was the nurse for the 100 hallway that day and the SSW. CNA 1 stated resident 33's family did not seam to pleased with resident 20, so she wanted to get resident 20 out of the situation quickly. CNA 1 stated resident 20 did not usually make sense when she was talking to other residents. CNA 1 stated other residents had expressed to her that they felt like they were being targeted by resident 20. CNA 1 stated she explained to other residents that resident 20 did not know what she was doing. CNA 1 stated resident 22 expressed to her that he felt like resident 20 was out to get him, and that resident 20 did not belong at the facility. CNA 1 stated resident 22 had gotten upset with resident 20 when she tired to move a table and resident 22 yelled at resident 20. CNA 1 stated another nurse was there when the incident happened and it was reported to the DON, SSW, and the Administrator. CNA 1 stated she was not interviewed or asked any questions about the incident. CNA 1 stated she reported the incident with resident 33's family member and resident 20 because the way the family member came at resident 20. CNA 1 stated the family member's demeanor felt like a get away from me, get away from her. CNA 1 stated also the way the family members voice sounded and he had a fist like he was ready to go like fight someone if he needed to. CNA 1 stated after the incident resident 33 and resident 20 seamed ok. On 7/11/24 at 11:42 AM, an interview was conducted with the Administrator. The Administrator stated she looked at the camera footage and resident 20 was standing by resident 33 and the family member. The Administrator stated resident 20 was asked to leave by resident 33's family member and then resident 20 started to play with a toy that was on the bedside table. The Administrator stated resident 20 was observed to lightly toss the toy on the ground. The Administrator stated the family member stood up and got big in stature and appeared irritated with resident 20. The Administrator stated CNA 1 was observed in the camera footage re-directing resident 20 away from resident 33. The Administrator stated that she immediately set-up a meeting with resident 33's family member to educate about not getting upset with resident's because it was their home. The Administrator stated the meeting was the next day. The Administrator stated the family member was educated if there were any problems, then staff needed to be alerted. The Administrator stated the family member felt bad after watching the clip, now the family member and resident 20 were friends. The Administrator stated she did not see anything willful or the intent to hurt by the family member. The Administrator stated the incident was not reported to the State Survey Agency because abuse was ruled out within two hours. The Administrator stated every morning nursing progress notes were reviewed for all residents in the facility. The Administrator stated camera footage was reviewed if there were any reported incidents. The Administrator stated she did not have documentation regarding how abuse was ruled out within two hours. The Administrator stated she ruled out the incident as nothing. The Administrator stated if there was a potential abuse situation, then the staff completed an incident report. The Administrator stated there was no incident report completed or alert charting. A note titled Abuse Reporting Reminder was located at the 200 hallway nurses station. The note revealed This is a very important subject that I need all your help with since I'm not here 24 hours. I only have 24 hours to report alleged abuse or abuse of any kind to the state authorities. This includes Resident to Resident Abuse and Staff to Resident Abuse. Abuse is defined as 'Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.' If there is any Resident to Resident altercation where contacts made, I need to know immediately so I can start my investigation and instruct you on what you need to do. We are a controlled setting so first and foremost we need to keep the residents involved apart and the nurse needs to assess both residents. If the resident to resident contact appeared in the common area we can watch the cameras to see exactly what happened. If a resident reports getting abused by another resident in a residents room and its unwitnessed by staff, you can interview and assess the residents. If a staff member witnesses it, have them write a statement immediately. If you are a CNA or housekeeper, tell the Charge Nurse and ten call or text me. [number removed] If you are the Nurse, please call or text me as soon as you have an understand of the event. Time is of the essence for our facility to abide by all abuse regulations. If the resident is injured, I only have 2 hours to call the State, the Police and the Ombudsman. If uninjured, I have 24 hours. If there is anything questionable, I need to be notified immediately. Even if you just want to talk through a situation, call or text anytime. I am the abuse coordinator, I take my job very seriously. [DON] and [SSW] also help with this but I am the one to immediately notify. [phone number removed]. Thanks for your help with this. I appreciate all you do to help keep our residents safe, healthy and happy. [signed by the Administrator and phone number removed] The facility Abuse Prevention Program policy and procedure dated December 2016 was reviewed and revealed the following: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy and Interpretation and Implementation As Part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family member, legal representatives, friends, visitor, or any other individual. 2. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of our residents. 4. 5. Implement measures to address factors that may lead to abusive situations. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframe's as required by federal requirements; 8. Protect residents during abuse investigations; 9. 10. (Cross refer to F609)

Based on interview and record review, the facility did not ensure that residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Specifically, for 1 out of 15 sampled residents, a Registered Nurse (RN) gave a resident an unprescribed 25 milligram (mg) dose of Trazodone in addition to the resident's prescribed nightly dose of 25 mg of Trazodone. Resident Identifier: 17. Findings Included: Resident 17 was admitted to the facility on [DATE] with diagnoses including aspiration of fluid, respiratory failure, amnesia, nocturia, constipation, and occlusion and stenosis of right posterior cerebral artery. Resident 17's medical record was reviewed from 7/8/24 through 7/11/24. On 5/10/24, resident 17's quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating no cognitive impairment. Resident 17's progress notes revealed the following: a. On 2/25/24 at 6:56 PM, an alert note documented, [Resident 17] was given at least one extra dose of trazadone [sic]. Monitor for altered LOC [level of consciousness] and other adverse affects for 72 hours. Complete a nursing note Qshift [every shift]. b. On 2/25/24 at 7:02 PM, a nurse note documented, [Resident 17] appeared more tired than usual this morning. She stated 'I just can't wake up.' Otherwise, Alert and oriented. She has been going to the restroom on her own without issues. She ambulated outdoors in the garden and came to the dining area for dinner. No signs of distress throughout the day. O2 sats [oxygen saturations] above 90%. c. On 2/26/24 at 10:39 PM, a nurse note documented, No a/e [adverse effects] noted from administration of additional trazadone [sic] this shift. d. On 2/27/24 at 5:39 PM, a nurse note documented, [Resident 17] has been very tired today. She had a fall early this morning and it seems to have taken a lot of energy. She has been accepting of care. Resident 17's Incident Reports revealed that on 2/25/24 at 9:00 AM, At 0800 [8:00 AM] this morning it was reported to the Administrator and DON [Director of Nursing], by 2 nurses, that resident may have received an extra dose of Trazadoe [sic] last night and potentially another night. Med [medication] error protocol initiated. Review of the facility investigation documentation for resident 17 revealed the following: The facility initial investigation, form 358, documented that an allegation of willful mistreatment occurred on 2/23/24. The form documented that staff became aware of the allegation at 8:00 AM on 2/25/24, and notified facility administration on 2/25/24. The form documented that the night shift nurse, RN 3 reported to the day shift nurse that she gave 50 mg of Trazodone to resident 17 in order to help her sleep. The facility final investigation summary, form 359, documented that the conclusion of the investigation was that the allegation was verified. The form documented, Allegation and admittance verified by perpetrator via text and by camera footage on 2-24-24 after 2200 [10:00 PM]. Perpetrator resigned after being suspended pending investigation. Resident 17's Medication Administration Record (MAR) for the month of February 2024 was reviewed. There were no documented additional doses of Trazodone on the MAR during the dates of the incident. On 7/8/24 at 2:33 PM, an interview was conducted with Resident 17. Resident 17 was unable to recall the incident. On 7/9/24 at 2:20 PM, a voice mail phone message was left for RN 3 after an attempt was made to call her. RN 3 did not return the call or voice mail. On 7/9/24 at 3:07 PM , an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she received her report from RN 3 when coming onto her shift on the morning of 2/24/24. LPN 1 stated that RN 3 told her that she had given resident 17 an extra dose of Trazodone. LPN 1 stated that RN 3 told her she was going to enter an order for the medication. LPN 1 stated that the next morning, RN 3 stated that she had given resident 17 another 25 mg of Trazodone after another nurse had already given resident 17 her prescribed dose of 25 mg of Trazodone. LPN 1 stated that she went over and talked to the nurse over the other unit at the facility, RN 4. LPN 1 stated that herself and RN 4 reviewed resident 17's chart and saw that resident 17 only had orders for 25 mg of Trazodone to be given each night. LPN 1 stated that Trazodone was a medication used to help residents at the facility sleep. LPN 1 stated that residents that received this medication should be monitored for excessive sleepiness. LPN 1 stated that herself and RN 4 reported the incident to the facility Administrator and the DON. LPN 1 stated that after the incident, all staff at the facility received additional training on reporting abuse and medication administration protocols. On 7/10/24 at 8:33 AM, an interview was conducted with RN 4. RN 4 stated that prior to the incident, resident 17 had a history of not sleeping well. RN 4 stated that on 2/24/24, RN 3 told her she had given resident 17 50 mg of Trazodone because she was frustrated with how often resident 17 had been pressing her call bell during the night. RN 4 stated that this was double the prescribed dose of 25 mg. RN 4 stated that RN 3 had asked her not to say anything, and RN 4 filed a request form for resident 17's medical provider to increase the prescribed dosage of Trazodone. RN 4 stated that on 2/25/24, she was told by a Certified Nursing Assistant (CNA) that the CNA had overheard RN 3 tell LPN 1 that she gave resident 17 an additional 25 mg of Trazodone the night of 2/24/24. RN 4 stated that she talked to LPN 1. RN 4 stated that LPN 1 told her that RN 3 had given resident 17 a double dose of Trazodone. RN 4 stated that herself and LPN 1 reviewed resident 17's chart and could not find documentation that extra doses of Trazodone had been administered. RN 4 stated that she notified the Administrator and the DON at 8:00 AM on 2/25/24, through text message. RN 4 stated that on the morning of 2/25/24, resident 17 was extremely sleepy, hard to ambulate, and that she required a one to two person assist. RN 4 stated that this was not resident 17's baseline and that she was typically more independent. RN 4 stated that resident 17 kept stating, I feel so sleepy, I can't wake up. RN 4 stated that she was not aware of any other residents at the facility receiving extra doses of Trazodone or any other medications. On 7/10/24 at 9:32 AM, an interview was conducted with the Administrator. The Administrator stated that on the morning of 2/25/24, she received a call from one of her nurses. The Administrator stated that the nurse told her that she needed to relay what she was told during the morning report. The Administrator stated that the day shift nurse told her that the night shift nurse, RN 3 told the day shift nurse that she had given resident 17 an extra 25 mg dose of Trazodone. The Administrator stated that she suspended RN 3 immediately and that RN 3 resigned immediately after the suspension. The Administrator stated that the incident was reported to the Department of Professional Licensing. The Administrator stated that resident 17 had no recollection of the incident, but that she had staff monitor resident 17 for extra sedation. The Administrator stated that RN 3 would have had to have obtained the extra dose of Trazodone from resident 17's own supply. The Administrator stated that she was able to verify that resident 17 received an extra dose of Trazodone on 2/24/24, from security footage that showed RN 3 obtained another dose of Trazodone. The Administrator stated that the camera footage showed the evening nurse giving the scheduled dose of 25 mg of Trazodone and that it showed RN 3 obtained another dose after coming on shift at 10:00 PM. The Administrator stated that in order for resident 17 to receive an additional dose of Trazodone, there would need to be a physician's order. The Administrator stated that after the incident, she reviewed resident 17's chart. The Administrator stated that the chart did not document any additional administrations of Trazodone other than the prescribed 25 mg dose. The Administrator stated that after the incident, she provided training to all nurses on staff about medication administration protocols and instructed them to not give residents medication that was not prescribed. The Administrator stated that she had not heard of any other residents receiving extra doses of any medications and that she had not received any complaints from residents or staff.

Based on observation, interview, and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made. Specifically, for 3 out of 15 sampled residents, management did not report or investigate when a staff member reported to management that a residents family member was observed to approach another resident and stand over a resident speaking loudly. In addition, another incident when residents yelled at each other and one resident threw a wet paper towel at another resident were not reported or investigated. Resident identifiers: 20, 22, 23, and 33. Findings included: On 7/10/24 at 9:41 AM, an observation was made of camera footage from the facility. The footage was from 4/22/24 at 10:57 AM. Resident 20 was observed standing next to resident 33 who was seated in a recliner with a family member sitting next to her. Resident 20 and resident 33 were observed to be talking but the audio was not clear to hear what they were talking about. Resident 20 was observed to pick up her stuffed animal from the bedside table that was in front of resident 33. Resident 20 was observed to throw the stuffed animal on the ground. Resident 33's family member was observed to stand up and walk over to resident 33. The family member was observed talking to resident 33 and standing over resident 33 with shoulders back and standing tall. The family member was observed to pick up the stuffed animal off the ground. Certified Nursing Assistant (CNA) 1 was observed to enter the area and re-directed resident 33 away from resident 20 and the family member. Resident 20 was observed to lean toward her family member and put her head on their shoulder. The family member was observed giving resident 33 a side hug. 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included dementia severity without behavioral disturbance, malignant, anxiety disorder, insomnia, tubulo-interstitial nephritis, and hypertension. Resident 20's medical record was reviewed on 7/8/24 through 7/11/24. Progress notes revealed on 4/22/24 at 5:51 PM, Behavior Note: Earlier today [resident 20] walked up to room [ROOM NUMBER] [resident 23] and picked up the cup she had in the living room. 214 preceded to yell at [resident 20], [resident 20] yelled back. This nurse heard from the hallway. Upon walking up it was observed that [resident 20] had thrown a wet paper towel at 214, [resident 23] redirected from the area. Both residents moved on within a few moments, neither appeared to having lingering upset feelings. It should be noted that there was no documentation regarding the incident viewed on the camera footage. 2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included dementia, type 2 diabetes mellitus, and hypertension. Resident 23's medical record was reviewed on 7/8/24 through 7/11/24. A behavior note dated 4/22/24 at 5:53 PM revealed, Earlier today room [ROOM NUMBER] [resident 20] heard yelling with [resident 23] in the living room after 218 had picked up her cup from the table. Upon entering the room this nurse noted that 218 had thrown a wet paper towel at [resident 23], they continued yelling at one another. 218 redirected away from the situation, both residents calmed within moments of the interaction. There was no follow-up alert charting. 3. Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness, and chronic kidney disease. Resident 33's medical record was reviewed on 7/8/24 through 7/11/24. There was no documentation of the incident with resident 20 on 4/22/24. On 7/9/24 at 1:21 PM, an interview was conducted with the Therapeutic Recreational Therapist (TRT). The TRT stated she was also a CNA. The TRT stated resident 20 wandered around the facility and stopped to talk with residents and staff. The TRT stated resident 20 was alert to person and family sometimes. The TRT stated resident 20 liked to walk with people and other times told people to go away. The TRT stated some residents had a difficult time with resident 20 because resident 20 had been known to yell at other residents. The TRT stated staff intervened as quickly as possible and re-directed resident 20. The TRT stated resident 20 had verbal and physical altercations with other residents in the past but could not remember who or when. The TRT stated she reported any of those interactions to the nurse and the Administrator because she did not know if it could be an abuse concern. The TRT stated she would report any hitting, scratching, biting, or purposefully running into another resident. The TRT stated mental abuse was a fine line. The TRT stated she did not try to determine if situations were abuse or not and that was why she reported everything to Administration. On 7/9/24 at 2:00 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that resident 20's needs were anticipated by staff. The MDS Coordinator stated resident 20's wandering patterns were tracked by the staff, for example when and where the resident was wandering. The MDS Coordinator stated that once in a while other residents were irritated by resident 20, for example when she walked up and stood close to them. The MDS Coordinator stated residents had been angry and asked resident 20 what she was doing and she sometimes yelled back at them. The MDS Coordinator stated staff needed to keep a close eye on resident 20 because staff knew she irritated other residents. The MDS Coordinator stated if there were raised voices, then staff always looked for resident 20 because she was probably irritating another resident. The MDS Coordinator stated some residents were more irritated by resident 20 than others. The MDS Coordinator stated the male residents usually did not understand why resident 20 stood close to them. The MDS Coordinator stated most of the male residents were in the 100 hallway and resident 20 resided in the 200 hallway. The MDS Coordinator stated resident 23 had raised her voice at resident 20 before and resident 20 threw something at resident 23. The MDS Coordinator stated that was something that would be investigated as potential abuse. The MDS Coordinator stated the Administrator and Director of Nursing (DON) conducted abuse investigations. The MDS Coordinator stated when conducting an abuse investigation the camera footage was reviewed. On 7/9/24 at 4:27 PM, an interview was conducted with the Administrator. The Administrator stated she was the abuse coordinator. The Administrator stated when an abuse allegation was reported to her and there were cameras throughout the facility so the camera footage was reviewed. The Administrator stated the camera footage was reviewed to see if it met the criteria of willful injury or if it was a stay out of my space type thing. The Administrator stated resident 20 was a sweetheart and would not hurt a fly. The Administrator stated some residents might yell back at her, like resident 23. The Administrator stated if the residents did not make physical contact with each other it was not abuse. The Administrator stated verbal abuse would be if residents used derogatory names toward each other. The Administrator stated abuse was the willful infliction of injury for physical abuse. The Administrator stated residents yelling at each other was not verbal abuse. The Administrator stated any verbal interaction would need to be looked at to determine if there was abuse or not. The Administrator stated she did not have any allegations of abuse since the previous survey to investigate. On 7/10/24 at 9:19 AM, a follow-up interview was conducted with the Administrator. The Administrator stated she reviewed the definitions of abuse and she looked for willful intent to harm when reviewing the camera footage. The Administrator stated residents that had dementia, could not help their actions but the interaction could still be willful. The Administrator stated there were no current residents that targeted each other. The Administrator stated she reviewed the camera footage from the incident between resident 20 and resident 23. The Administrator stated it looked like resident 20 had a napkin rolled up and she tossed it into resident 23's lap. The Administrator stated if staff observed the incident and there was no harm, then staff did not need to contact Administration. The Administrator stated if staff felt there was something questionable, that Administration needed to review then it was reviewed. The Administrator stated there would be a care plan for residents after an incident. The Administrator stated an incident report would be completed if the resident was super aggressive and then alert charting would be completed. The Administrator stated if staff felt it was an occasional argument with no harm of any sort then there would not be an incident report or alert charting. The Administrator stated alert charting was completed in the psychotropic's area, daily nursing notes, alert notes, or behavior charting. The Administrator stated resident 20 and resident 23 had so many good interactions but only the negative ones were documented. The Administrator stated the incident between resident 20 and resident 23 was ruled out to not be abuse within two hours. The Administrator stated she did not have documentation on how abuse was ruled out besides it was an interaction and there was no harm. On 7/10/24 at 9:41 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated on 4/22/24, she witnessed resident 20 cleaning up resident 23's spilled coffee on an over bed table. LPN 2 stated she heard resident 23 and resident 20 yelling at each other. LPN 2 stated she re-directed the residents away from each other and checked to make sure they were okay. LPN 2 stated she reported to the DON and Administrator to make sure no one was hurt and then put a behavior note in each residents medical record. LPN 2 stated if there had been an injury or abuse then she would have filled out an incident report, called the families, notified the physician's, and notified the Administrator and DON about the incident. LPN 2 stated she did not witness the incident between resident 33's family member and resident 20. LPN 2 stated the incident was reported to her and she assumed that the DON investigated it and took care of the notifications. On 7/10/24 at 9:45 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that the Social Service Worker (SSW) showed resident 33's family member the camera footage because the family member was standing over resident 20. The MDS coordinator stated the SSW, DON, and Administrator had a meeting with resident 33's family member. The MDS coordinator stated there was an informal investigation into abuse and sometimes the abuse investigations were so smooth no one noticed they were completed. On 7/10/24 at 9:51 AM, an interview was conducted with the SSW. The SSW stated she watched camera footage of an incident on 4/22/24, between resident 33's family member and resident 20. The SSW stated she was notified of the incident the following morning during the morning meeting. The SSW stated a staff member that reported the incident was very concerned that resident 33's family member was out of control with one of the residents. The SSW stated she observed resident 20 standing by resident 33 and her family member. The SSW stated resident 33's family member was irritated by the way he physically carried himself. The SSW stated that resident 20 needed to be acknowledged and then she moved along. The SSW stated if resident 20 did not get attention then she became feisty. The SSW stated her impression of the camera footage was resident 20 was ignored and when resident 20 picked up the stuffed animal it was to get attention. The SSW stated resident 33's family member stood up out of the chair, said words to resident 20, then picked up the stuffed animal off the floor and yelled for staff to come get resident 20. The SSW stated she had a meeting with resident 33's family member and showed the camera footage and the family member stated it was an overreaction and humbly apologized. The SSW stated she monitored resident 20 after the incident and she did not seam to be upset about it. The SSW stated resident 20's reaction in the camera footage was observed closely because staff needed to make sure resident 20 was protected. The SSW stated resident 33 was not as upset after the incident. The SSW stated there was lots of alert charting completed, staff tried to provide resident 20 with one on one supervision because she wandered. The SSW stated the incident was not abuse because of how the receiving party felt about it. The SSW stated if there would have been any physical or verbal interaction, that could be construed as an attack. The SSW stated if resident 20 would have responded as being scared or threatened in any way that would have been abuse. The SSW stated resident 33's body language in the video, was not a change in how she usually was with her family member. The SSW stated resident 20 did not have the comprehension of what was going on and did not appear to be threatened or afraid. The SSW was observed to review resident 20's and resident 33's medical record and stated there was no documentation regarding the incident. The SSW stated the biggest thing was, resident 33's family member was not allowed back into the facility if there were anymore interactions like that with other residents. The SSW stated people did not understand resident 20 and would get frustrated with her. The SSW stated that resident 23 was a grumbler and was upset with others. The SSW stated the same day resident 20 knocked over things of resident 23 and resident 23 yelled at resident 20. The SSW stated resident 20 and resident 23 did not know what was going on the day they yelled at each other. On 7/10/24 at approximately 10:00 AM, an interview was conducted with LPN 2. LPN 2 stated there was no alert charting after the situation with resident 33's family member and resident 20. LPN 2 stated she communicated with staff that something happened and to be more aware of how resident 20 interacted with others. LPN 2 stated she reported the incident to administration and it was reported the following morning in the morning meeting. LPN 2 stated resident 20 did not realize the situation happened. LPN 2 stated that CNA 1 reported what happened to her that day with resident 20 and resident 33's family member. LPN 2 stated the same day resident 23 was yelling and resident 20 picked up a wet paper towel and threw it at resident 23. LPN 2 stated that resident 20 and resident 23 were both very reactive but easily re-directed. LPN 2 stated she reported the situation to administration because she was worried about the yelling. On 7/11/24 at 8:44 AM, an interview was conducted with CNA 1. CNA 1 stated abuse training had been provided through a computer based system, in-services and pamphlets distributed from management. CNA 1 stated on 4/22/24, she was walking down the 100 hallway, saw resident 33's family member telling resident 20 to get away. CNA 1 stated she redirected resident 20 out of the area. CNA 1 stated she did not see what happened prior. CNA 1 stated resident 33's family member seamed a little aggressive because of his posture toward resident 20. CNA 1 stated she reported the incident to LPN 2 who was the nurse for the 100 hallway that day and the SSW. CNA 1 stated resident 33's family did not seam to pleased with resident 20, so she wanted to get resident 20 out of the situation quickly. CNA 1 stated resident 20 did not usually make sense when she was talking to other residents. CNA 1 stated other residents had expressed to her that they felt like they were being targeted by resident 20. CNA 1 stated she explained to other residents that resident 20 did not know what she was doing. CNA 1 stated resident 22 expressed to her that he felt like resident 20 was out to get him, and that resident 20 did not belong at the facility. CNA 1 stated resident 22 had gotten upset with resident 20 when she tired to move a table and resident 22 yelled at resident 20. CNA 1 stated another nurse was there when the incident happened and it was reported to the DON, SSW, and the Administrator. CNA 1 stated she was not interviewed or asked any questions about the incident. CNA 1 stated she reported the incident with resident 33's family member and resident 20 because of the way the family member came at resident 20. CNA 1 stated the family member's demeanor felt like a get away from me, get away from her. CNA 1 stated also the way the family members voice sounded and he had a fist like he was ready to go like fight someone if he needed to. CNA 1 stated after the incident resident 33 and resident 20 seamed ok. On 7/11/24 at 11:42 AM, an interview was conducted with the Administrator. The Administrator stated she looked at the camera footage and resident 20 was standing by resident 33 and the family member. The Administrator stated resident 20 was asked to leave by resident 33's family member and then resident 20 started to play with a toy that was on the bedside table. The Administrator stated resident 20 was observed to lightly toss the toy on the ground. The Administrator stated the family member stood up and got big in stature and appeared irritated with resident 20. The Administrator stated CNA 1 was observed in the camera footage re-directing resident 20 away from resident 33. The Administrator stated that she immediately set-up a meeting with resident 33's family member to educate about not getting upset with resident's because it was their home. The Administrator stated the meeting was the next day. The Administrator stated the family member was educated if there were any problems, then staff needed to be alerted. The Administrator stated the family member felt bad after watching the clip, now the family member and resident 20 were friends. The Administrator stated she did not see anything willful or the intent to hurt by the family member. The Administrator stated the incident was not reported to the State Survey Agency because abuse was ruled out within two hours. The Administrator stated every morning nursing progress notes were reviewed for all residents in the facility. The Administrator stated camera footage was reviewed if there were any reported incidents. The Administrator stated she did not have documentation regarding how abuse was ruled out within two hours. The Administrator stated she ruled out the incident as nothing. The Administrator stated if there was a potential abuse situation, then the staff completed an incident report. The Administrator stated there was no incident report completed or alert charting. A note titled Abuse Reporting Reminder was located at the 200 hallway nurses station. The note revealed This is a very important subject that I need all your help with since I'm not here 24 hours. I only have 24 hours to report alleged abuse or abuse of any kind to the state authorities. This includes Resident to Resident Abuse and Staff to Resident Abuse. Abuse is defined as 'Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.' If there is any Resident to Resident altercation where contacts made, I need to know immediately so I can start my investigation and instruct you on what you need to do. We are a controlled setting so first and foremost we need to keep the residents involved apart and the nurse needs to assess both residents. If the resident to resident contact appeared in the common area we can watch the cameras to see exactly what happened. If a resident reports getting abused by another resident in a residents room and its unwitnessed by staff, you can interview and assess the residents. If a staff member witnesses it, have them write a statement immediately. If you are a CNA or housekeeper, tell the Charge Nurse and then call or text me. [number removed] If you are the Nurse, please call or text me as soon as you have an understanding of the event. Time is of the essence for our facility to abide by all abuse regulations. If the resident is injured, I only have 2 hours to call the State, the Police and the Ombudsman. If uninjured, I have 24 hours. If there is anything questionable, I need to be notified immediately. Even if you just want to talk through a situation, call or text anytime. I am the abuse coordinator, I take my job very seriously. [DON] and [SSW] also help with this but I am the one to immediately notify. [phone number removed]. Thanks for your help with this. I appreciate all you do to help keep our residents safe, healthy and happy. [signed by the Administrator and phone number removed]. The facility Abuse Investigating and Reporting Policy and Procedures revised July 2017 were reviewed and revealed the following: Policy Statement All reports of residents, abuse, neglect, exploitation, misappropriate of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; . 2. An alleged violation of abuse, neglect, exploitation or mistreatment .will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. (Cross refer to F600)

Based on observation, interview, and record review, the facility did not keep the resident environment as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 15 sampled residents, a resident that choked on their food and required the Heimlich maneuver did not have interventions implemented to prevent future choking. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, systolic congestive heart failure, left bundle branch block, cardiac arrhythmia, basal cell carcinoma of skin, schizophrenia, adult failure to thrive, and insomnia due to medical condition. On 7/9/24 at 1:55 PM, an interview was conducted with resident 31. Resident 31 stated that breakfast that morning was really good. Resident 31 stated that she coughed all the time on her food because she had problems with her lungs. Resident 31 stated that she was able to eat lunch today and the staff served spaghetti. Resident 31's medical record was reviewed on 7/9/24. A care plan Focus dated 1/2/24, documented I have adult failure to thrive, r/t [related to] nausea, Na+ [Sodium] Diet restrictions, and Fluid restriction of 1800ml [milliliters] Hyperlipidemia. The interventions included, but were not limited to, RD [Registered Dietician] to evaluate and make diet change recommendations PRN [as needed]. An additional care plan Focus dated 1/2/24, documented I have an ADL [activities of daily living] self-care performance deficit r/t Disease Process CHF [congestive heart failure], Fatigue. The interventions included, but were not limited to, EATING: The resident is able to: eat independently with set up. On 1/3/24, the Nutrition/Dietary Assessment documented that the ordered diet was low sodium/fluid restriction. It was marked on the assessment that resident 31 required Continual Assistance: Requires constant assistance and/or supervision throughout meal. On 1/9/24, a physician's order documented low salt diet, regular texture. On 3/25/24 at 9:23 AM, a Nursing Note documented Note Text : During breakfast [resident 31] felt that she could not breath. Her vitals were BP [blood pressure] 115/80, HR [heart rate] 111, Resp [respirations] 20, o2 [oxygen] 95 RA [room air], temp [temperature] 97.0. [Resident 31] states that she was eating her cereal and swallowed wrong causing her to be short of breath. I had her cough, take deep breaths and rest in the chair for a moment. After about 5 minutes [resident 31] said she was feeling and breathing better. [Resident 31] sounded as though she has some phlem [sic] in her throat. A quarterly (state optional) Minimum Data Set (MDS) assessment dated [DATE], documented that resident 31 required supervision of one person with eating. The MDS further documented that resident 31 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated cognitive cognition intact. On 6/1/24 at 6:42 PM, a COMMUNICATION - with Physician documented Situation: The Heimlich maneuver was performed. Background: [resident 31] choked at dinnertime (1700) [5:00 PM]. Assessment (RN) [Registered Nurse] /Appearance (LPN) [Licensed Practical Nurse]: [resident 31] walked into the dining area and when observed, she had her mouth wide open, gasping for air. She raised her hand up to her throat and when asked if she could breathe, stated 'no' by shaking her head. Her lips turned purple/blue. A piece of meat surfaced with the attempt of the Heimlich maneuver. She was continuously reminded/encouraged to cough. O2 saturations were monitored and remained stable. Once returned to her room, [resident 31's] O2 saturations were 96% RA and HR 80bpm [beats per minute]. She had no further complaints of shortness of breath. Reccomendations [sic]: Monitor for signs/symptoms of aspiration pneumonia and respiratory distress. On 6/1/24 at 6:51 PM, an Alert Note documented Note Text: [resident 31] was seen walking into the dining area at dinner time, when [name redacted], CNA [Certified Nursing Assistant] stated 'She's choking.' When I turned to observe the situation, [resident 31] had her mouth open gasping for air and raised her hand up to her neck. When asked if she could breathe, she shook her head 'no.' Her lips started turning purple/blue, so I immediately took action and attempted the Heimlich maneuver. I encouraged her to cough, to which she coughed up a piece of ground meat. She continued to complain that she couldn't breathe, gasping for air once more, so another attempt was made. She was, again encouraged to cough. I encouraged her to sit down and checked her O2 saturations, which were 95% RA and her heart rate was 102 bpm. She started saying 'I'm okay, it's getting better.' She returned to her chair in the common living area to finish her dinner. She had no further difficulty or complaints of shortness of breath. On 6/1/24 at 9:29 PM, a Behavior Note documented Note Text: [resident 31] was calm and accepting of care. She experienced a choking episode during dinner. She was heard talking to herself after dinner in her room while watching television. On 6/2/24 at 2:51 PM, a Behavior Note documented Note Text: Pleasant and cooperative with staff and peers. n [sic] choking episodes this shift. On 6/2/24 at 8:54 PM, an Alert Note documented Note Text: No adverse effects noted from increase to Coumadin dose. [Resident 31] has had no coughing or wheezing this shift. O2 sat [saturation] at baseline. On 6/3/24 at 5:44 PM, an Alert Note documented Note Text: Resident remains at baseline, no respiratory symptoms noted, appetite good. On 6/6/24, an Office Visit note documented by the provider revealed . [resident 31] did choke on a piece of meat a few days ago while eating her dinner. She did require Heimlich maneuver to be performed by nurse. [Resident 31] does have a tendency to eat very quickly. She also mentions that she coughs when she drinks water. Instead she chews on ice which she has no trouble swallowing. Assessment & Plan (2) Esophageal dysmotility: Problem Comment: mild esophageal dysmotility noted on esophagram October 2023. This study was ordered by pulmonologist, who she saw during her hospitalization at [name redacted]. The study was done in [name redacted]. This did show mild esophageal dysmotility and transient stasis of a barium tablet at the hypopharynx, but eventual passage. This probably does explain her frequent coughing when drinking water. She instead will chew ice which she has no trouble swallowing. On 6/6/24 at 4:19 PM, a Nursing Note documented Note Text: [resident 31] had her recertification appointment with [name redacted] today. [Resident 31] and the doctor talked about the benefits of being at the care center, specifically the drastic improvement in her CHF. The doctor was informed of the choking episode on Saturday. [Resident 31] told the doctor that she has a difficult time swallowing especially fluids. She told [name redacted] the reason she chews ice chips rather than drinks water is because the water goes down the wrong tube. [Name redacted] ordered an esophagram to be done next week. On 6/6/24 at 8:20 PM, a Behavior Note documented Note Text: [resident 31] was calm and cooperative with care today. She denies any lingering issues from her choking episode a couple days ago. She had a Dr's [doctors] appointment today, a swallow study was ordered. On 6/7/24 at 11:53 AM, a Nursing Note documented Note Text: [name redacted] messaged me this morning and said she has decided not to order the swallow study for [resident 31] because she had one completed in October. On 6/9/24 at 1:52 PM, a Behavior Note documented Note Text : [resident 31] chooses to self isolate away from others during meals. She usually eats in the Livining [sic] room. She eats her meal in less than 5 minutes and is back to her room. She has an occasional deep cough, O2 93% on RA. On 6/15/24 at 12:39 PM, a Nutrition/Dietary Note documented Note Text: [resident 31's] weight is 127.8 pounds, this has been stable for he past 3 months, and has increased since admission. She is getting a low sodium diet, with regular consistency. She has had some choking with fluids, and has talked with her MD [Medical Doctor] regarding this. Currently, she is continuing with regular consistency of foods and fluids. Continue to encourage PO [by mouth] intake. I will continue to follow her care. On 7/10/24 at 1:27 PM, an interview was conducted with RN 2. RN 2 stated that choking would be defined as a food obstruction or blockage of air flow. RN 2 stated that using the Heimlich maneuver would be choking. RN 2 stated coughing was phlem or a sickness. RN 2 stated that choking was not normal. RN 2 stated the facility did not have a Speech Therapist (ST) on site but if an ST was needed she would have the doctor order a ST evaluation or she would send the resident out. RN 2 stated the residents worked with their individual providers and the providers would come to the facility and do the resident recertification visits. RN 2 stated the staff were able to send a 24 notice to the provider through the computer if anything was needed. RN 2 stated that management made appointments for the residents. RN 2 stated she had worked the shift after resident 31 had choked. RN 2 stated that she had received in report that resident 31 was eating in a recliner in the TV area and resident 31 started to choke and walked to the nurses station. RN 2 stated the nurse that was on shift turned resident 31 away from the dining room area facing the wall and performed the Heimlich maneuver. On 7/10/24 at 6:28 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she was standing by the nurses station and the CNA was there and everyone was getting their dinner trays. LPN 1 stated she was talking to the CNA and turned around to go to the nurses station when the CNA stated that resident 31 was chocking. LPN 1 stated that resident 31 could not breath and was gasping. LPN 1 stated that she asked resident 31 if she could breath and resident 31 shook her head no. LPN 1 stated that she took resident 31 to the nurses station and did the Heimlich maneuver and a piece of meat came up. LPN 1 stated that she told resident 31 to keep coughing and had resident 31 sit down. LPN 1 stated she got resident 31's oxygen saturation and everything seemed okay. LPN 1 stated that resident 31's lips were blue. LPN 1 stated that she was not sure of a protocol after doing the Heimlich maneuver on a resident. LPN 1 stated she reported to the Director of Nursing (DON), the doctor, and made a note about the event to monitor resident 31 for aspiration pneumonia. LPN 1 stated that resident 31 was monitored for lung sounds but not vital signs. LPN 1 stated that resident 31 did get her blood pressure monitored every shift. LPN 1 stated that she did mention to someone but she was not sure who about changing resident 31's diet to a ground meat. LPN 1 stated the RD was responsible for the hospital side. LPN 1 stated she was not sure if there was anyone that did swallow evaluations anymore. LPN 1 stated she had worked at the facility for eight years and had not seen anyone do a swallow evaluation in a long time. On 7/11/24 at 8:55 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 31 was pretty independent but resident 31 did require help with her bath. CNA 1 stated that the staff cut up resident 31's food because resident 31 choked a lot. CNA 1 stated that resident 31 needed assistance with cutting up meats. CNA 1 stated if a resident required supervision with eating that would require then to que the resident. CNA 1 stated that resident 31 mainly ate in the living room. CNA 1 stated that resident 31 did pretty good eating if her food was cut up super small. CNA 1 stated the CNA staff had an alert charting in the front of the CNA book that documented that resident 31 needed her food cut up. An observation of the CNA book was conducted with CNA 1. CNA 1 stated if the documentation was highlighted yellow the CNAs did not need to worry about it because it was completed. The front of the CNA book documented Attention: Please Read alert charting daily! CNA 1 stated the documentation would indicate what was current or what happened on the prior shift. The second page of the alert charting documented 6/1/24 203 [resident 31] choked @ dinner on 6/1/2024 cut up her food for her to reduce choking hazard. On 7/11/24 at 12:12 PM, an interview was conducted with the Administrator. The Administrator stated if a resident required the Heimlich maneuver it should go into alert charting to monitor the resident. The Administrator stated the staff should monitor oxygen saturations and pass along to monitor for complications. The Administrator stated that a speech evaluation would be done if the doctor said to order those assessments. The Administrator stated there was not a ST anywhere in the town. The Administrator stated that she thought Occupational Therapy had a speech endorsement. The Administrator stated anything the doctor ordered they could do at the facility. The Administrator stated that staff could recommend a diet change. The Administrator stated resident 31 did what she wanted and was high functioning. The Administrator stated that resident 31 would check herself out of the facility and would go to the corner market. The Administrator stated that she was not sure if anyone had spoken to resident 31 regarding a diet change or ways to prevent choking in the future.

Based on interview and record review, it was determined that for 1 of 18 sampled residents, the facility did not ensure the resident was free from physical abuse. Specifically, facility staff did not ensure that a resident, known to wander into other residents rooms, was prevented or redirected away from other resident rooms. As a result, another resident, angry by recurring intrusions into his private space, threw a plastic mug striking the uninvited resident on the head, causing a laceration. Resident identifiers: 9 and 27. Cross-refer to F675 regarding noncompliance associated with resident 27's Quality of Life. Findings include: Resident 27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 11:26 AM, CNA 3 was interviewed. CNA 3 resident 27 did not like other residents entering his room. She stated she has witnessed residents, including resident 9, enter resident 27's room, several times a week. CNA 3 stated when residents wandered into resident 27's room, she would remove the resident and inform the Social Service Director (SSD), as the SSD had a good rapport with resident 27. CNA 3 stated that although staff have closed resident 27's door, other residents other residents have continued to enter his room. On 8/17/22 at 11:37 AM, CNA 4 was interviewed. CNA 4 stated there were a lot of wanderers in the facility. CNA 4 stated facility staff had placed stop signs on some resident doors to prevent residents from wandering into other residents rooms, but sometimes the signs were taken off. CNA 4 stated resident 27 had expressed frustration about other residents entering his room. CNA 4 stated she was aware resident 27 had injured a resident who entered his room and that he has threatened others, but had not hurt them. CNA 4 stated resident 27 builds up a lot of anger and wants to stay in his room, away from the other residents. On 8/17/22 at 11:46 AM, CNA 5 was interviewed. CNA 5 stated there were several residents whowandered the facility. CNA 5 stated if a resident wandered into another resident's room without permission, staff assisted the resident out of the room. CNA 5 stated she has kept resident 27's door shut to keep other residents from entering his room, but if a resident did enter resident 27's room, she would remove them. CNA 5 stated that staff tried to respond quickly when resident 27 was yelling at a resident who had entered his room. On 8/17/22 at 12:23 PM, an interview was conducted the Social Services Director (SSD). The SSD stated that resident 27 had expressed frustration with resident 9 when she was touching the blinds. The SSD stated that resident 27 was frustrated because he couldn't walk, and had moved to his room to avoid the commotion in the dining room. The SSD stated that staff were ineffective in keeping wandering residents out of resident 27's room. On 8/18/22 at 12:05 PM, the Director of Nursing (DON) and Administrator (ADM) were interviewed. The DON stated that when someone entered resident 27's room, resident 27 was proud of himself when he didn't get mad and pushed his call light instead. The DON stated that the nursing and behavioral notes showed improved behavior by resident 27. The ADM stated that staff working at night have increased their number of rounds to monitor more closely to prevent residents from wandering into others rooms. The ADM stated staff reviewed the security cameras to evaluate how often residents wander into other residents' rooms. The DON stated resident 9 was still going into other residents' rooms, but it's not as bad. The ADM stated she substantiated abuse when resident 27 threw his mug at resident 9, causing a head laceration. The ADM stated resident 27 willfully picked up the mug and threw it at resident 9. Resident 27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of resident 27's medical record was completed on 8/18/22, and the following entries were documented: a. On 9/9/21 at 10:43 AM, a behavioral note revealed that resident 27 expressed anxiety and anger about what other people are doing and how it affects him b. On 9/23/21 at 3:18 PM, resident 27's doctor was informed about his having increased outbursts, especially toward other residents c. On 10/5/21 at 11:17 AM, a social service note revealed, . [Resident 27] complains about other resident's bad habits but continues to try and solve his own problems and talk with staff bout his needs. He will remove himself from the situation without causing and issues or resolving it more readily Has a communication problem related to stuttering, and has difficulty finding the correct wording . He tries very hard to discuss his needs and concerns with staff and is successful in getting his points across Extra time and patience with [Resident 27] encourages him to speak up for himself and interact with others in a positive manner. [Resident 27] is getting better at taking responsibility for [his] behaviors and correcting his interpersonal behaviors d. A nursing description created on 12/15/21 at 5:54 PM, revealed that there was a stop sign in front of the doorway to resident 27's room and that resident 9 entered under the sign. The nurse documented that both resident 27 and resident 9 were yelling at each other. The nurse documented resident 9 sustained a laceration to the right side of her head that was approximately 1.5 inches long. The nurse documented that the following action was taken, .door will remain closed for the evening per his [resident 27's] choice and his door will be closely monitored to prevent any other residents from wandering into his room. A facility Incident Report was completed for the incident involving resident 27 and resident 9. The Incident Report is dated 12/16/21 at 2L14 PM. A facility staff member documented that resident 9 wandered into resident 27's room and that resident 9 was not invited. Per the Incident Report, resident 27 yelled at resident 9 to leave. Resident 9 did not understand, and resident 27 threw a plastic mug at resident 9, hitting her on the head. Resident 9 required first aid, followed by an emergency room visit and staple closure to a laceration to her head. Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of nursing notes for resident 9 was completed 8/18/22. Between 11/30/20 and 3/14/22, facility nursing staff documented resident 9 exhibiting the behavior of wandering into other residents' rooms.

Based on observation, interview, and record review it was determined, for 3 of 18 sample residents, that the facility assessments did not accurately reflect the resident's status. Specifically, a resident who wandered was not coded accurately on the Minimum Data Set (MDS) and was therefore not identified as a wanderer on the care plan. Resident identifiers: 5, 16 and 33. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 11:23 AM, an observation of resident 16 was made. Resident 16 was observed wandering in the hallway. At 11:47 AM, resident 16 wandering into an unsampled resident's room. Resident 16 was observed looking at the decorations for one minute, then exiting the room. No other residents were in the room. At 11:50 AM resident 16 was then observed walking around the nurses' station, and then entered the unsampled resident's room. At 11:51 AM resident 16 was observed pulling her pants down and sitting on a chair next to the window in the resident's room. At 11:55 AM, resident 16 stood up, pulled her pants up, and walked out of the room. No other residents were in the room. At 11:55 AM resident 16 was observed sitting in a recliner in the day room. No staff members were observed to be watching resident 16 enter the unsampled resident's room. On 8/17/22 at 12:25 PM an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated that resident 16 often wandered around the facility. CNA 1 stated that resident 16 often wandered into other resident rooms, which would upset some residents. CNA 1 stated the interventions to keep resident 16 out of certain residents' rooms were to use stop signs posted on residents' doors, and to redirect resident 16 when staff noticed her wandering into other residents' rooms. On 8/17/22 at 1:00 PM an interview with CNA 2 was conducted. CNA 2 stated that resident 16 wandered around the facility and sometimes into other residents' rooms. CNA 2 stated that staff would attempt to redirect her if she was wandering into other residents' rooms. On 8/17/22 resident 16's electronic medical record was reviewed. a. A Behavior Note from 8/17/22 at 6:41 PM documented, [Resident 16] has been calm and cooperative for her care this afternoon .She has been wandering around the facility and can occasionally [be] found on the [other] wing lounging in the recliner. b. A Behavior Note from 8/17/22 at 1:24 PM documented, She [Resident 16] has been wandering the hallways . c. A Behavior Note from 8/14/22 at 8:32 PM documented, [Resident 16] has wandered throughout the day . d. A Behavior Note from 8/8/22 at 9:33 PM documented, [Resident 16] has wandered throughout the day . e. A Behavior Note from 8/5/22 at 9:17 PM documented, [Resident 16] has wandered throughout the day . f. A Behavior Note from 7/31/22 at 5:24 PM documented, [Resident 16] has been pacing in the [the other wing's] kitchen area for the past hour or so. She frequently goes in other resident's room or attempts to remove items from the nurse station. When she is redirected, she yells at staff and is combative. g. A Behavior Note from 7/22/22 at 9:12 PM documented, [Resident 16] has wandered throughout the day. Resident 16's most recent Annual MDS Section E - Behaviors from 6/14/22 was reviewed. The section for Wandering - Presence and Frequency. Has the resident wandered? was coded as Behavior not exhibited. 2. Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes revealed that resident 5 wandered the hallways of the facility in her wheelchair. Nurses documented wandering in October, 2021, January 2022, and August, 2022. A MDS assessment, dated 5/17/22 revealed that resident 5 was not identified as wandering. 3. Resident 33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes revealed that resident 33 wandered the hallways of the facility in her wheelchair. Nursing notes documented that resident 33 wandered into other residents' rooms in April, May, June, July and August, 2022. A MDS assessment, dated 7/20/22 revealed that resident 33 was not identified as wandering. On 8/17/22 at 12:23 PM, an interview with the Social Services Director (SSD) was conducted. The SSD reported that resident 16 wandered throughout the facility and would sometime urinate in trash cans in various locations around the facility, including in other residents' rooms. The SSD reported that she would complete the MDS section for wandering. The SSD stated that she was instructed to only code for wandering if the wandering was something outside of what the resident normally does. The SSD stated that resident 5 did not wander as much because she was in a wheelchair, but resident 33 was always walking around. The SSD stated that resident 33's wandering had caused some problems, so resident 33 should have been identified as a wanderer. On 8/18/22 at 1:00 PM an interview with the Administrator was conducted. The ADMIN stated that the reason why the MDS documented Behavior not exhibited regarding residents' wandering, was because it was resident' 16's routine and the staff did not even consider it as wandering because wandering was just a part of who she was. The ADMIN stated that resident 33 was always walking somewhere, and was usually looking for family or objects.

Based on observation, interview, and record review it was determined, for 1 of 18 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, a resident who wanders did not have a care plan to address wandering. Resident identifiers: 16 Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 at 11:23 AM, an observation of resident 16 was made. Resident 16 was observed wandering in the hallway. At 11:47 AM, resident 16 wandering into another resident's room. Resident 16 was observed looking at the decorations for one minute, then exiting the room. No other residents were in the room. At 11:50 AM resident 16 was then observed walking around the nurses' station, and then entered the same resident's room. At 11:51 AM resident 16 was observed pulling her pants down and sitting on a chair next to the window in the resident's room. At 11:55 AM, resident 16 stood up, pulled her pants up, and walked out of the room. At 11:55 AM resident 16 was observed sitting in a recliner in the day room. No staff members were observed to be watching resident 16 enter the unsampled resident's room. On 8/17/22 at 12:25 PM an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated that resident 16 often wandered around the facility. CNA 1 stated that resident 16 often wandered into other resident rooms, which would upset some residents. CNA 1 stated the interventions to keep resident 16 out of certain residents' rooms were to use stop signs posted on residents' doors, and to redirect resident 16 when staff noticed her wandering into other residents' rooms. On 8/17/22 at 1:00 PM an interview with CNA 2 was conducted. CNA 2 stated that resident 16 wandered around the facility and sometimes into other residents' rooms. CNA 2 stated that staff would attempt to redirect resident 16 if she was wandering into other residents' rooms. On 8/17/22 resident 16's electronic medical record was reviewed. a. A Behavior Note from 8/17/22 at 6:41 PM documented, [Resident 16] has been calm and cooperative for her care this afternoon .She has been wandering around the facility and can occasionally [be] found on the [other] wing lounging in the recliner. b. A Behavior Note from 8/17/22 at 1:24 PM documented, She [Resident 16] has been wandering the hallways . c. A Behavior Note from 8/14/22 at 8:32 PM documented, [Resident 16] has wandered throughout the day . d. A Behavior Note from 8/8/22 at 9:33 PM documented, [Resident 16] has wandered throughout the day . e. A Behavior Note from 8/5/22 at 9:17 PM documented, [Resident 16] has wandered throughout the day . f. A Behavior Note from 7/31/22 at 5:24 PM documented, [Resident 16] has been pacing in the [the other wing's] kitchen area for the past hour or so. She frequently goes in other resident's room or attempts to remove items from the nurse station. When she is redirected, she yells at staff and is combative. g. A Behavior Note from 7/22/22 at 9:12 PM documented, [Resident 16] has wandered throughout the day. Resident 16's care plan was reviewed, and it was revealed that resident 16 did not have a care plan for wandering. On 8/18/22 at 1:05 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that in resident 16's care plan, there are activities documented which have helped prevent resident 16 from wandering, however the DON confirmed that there was no specific care plan for wandering. The DON stated a care plan should have been developed for wandering for resident 16.

Based on observation, interview and medical record review, it was determined, for 2 of 18 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, residents that wandered and took other resident's posessions were not prevented from wandering into other residents' rooms, resulting in those residents' psychological distress. Resident identifiers: 27 and 29. Findings include: 1. Resident 27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 at 10:00 AM, resident 27 was interviewed. Resident 27 stated that other residents wandered into his room. Resident 27 stated that he kept his door closed and had a stop sign, but it didn't do any good. On 8/18/22, resident 27's medical record review was completed. Nursing notes revealed that resident 27 had residents wander into his room, including residents 9, 16 and 33. Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 27 isolated in his room to avoid other residents after incidents. Resident 27's nursing notes revealed the following: a. On 9/9/21 at 10:43 AM, a behavioral note revealed that resident 27 expressed anxiety and anger about what other people are doing and how it affects him b. On 9/23/21 at 3:18 PM, resident 27's doctor was informed about his having increased outbursts, especially toward other residents c. On 10/5/21 at 11:17 AM, a social service note revealed, . [Resident 27] complains about other resident's bad habits but continues to try and solve his own problems and talk with staff bout his needs. He will remove himself from the situation without causing and issues or resolving it more readily Has a communication problem related to stuttering, and has difficulty finding the correct wording . He tries very hard to discuss his needs and concerns with staff and is successful in getting his points across Extra time and patience with [Resident 27] encourages him to speak up for himself and interact with others in a positive manner. [Resident 27] is getting better at taking responsibility for [his] behaviors and correcting his interpersonal behaviors d. On 10/5/21 at 4:39 PM, a behavior note revealed that resident 27, .was observed yelling at the resident from room [ROOM NUMBER] as she walked by him while he sat at the dining table he yelled 'You don't belong here, now get out,' .asked [Resident 27] not to yell at this resident . e. On 10/12/21 at 9:41 PM, resident 27 became upset at the dinner table tonight as another resident almost backed into him in his electric w/c (wheelchair) f. On 11/3/21 at 1:52 PM, a social service note revealed that resident 27 remained in his room. He has a good attitude about isolating, but reports that [he] won't go out of his room, because he wants to respect others and stay safe . g. On 11/16/21 at 11:38 AM, a behavior late entry revealed that resident 16 was walking past [Resident 27] as he sat in the hallway. in the dining room in his wheelchair and raising her voice. [Resident 27] responded angrily making verbal threats to [resident 16] such as 'I'm going to kill you if come near me again'. This RN calmly intervened and told [resident 27] calmly and gently 'That is not appropriate, that [resident 16] doesn't understand what she said to you.' [Resident 27] responded I'm going to talk to [the social worker]'. This RN responded 'That is a very good idea' No other angry outburst were observed. h. On 12/6/21 at 1:11 PM, CNA's (certified nursing assistants) have observed [resident 27] attempting to bump another resident with his w/c while he was propelling himself up the hall to attend activities. [Resident 27] was counselled to leave other residents alone; he became angry and said he was going to 'walk right out of here'. Will continue to monitor for threatening behavior towards others. An incident report created 12/16/21 at 2:14 PM, revealed that resident 9 wandered into resident 27's room. Resident 9 was not invited, and resident 27 yelled at resident 9 to leave. Resident 9 did not understand, and resident 27 threw a plastic mug at resident 9, hitting her on the head. Resident 9 required first aid, followed by an emergency room visit and staple closure of a laceration. A nursing description created on 12/15/21 at 5:54 PM, revealed that there was a stop sign in front of the doorway, and resident 9 entered under the sign. Both resident 27 and resident 9 were yelling at each other. The laceration resident 9 received was approximately 1.5 inches long on the right side of her head. The action taken was to have the .door will remain closed for the evening per his choice and his door will be closely monitored to prevent any other residents from wandering into his room. Resident 9's record review was completed on 8/18/22. Cross-Refer to F-600. Resident 9's nursing notes included documented wandering into other resident's rooms from 11/13/2020 through 3/14/22. On 3/14/22, a behavior note revealed that resident 9 was in another resident's room, causing distress to another resident. Resident 9 had a physical interaction with another resident on 9/8/21 when resident 9 thought that another resident's belongings were hers. Nursing notes for resident 27 revealed the following incidents after resident 9 was injured: a. On 1/18/22 at 1:38 PM, a behavior note revealed that he needs to be with someone when he participates in group activities, due to his recent behaviors with other residents. b. On 1/19/22 at 11:24 AM, a social service not revealed that resident 27 .reported that he got really angry at the female resident on a previous day because she was talking so loud that it interrupted the program that was on. He complained that he didn't get to see all of the program .stewed on this for a day or two and when he was alone in the activity room and the female resident in question came in, he lost his temper and started yelling at her and approaching her in his wheel chair . c. On 1/19/22 at 3:57 PM, a behavior note revealed that resident 27 was yelling at a female resident in the activity room and telling her to leave. A video was available that shows him in his wheelchair moving rapidly towards another female resident in her wheelchair and telling her to leave and attempting to hit her (no physical contact was made). The female resident stood her ground and told him that she wouldn't leave and that he was being mean. [Resident 27] continued to get more upset at her as she tried to defend herself d. On 1/21/22 at 6:28 PM, resident 27 spent most of the time in his room, and when one on one time is spent with him, he repeats I wont [hurt] anyone. I reminded him he already did, his verbalizations didn't change. e. On 3/15/22 at 11:19 PM, resident 27 was at a BBQ when another resident came outside, so he went inside to avoid letter her 'ruin everything.' f. On 3/24/22 at 1:52 PM, resident 27 was fixated on his dislike for a female resident .states he can't go to activities if she's there . g. On 3/30/22 at 4:23 PM, resident 27 had stated that a resident .came into his room . h. On 5/10/22 at 9:33 PM, Female [resident 16] took down the stop sign across [resident 27's] door and proceeded into his room. [Resident 27] was in his w/c (wheelchair) and approached resident [16] to try to get his stop sign back. Witnessed by female resident [16] who reported that [resident 27] was saying, Get out of my room .that's mine. Resident from room [ROOM NUMBER] activated her call-light to get staff attention; 2 CNA's intervened before an altercation could occur. [Resident 27] went to talk to [the social worker] about the occurrence. [Resident 27] has been calm this evening and has not threatened any harm Resident 16 had the following nursing notes: a. On 5/11/22 at 10:22 AM, a behavior note revealed that resident 27 did not intend to hurt her and make her feel bad. Resident 27 tried to take his stop sign back from resident 16. Resident 27 was still dwelling on the confrontation from 5/10/22. b. On 5/14/22 at 11:36 PM, a behavior note revealed that a resident went into resident 27's room after 8:00 PM, and stood at the bottom of his bed. Resident 27 activated his call light and was yelling. Resident 27 was glassy-eyed with a reddened face and told staff to get the female resident out of his room. Resident 27 stated I need to protect myself, and resident 27 was reassured and instructed to remain calm. Resident 27 continued to yell and demanded he be provided with 'a stick or a [NAME] or a gun so I can defend myself.' .As resident 27 thought more about the incident in the evening, he became progressively more agitated while doing so Each time he was assured that the other resident was asleep and would not bother him again. [Note: the resident was resident 16, according to the social services director.] c. On 5/16/22 at 2:58 PM, resident 27 expressed frustration and stating he no longer wants the stop sign across his doorway because [resident 16] removed it from where it was . d. On 5/18/22 at 10:57 AM, a social services note revealed that resident 27 was concerned that another resident came into his room and took his things. e. On 5/19/22, resident 27 used call light to notify this nurse that [a resident] had entered his room . f. On 5/27/22 at 11:06 AM, resident 27 was proud of himself that he calmly handled a situation when a confused resident entered his room. He pressed the call light and told the unwanted visitor that it wasn't her room . g. On 6/12/22 at 8:02 PM, resident 27 threw a water bottle and other objects at the nurse who he did not want in his room. h. On 6/27/22 at 11:00 AM, one of the female residents was touching/flirting with [resident 27] .attempted to tell her to go away without her understanding. After this it was reported that [resident 27] was swatting/[ushing her wheelchair away . i. On 6/27/22 at 1:39 PM, resident 27 spoke with the social services director. Resident 27 .was concerned that the woman who comes into his room is being disrespectful and he is mad at himself for getting to upset . j. On 6/28/22 at 3:40 PM, resident 27 is frustrated with another resident today, he says he will go tell on her if she comes after him again. k. On 6/29/22 at 11:27 PM, resident 27 became upset at BINGO this afternoon when another resident bumped into his wheelchair. [Resident 27] wheeled himself to his room and was threatening to break the window to 'get out of here.' H was upset that [the social services director] was not here to talk to . l. On 7/5/22 at 8:29 AM, a social services note included with Goal 2, resident 27 is capable of getting his needs and wants met. With patience and self-assurance and he can be understood. [Resident 27] just gets better and better at solving his own problems and talking with staff about his needs and frustrations. He will remove himself from the situation without causing and issues or resolving it more readily. m. On 7/9/22 at 4:01 PM, resident 27 was agitated today .He screamed out into the hall and yelled at other residents to go away . n. On 8/5/22, resident 27 was upset that resident 16 walked into his room. Resident 27 was Stating over and over 'I wont let her take any of my stuff, I wont let her take my stuff' This RN assured him to use his calllight (sic) if this happens again and staff will prevent the resident from taking his stuff, but [resident 27] remained upset. Resident 16's medical record review was completed on 8/18/22. Resident 16's Brief Interview for Mental Status (BIMS) was not able to be obtained as resident 16 was rarely or never understood. Resident 16's nursing notes included the following: a. On 7/2/21 at 3:57 PM, resident 16 spends most of the shift pacing up and down the halls, and was observed trying to go into the other residents rooms . b. On 7/3/21 at 11:02 PM, resident 16 is consistently pacing in and out of the other residents rooms, the other residents have expressed that they do not like her going into their rooms . c. On 7/8/21 at 7:26 PM, resident 16 paces around the hallways, and into the other residents room . d. On 7/12/21 at 4:13 PM, resident 16 .requires continual redirection from going into other resident's rooms. e. Additional nursing notes that reveal resident 16's wandering included 7/14/21, 7/17/21, 7/18/21, 7/30/21, 8/3/21, 9/9/21, 9/13/21, 10/19/21, 2/12/22, 2/26/22, 2/27/22, 3/2/22, 3/10/22, 3/26/22, 4/1/22, 4/9/22, and 5/14/22 f. On 6/14/22 at 5:25 PM, resident 16 .has been known to look into other resident's rooms, but is easily redirected .enjoys visiting on both halls . g. On 7/31/22 at 5:24 PM, resident 16 has been pacing .She frequently goes into other resident's room . 2. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22 at approximately 3:18 PM, an interview was conducted with resident 29. Resident 29 stated that he had problems with people coming into his room. Resident 29 stated that he was concerned that his door was closed at all times, because it slowed them down a little. On 8/18/22 at 10:42 AM, resident 29 was re-interviewed. Resident 29 stated that people continued to wander into his room about every other day, and sometimes they took his things. Resident 29 stated that the stop sign did not work, because the wanderers just take it down. Resident 29 stated that staff did not keep the residents out of his room, and it was really annoying. Nursing notes revealed the following: a. On 5/13/22 at 5:50 PM, resident 16 went into [resident 29's] room and unplugged his clock and was upset that she was in his room. His clock was replugged in and his [NAME] setting was fixed. I assured him I would close his door and put his stop sign up . b. On 5/17/22 at 6:45 PM, resident 29 was frustrated today with the two women that kept coming in his room and taking his stuff. He feels that they should respect his space and things. Staff did not prevent residents from wandering into resident 27 and resident 29's rooms. On 8/17/22 at 11:26 AM, CNA 3 was interviewed. CNA 3 stated that when residents wandered into resident 27's room, she would remove the resident and inform the SSD, who had a good rapport with resident 27. CNA 3 stated that she witnessed residents enter resident 27's room several times a week. CNA 3 stated that staff closed resident 27's door, but that was not always effective in keeping other residents out of his room. CNA 3 stated that she was aware of three residents who wandered into resident 27's room. CNA 3 stated that resident 29 also had residents wander into his room. On 8/17/22 at 11:37 AM, CNA 4 was interviewed. CNA 4 stated that there were a lot of wanderers in the facility. CNA 4 stated that there were stop signs on the doors, but sometimes they are taken off. CNA 4 stated that two gentlemen had stop signs on their doors (resident 27 and resident 29) because these residents did not want the wanderers in their rooms. CNA 4 stated that resident 27 had expressed frustration about people in his room. CNA 4 stated that she was aware that resident 27 had injured another resident, and stated that resident 27 threatens the residents who wandered into his room, but did not hurt them. CNA 4 named four residents who wandered into resident 27's room. CNA 4 stated that resident 27 builds up a lot of anger and wants to stay in his room, away from the other residents. On 8/17/22 at 11:46 AM, CNA 5 was interviewed. CNA 5 stated that after residents had an altercation, staff would try to help calm the residents. CNA 5 stated that there were several residents who wandered the facility, and if they entered another resident's room, staff assisted them out. CNA 5 stated that she had not been told of any specific problems residents had with any other residents. CNA 5 stated that she kept resident 27's door shut so that other residents didn't enter his room, but if they did, CNA 5 would remove them. CNA 5 stated that resident 27 did well just sitting through several residents entering his room. CNA 5 stated that staff tried to get there quickly, especially when they heard resident 27 yelling. CNA 5 stated that resident 29 asked staff to keep his door shut, the stop sign in front of his room, and would use his call light when a resident wandered into his room. On 8/17/22 at 12:23 PM, an interview was conducted the Social Services Director (SSD). The SSD stated that resident 16 was wandering, exit seeking, and had a difficult time when first admitted . The SSD stated that resident 27 was very annoyed with resident 16 and felt threatened by her, but the staff had helped him build a relationship with her. The SSD stated that staff educated the other residents to inform staff when resident 16 was in their rooms, and not to scold or punish resident 16. The SSD stated that some residents had threatened resident 16, but we hope that they don't follow through. The SSD stated that resident 27 had expressed frustration with resident 9 when she was touching the blinds. The SSD stated that resident 27 was frustrated because he couldn't walk, and had moved to his room to avoid the commotion in the dining room. The SSD stated that resident 27 had hit another resident with his walker when he felt trapped in the dining room. The SSD stated that staff worked on behavior modification with resident 27. The SSD stated that earlier on this day, two women were in resident 27's room, resident 25 and resident 16. The SSD stated that resident 27 was raising his fists toward resident 25 when staff removed the two residents from resident 27's room. The SSD stated that resident 27 does not like resident 25. The SSD stated that resident 25 will touch men, including resident 27, which resident 27 did not like. The SSD stated that if resident 25 was near resident 27, she's always touching him. The SSD stated that resident 27 left activities if resident 25 was there, and sometimes resident 27 did not return to activities for months. The SSD stated that some residents had threatened resident 16, including resident 29. The SSD stated resident 16 would urinate in other resident's trash cans, push other residents, and sometimes take off her pants. The SSD stated that staff were ineffective in keeping wandering residents out of resident 27's room. The SSD stated that she heard resident 20 tell resident 16 to get the hell away from me. On 8/17/22 at 2:25 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 16 was causing the least amount of trouble, just walking through the facility on her own. CNA 6 stated that resident 33 caused the most problems going into other residents' rooms, because she was the hardest resident to redirect. CNA 6 stated that resident 27 got mad and aggressive with the residents who wandered into his room, threatened some residents, and hit one resident. CNA 6 stated that resident 33 took some items out of resident 27's room earlier today, but staff took it right back. CNA 6 stated that resident 27 had grabbed resident 33's arm once and pushed her toward the door to get her out of his room. CNA 6 stated that she had not heard that resident 29 had hurt any residents, but did have a problem with wanderers entering his room. On 8/18/22 at 11:03 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator (MDSC). The MDSC stated that for residents who were exit seeking, they were coded in their MDS as wanderers, but the social worker entered behaviors into the MDS evaluations. The MDSC stated that those who walked up and down the halls, and into other resident's rooms, were not wandering. The MDSC stated that sometimes residents were upset with the residents who wandered in their rooms, because that was their private space. The MDSC stated that staff tried to keep an eye on all the residents. The MDSC stated that residents really liked to go into resident 27's room the most. The MDSC stated that though she was not always on the floor, about once a month she had to assist residents out of resident 27's room who had wandered in. The MDSC stated that the behaviors that triggered on the MDS were entered into the car plan, but if the resident wasn't identified as a wanderer, the care plan did not include wandering interventions. The MDSC stated that she thought the wandering residents should have a care plan for wandering. On 8/18/22 at 11:22 AM, the SSD was reinterviewed. The SSD stated that when she entered the behaviors on the MDS, she did not put wandering on the MDS if it was something that the resident normally did. The SSD stated that for residents 16 and 33, wandering was an everyday pattern, so wandering was not documented in the MDS. The SSD stated that the wandering of the residents was a problem because of how it affected other residents. The SSD stated that they discouraged residents from wandering into other residents' rooms. On 8/18/22 at 12:05 PM, the Director of Nursing (DON) and Administrator (ADM) were interviewed. The DON stated that resident 16 walks around looking for her brother all day, but staff did not consider it to be wandering. The DON stated that she just went from place to place, and everyone is so used to it. The DON stated that staff attempted to keep everyone out of resident 27's room, and he no longer minded having resident 16 in his room. The DON stated that resident 16 gravitated toward resident 27. The DON stated that staff provided resident 16 with objects in the common areas to help keep her from wandering into as many rooms. The DON stated that when someone entered resident 27's room, resident 27 was proud of himself when he didn't get mad and pushed his call light instead. The DON stated that the nursing and behavioral notes showed improved behavior by resident 27. The ADM stated that staff working at night have increased their number of rounds to monitor more closely. The ADM stated that when resident 29 complained about people coming into his room, staff reviewed the security cameras. The DON stated that resident 9 was still going into other residents' rooms, but it's not as bad. The ADM stated that if there were complaints from other residents, the MDS should have reflected that there was a problem with wandering. The ADM stated that she substantiated the abuse from resident 27 to resident 9. The ADM stated that resident 27 willfully picked up the cup and inflicted a cut on resident 9. The ADM stated that on 6/27/22, resident 27 was pushing resident 5 away from him, but staff did not see him slap her on the face.

Based on observation, interview and record review, it was determined for 3 of 18 sample residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as possible; and that the residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents were wandering throughout the facility and into other residents' rooms that could pose accident hazards. Wandering residents entered residents' rooms who had threatened them, and supervision was not provided to avoid tripping hazards. Resident identifiers: 9, 16 and 33. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, [CONDITION(S)], anxiety disorder, dysphagia, and [CONDITION(S)]. On 8/18/22, resident 9's medical record review was completed. On 6/1/22, resident 9 received a Minimum Data Set (MDS) quarterly assessment. Resident 9's cognitive status was evaluated at 4/15, meaning severe cognitive impairment. Nursing notes revealed that resident 9 wandered in other residents rooms between 11/13/2020 and 3/14/22. On 8/26/22, resident 9 has been seen walking more the past 2 weeks using her walker to ambulate up and down the halls . Resident 9's weekly nursing assessment, completed on 8/17/22, revealed that resident 9 was confused, was hard of hearing, had poor safety awareness, ambulated with a walker, and needed constant monitoring. Resident 9 wanders hallways independently . Resident 9's social services careplan includes an intervention for resident 9 because she likes to wander .Encourage her to stay in the hallways, not going into other residents rooms uninvited. An incident report created 12/16/21 at 2:14 PM, revealed that resident 9 wandered into resident 27's room. Resident 9 was not invited, and resident 27 yelled at resident 9 to leave. Resident 9 did not understand, and resident 27 threw a plastic mug at resident 9, hitting her on the head. Resident 9 required first aid, followed by an emergency room visit and a staple to close the laceration. A nursing description created on 12/15/21 at 5:54 PM, revealed that there was a stop sign in front of the doorway, and resident 9 entered under the sign. Both resident 27 and resident 9 were yelling at each other. The laceration resident 9 received was approximately 1.5 inches long on the right side of her head. The action taken was to have the .door will remain closed for the evening per his choice and his door will be closely monitored to prevent any other residents from wandering into his room. [Resident 9 had health issues that significantly decreased her walking until approximately 8/1/22.] 2. Resident 33 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, hypertension and [CONDITION(S)]. On 8/18/22, resident 33's medical record review was completed. On 7/26/22, resident 33's received an MDS quarterly assessment. Resident 33's cognitive status was evaluated at 1/15, meaning severe cognitive impairment. Resident 33's social services care plan included a focus I am an elopement risk/wanderer r/t (related to) Disoriented to place, Impaired safety awareness Interventions included a. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: b. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. c. Monitor location every 15-30 min, or keep in line of sight as much as possible Document wandering Resident 33's documented walking in the hallway for the pat 30 days, including 7/20/22 through 8/17/22, revealed that resident 33 walked daily. Resident 33's weekly nursing assessment was completed on 8/16/22. Resident 33 was identified as confused, and wanders up and down hallways during the day, and wanders into other residents rooms, requiring redirection and one on one cares by .staff. Resident 33 had unsteady gait, poor safety awareness, dementia, fall risk. Nursing notes revealed wandering into other residents' rooms. From 5/1/22 through 8/117/22, resident 33 was recorded as wandering into other residents's rooms six times in May, one time in June, two times in July, and two times in August. Additional wandering without mentioning wandering into other residents' rooms occurred three times in May, five times in June and one time in July. On 8/18/22 at approximately 7:00 AM, resident 33 wandered into resident 27's room. On 6/18/22 at 3:49 AM, a nursing note revealed that resident 1 had yelled at the beginning of the shift Somebody help, we need help down here, emergency! and stated that the foreigner [resident 33] was in her room. Resident 33 was escorted out of resident 1's room. On 8/15/22 at approximately 3:18 PM, an interview was conducted with resident 29. Resident 29 stated that he had problems with people coming into his room. Resident 29 stated that he was concerned that his door was closed at all times, because it slowed them down a little. On 8/18/22 at 10:42 AM, resident 29 was re-interviewed. Resident 29 stated that people continued to wander into his room about every other day, and sometimes they took his things. Resident 29 stated that the stop sign did not work, because the wanderers just take it down. Resident 29 stated that staff did not keep the residents out of his room, and it was really annoying. On 8/17/22 at 11:26 AM, CNA 3 was interviewed. CNA 3 stated that when residents wandered into resident 27's room, she would remove the resident and inform the Social Services Director, who had a good rapport with resident 27. CNA 3 stated that she witnessed residents enter resident 27's room several times a week. CNA 3 stated that staff closed resident 27's door, but that was not always effective in keeping other residents out of his room. CNA 3 stated that she was aware of three residents who wandered into resident 27's room. On 8/17/22 at 11:37 AM, CNA 4 was interviewed. CNA 4 stated that there were a lot of wanderers in the facility. CNA 4 stated that there were stop signs on the doors, but sometimes they are taken off. CNA 4 stated that two gentlemen had stop signs on their doors because they did not want the wanderers in their rooms. CNA 4 stated that resident 27 had expressed frustration about people in his room. CNA 4 stated that she was aware that resident 27 had injured another resident, and stated that resident 27 threatens the residents who wandered into his room, but did not hurt them. CNA 4 named four residents who wandered into resident 27's room. CNA 4 stated that resident 27 builds up a lot of anger and wants to stay in his room, away from the other residents. On 8/17/22 at 11:46 AM, CNA 5 was interviewed. CNA 5 stated that after residents had an altercation, staff would try to help calm the residents. CNA 5 stated that there were several residents who wandered the facility, and if they entered another resident's room, staff assisted them out. CNA 5 stated that she had not been told of any specific problems residents had with any other residents. CNA 5 stated that she kept resident 27's door shut so that other residents didn't enter his room, but if they did, CNA 5 would remove them. CNA 5 stated that resident 27 did well just sitting through several residents entering his room. CNA 5 stated that staff tried to get there quickly, especially when they heard resident 27 yelling. On 8/17/22 at 12:23 PM, an interview was conducted the Social Services Director (SSD). The SSD stated that resident 16 was wandering, exit seeking, and had a difficult time when first admitted . The SSD stated that resident 27 was very annoyed with resident 16 and felt threatened by her, but the staff had helped him build a relationship with her. The SSD stated that staff educated the other residents to inform staff when resident 16 was in their rooms, and not to scold or punish resident 16. The SSD stated that some residents had threatened resident 16, but we hope that they don't follow through. The SSD stated that resident 1 was aggressive toward resident 16, but the SSD stated she did not think resident 1 bumped resident 16. The SSD stated that resident 27 had expressed frustration with resident 9 when she was touching the blinds. The SSD stated that resident 27 was frustrated because he couldn't walk, and had moved to his room to avoid the commotion in the dining room. The SSD stated that resident 27 had hit another resident with his walker when he felt trapped in the dining room. The SSD stated that staff worked on behavior modification with resident 27. The SSD stated that earlier on this day, two women were in resident 27's room, resident 25 and resident 16. The SSD stated that resident 27 was raising his fists toward resident 25 when staff removed the two residents from resident 27's room. The SSD stated that resident 27 does not like resident 25. The SSD stated that resident 25 will touch men, including resident 27, which he didn't like. The SSD stated that if resident 25 was near resident 27, she's always touching him. The SSD stated that resident 27 will leave activities if she is there, and sometimes did not return to activities for months. The SSD stated that some residents had threatened resident 16, including resident 29. The SSD stated resident 16 would urinate in other resident's trash cans, push other residents, and sometimes take off her pants. The SSD stated that staff were ineffective in keeping wandering residents out of resident 27's room. The SSD stated that she heard resident 20 tell resident 16 to get the hell away from me. On 8/17/22 at 2:25 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 16 was causing the least amount of trouble, just walking through the facility on her own. CNA 6 stated that resident 33 caused the most problems going into other residents' rooms, because she was the hardest resident to redirect. CNA 6 stated that resident 27 got mad and aggressive with the residents who wandered into his room, threatened some residents, and hit one resident. CNA 6 stated that resident 33 took some items out of resident 27's room earlier today, but staff took it right back. CNA 6 stated that resident 27 had grabbed resident 33's arm once and pushed her toward the door to get her out of his room. On 8/18/22 at 11:03 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator (MDSC). The MDSC stated that for residents who were exit seeking, they were coded in their MDS as wanderers, but the social worker entered behaviors into the MDS evaluations. The MDSC stated that those who walked up and down the halls, and into other resident's rooms, were not wandering. The MDSC stated that sometimes residents were upset with the residents who wandered in their rooms, because that was their private space. The MDSC stated that staff tried to keep an eye on all the residents. The MDSC stated that residents really liked to go into resident 27's room the most. The MDSC stated that though she was not always on the floor, about once a month she had to assist residents out of resident 27's room who had wandered in. The MDSC stated that the behaviors that triggered on the MDS were entered into the car plan, but if the resident wasn't identified as a wanderer, the care plan did not include wandering interventions. The MDSC stated that she thought the wandering residents should have a care plan for wandering. On 8/18/22 at 11:22 AM, the SSD was re-interviewed. The SSD stated that when she entered the behaviors on the MDS, she did not put wandering on the MDS if it was something that the resident normally did. The SSD stated that for residents 16 and 33, that was an everyday pattern, so wandering was not documented in the MDS. The SSD stated that the wandering of the residents was a problem because of how it affected other residents. The SSD stated that they discouraged residents from wandering into other residents' rooms. On 8/18/22 at 12:05 PM, the Director of Nursing (DON) and Administrator (ADM) were interviewed. The DON stated that resident 16 walks around looking for her brother all day, but staff did not consider it to be wandering. The DON stated that she just went from place to place, and everyone is so used to it. The DON stated that staff attempted to keep everyone out of resident 27's room, and he no longer minded having resident 16 in his room. The DON stated that resident 16 gravitated toward resident 27. The DON stated that staff provided resident 16 with objects in the common areas to help keep her from wandering into as many rooms. The DON stated that when someone entered resident 27's room, resident 27 was proud of himself when he didn't get mad and pushed his call light instead. The DON stated that the nursing and behavioral notes showed improved behavior by resident 27. The ADM stated that staff working at night have increased their number of rounds to monitor more closely. The ADM stated that when resident 28 complained about people coming into his room, staff reviewed the security cameras. The DON stated that resident 9 was still going into other residents' rooms, but it's not as bad. The ADM stated that if there were complaints from other residents, the MDS should have reflected that there was a problem with wandering. The ADM stated that she substantiated the abuse from resident 27 to resident 9. The ADM stated that resident 27 willfully picked up the cup and inflicted a cut on resident 9. The ADM stated that on 6/27/22, resident 27 was pushing resident 5 away from him, but staff did not see him slap her on the face. The ADM stated that the report that resident 33 went into resident 1's room and was slapped by her was not accurate. 3. Resident 16 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia without behavioral disturbance, [CONDITION(S)], tubulo-interstitial [CONDITION(S)], chronic obstructive pulmonary disease, [CONDITION(S)], hypertension, and gastro-[CONDITION(S)] reflux disease. On 8/17/22 at 11:23 AM, an observation of resident 16 was made. Resident 16 was observed wandering in the hallway. At 11:47 AM, resident 16 wandering into an unsampled resident's room. Resident 16 was observed looking at the decorations for one minute, then exiting the room. No other residents were in the room. At 11:50 AM resident 16 was then observed walking around the nurses' station, and then entered the unsampled resident's room. At 11:51 AM resident 16 was observed pulling her pants down and sitting on a chair next to the window in the resident's room. At 11:55 AM, resident 16 stood up, pulled her pants up, and walked out of the room. No other residents were in the room. At 11:55 AM resident 16 was observed sitting in a recliner in the day room. No staff members were observed to be watching resident 16 enter the unsampled residents' room. On 8/17/22 at 12:25 PM an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated that resident 16 often wandered around the facility. CNA 1 stated that resident 16 often wandered into other resident rooms, which would upset some residents. CNA 1 stated the interventions to keep resident 16 out of certain residents' rooms were to use stop signs posted on residents' doors, and to redirect resident 16 when staff noticed her wandering into other residents' rooms. On 8/17/22 at 1:00 PM an interview with CNA 2 was conducted. CNA 2 stated that resident 16 wandered around the facility and sometimes into other residents' rooms. CNA 2 stated that staff would attempt to redirect her if she was wandering into other residents' rooms. On 8/17/22 resident 16's electronic medical record was reviewed. a. A Behavior Note from 8/17/22 at 6:41 PM documented, [Resident 16] has been calm and cooperative for her care this afternoon .She has been wandering around the facility and can occasionally [be] found on the [ither] wing lounging in the recliner. b. A Behavior Note from 8/17/22 at 1:24 PM documented, She [Resident 16] has been wandering the hallways . c. A Behavior Note from 8/14/22 at 8:32 PM documented, [Resident 16] has wandered throughout the day . d. A Behavior Note from 8/8/22 at 9:33 PM documented, [Resident 16] has wandered throughout the day . e. A Behavior Note from 8/5/22 at 9:17 PM documented, [Resident 16] has wandered throughout the day . f. A Behavior Note from 7/31/22 at 5:24 PM documented, [Resident 16] has been pacing in the [other wing's] kitchen area for the past hour or so. She frequently goes in other resident's room or attempts to remove items from the nurse station. When she is redirected, she yells at staff and is combative. g. A Behavior Note from 7/22/22 at 9:12 PM documented, [Resident 16] has wandered throughout the day. Resident 16's most recent Annual MDS Section E - Behaviors from 6/14/22 was reviewed. The section for Wandering - Presence and Frequency. Has the resident wandered? was coded as Behavior not exhibited. On 8/17/22 at 12:23 PM an interview with the Social Services Director (SSD) was conducted. The SSD reported that resident 16 wandered throughout the facility and would sometime urinate in trash cans in various locations around the facility, including in other residents' rooms. The SSD reported that she would complete the MDS section for wandering. The SSD stated that she was instructed to only code for wandering if the wandering was something outside of what the resident normally does. On 8/18/22 at 1:00 PM an interview with the Administrator was conducted. The ADMIN stated that the reason why the MDS documented Behavior not exhibited regarding resident 16 wandering, was because it's resident 16's routine and the staff did not even consider it as wandering because that is just who she was. Resident 16's care plan was reviewed, and it was revealed that resident 16 did not have a care plan for wandering. On 8/18/22 at 1:05 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that in resident 16's care plan, there are activities documented which have helped prevent resident 16 from wandering, however the DON confirmed that there was no specific care plan for wandering. The DON stated a care plan should have been developed for wandering for resident 16. The DON stated that if the MDS was coded for wandering, then there would have been a trigger to make a care plan for wandering for resident 16.

Based on observation, interview, and record review it was determined, for 4 of 18 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident with a wanderguard elopement alarm was not coded accurately on the Minimum Data Set (MDS) assessment as having the alarm. Two residents with bed rails were not coded accurately on the MDS assessments as having the bed rails in place . In addition, a resident had not received [MEDICATION NAME] feedings was coded as receiving feedings on the MDS assessments. Resident identifiers: 10, 15, 23, and 28. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/2/20 at 2:41 PM, observations were made of resident 10's bed. Resident 10's bed was observed to have bilateral bed rails extending from the head of the bed to the approximate middle of the bed. The bed rails were observed in the up position. Resident 10's medical record was reviewed on 3/3/20. A Significant Change in status MDS assessment dated [DATE], was reviewed and documented the following information: . Section P - Restraints and Alarms . A. Bed rail . 0. Not used . On 3/4/20 at 9:27 AM, observations were made of resident 10's bed. Resident 10's bed was observed to have bilateral bed rails extending from the head of the bed to the approximate middle of the bed. The bed rails were observed in the up position. On 3/4/20 at 10:49 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that all resident beds have bed rails or arm rest. RN 1 stated that the bed rails were not a restraint. RN 1 stated that the bed rails were to help residents with positioning. RN 1 stated that no attempts had been made to try other things. RN 1 stated that the bed rails were able to be lowered on the beds. On 3/4/20 at 11:06 AM, an interview was conducted with the Acting Administrator (AA). The AA stated that resident 10 would use the bed rails to assist the staff with changing her brief at night. The AA stated that resident 10 had [DIAGNOSES REDACTED] from a stroke on the right side. The AA stated that she did not have bed rail assessments for any of the residents using bed rails because the bed rails were not on her radar. The AA further stated that she was aware that the MDS assessments were not coded accurately for residents using bed rails. On 3/4/20 at 11:14 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 10 would use the bed rails to reposition at night. 2. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's medical record was reviewed on 3/3/20. A care plan dated 9/30/19, and revised 11/27/19, documented that resident 15 was at risk for elopement and wandering. The care plan further documented that resident 15 required a wanderguard device to monitor her safety. A physician's orders [REDACTED]. Resident 15's MDS assessments were reviewed and documented the following information: a. A Significant Change MDS assessment dated [DATE], was reviewed and documented the following information: . Section P - Restraints and Alarms . E. Wander/elopement alarm . 0. Not used . b. A Quarterly MDS assessment dated [DATE], was reviewed and documented the following information: . Section P - Restraints and Alarms . E. Wander/elopement alarm . 0. Not used . On 3/4/20 at 8:33 AM, observations were made of resident 15. Resident 15 was observed sitting in her room with a wanderguard device around her right wrist. On 3/4/20 at 11:51 AM, an interview was conducted with the Acting Director of Nursing (ADON). The ADON stated she also served as the MDS Coordinator, and resident 15's MDS assessments should have documented that she utilized a wander guard. 3. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/3/20 at 11:22 AM, observations were made of resident 23's bed. Resident 23's bed was observed to have bilateral side rails extending from the head of the bed to the approximate middle of the bed. The bed rails were observed in the up position. Resident 23's medical record was reviewed on 3/3/20. Resident 23's Annual MDS assessment dated [DATE], was reviewed and documented the following information: . Section P - Restraints and Alarms . A. Bed rail . 0. Not used . On 3/4/20 at 8:37 AM, an interview was conducted with the ADON. The ADON stated she did not interpret the MDS question to apply to resident 23's side rails. 4. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28's medical record was reviewed on 3/3/20. Resident 28's Discharge Return Anticipated MDS assessment dated [DATE], was reviewed and documented the following information: . Section K - Swallowing / Nutritional Status . A. [MEDICATION NAME]/IV (intravenous) feeding . 1. Checked (Yes) . On 3/4/20 at 7:40 AM, an interview was conducted with the Lead CNA. The Lead CNA stated resident 28 did not and never had [MEDICATION NAME] nutrition. On 3/4/20 at 11:51 AM, an interview was conducted with the ADON. The ADON stated resident 28 never had a tube feeding or [MEDICATION NAME] nutrition, and it was an error on her MDS assessment.

Based on interview and record review it was determined, for 2 of 18 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident who had three recent urinary tract infections (UTIs), did not have current interventions listed on the care plan. Additionally, a resident whose annual Minimum Data Set (MDS) assessment triggered care areas for falls and nutrition, had no documented care plans for falls and nutrition. Resident identifiers: 12 and 28. Findings include: 1. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/3/20 at approximately 8:30 AM, an interview was conducted with resident 12. Resident 12 stated that he frequently got UTIs. Resident 12 further stated that he had used a straight catheter for years and that he currently required a straight catheter three to four times a day. Resident 12's medical record was reviewed on 3/3/20. Resident 12 had three recent UTIs on 9/26/19, 12/5/19, and 2/10/20. Resident 12's care plan included a Focus initiated on 12/12/18 and revised on 1/3/19, I need Intermittent Catheter and is able to self cath (catheter), needs reminders of technique and hand. A Goal initiated on 12/13/18 and revised on 1/9/20, documented will show no s/sx (signs or symptoms) of Urinary infection through review date. The Interventions initiated were as follows: a. Antibiotics per MD (medical doctor) order if needed. b. Assess/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp. (temperature), Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. c. Offer frequent fluids. (Resident 12) likes tea, and sprite, root beer, lemon aide the best. On 3/4/20 at approximately 8:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she checks on resident 12 every 2 hours to anticipate his needs. CNA 1 further stated that if resident 12 needs to urinate she would notify the nurse, who would assist resident 12 with a straight catheter. On 3/4/20 at approximately 8:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would help resident 12 prevent UTIs by encouraging fluids, increasing the frequency she would straight catheter resident 12, and she would use a new all-in-one sterile catheter kit that the facility had recently purchased. LPN 1 stated that in the past she had to gather all the catheter supplies separately when resident 12 needed a straight catheter. On 3/4/20 at approximately 8:41 AM, an interview was conducted with the Infection Control Registered Nurse (IC RN). The IC RN stated that following resident 12's recent UTIs, she developed and initiated some new interventions for staff to help prevent resident 12 from getting more UTIs. The IC RN stated that Resident 12 used to straight catheter himself and was not good at following sterile technique. The IC RN stated that she had convinced resident 12 to allow the nurses, who are trained to use sterile technique, to straight catheter every 6 hours. The IC RN stated that a new all-in-one catheter kit was purchased for resident 12, which helps nurses maintain sterility when they straight catheter resident 12. The IC RN stated that resident 12's family has insisted that the facility obtain a urinalysis test each time resident 12 has been confused. The IC RN stated she thinks resident 12's confusion was more related to his progressing dementia rather than resident 12 having an active UTI. The IC RN stated she had been educating resident 12, his family, and facility staff about antibiotic stewardship and not getting a urinalysis unless resident 12 was symptomatic. The IC RN stated she thought that resident 12 may have been colonized with bacteria rather than having an active UTI. On 3/4/20 at approximately 9:08 AM, an interview was conducted with LPN 1. LPN 1 stated that the Acting Director of Nursing (ADON) developed and updated resident care plans and would put them in a Care Plan binder at the nurse's desk. LPN 1 further stated that the care plan was there to communicate each residents' needs to facility staff. Resident 12's care plan was reviewed and it did not include the new interventions recently developed and initiated by the IC RN for staff to prevent UTIs. On 3/4/20 at approximately 12:46 PM, an interview was conducted with the IC RN. The IC RN stated she did not think the new interventions to prevent UTIs needed to be added to resident 12's care plan. On 3/4/20 at approximately 3:17 PM, an interview was conducted with the Acting Administrator (AA) and the ADON. The AA stated she would expect resident 12's care plan be updated with current interventions that the staff were using to prevent resident 12's UTIs. 2. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28's medical record was reviewed on 3/3/20. Resident 28's Annual MDS assessment dated [DATE], was reviewed and documented the following information: . Section V - Care Area Assessment (CAA) Summary . 11. Falls . 12. Nutritional Status . (Note: The Falls and Nutritional Status care areas were highlighted, which indicated that they were triggered care areas for care planning.) Resident 28's care plans were reviewed. There was not a documented care plan related to resident 28's risk of falling. Furthermore, there was not a documented care plan related to resident 28's nutritional status. On 3/4/20 at 11:51 AM, an interview was conducted with the ADON. The ADON stated she developed residents' care plans based on the triggered care areas within section V of residents' MDS assessments. The ADON further stated resident 28's MDS assessment triggered care plan development related to falls and nutrition, and she was not aware that there were not active care plans within resident 28's medical record related to these care areas. The ADON further stated resident 28 had experienced recent falls and was assessed as high-risk for falling. On 3/4/20 at 12:44 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated resident 28 had multiple swallowing issues and was recently admitted to the hospital with [REDACTED]. The RD further stated she was not aware that there was not an active nutrition-related care plan within resident 28's medical record. On 3/4/20 at 12:49 PM, a follow up interview was conducted with the ADON. The ADON stated resident 28's nutrition component of the care plans was taken out last May, and she should have created a replacement care plan at that time.

Based on observation, interview, and record review, it was determined the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 18 sampled residents, a resident was not provided with feeding assistance during snack meals in accordance with her plan of care. Resident identifier: 28. Findings include: Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/2/20 at approximately 2:30 PM, observations were made of resident 28. Resident 28 was observed in her room and taking bites of an unwrapped snack in her hand. (Note: There was no staff present throughout this observation.) Resident 28's medical record was reviewed on 3/3/20. Resident 28's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was reviewed and documented that resident 28 required, at minimum, limited assistance with eating and, at maximum, one-person physical assistance with eating. (Note: The MDS assessment defined limited assistance as the resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance.) An emergency room Report dated 1/9/20, was reviewed and documented that resident 28 was transferred to the hospital with complaints of cough and shortness of breath for several days, and gradually decreasing oxygen saturations. The report further documented that resident 28 was admitted to the hospital with [REDACTED]. Resident 28's progress notes throughout her admission to the hospital documented the following entries: a. On 1/16/20, (Resident 28) was started on [MEDICATION NAME] on 1/12/20 for aspiration pneumonia . Patient continues to aspirate in spite of working with OT (occupational therapy) and consuming thickened liquids . Assessment and plan . Aspiration pneumonia . Her chest x-ray shows worsening opacities bilaterally. Patient actively aspirates everything that she eats . b. On 1/19/20, . admitted with aspiration pneumonia . ASSESSMENT AND PLAN . 1. Aspiration pneumonia. Continue on [MEDICATION NAME]([MEDICATION NAME]) . Anticipate that she can go back to the Care Center if we can get her off oxygen or with oxygen over the next 24 to 48 hours . Resident 28's Discharge Note from the hospital dated 1/20/20, was reviewed and documented that resident 28 was treated for [REDACTED]. On 3/4/20 at 7:40 AM, an interview was conducted with the Lead Certified Nursing Assistant (CNA). The Lead CNA stated resident 28 got pneumonia a couple months ago and was admitted to the hospital for a while, and was not able to swallow well upon her return to the facility. The Lead CNA further stated staff ensure that resident 28 was upright and supervised by a Restorative Aide (RA) during meals. On 3/4/20 at 9:06 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 28 was sat up all the way prior to eating and there was always someone with her in order to help her. RN 1 further stated resident 28 was supervised by either a caregiver or staff member any time she had food including meals and snacks. On 3/4/20 at 9:21 AM, an interview was conducted with the RA. The RA stated swallowing exercises were conducted with resident 28 before meals, which included mouth, tongue, and jaw exercises. The RA further stated between herself, the other RA, and resident 28's sitter, there was someone who monitored resident 28 for signs and symptoms of aspiration during meals. The RA further stated she believed resident 28's sitter was with her while eating snacks. Resident 28's Bedside Kardex Report dated 3/4/20, was reviewed and documented the following information: . Eating/Nutrition . (Resident 28) is on Aspiration precautions, and someone must be with her when she eats . Watch her for choking, drooling, difficulty breathing and being unable to speak. If she is choking, unable to speak, of cough, do the [MEDICATION NAME] maneuver, and call a nurse . On 3/4/20 at 11:51 AM, an interview was conducted with the Acting Director of Nursing (ADON). The ADON stated the hospital documentation did not say for sure whether or not resident 28 experienced aspiration pneumonia. The ADON further stated the RA conducted swallowing exercises with resident 28 during meals, which was written into her plan of care related to activities of daily living. On 3/4/20 at 12:44 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated resident 28 had multiple swallowing issues and was recently admitted to the hospital with [REDACTED]. The RD further stated resident 28 was diagnosed with [REDACTED]. The RD further stated upon resident 28's return to the facility, a CNA or nurse conducted swallowing exercises with resident 28 before she ate and she required monitoring while she is eating. (Note: An Illness Report Form dated 2/24/20, documented that resident 28 was transferred to the hospital on [DATE] and diagnosed with [REDACTED]. On 3/4/20 at 1:33 PM, a follow up interview was conducted with the RA. The RA stated swallowing exercises were conducted with resident 28 during mealtimes, but not when snacks were provided. On 3/5/20 at 8:30 AM, an interview was conducted with the Acting Administrator (AA). The AA stated resident 28's family brought snacks for her and she probably had food in her room.

Based on observation, interview and record review, it was determined, for 1 of 25 sample residents, the facility failed to ensure that residents were free from physical and mental abuse, and failed to identify or protect resident 16 when such abuse had occurred. The deficient practice identified for resident 16 was found to have occurred at an Immediate Jeopardy level. Resident identifier: 16. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 5/15/14 at approximately 9:30 AM. The Administrator was asked to develop an immediate plan of correction to ensure resident safety related to unsupervised spousal visits resulting in bruising, skin tears and emotional distress. On 5/15/14 at 12:38 PM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to resident 16. The written plan, dated 5/15/14, stated the following: "May 15, 2014 (Name of Long Term Care Manager) Long Term Care Survey Section Bureau of Health Facility Licensure, Certification and Resident Assessment 288 North 1460 West Salt Lake City, UT -4103 Dear Mr. (Name of Long Term Care Manager): Pursuant to deficiencies identified by the Medicare/Medicaid Certification Survey Team during the certification survey of Canyonlands Care Center, Moab Utah conducted this date as regarding 'F' tags 223 and 226, specifically: F223 'The resident has the right to be free from verbal, physical, and mental abuse, corporal punishment, and involuntary seclusion.' F226 'The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.' the (sic) following Plan of Correction (POC) has been developed and will be implemented immediately: 1. As regarding the care, treatment, and protection from abuse and bodily harm for resident (16): a. One-on-one observation and monitoring by assigned Care Center staff of all contact with her husband, (name of resident 16's husband), during each of his regular visits to his wife, effective immediately. b. Immediate intervention by the monitoring staff member, as indicated, to prevent any contact with her by him that presents the potential risk of bodily injury, including bruising, skin tears, or other potentially harmful outcomes. c. Immediate reporting of all staff interventions (as necessitated by item 'b' above) to appropriate agencies and entities and designated Center administrative staff. d. Discussions with family members, especially the designated family representatives, (names removed), to determine and implement appropriate interventions on their part to preclude any further untoward behaviors on the part of their father when visiting their mother. 2. As regarding the orientation of the staff to the subject of abuse recognition and prevention: a. Scheduling of an (sic) mandatory staff in-service on abuse recognition and prevention to be presented by Utah State Adult Protective Services as (sic) the earliest time possible, as dictated by their schedule, but no later than seven (7) days from this date, as allowed by those schedules. b. Revision of Care Center's Abuse Identification and Prevention policy to include i. More detailed description of the employee screening process and the sources to be accessed for the desired information on prior abuse situations (if any); ii. Process to be followed to ensure protection of the abused party during the investigation; iii. Content of the mandatory reporting requirement, to include physical and verbal abuse, neglect, and misappropriation of resident funds as key focus areas. iv. Complete listing of all agencies and parties to be notified of the abuse or suspected abuse event, including Bureau of Licensing, Certification and Resident Assessment, and the mandatory time frames for reporting and any other factors relevant to an acceptable reporting protocol. c. In-services to be presented by Administrative staff members for staff review of the Care Center's revised policy on abuse and abuse prevention and the consequences to staff members of violation of the policy. d. Immediate adoption of a 'zero-tolerance' policy for any confirmed situations of resident abuse by a staff member. e. Documented mandatory follow-up sessions for review of the subject matter to be scheduled on a quarterly basis for the remainder of this calendar year. 3. As regarding the investigation and reporting of abuse or suspected abuse incidents in the Center: a. Immediate implementation of an expanded process for the internal investigation of abuse and suspected abuse incidents. Process to be detailed in Care Center policies on this subject, including protocols to be followed and established time limits for the completion of the investigation and the implementation of interventions as indicated. b. Continuation of timely reporting (as set forth in applicable regulations) of all such incidents or suspected incidents to appropriate State and Federal agencies and entities, to include the Utah Adult Protective Services and the Utah State Ombudsman, and commencement of mandatory reporting to the Bureau of Licensing, Certification, and Resident Assessment of the events. c. The maintenance of a log of such reports by the designated Abuse Investigation Coordinator for the Center with a review of the log by the Administrator or his/her designee on a monthly basis. d. Reports of the implementation/completion of each of the above interventions will be made to the Bureau as they occur but at minimum on a weekly basis for the period of the imposed restrictions. 4. As regarding monitoring and surveillance of the operations of the Care Center on those days the survey team is not on site: a. Daily reporting to you of all incidents that occurred during the previous day together with a description of the actions taken or planned to be taken (as circumstances may dictate) to address the factors causing the incident. b. Verification of the daily report in the form of signatures of the Administrator, the Director of Nursing Services, and the Social Service Worker. We respectfully request a timely and favorable review of this POC for the benefit of the Center and the residents who reside here, and to facilitate the expeditious resolution of this matter. Thank you. ..." The Immediate Plan of Correction was signed by the facility Administrator and Attested by the State Survey Agency. An "ADDENDUM TO POC FOR ABUSE INCIDENT INVOLVING (RESIDENT 16)" WAS OBTAINED. The facility Administrator documented: "...OBJECTIVE To ensure that every staff member of Canyonlands Care Center is oriented to the Plan of Correction (POC) for the abuse incident involving (Resident 16), the following arrangement will be followed to completion: 1. All employees not in attendance at the initial 'Abuse Identification and Prevention' service/orientation meeting on Friday, May 16, 2014 will be contacted individually to make arrangements for their participation in the follow-up session. a. Follow up sessions on abuse identification and prevention will be scheduled weekly until every staff member has participated and documented his/her participation by signing the attendance roster for the session attended. b. Employees not able to attend any of the scheduled group meetings will be provided with a DVD (Digital Video Disc) on abuse identification and prevention and copy of the revised abuse identification and prevention policy. Upon returning the items, the employee will be asked general questions about the subject matter to confirm understanding of the material. c. The orientation of each staff member must be completed before the staff member will be allowed to work on the floor. 2. Orientation of all staff members to the specific stipulations of the POC for (Resident 16) will be completed as follows: a. The subject matter will be made part of 'report' at the staff change over each shift, effective immediately. b. The charge nurse will query each care giver assigned to that wing for that shift as to the requirement of providing one-on-one monitoring and, as necessary, one-on-one accompaniment whenever (resident 16's husband) is in the facility; c. If the caregiver answers in the affirmative by stating back to the charge nurse the requirement, the check will be considered adequate. If the care giver cannot answer the question by stating the requirement, the charge nurse will summarize the question by stating the requirement, the charge nurse will summarize the requirement for the care giver. d. These activities will continue until it is established that all staff members - care givers and non-care givers - can demonstrate knowledge of the required arrangement whenever (Resident 16's) husband is in the Center." The addendum was signed by the Administrator and co-signed by the State survey agency. The Administrator alleged that conditions constituting Immediate Jeopardy were abated on 5/19/14. During the recertification survey on 5/20/14, the surveyors confirmed the removal of the Immediate Jeopardy situation as of 5/19/14. Deficient practice at the harm level at the scope and severity of a "G" remained for the right to remain free from abuse. Findings include: On 5/12/14 at 1:37 PM, an observation was made of resident 16. Resident 16 was noted to have dark purple bruising to her left forearm. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 16's medical record was reviewed on 5/13/14. Review of the annual MDS (Minimum Data Set) assessment, dated 2/10/14, revealed the facility staff assessed resident 16 as being totally dependent with a one person physical assist with transfers, wheelchair propelling, dressing, eating, personal hygiene, bathing, and a two person assist with bed mobility. Additionally, facility staff assessed resident 16 as being rarely or never understood and having severely impaired cognitive skills for daily decision making. Review of the quarterly MDS assessment, dated 5/12/14, revealed facility staff assessed resident 16 as being totally dependent with a one person physical assist with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Additionally, facility staff assessed resident 16 as being rarely or never understood and having severely impaired cognitive skills for daily decision making. On 4/28/14 at 7:00 PM, a facility Registered Nurse (RN) documented in a progress note "Observed pt. (patient) husband (name removed) shaking her left arm violently (and) purposefully. Had to tell him 4 times before to stop (and) would not until I was able to get to her side. Explained to husband that he cannot do that to her. (Checked) for injury (and) none noted (at) this time. Will continue to observe." No documentation could be found in the medical record to indicate the facility staff continued to monitor resident 16 for injuries after 4/28/14 or that the facility Social Services Worker (SSW), the Director of Nursing (DON), the Administrator (ADM), resident 16's responsible party, or resident 16's physician were notified of the incident. On 10/29/13, the facility SSW developed a "Resident Safety Plan" as follows: " ...Anticipated Crisis: Resident becomes noticeably upset with increased agitation after husband fondles her and touches her in the area under her briefs or in a sexual nature. Resident is not able to consent due to her Hypoxic [MEDICAL CONDITION] and needs to be monitored to ensure her wellbeing (sic) and safety as well as maintain that physical contact is not distressing or upsetting to her. Intervention Plan: 1. Encourage and assert that visitation between husband and resident occur in the common areas of the facility ensuring that they remain in a location visible to staff members at all times. 2. If resident is in her room, move her to the living room areas where her well being can be monitored during visits. 3. Monitor resident during visits, check in frequently on resident to ensure residents emotional wellbeing (sic). 4. Remind husband that it is very important to keep resident as comfortable as possible and not to engage in any behaviors that may be upsetting to her. 5. Don't be afraid to ask questions, if resident appears distressed ask husband what behaviors he was engaging in and to please discontinue touching her in that manner as it is causing her apparent distress. ...Safety Plan if Resident is being fondled in a sexual nature: 1. If resident is visibly or noticeably upset during a visit intervene and ask husband to discontinue behaviors, if necessary ask him to please leave the facility and discontinue that visit. 2. Call daughter, (name removed) and advise why it is necessary to intervene and or terminate visit. 3. Notify social worker of concerns and behaviors during or after these visits so that they can be addressed with family. Other Vital Information: Be familiar with residents care plan and ensure you are addressing, responding, and interacting to resident appropriately and consistent with such. Be familiar and aware of resident's location during visits with her husband, check in frequently and ensure that these visits are appropriate in nature and are not distressing to her. ..." On 1/15/14, an "Anticipated Crisis" safety plan was updated by the facility SSW. The SSW documented: "...Anticipated Crisis Resident becomes noticeably upset with increased agitation after husband visits with her and physically touches her in a forceful and inappropriate way. Resident is not able to consent due to her Hypoxic [MEDICAL CONDITION] and needs to be monitored to ensure her wellbeing (sic) and safety as well as maintain that physical contact is not distressing or upsetting to her. Intervention Plan: 1. Encourage and assert that visitation between husband and resident occur in the common areas of the facility ensuring that they remain in a location visible to staff members at all times. 2. If resident is in her room, move her to the living room or an area where her well being can be monitored during visits. 3. Do not allow husband to push resident through the facility, resident needs to be in a stationary position so that she can be monitored effectively. 4. Monitor resident during visits, check in frequently on resident to ensure residents emotional wellbeing (sic). 5. Remind husband that it is very important to keep resident as comfortable as possible and not to engage in any behaviors that may be upsetting to her. 6. Don't be afraid to ask questions, if resident appears distressed ask husband what behaviors he was engaging in and to please discontinue touching her in that manner as it is causing her apparent distress. 7. Document, chart, and report any and all unusual occurrences or behavior after visits. Safety Plan if Resident is being fondled in a sexual or abusive nature: 1. If resident is visibly or noticeably upset during a visit intervene and ask husband to discontinue behaviors, if necessary ask him to please leave the facility and discontinue that visit. 2. Call daughter, (name removed) and advise why it is necessary to intervene and or terminate visit. 3. Notify social worker of concerns and behaviors during or after these visits so that they can be addressed with family. Other Vital Information: Be familiar with residents (sic) care plan and ensure you are addressing, responding, and interacting to resident appropriately and consistent with such. Be aware of resident's location during visits with her husband, check in frequently and ensure that these visits are appropriate in nature and are not distressing to her." The facility SSW Progress Notes were reviewed. The SSW documented: 1. 9/20/13 at 12:09 PM: "APS (Adult Protective Services) called. They will not be opening a case and would me (sic) to report this to the ombudsman as a human rights issue." 2. 9/22/13 at 1:35 PM: "Observed resident in common area, resident appears calm I have not noticed her recently saying 'Get (name removed)' which she had been repeating over and over recently. Staff still has concerns with husband barricading himself in her room and increased agitation that is apparent with resident after. I have reported this to APS and they referred me to report these incidents to ombudsman." 3. 9/30/13 at 12:08 PM: "Reported incident of husbands sexual activities and how upsetting they are to resident and how distressed she appears afterwards to APS as resident is not able to give consent due to her medical condition." (Note: A safety plan was not developed to protect resident 16 from abuse until 10/29/13.) 4. 10/29/13 at 9:22 AM: "Reported the following to APS: Sexual abuse of a person who is unable to consent, (RN 1) has reported to me that after (resident 16's) husband comes in and fondles her, she becomes very wound up and upset, she has caught the perpetrator a number of times with his hands in her private areas and (resident 16) visibly shaken, as soon as the nurse enters the room his hands are under her briefs. While the perpetrator is (resident 16's) husband we do not believe that she is consenting to these acts and would like to protect her privacy and dignity. We are requesting that APS look into this situation further to better assist us in being able to protect this resident from sexual acts that she cannot consent to." (Note: Refer to safety plan developed on 10/29/13.) 5. 11/6/13 at 2:22 PM: "Resident's room was moved after IDT (Interdisciplinary Team) meeting this morning, resident needs to be closer to nurses station so that contact between her and her husband can be monitored by staff to ensure that resident is safe from harm." 6. 11/12/13 at 11:40 AM: "...Resident frequently gets upset and agitated after visits with her husband; there is an ongoing case with Adult Protective Services to ensure that resident's rights are not being violated. A safety plan has been put in place to assist staff to keep resident safe during these visits. Residents guardian, (name removed), (daughter) has been notified and made aware of the issues concerning the visits between resident and husband and will talk with husband in an attempt to get him to stop." 7. 1/15/14 at 11:56 AM: "Reported to APS: It was reported that (resident 16's husband) was repeatedly pushing forcefully on (resident 16's arms) pressing them repeatedly into her chest (arms were folded) (resident 16's husband) continued to do this over and over again despite being requested to not do it. (Resident 16) was in view of staff members as per prior safety plan and was not alone with resident however, this behavior continued causing enough agitation that (resident 16) required a dose of [MEDICATION NAME] to calm her down, she repeatedly kept repeating 'Come (name removed), come (name removed') over and over which is something she does when she is extremely agitated. (Resident 16) also had bruises on her arms this morning that appear to be caused from this incident yesterday. (Resident 16's husband) also has severe health problems and possibly dementia as well, his family drops him off unattended at the care center for hours at a time for these visits which are not appropriate. (Resident 16's husband) is a serious fall risk as well as exhibiting constant concerning behaviors towards (Resident 16). These visits do not appear to be beneficial for (resident 16) and cause her anguish and agitation as well, due to (resident 16's husband's) diminished mental capacity the staff at the care center is unable to reason or effectively control (resident 16's husband's) behavior while in our facility. ..." (Note: Refer to "Anticipated Crisis" safety plan that was updated on 1/15/14.) 8. On 1/24/14 at 3:03 PM: "Observed resident in common area, staff made me aware that resident has another bruise on her arm today on (sic) unknown origin, it will be charted and documents (sic). Concerned that bruises are a result of continued contact with spouse, staff tries but has a hard time controlling him due to his cognitive deficits." 9. 4/21/14 at 10:49 AM: "Resident's husband visits her daily, there have been some issues and concerns were (sic) raised by staff regarding some inappropriate contact causing resident to become increasingly agitated during these visits. A safety plan was developed and is being followed by staff and the contact appears to have somewhat improved. APS is also working with the family to ensure that resident continues to receive visits from family but, that they are not causing her undue distress or increased agitation." 10. 4/21/14 at 10:49 AM: "Resident needs to have appropriate visits and interactions with her husband, staff needs to follow the safety plan and notify SSW and family when issues or concerns arise during or after visits." Review of the Nurse's Notes revealed the following entries: 1. 10/26/13, RN 2 documented "Noticeable (increase) in agitation (with resident 16 after) spouse has fondled her for a lengthly (sic) time. (Question) is this considered Elder abuse. I know you guys are on it, but do I need to intervene at all when I catch him?" 2. On 10/28/13, RN 1 documented "(Resident 16's) husband messes (with) her and gets her very wound up. I often have to calm her (with) antianxiety meds (medications). I've caught him a number of times (with) his hands on her, and (resident 16) visibly shaken. I can't say for sure what he is doing because he stops when I enter the room, but often his hands a (sic) places her brief normally covers. I know he is her husband, but I don't know that we can consider (resident 16) 'consenting'. I feel that something needs to happen to protect (resident 16's) privacy and dignity." (Note: A crisis safety plan was developed on 10/29/14.) 3. On 12/21/13 at 4:31 PM, a facility RN documented "(Resident 16's husband) found with (resident 16) his hands were under the blanket around the thigh area. He had taken her for a walk, but stopped in the activity room when no other residents were there, staff member found them immediately told RN who removed (resident 16) from the situation. Reminded her husband that his behaviors frequently upset (resident 16), and (resident 16) cannot make her own decisions, or stop him from doing things to her. (Resident 16) was not upset. Did not begin to repeat verbalizations until she was removed to the TV room. At that time I asked (resident 16) if she wanted a pill to calm her down, and she repeated "Come (name removed)" loudly a number of times. I administered 0.5 mg (milligrams) [MEDICATION NAME] orally." (Note: Resident 16 was to be in a location visible to staff members at all times when her husband visited her.) 4. On 1/20/14 at 3:00 PM, a facility RN documented, "... (Resident 16) has old, purple bruises on both forearms ..." (Note: The facility staff did not complete an investigation into the bruise of unknown origin.) 5. On 2/14/14 at 8:00 PM, a facility RN documented, "It was reported to me by (RN 2) that residents husband, (name removed) giving pt. water (and) she was choking (and) hovering over her. Nurse brought pt back from activity room where he had taken her. I instructed (resident 16's husband) to only give her water (with) her cup that has a straw in it for her to suck on to get water." 6. On 2/22/14 at 8:00 PM, a facility RN documented "Husband wheeling pt about in w/c (wheelchair) brought her to me (and) pointed to an (sic) skin tear on her (left) anterior for arm (sic). ..." 7. On 2/25/14 at 4:00 PM, a facility RN documented, "CNA (Certified Nurse Assistant) called me in to show me new skin tear on res. Dorsal (right) forearm appears to be from the Hoyer but not certain ..." (Note: The facility staff did not complete an investigation into how the skin tear occurred.) 8. On 4/18/14, a facility RN documented in a "Weekly Nursing Assessment," "Healing skin tears 1 cm (centimeter) on L (left) arm. Edges approximated. Dorsum of R (right) hand U shaped 1.2 cm X 2 cm steristrips (sic) intact. Base of R thumb on hand dorsum skin tear measures 1 cm X 1.5 cm covered (with) steristrips (sic). I believe it is also U shaped. Bruise measures 1 cm X 3 cm at base of skin tear." (Note: There was no documentation or investigation into how resident 16 sustained skin tears or bruising.) On 5/15/14 at 7:31 AM, an interview was conducted with CNA 1. CNA 1 stated that, "(Resident 16) is not supposed to be left in the room alone with him (her husband)." CNA 1 also stated, "That's fine" when asked if resident 16's husband can take her for a walk in the facility," As long as they are not behind closed doors." CNA 1 then stated that the supervision between resident 16 and her husband was, "Just oversight, not direct supervision unless he is alone with her in the room." On 5/15/14 at 7:37 AM, an interview was conducted with CNA 2. CNA 2 stated that staff, "Just make sure that when her husband comes they are not left alone in her room and are in a public area. He can walk her in the halls and things like that; he can just not be alone with her in her room." CNA 2 then stated that she didn't follow resident 16 and her husband when he was walking her around the building. On 5/15/14 at 9:04 AM, an interview was conducted with CNA 3. CNA 3 stated, "With her (resident 16) I have heard to keep an eye out when (Resident 16's husband) is around." CNA 3 also stated, "Some people tell me to watch him (resident 16's husband) and others tell me it's fine." CNA 3 then stated, "I don't remember (who told her not to watch resident 16's husband when he visit's resident 16) probably just the other CNA gave me the idea that it was her husband and it was not a big deal to watch them." CNA 3 then stated, "He (resident 16's husband) was able to go in her room alone as long as the door is open and we can see in." CNA 3 also stated, "Yes he (resident 16's husband) can take her for a walk," and the CNA had not followed them when they went for walks. On 5/15/14 at 9:09 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 16 was not supposed to be alone with her husband, and that she was supposed to be in a common area when he visited. CNA 4 then stated that she did not provide one-on-one supervision with resident 16 and her husband. On 5/15/14 at 7:27 AM, an interview was conducted with RN 3. RN 3 stated that staff were supposed to watch resident 16 when she was with her husband. RN 3 stated, "We are not supposed to have him alone with her ...It's not a close supervision, just in eyesight to make sure he is not in the room with her alone." RN 3 further stated that resident 16's husband could be with her in the hallway or the TV room but that the facility staff did not follow up when he walked with her in the hallways. On 5/15/14 at 9:02 AM, an interview was conducted with RN 4. RN 4 stated that, "(Resident 16) is supposed to be supervised with her husband." RN 4 also stated that staff didn't directly supervise resident 16 and her husband when he was taking her for a walk through the facility, "As long as she is in a place where people are coming and going so he won't do anything." On 5/15/14 at 9:29 AM, an interview was conducted with the DON. The DON stated that resident 16's husband was not allowed to be in resident 16's room with resident 16 unsupervised. The DON then stated, "They are supposed to be supervised if in a common area. We don't have to stand over him and hover, just keep an eye on him." When asked why incidents were still occurring between resident 16 and her husband the DON stated, "I guess we don't have the staff to be one-on-one with him when they are out in the common areas." On 5/15/14 at 9:47 AM, an interview was conducted with the facility Administrator. The Administrator stated that he felt the interactions that have occurred between resident 16 and her husband were not abuse. The administrator also stated, "We just try and monitor," interactions between resident 16 and her husband, but had not initiated, "direct staff at all times." The administrator then stated, "They (the facility staff) had attempted to keep their interactions out in a public space." The Administrator further stated that incidents between resident 16 and her husband have reoccurred. Additionally, the incidents were not reported to the state office as required. The facility "Elder/Dependent Adult Abuse Assessment and Reporting" Policy and Procedure was reviewed. "POLICY: It is the policy of this facility to report any suspected cases of elder abuse or dependent adult abuse. This is in compliance (sic) mandatory reporting requirements for elder/dependent adult abuse. Employees subject to the reporting requirements include any employee who provides direct resident care and any other employee whose official duties require him/her to regularly work directly with elders or dependent adults. ...Mandatory Reporting: A report is required when the following has occurred: When an employee has observed an incident that reasonably appears to be physical abuse. When an employee has observed a physical injury where the nature of the injury, its location on the body or the repetition of the injury clearly indicates that physical abuse has occurred. When an employee is told by an elder or a dependent adult that he or she has experienced behavior constituting physical abuse. Non-Mandatory Reporting: Report is permitted in other known or suspected types of abuse: Neglect Intimidation Fiduciary abuse Abandonment Procedure For Reporting: Instances of physical abuse shall continue to be reported to either the long term care ombudsman or local law enforcement agency when it is alleged to have occurred in a long term care facility. Instances of physical abuse occurring elsewhere must be reported to either the local adult protective services agency or to the law enforcement agency. In cases of suspected elder or dependent adult abuse, immediately call the Department of Public Social Services. ...The report should include: The name of the person making the report The name, age and present location of the elder or dependent adult The names and addresses of family members or other persons responsible for the elder or dependent adult's care, if known The nature and extent of the abused person's condition Any other information requested by the protective agency The date of the incident Follow-up written reports should be completed within 32 hours and sent to the elder/dependent adult protective agency previously contacted. The Social Service Department of this facility will also be notified. Reports are to be called and mailed to Adult Protective Services and Long Term Care Ombudsman. ...The Department of Patient and Family services is to be notified of all cases of suspected elder or dependent adult abuse for consultation in the assessment of the resident, evaluation of the family/caretaker and the referral process. Additional Nursing Responsibilities: Documentation on the admission assessment sheet and in the nurses' notes describing the condition of the resident When appropriate, nursing will take photographs of suspected areas of decubiti or neglect If such resident is admitted after Social Service Department hours, nursing will notify the social worker first thing in the morning of the next day. INDICATORS OF POSSIBLE ELDER ABUSE: The following indicators do not necessary signify abuse or neglect, but then can be helpful in assessing residents. Physical Indicators: Injury that has not been cared for properly Any injury incompatible with history ...Cuts, lacerations, puncture wounds Bruises, welts, discoloration ...Behavioral Indicators: Fear Withdrawal Depression..." The Abuse Policy and Procedure did not address investigations of allegations of abuse, protection of the resident who was being abused, or the reporting requirements to the State agency as required.

Based on observation, interview and record review, it was determined the facility had not operationalized written policies and procedures to ensure 1 of 25 sampled residents was free from abuse by a visitor. Although facility staff suspected resident 16 was being physically abused by a visitor, they did not put in place protective measures, thoroughly investigate all alleged occurrences, or report to required oversight agencies, as directed by written policies, to prevent multiple occurrences between September 2013 and April 28, 2014. The facility's failure to operationalize policies and procedures to prevent abuse was determined to constitute immediate jeopardy to resident safety. Resident Identifier: 16. In addition, at the level of no actual harm with potential for more that minimal harm that is not immediate jeopardy, it was determined, for 3 of 25 residents, the facility did not operationalize written policies and procedures relating to the prevention, investigation, and reporting of allegations of abuse. Resident identifiers: 9, 13 and 25. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 5/15/14 at approximately 9:30 AM. At that time, the Administrator was asked to develop an immediate plan to ensure resident 16, and all residents were free from abuse. On 5/15/14 at 12:38 PM, the Administrator provided the surveyors with a written plan of action to remove the immediate jeopardy relative to resident 16 while ensuring all residents were free from abuse. The written plan, dated 5/15/14, stated the following: "May 15, 2014 (Name of Long Term Care Manager) Long Term Care Survey Section Bureau of Health Facility Licensure, Certification and Resident Assessment 288 North 1460 West Salt Lake City, UT -4103 Dear Mr. (Name of Long Term Care Manager): Pursuant to deficiencies identified by the Medicare/Medicaid Certification Survey Team during the certification survey of Canyonlands Care Center, Moab Utah conducted this date as regarding 'F' tags 223 and 226, specifically: F223 'The resident has the right to be free from verbal, physical, and mental abuse, corporal punishment, and involuntary seclusion.' F226 'The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.' the (sic) following Plan of Correction (POC) has been developed and will be implemented immediately: 1. As regarding the care, treatment, and protection from abuse and bodily harm for resident (16): a. One-on-one observation and monitoring by assigned Care Center staff of all contact with her husband, (name of resident 16's husband), during each of his regular visits to his wife, effective immediately. b. Immediate intervention by the monitoring staff member, as indicated, to prevent any contact with her by him that presents the potential risk of bodily injury, including bruising, skin tears, or other potentially harmful outcomes. c. Immediate reporting of all staff interventions (as necessitated by item 'b' above) to appropriate agencies and entities and designated Center administrative staff. d. Discussions with family members, especially the designated family representatives, (names removed), to determine and implement appropriate interventions on their part to preclude any further untoward behaviors on the part of their father when visiting their mother. 2. As regarding the orientation of the staff to the subject of abuse recognition and prevention: a. Scheduling of an (sic) mandatory staff in-service on abuse recognition and prevention to be presented by Utah State Adult Protective Services as (sic) the earliest time possible, as dictated by their schedule, but no later than seven (7) days from this date, as allowed by those schedules. b. Revision of Care Center's Abuse Identification and Prevention policy to include i. More detailed description of the employee screening process and the sources to be accessed for the desired information on prior abuse situations (if any); ii. Process to be followed to ensure protection of the abused party during the investigation; iii. Content of the mandatory reporting requirement, to include physical and verbal abuse, neglect, and misappropriation of resident funds as key focus areas. iv. Complete listing of all agencies and parties to be notified of the abuse or suspected abuse event, including Bureau of Licensing, Certification and Resident Assessment, and the mandatory time frames for reporting and any other factors relevant to an acceptable reporting protocol. c. In-services to be presented by Administrative staff members for staff review of the Care Center's revised policy on abuse and abuse prevention and the consequences to staff members of violation of the policy. d. Immediate adoption of a 'zero-tolerance' policy for any confirmed situations of resident abuse by a staff member. e. Documented mandatory follow-up sessions for review of the subject matter to be scheduled on a quarterly basis for the remainder of this calendar year. 3. As regarding the investigation and reporting of abuse or suspected abuse incidents in the Center: a. Immediate implementation of an expanded process for the internal investigation of abuse and suspected abuse incidents. Process to be detailed in Care Center policies on this subject, including protocols to be followed and established time limits for the completion of the investigation and the implementation of interventions as indicated. b. Continuation of timely reporting (as set forth in applicable regulations) of all such incidents or suspected incidents to appropriate State and Federal agencies and entities, to include the Utah Adult Protective Services and the Utah State Ombudsman, and commencement of mandatory reporting to the Bureau of Licensing, Certification, and Resident Assessment of the events. c. The maintenance of a log of such reports by the designated Abuse Investigation Coordinator for the Center with a review of the log by the Administrator or his/her designee on a monthly basis. d. Reports of the implementation/completion of each of the above interventions will be made to the Bureau as they occur but at minimum on a weekly basis for the period of the imposed restrictions. 4. As regarding monitoring and surveillance of the operations of the Care Center on those days the survey team is not on site: a. Daily reporting to you of all incidents that occurred during the previous day together with a description of the actions taken or planned to be taken (as circumstances may dictate) to address the factors causing the incident. b. Verification of the daily report in the form of signatures of the Administrator, the Director of Nursing Services, and the Social Service Worker. We respectfully request a timely and favorable review of this POC for the benefit of the Center and the residents who reside here, and to facilitate the expeditious resolution of this matter. Thank you. ..." The Immediate Plan of Correction was signed by the facility Administrator and Attested by the State Survey Agency. An "ADDENDUM TO POC FOR ABUSE INCIDENT INVOLVING (RESIDENT 16)" WAS OBTAINED. The facility Administrator documented: "...OBJECTIVE To ensure that every staff member of Canyonlands Care Center is oriented to the Plan of Correction (POC) for the abuse incident involving (Resident 16), the following arrangement will be followed to completion: 1. All employees not in attendance at the initial 'Abuse Identification and Prevention' service/orientation meeting on Friday, May 16, 2014 will be contacted individually to make arrangements for their participation in the follow-up session. a. Follow up sessions on abuse identification and prevention will be scheduled weekly until every staff member has participated and documented his/her participation by signing the attendance roster for the session attended. b. Employees not able to attend any of the scheduled group meetings will be provided with a DVD (Digital Video Disc) on abuse identification and prevention and copy of the revised abuse identification and prevention policy. Upon returning the items, the employee will be asked general questions about the subject matter to confirm understanding of the material. c. The orientation of each staff member must be completed before the staff member will be allowed to work on the floor. 2. Orientation of all staff members to the specific stipulations of the POC for (Resident 16) will be completed as follows: a. The subject matter will be made part of 'report' at the staff change over each shift, effective immediately. b. The charge nurse will query each care giver assigned to that wing for that shift as to the requirement of providing one-on-one monitoring and, as necessary, one-on-one accompaniment whenever (resident 16's husband) is in the facility; c. If the caregiver answers in the affirmative by stating back to the charge nurse the requirement, the check will be considered adequate. If the care giver cannot answer the question by stating the requirement, the charge nurse will summarize the question by stating the requirement, the charge nurse will summarize the requirement for the care giver. d. These activities will continue until it is established that all staff members - care givers and non-care givers - can demonstrate knowledge of the required arrangement whenever (Resident 16's) husband is in the Center." The addendum was signed by the Administrator and co-signed by the State survey agency. The Administrator alleged that conditions constituting Immediate Jeopardy were abated on 5/19/14. During the recertification survey on 5/20/14, the surveyors confirmed the removal of the Immediate Jeopardy situation as of 5/19/14. Deficient practice at the harm level at the scope and severity of a "G" remained for the right to remain free from abuse. Findings include: On 5/12/14 at 1:37 PM, an observation was made of resident 16. Resident 16 was noted to have dark purple bruising to her left forearm. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 16's medical record was reviewed on 5/13/14. Review of the annual MDS (Minimum Data Set) assessment, dated 2/10/14, revealed the facility staff assessed resident 16 as being totally dependent with a one person physical assist with transfers, wheelchair propelling, dressing, eating, personal hygiene, bathing, and a two person assist with bed mobility. Additionally, facility staff assessed resident 16 as being rarely or never understood and having severely impaired cognitive skills for daily decision making. Review of the quarterly MDS assessment, dated 5/12/14, revealed facility staff assessed resident 16 as being totally dependent with a one person physical assist with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Additionally, facility staff assessed resident 16 as being rarely or never understood and having severely impaired cognitive skills for daily decision making. On 4/28/14 at 7:00 PM, a facility Registered Nurse (RN) documented in a progress note "Observed pt. (patient) husband (name removed) shaking her left arm violently (and) purposefully. Had to tell him 4 times before to stop (and) would not until I was able to get to her side. Explained to husband that he cannot do that to her. (Checked) for injury (and) none noted (at) this time. Will continue to observe." No documentation could be found in the medical record to indicate the facility staff continued to monitor resident 16 for injuries after 4/28/14 or that the facility Social Services Worker (SSW), the Director of Nursing (DON), the Administrator (ADM), resident 16's responsible party, or resident 16's physician were notified of the incident. On 10/29/13, the facility SSW developed a "Resident Safety Plan" as follows: " ...Anticipated Crisis: Resident becomes noticeably upset with increased agitation after husband fondles her and touches her in the area under her briefs or in a sexual nature. Resident is not able to consent due to her Hypoxic [MEDICAL CONDITION] and needs to be monitored to ensure her wellbeing (sic) and safety as well as maintain that physical contact is not distressing or upsetting to her. Intervention Plan: 1. Encourage and assert that visitation between husband and resident occur in the common areas of the facility ensuring that they remain in a location visible to staff members at all times. 2. If resident is in her room, move her to the living room areas where her well being can be monitored during visits. 3. Monitor resident during visits, check in frequently on resident to ensure residents emotional wellbeing (sic). 4. Remind husband that it is very important to keep resident as comfortable as possible and not to engage in any behaviors that may be upsetting to her. 5. Don't be afraid to ask questions, if resident appears distressed ask husband what behaviors he was engaging in and to please discontinue touching her in that manner as it is causing her apparent distress. ...Safety Plan if Resident is being fondled in a sexual nature: 1. If resident is visibly or noticeably upset during a visit intervene and ask husband to discontinue behaviors, if necessary ask him to please leave the facility and discontinue that visit. 2. Call daughter, (name removed) and advise why it is necessary to intervene and or terminate visit. 3. Notify social worker of concerns and behaviors during or after these visits so that they can be addressed with family. Other Vital Information: Be familiar with residents care plan and ensure you are addressing, responding, and interacting to resident appropriately and consistent with such. Be familiar and aware of resident's location during visits with her husband, check in frequently and ensure that these visits are appropriate in nature and are not distressing to her. ..." On 1/15/14, an "Anticipated Crisis" safety plan was updated by the facility SSW. The SSW documented: "...Anticipated Crisis Resident becomes noticeably upset with increased agitation after husband visits with her and physically touches her in a forceful and inappropriate way. Resident is not able to consent due to her Hypoxic [MEDICAL CONDITION] and needs to be monitored to ensure her wellbeing (sic) and safety as well as maintain that physical contact is not distressing or upsetting to her. Intervention Plan: 1. Encourage and assert that visitation between husband and resident occur in the common areas of the facility ensuring that they remain in a location visible to staff members at all times. 2. If resident is in her room, move her to the living room or an area where her well being can be monitored during visits. 3. Do not allow husband to push resident through the facility, resident needs to be in a stationary position so that she can be monitored effectively. 4. Monitor resident during visits, check in frequently on resident to ensure residents emotional wellbeing (sic). 5. Remind husband that it is very important to keep resident as comfortable as possible and not to engage in any behaviors that may be upsetting to her. 6. Don't be afraid to ask questions, if resident appears distressed ask husband what behaviors he was engaging in and to please discontinue touching her in that manner as it is causing her apparent distress. 7. Document, chart, and report any and all unusual occurrences or behavior after visits. Safety Plan if Resident is being fondled in a sexual or abusive nature: 1. If resident is visibly or noticeably upset during a visit intervene and ask husband to discontinue behaviors, if necessary ask him to please leave the facility and discontinue that visit. 2. Call daughter, (name removed) and advise why it is necessary to intervene and or terminate visit. 3. Notify social worker of concerns and behaviors during or after these visits so that they can be addressed with family. Other Vital Information: Be familiar with residents (sic) care plan and ensure you are addressing, responding, and interacting to resident appropriately and consistent with such. Be aware of resident's location during visits with her husband, check in frequently and ensure that these visits are appropriate in nature and are not distressing to her." The facility SSW Progress Notes were reviewed. The SSW documented: 1. 9/20/13 at 12:09 PM: "APS (Adult Protective Services) called. They will not be opening a case and would me (sic) to report this to the ombudsman as a human rights issue." 2. 9/22/13 at 1:35 PM: "Observed resident in common area, resident appears calm I have not noticed her recently saying 'Get (name removed)' which she had been repeating over and over recently. Staff still has concerns with husband barricading himself in her room and increased agitation that is apparent with resident after. I have reported this to APS and they referred me to report these incidents to ombudsman." 3. 9/30/13 at 12:08 PM: "Reported incident of husbands sexual activities and how upsetting they are to resident and how distressed she appears afterwards to APS as resident is not able to give consent due to her medical condition." (Note: A safety plan was not developed to protect resident 16 from abuse until 10/29/13.) 4. 10/29/13 at 9:22 AM: "Reported the following to APS: Sexual abuse of a person who is unable to consent, (RN 1) has reported to me that after (resident 16's) husband comes in and fondles her, she becomes very wound up and upset, she has caught the perpetrator a number of times with his hands in her private areas and (resident 16) visibly shaken, as soon as the nurse enters the room his hands are under her briefs. While the perpetrator is (resident 16's) husband we do not believe that she is consenting to these acts and would like to protect her privacy and dignity. We are requesting that APS look into this situation further to better assist us in being able to protect this resident from sexual acts that she cannot consent to." (Note: Refer to safety plan developed on 10/29/13.) 5. 11/6/13 at 2:22 PM: "Resident's room was moved after IDT (Interdisciplinary Team) meeting this morning, resident needs to be closer to nurses station so that contact between her and her husband can be monitored by staff to ensure that resident is safe from harm." 6. 11/12/13 at 11:40 AM: "...Resident frequently gets upset and agitated after visits with her husband; there is an ongoing case with Adult Protective Services to ensure that resident's rights are not being violated. A safety plan has been put in place to assist staff to keep resident safe during these visits. Residents guardian, (name removed), (daughter) has been notified and made aware of the issues concerning the visits between resident and husband and will talk with husband in an attempt to get him to stop." 7. 1/15/14 at 11:56 AM: "Reported to APS: It was reported that (resident 16's husband) was repeatedly pushing forcefully on (resident 16's arms) pressing them repeatedly into her chest (arms were folded) (resident 16's husband) continued to do this over and over again despite being requested to not do it. (Resident 16) was in view of staff members as per prior safety plan and was not alone with resident however, this behavior continued causing enough agitation that (resident 16) required a dose of [MEDICATION NAME] to calm her down, she repeatedly kept repeating 'Come (name removed), come (name removed') over and over which is something she does when she is extremely agitated. (Resident 16) also had bruises on her arms this morning that appear to be caused from this incident yesterday. (Resident 16's husband) also has severe health problems and possibly dementia as well, his family drops him off unattended at the care center for hours at a time for these visits which are not appropriate. (Resident 16's husband) is a serious fall risk as well as exhibiting constant concerning behaviors towards (Resident 16). These visits do not appear to be beneficial for (resident 16) and cause her anguish and agitation as well, due to (resident 16's husband's) diminished mental capacity the staff at the care center is unable to reason or effectively control (resident 16's husband's) behavior while in our facility. ..." (Note: Refer to "Anticipated Crisis" safety plan that was updated on 1/15/14.) 8. On 1/24/14 at 3:03 PM: "Observed resident in common area, staff made me aware that resident has another bruise on her arm today on (sic) unknown origin, it will be charted and documents (sic). Concerned that bruises are a result of continued contact with spouse, staff tries but has a hard time controlling him due to his cognitive deficits." 9. 4/21/14 at 10:49 AM: "Resident's husband visits her daily, there have been some issues and concerns were (sic) raised by staff regarding some inappropriate contact causing resident to become increasingly agitated during these visits. A safety plan was developed and is being followed by staff and the contact appears to have somewhat improved. APS is also working with the family to ensure that resident continues to receive visits from family but, that they are not causing her undue distress or increased agitation." 10. 4/21/14 at 10:49 AM: "Resident needs to have appropriate visits and interactions with her husband, staff needs to follow the safety plan and notify SSW and family when issues or concerns arise during or after visits." Review of the Nurse's Notes revealed the following entries: 1. 10/26/13, RN 2 documented "Noticeable (increase) in agitation (with resident 16 after) spouse has fondled her for a lengthly (sic) time. (Question) is this considered Elder abuse. I know you guys are on it, but do I need to intervene at all when I catch him?" 2. On 10/28/13, RN 1 documented "(Resident 16's) husband messes (with) her and gets her very wound up. I often have to calm her (with) antianxiety meds (medications). I've caught him a number of times (with) his hands on her, and (resident 16) visibly shaken. I can't say for sure what he is doing because he stops when I enter the room, but often his hands a (sic) places her brief normally covers. I know he is her husband, but I don't know that we can consider (resident 16) 'consenting'. I feel that something needs to happen to protect (resident 16's) privacy and dignity." (Note: A crisis safety plan was developed on 10/29/14.) 3. On 12/21/13 at 4:31 PM, a facility RN documented "(Resident 16's husband) found with (resident 16) his hands were under the blanket around the thigh area. He had taken her for a walk, but stopped in the activity room when no other residents were there, staff member found them immediately told RN who removed (resident 16) from the situation. Reminded her husband that his behaviors frequently upset (resident 16), and (resident 16) cannot make her own decisions, or stop him from doing things to her. (Resident 16) was not upset. Did not begin to repeat verbalizations until she was removed to the TV room. At that time I asked (resident 16) if she wanted a pill to calm her down, and she repeated "Come (name removed)" loudly a number of times. I administered 0.5 mg (milligrams) [MEDICATION NAME] orally." (Note: Resident 16 was to be in a location visible to staff members at all times when her husband visited her.) 4. On 1/20/14 at 3:00 PM, a facility RN documented, "... (Resident 16) has old, purple bruises on both forearms ..." (Note: The facility staff did not complete an investigation into the bruise of unknown origin.) 5. On 2/14/14 at 8:00 PM, a facility RN documented, "It was reported to me by (RN 2) that residents husband, (name removed) giving pt. water (and) she was choking (and) hovering over her. Nurse brought pt back from activity room where he had taken her. I instructed (resident 16's husband) to only give her water (with) her cup that has a straw in it for her to suck on to get water." 6. On 2/22/14 at 8:00 PM, a facility RN documented "Husband wheeling pt about in w/c (wheelchair) brought her to me (and) pointed to an (sic) skin tear on her (left) anterior for arm (sic). ..." 7. On 2/25/14 at 4:00 PM, a facility RN documented, "CNA (Certified Nurse Assistant) called me in to show me new skin tear on res. Dorsal (right) forearm appears to be from the Hoyer but not certain ..." (Note: The facility staff did not complete an investigation into how the skin tear occurred.) 8. On 4/18/14, a facility RN documented in a "Weekly Nursing Assessment," "Healing skin tears 1 cm (centimeter) on L (left) arm. Edges approximated. Dorsum of R (right) hand U shaped 1.2 cm X 2 cm steristrips (sic) intact. Base of R thumb on hand dorsum skin tear measures 1 cm X 1.5 cm covered (with) steristrips (sic). I believe it is also U shaped. Bruise measures 1 cm X 3 cm at base of skin tear." (Note: There was no documentation or investigation into how resident 16 sustained skin tears or bruising.) On 5/15/14 at 7:31 AM, an interview was conducted with CNA 1. CNA 1 stated that, "(Resident 16) is not supposed to be left in the room alone with him (her husband)." CNA 1 also stated, "That's fine" when asked if resident 16's husband can take her for a walk in the facility," As long as they are not behind closed doors." CNA 1 then stated that the supervision between resident 16 and her husband was, "Just oversight, not direct supervision unless he is alone with her in the room." On 5/15/14 at 7:37 AM, an interview was conducted with CNA 2. CNA 2 stated that staff, "Just make sure that when her husband comes they are not left alone in her room and are in a public area. He can walk her in the halls and things like that; he can just not be alone with her in her room." CNA 2 then stated that she didn't follow resident 16 and her husband when he was walking her around the building. On 5/15/14 at 9:04 AM, an interview was conducted with CNA 3. CNA 3 stated, "With her (resident 16) I have heard to keep an eye out when (Resident 16's husband) is around." CNA 3 also stated, "Some people tell me to watch him (resident 16's husband) and others tell me it's fine." CNA 3 then stated, "I don't remember (who told her not to watch resident 16's husband when he visit's resident 16) probably just the other CNA gave me the idea that it was her husband and it was not a big deal to watch them." CNA 3 then stated, "He (resident 16's husband) was able to go in her room alone as long as the door is open and we can see in." CNA 3 also stated, "Yes he (resident 16's husband) can take her for a walk," and the CNA had not followed them when they went for walks. On 5/15/14 at 9:09 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 16 was not supposed to be alone with her husband, and that she was supposed to be in a common area when he visited. CNA 4 then stated that she did not provide one-on-one supervision with resident 16 and her husband. On 5/15/14 at 7:27 AM, an interview was conducted with RN 3. RN 3 stated that staff were supposed to watch resident 16 when she was with her husband. RN 3 stated, "We are not supposed to have him alone with her ...It's not a close supervision, just in eyesight to make sure he is not in the room with her alone." RN 3 further stated that resident 16's husband could be with her in the hallway or the TV room but that the facility staff did not follow up when he walked with her in the hallways. On 5/15/14 at 9:02 AM, an interview was conducted with RN 4. RN 4 stated that, "(Resident 16) is supposed to be supervised with her husband." RN 4 also stated that staff didn't directly supervise resident 16 and her husband when he was taking her for a walk through the facility, "As long as she is in a place where people are coming and going so he won't do anything." On 5/15/14 at 9:29 AM, an interview was conducted with the DON. The DON stated that resident 16's husband was not allowed to be in resident 16's room with resident 16 unsupervised. The DON then stated, "They are supposed to be supervised if in a common area. We don't have to stand over him and hover, just keep an eye on him." When asked why incidents were still occurring between resident 16 and her husband the DON stated, "I guess we don't have the staff to be one-on-one with him when they are out in the common areas." On 5/15/14 at 9:47 AM, an interview was conducted with the facility Administrator. The Administrator stated that he felt the interactions that have occurred between resident 16 and her husband were not abuse. The administrator also stated, "We just try and monitor," interactions between resident 16 and her husband, but had not initiated, "direct staff at all times." The administrator then stated, "They (the facility staff) had attempted to keep their interactions out in a public space." The Administrator further stated that incidents between resident 16 and her husband have reoccurred. Additionally, the incidents were not reported to the state office as required. 6. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/14 resident 12's medical record was reviewed. Review of the "Nurses Progress Notes" revealed an entry on 1/10/14 at 9:55 AM where a facility licensed nurse documented: "Resident has bruise on right hip. Measures 3.4 x 1.7 cm. Bruise is blue/purple in color. Bruise is of unknown origin." On 5/20/14 at 9:54 AM, the facility DON and SSW were interviewed related to the bruise on resident 12's right hip. The DON and SSW stated that an investigation was not conducted to determine how resident 12 sustained the bruise to the right hip. The DON further stated that incident was not reported to the State survey and certification agency as required. The facility "Elder/Dependent Adult Abuse Assessment and Reporting" Policy and Procedure was reviewed. "POLICY: It is the policy of this facility to report any suspected cases of elder abuse or dependent adult abuse. This is in compliance (sic) mandatory reporting requirements for elder/dependent adult abuse. Employees subject to the reporting requirements include any employee who provides direct resident care and any other employee whose official duties require him/her to regularly work directly with elders or dependent adults. ...Mandatory Reporting: A report is required when the following has occurred: When an employee has observed an incident that reasonably appears to be physical abuse. When an employee has observed a physical injury where the nature of the injury, its location on the body or the repetition of the injury clearly indicates that physical abuse has occurred. When an employee is told by an elder or a dependent adult that he or she has experienced behavior constituting physical abuse. Non-Mandatory Reporting: Report is permitted in other known or suspected types of abuse: Neglect Intimidation Fiduciary abuse Abandonment Procedure For Reporting: Instances of physical abuse shall continue to be reported to either the long term care ombudsman or local law enforcement agency when it is alleged to have occurred in a long term care facility. Instances of physical abuse occurring elsewhere must be reported to either the local adult protective services agency or to the law enforcement agency. In cases of suspected elder or dependent adult abuse, immediately call the Department of Public Social Services. ...The report should include: The name of the person making the report The name, age and present location of the elder or dependent adult The names and addresses of family members or other persons responsible for the elder or dependent adult's care, if known The nature and extent of the abused person's condition Any other information requested by the protective agency The date of the incident Follow-up written reports should be completed within 32 hours and sent to the elder/dependent adult protective agency previously contacted. The Social Service Department of this facility will also be notified. Reports are to be called and mailed to Adult