Every finding on record at Center at Foresight LLC, The

Based on observations, record review and interviews the facility failed to ensure the self-administration of medications was clinically appropriate for four (#1, #15, #28 and #40) of four residents reviewed for self-administration of medications out of 33 sample residents. Specifically, the facility failed to ensure an assessment was completed in order to determine if the self-administration of medications was clinically appropriate for Resident #1, Resident #15, Resident #28 and Resident #40.Findings include:I. Facility policy and procedure The Self-Administration of Medication policy, revised 2/8/23, was received from the medical records director on 3/19/26 at 11:02 a.m. The policy read, Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the nursing staff will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. In addition to general evaluation of decision -making capacity, the nursing staff will perform a more specific skill assessment, including (but not limited to) the residents:-Ability to read and understand medication labels;-Comprehension of the purpose and proper dosage and administration time fo his or her medications;-Ability to remove medicine from a container and to ingest and swallow (or otherwise administer) the medications; and, -Ability to recognize the risks and major adverse consequences of his or her medications. The nursing staff will document their findings and the choices of residents who are able to self-administer medication.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (hemiparesis is characterized by partial muscle weakness or reduced coordination, whereas hemiplegia is defined by total paralysis or complete loss of movement on that side), following a cerebral infarction, aphasia, acute respiratory failure, chronic obstructive pulmonary disease (COPD) and atrial fibrillation (the most common type of irregular heart rhythm).The 2/10/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He required maximum assistance with activities of daily living (ADL). B. Observations On 3/16/26 at 3:30 p.m. a container of Voltaren medication (a topical pain medication) was observed on Resident #1's bedside table. On 3/17/26 at 10:11 a.m. a container of Voltaren medication was observed on Resident #1's bedside table. On 3/18/26 at 12:15 p.m. a container of Voltaren medication was observed on Resident #1's bedside table. C. Resident interviewResident #1 was interviewed on 3/18/26 at 12:26 p.m. Resident #1 said his wife assisted him to administer the Voltaren cream medication to himself when needed. He said he kept the cream at his bedside. D. Record reviewThe self-administration of medications care plan, initiated 2/10/26, revealed Resident #1 could self-administer Biotene Dry Mouth Moist Spray Mouth/Throat solution per physician's orders. Interventions included assessing/monitoring the resident's ability to self-administer medications, monitoring the residents' self-administration frequently and obtaining an order from the physician to self-administer medication.-However, the care plan failed to indicate Resident #1 was able to self-administer Voltaren cream.A self-administration of medications assessment, dated 2/17/26, documented Resident #1 was able to self-administer two medications, fluticasone, and nasal suspension. -The self-administration assessment failed to indicate the resident had been assessed to self-administer Voltaren cream. -A review of Resident #1's March 2026 CPO on 3/17/26 did not reveal a physician's order for Voltaren cream nor a physician's order for self-administration of Voltaren cream. A second review of Resident #1's March 2026 CPO on 3/19/26 revealed the following physician's order: Patient may have Voltaren, fluticasone and Biotene at bedside for self-administration, ordered 3/19/26 at 8:31 a.m -However, the physician's order was not obtained until after the concern was identified during the survey. III. Resident #40A. Resident status Resident #40, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD).The 3/13/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required maximum assistance with ADLs. B. Resident observations and interviewOn 3/17/26 at 8:40 a.m. an albuterol inhaler and Ayr nasal gel medication were observed on Resident #40's bedside table. The albuterol inhaler was in reach for her to use.Resident #40 said she had had the albuterol inhaler next to her since she was admitted to the facility because she had trouble breathing and used the medication frequently. On 3/18/26 at 9:35 a.m. an albuterol inhaler and Ayr nasal gel medication remained on Resident #40's bedside table. The albuterol inhaler was in reach for her to use.C. Record review -Review of Resident #40's electronic medical record (EMR) failed to reveal a self-administration of medications care plan, a physician's order to self-administer the albuterol inhaler and Ayr nasal gel, or that a self-administration of medications assessment had been completed to determine if the resident was clinically appropriate to self administer medications.IV. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included arthritis, type 2 diabetes, hypertension, edema and pulmonary disease. The 12/29/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 12 out of 15. She required maximum assistance with ADLs. B. Resident observations and interviewOn 3/16/26 at 4:05 p.m. saline nasal spray and Ayr nasal gel medications were observed on Resident #28's bedside table. On 3/17/26 at 10:02 a.m. saline nasal spray and Ayr nasal gel medications were observed on Resident #28's bedside table.Resident #28 said she used the nasal spray and the nasal gel to keep her airway open due to the dryness in the facility. She said she used the medication at home and told the nurse she wanted the medication next to her. On 3/18/26 at 11:43 a.m. the saline nasal spray and Ayr nasal gel medications remained on Resident #28's bedside table.C. Record review -Review of Resident #28's electronic medical record (EMR) failed to reveal a self-administration of medications care plan, a physician's order to self-administer the Ayr nasal gel and saline nasal spray, or that a self-administration of medications assessment had been completed to determine if the resident was clinically appropriate to self administer medications.V. Resident #15A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included femur fracture and hypertension. The 3/3/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. She required maximum assistance with ADLs. B. Resident observations and interviewOn 3/18/26 at 8:51 a.m. a bottle of AlgaeCal (a plant-based calcium supplement designed to support bone health) was observed on Resident #15's bedside table.On 3/19/26 at 9:08 a.m. the bottle of AlgaeCal remained on Resident #15's bedside table.Resident #15 was interviewed on 3/19/26 at 9:08 a.m., she said she wanted the AlgaeCal left at her bedside because she took the supplement with her meals. She said the bottle of AlgaeCal was labeled with her name and the facility knew she had the medications next to her. C. Record reviewThe self-administration of medications care plan, initiated 3/17/26 (during the survey), revealed Resident #15 could self-administer medications per physician's orders. Interventions included assessing/monitoring the resident's ability to self-administer medications, monitoring the residents' self-administration frequently and obtaining an order from the physician to self-administer medication.-However, the care plan failed to specify what medications the resident was able to self-administer.Review of Resident #15's March 2026 CPO revealed the following physician's order:Patient may self-administer and keep medications at bedside two times a day for vitamin deficiency. -However, the physician's order failed to specify which medication Resident #15 was able to keep at her bedside.-Review of Resident #15's EMR failed to reveal that a self-administration of medications assessment had been completed to determine if the resident was clinically appropriate to self administer medications. VI. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/18/26 at 4:30 p.m. LPN #1 said medications left at the residents' bedsides needed to have a physician's order and an assessment had to be completed for safe administration. Registered nurse (RN) #1 was interviewed on 3/18/26 at 12:35pm. RN #1 said in order to have medications left at residents' edsides, a physician's order needed to be obtained and an assessment for safety of self-administration of medications had to be completed. The director of nursing (DON) was interviewed on 3/19/26 at 10:25 a.m. The DON said the residents often asked to have their own medications at their bedside. She said the process for residents to be able to keep medications at their bedside was to obtain a physician's order and to complete a self-administration medication assessment for evaluation of safe administration. VII. Facility follow-upOn 3/18/26 at 4:30 p.m. the medical records director provided the following information via email:For Resident #1:Resident #1's self-administration of medications care plan was revised on 3/18/26 to include the self-administration of fluticasone propionate nasal suspension per physician's orders.-However, the care plan was not updated until the concern was brought to the facility's attention during the survey (see record review above). -Additionally, the 3/18/26 revised care plan failed to include the self-administration of Voltaren cream, which was the medication observed at the resident's bedside on 3/16/26, 3/17/26 and 3/18/26 (see observations above).-There was no documentation provided by the medical records director to indicate that a self-administration assessment was completed to include the self-administration of Voltaren cream.For Resident #28:A self-administration of medications was care plan was initiated on 3/18/26 (during the survey) and indicated Resident #28 could self-administer medications per physician's orders. Interventions included completing a self-administration evaluation to ensure the resident was able to self-administer medications safely, assessing/monitoring the resident's ability to self-administer medications, monitoring the residents' self-administration frequently and obtaining an order from the physician to self-administer medication.-However, the care plan failed to specify what medications the resident was able to self-administer. -Additionally, the care plan was not initiated until the concern was brought to the facility's attention during the survey (see record review above).The following physician's order was obtained for Resident #28:Okay to keep Ayr nasal gel and saline nasal spray at bedside, ordered 3/18/26 at 4:01 p.m. (during the survey).-However, the physician's order was not obtained until the concern was brought to the facility's attention during the survey (see record review above).A self-administration assessment was completed by the DON on 3/18/26 at 4:05 p.m. (during the survey). The assessment indicated Resident #40 was able to self-administer her albuterol inhaler.-However, the self-administration assessment was not completed until the concern was brought to the facility's attention during the survey (see record review above).For Resident #15:A self-administration assessment was completed by the DON on 3/18/26 at 2:26 p.m. (during the survey). The assessment indicated Resident #15 was able to self-administer AlgaeCal two times daily. -However, the self-administration assessment was not completed until the concern was brought to the facility's attention during the survey (see record review above).On 3/23/26 at 6:28 p.m. (after the survey exit) RN #2 provided the following information via email:For Resident #40:A self-administration of medications was care plan was initiated on 3/19/26 (during the survey) and indicated Resident #40 could self-administer medications per physician's orders. Interventions included completing a self-administration evaluation to ensure the resident was able to self-administer medications safely, assessing/monitoring the resident's ability to self-administer medications, monitoring the residents' self-administration frequently and obtaining an order from the physician to self-administer medication.-However, the care plan failed to specify what medications the resident was able to self-administer. -Additionally, the care plan was not initiated until the concern was brought to the facility's attention during the survey (see record review above).The following physician's order was obtained for Resident #40:Okay to have albuterol inhaler at bedside for self-administration, ordered 3/19/26 at 8:32 a.m. (during the survey).-However, the physician's order was not obtained until the concern was brought to the facility's attention during the survey (see record review above).A self-administration assessment was completed by the DON on 3/19/26 at 8:33 a.m. (during the survey). The assessment indicated Resident #40 was able to self-administer her albuterol inhaler.-However, the self-administration assessment was not completed until the concern was brought to the facility's attention during the survey (see record review above).-There was no documentation provided by RN #2 to indicate that a physician's order had been obtained and a self-assessment had been completed to determine if Resident #40 was clinically appropriate to administer the Ayr nasal gel medication observed at the resident's bedside on 3/17/26 and 3/18/26 (see observations above).

Based on record review and interviews the facility failed to ensure antibiotics were not ordered or administered prior to receiving culture and sensitivity for three (#20, #60 and #72) of nine residents reviewed for antibiotic stewardship out of 33 sample residents. Specifically, the facility failed to ensure the urinalysis culture and sensitivity (a test that detects bacteria or yeast in urine, identifies the specific organism causing an infection, and determines which antibiotics will treat it effectively) test results were obtained prior to starting Resident #20, Resident #60 and Resident #72 on antibiotics for potential urinary tract infections (UTI).Findings include:I. Facility policy and procedure The Antibiotic Stewardship policy and procedure, revised 1/29/25, was provided by the medical records director on 3/19/26 at 1:44 p.m. The policy read, The Antibiotic Stewardship Program has been developed to promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. The goal of this policy is to limit antibiotic resistance in the post-acute setting, while improving treatment efficacy and patient safety. Antibiotic stewardship activities should, at a minimum, include these basic elements: leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, patients and families about antibiotic resistance and opportunities for improvement. The infection preventionist (IP) or designee will be responsible for infection surveillance and monitoring, detecting and reporting multi-drug resistance organisms (MDRO) tracking. The IP will collect and review data such as:-Type of antibiotic ordered, and route of administration;-Whether appropriate tests such as cultures were obtained before ordering antibiotics; and,-Whether the antibiotic was changed during the course of treatment. Patients that are admitted from the hospital will also be tracked. The infection preventionist or designee will assess if the resident meets criteria to continue antibiotics from the hospital. If the resident does not meet criteria, the physician is to be notified to see if they want to continue with the antibiotic as ordered or discontinue it.II. Resident #72 A. Resident statusResident #72, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, heart failure, acute respiratory failure and diabetes.The 3/18/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. She required minimum assistance with activities of daily living (ADL). B. Record review-Review of Resident #72's comprehensive care plan review revealed no care plan focus for a UTI. Review of the urinalysis (UA) results for Resident #72, dated 3/17/26 at 4:04 p.m. revealed the resident's urine was positive for urine nitrites (typically indicate a urinary tract infection (UTI), where bacteria convert dietary nitrates in the urine into nitrites) and urine leukocytes (white blood cells which typically indicate an immune response to UTIs, kidney infections or inflammation). Review of Resident #72's urine culture and sensitivity (C&S) final test results, dated 3/19/26 at 8:08 a.m., revealed multiple bacterial morphotypes present, indicating probable contamination. The laboratory suggested appropriate recollection of another urine specimen with timely delivery to the laboratory, if clinically indicated.Review of Resident #72's March 2026 CPO revealed the following physician's orders:Macrobid (antibiotic) 100 milligrams (mg), give one tablet by mouth two times a day for seven days for a urinary tract infection (UTI), ordered 3/18/26 at 4:41 p.m.-However, the physician's order was obtained prior to the facility receiving the UA C&S test results on 3/19/26 (which indicated the resident's urine sample was likely contaminated and required recollection (see C&S test results above). Please check urinalysis for dysuria on 3/20/26, ordered 3/10/26 at 11:58 a.m Review of Resident #72's March 2026 medication administration record (MAR) revealed the resident received two doses of Macrobid 100 mg (on 3/18/26 at 8:00 p.m. and 3/19/26 at 8:00 a.m.).III. Resident #20 A. Resident statusResident #20, age [AGE], was admitted on [DATE]. According to the 1/20/26 CPO, diagnoses included fusion of the spine, muscle weakness and spinal stenosis.The 1/26/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. She required substantial maximum assistance with ADLs. B. Record reviewThe antibiotic use care plan, initiated 3/18/26, revealed Resident #20 had a UTI. Interventions included administering antibiotics per physician's orders.Review of Resident #20's UA laboratory results, dated 3/17/26 at 8:41 a.m. revealed the resident's urine was positive for urine nitrites. -Review of Resident #20's electronic medical record (EMR) revealed there were no laboratory results for the UA C&S. Review of Resident #20's March 2026 CPO revealed the following physician's orders:Macrobid 100 mg, give one tablet by mouth two times a day for five days for an uncomplicated UTI, ordered 3/17/26 at 9:47 a.m.-However, the physician's order was obtained prior to the facility receiving the resident's UA C&S test results. -A second review of Resident #20's EMR on 3/19/26 revealed a physician's order to discontinue the Macrobid medication, ordered 3/19/26 at 12:59 p.m., following the interview with the director of nursing (DON) regarding antibiotic stewardship (see interview below). Review of Resident #20's March 2026 MAR revealed the resident received five dose of Macrobid 100 mg (on 3/17/26 at bedtime, on 3/18/26 in the morning and at bedtime and on 3/19/26 in the morning).IV. Resident #60 A. Resident statusResident #60, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included displaced femur fracture, unspecified fall, hypertension and acute kidney failure. The 3/13/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. She required maximum assistance with ADLs. B. Record reviewThe antibiotic use care plan, initiated 3/18/26, revealed Resident #60 had a UTI. Interventions included administering antibiotics per physician's orders.Review of Resident #60's UA laboratory results, dated 3/17/26 at 8:47 a.m. revealed the resident's urine was positive for leukocytes. -Review of Resident #60's EMR revealed there were no laboratory results for the UA C&S. Review of Resident #60's March 2026 CPO revealed the following physician's order:Cefuroxime Axetil (antibiotic) 250 mg, give one tablet two times a day for five days for a UTI, ordered 3/17/26 at 7:00 p.m.Review of Resident #60's March 2026 MAR revealed the resident received five doses of Macrobid 100 mg (on 3/17/26 at bedtime, on 3/18/26 in the morning and at bedtime and on 3/19/26 in the morning). V. Staff interview The director of nursing (DON) was interviewed on 3/19/26 at 11:10 a.m. The DON said nine residents in the facility were currently being treated with antibiotics. She said three of the residents were on antibiotics for urinary tract infections. She said Resident #20 had exhibited signs of pain and urinary frequency, so the physician had ordered an antibiotic for the resident before the C&S results were back. The DON said Resident # 72 reported to the physician that she felt like she had a UTI, so the physician ordered antibiotics. The DON was reading the physician notes during the interview, and said it indicated there were no white blood cells in the urinalysis for Resident #72. The DON said Resident #60 acquired a UTI at the facility and had symptoms of urinary frequency and hallucinations. She said no culture or sensitivity test results had been reported to her prior or during the interview for Residents #20, Resident #60 and Resident #72. The DON said she would expect the C&S results to come back before starting residents on antibiotics. She said the physician had been with the facility for over a year and was still learning. VI. Facility follow-upAn email sent by the medical records director on 3/19/26 at 1:44 p.m. revealed no final culture and sensitivity results were back from the laboratory yet for Resident #20 and #60.On 3/19/26 at 3:33 p.m. the medical records director sent an email which contained Risk Versus Benefit Time Out Sheets (clinical tool or checklist used to reassess antibiotic therapy) for Resident #72, Resident #20 and Resident #60. The documentation revealed the following:Review of Resident #72's Risk Versus Benefit Time Out Sheet, dated 3/19/26, revealed the resident did not meet McGeer's (standardized surveillance definitions used to identify and track infections) or Loeb's criteria (an established minimum set of signs and symptoms to be met for initiation of antibiotics in long-term care facilities) and may be considered unnecessary medication. The document indicated the resident had a history of urinary tract infections with confusion. However, the risk of discontinuing the antibiotics did not outweigh the benefits of the medication.-However, the resident received two doses of antibiotics prior to the facility receiving the UA C&S back and the results of the C&S when obtained on 3/19/26 indicated the resident's urine sample had been contaminated and a recollection of the urine was recommended for testing (see record review above).-Additionally, the document indicated the resident did not meet McGeer's or Loeb's criteria for initiating antibiotics.Review of Resident #20's antibiotic Risk Versus Benefit Time Out Sheet, dated 3/19/26, revealed the resident did not meet McGeer's or Loeb's criteria and may be considered unnecessary medication. The document indicated discontinuing the medication may lead to an increase in potential or complications for sepsis. However, the facility notified the resident and discontinued the antibiotic. The facility would continue to monitor the resident and wait for the UA C&S results.Review of Resident #60's antibiotic Risk Versus Benefit time Out Sheet, dated 3/19/26, revealed the resident did not meet McGeer's or Loeb's criteria and may be considered unnecessary medication. The document indicated the resident was confused and a high fall risk, but the confusion was clearing. The medication would be continued until the C&S results were obtained. -However, the document indicated the resident did not meet McGeer's or Loeb's criteria for initiating antibiotics.

Based on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for five (#10, #38, #96, #194 and #198) of six residents out of 28 sample residents. Specifically, the facility failed to: -Thoroughly explain the arbitration agreement in a form and in a manner the residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents the arbitration agreement was a binding agreement before the agreement was signed; -Accurately inform residents the agreement could be rescinded by written notice within 90 days of the signing of the agreement; and, -Ensure staff reviewing the arbitration agreement with residents and the residents' representatives understood the components of the agreement. Findings include: I. The arbitration agreement The Dispute Resolution and Arbitration Agreement, undated, was provided by the nursing home administrator (NHA) on 4/24/24 at 8:57 a.m. via email. The agreement read in part: Arbitration is a method of resolving disputes outside of the court system. Each party may be represented by his own lawyer if desired, but arbitration cases are decided by an arbitrator, rather than by a judge or jury. The parties agree that any legal dispute, controversy, demand or claim shall be resolved exclusively by binding arbitration. This arbitration agreement may be rescinded by written notice to the facility from you within 90 days as set forth below. This agreement is signed in contemplation of admission to the facility, not to a hospital even if the patient later goes to the hospital for any reason. If not rescinded, this arbitration agreement shall remain in effect even if you are sent to the hospital and return to the facility. Note: By signing this agreement you are agreeing to have any issue of medical malpractice decided by a neutral binding arbitration rather than by a jury or court trial. You have the right to seek legal counsel and you have the right to rescind this agreement within 90 days from the date of signature by both parties unless the agreement was signed in contemplation of hospitalization in which you have 90 days after discharge or released from the hospital to rescind the agreement. No healthcare provider shall withhold the provision of emergency medical services to any person because of that person's failure or refusal to sign an agreement containing a provision for binding arbitration of any dispute arising as to professional negligence of the provider. No healthcare provider shall refuse to provide medical care services to any patient solely because such patient refused to sign such an agreement or exercise the 90 day right of rescission. II. Explanation of arbitration to the residents Admissions coordinator (AC) #1 and AC #2 were interviewed on 4/25/24 at 4:14 p.m. AC #1 said during the admission process she told residents the arbitration agreement stated if there were any issues with care at the facility, staff wanted to have the opportunity to correct the concern before it went to legal matters. She said she had not told the residents they could rescind after signing the agreement or given them a timeline for when the residents could rescind the agreement because she was not aware it was a needed option. She said the question had never come up because the arbitration agreement was not a binding agreement. She said there was nothing binding. She said the facility wanted to try to take care of issues here at the facility. She said the residents could rescind the agreement anytime the resident wanted to. She said if the resident requested a copy she would provide it for them at the time of the admission or the resident could request a copy of the arbitration agreement from medical records. AC #2 said she did not tell residents anything different then what AC #1 said above. AC #2 said she did not inform the residents of a timeline they could rescind the agreement if they signed it. AC #2 said she had been in her position for the past two years and had only one resident that she could recall choosing not to sign the arbitration agreement. She said she offered the residents a copy of the agreement but most residents said they did not want a copy. III. Resident group interview A group interview was conducted on 4/29/24 at 10:30 a.m. with Resident #10, Resident #38, Resident #194, Resident #195 and Resident #198. The residents were deemed alert and oriented by the facility assessment . Arbitration and the arbitration agreement was reviewed with the residents. Resident #10 said she signed so much paperwork and was on so much pain medication when she was first admitted she was having a hard time paying attention during the admission process. She believed she was told arbitration was available if she needed it. She said did not know if she signed the arbitration agreement or not. She said she did not think she was told a timeline for when she could change her mind if she signed the agreement. Resident #198 said he signed the arbitration agreement but was not told he could change his mind as long as he rescinded the agreement within a certain number of days. He said he was not sure if he got a copy of the agreement. Resident #38 said when she was signing all the facility paperwork, she was highly medicated and in pain. She said she did not know what she was signing when she was admitted to the facility. Resident #194 said she remembered staff mentioning arbitration was available if she desired it or if she felt she needed it. She said there was nothing discussed about a timeline to rescind if she signed the agreement. IV. Record review The facility admission packet was provided by the NHA on 4/24/24 at 8:57 a.m. via email. The admission packet included the binding arbitration agreement. Requested arbitration agreements were provided by the human resources director (HRD) on 4/29/24 at 4:15 p.m. The provided arbitration agreements were signed by either AC #1 or AC #2 as the facility representatives. The arbitration agreements were each signed by the resident. The arbitration agreements were reviewed for Resident #10, Resident #38, Resident #96, Resident #194 and Resident #198. Resident #10 was admitted on [DATE]. The arbitration agreement was signed by AC #2 on 3/18/24. The arbitration agreement was signed by Resident #10 on 3/18/24. Resident #38 was admitted on [DATE]. The arbitration agreement was signed by AC #1 on 4/2/24. The arbitration agreement was signed by Resident #38 on 4/2/24. Resident #96 was admitted on [DATE]. The arbitration agreement was signed by AC #2 on 4/22/24. The arbitration agreement was signed by Resident #96 on 4/22/24. Resident #194 was admitted on [DATE]. The arbitration agreement was signed by AC #1 on 4/11/24. The arbitration agreement was signed by Resident #194 on 4/11/24. Resident #198 was admitted on [DATE]. The arbitration agreement was signed by AC #1 on 4/25/24. The arbitration agreement was signed by Resident #198 on 4/25/24. V. Additional resident interviews Resident #96 was interviewed on 4/29/24 at 2:06 p.m. Resident #96 said she did not know what arbitration was in reference to paper work she signed or how it pertained to her as a resident at the facility. She said she did not remember anyone talking to her about it or how long she had to change her mind if she signed the agreement. Resident #38 was interviewed again on 4/30/24 at 11:10 a.m. Resident #38 reviewed the paper work provided by the facility. She said she could not find anything from the facility on arbitration. Resident #38 said she did not know she signed an arbitration agreement. She said she would have wanted to know if she signed the binding agreement. She said it was okay with her that she signed the agreement but felt she should have been made more aware of it and told she had the option to change her mind and how long she had to decide if she wanted to keep the agreement in place. She said she did not remember signing the agreement. She said she just signed all the paperwork offered when she first admitted . She said she had just had surgery a couple of days before she was admitted to the facility and was not very lucid. Resident #38 said she would have wanted someone from the facility to explain the arbitration agreement to her when she felt more lucid. She said she felt that having her sign legal paperwork when she first admitted was the wrong time to give it to her. Resident #194 was interviewed again on 4/30/24 at 11:31 a.m. She said some of the other residents said they were in pain when they were asked to sign admission paperwork. She said when someone was in pain they were not thinking about anything but their discomfort. Resident #194 said she was not in pain when she signed all her paperwork but she was just focusing on the day to day unknown issues and what would happen next for her. She said she was not thinking about what she may have signed or the implications. IV. Staff interviews AC #1 was interviewed again on 4/30/24 at 11:39 a.m. AC #1 said she had reviewed the arbitration agreement and was provided education on the agreement after the 4/25/24 interview. AC #1 said she was originally trained by AC #2 on the arbitration agreements. She said she offered to give the residents a copy of the agreement but was not going over all of the agreement with them. She said she was not aware the arbitration agreement was binding or the residents had only 90 days to rescind the agreement. She said her focus was to inform the residents the facility wanted to hear about any issues or concerns so the facility could attempt to correct the concerns. AC #1 said residents could sign their own admission paperwork, including the arbitration agreement, if the resident was alert and oriented and if their dominant hand was able to sign the forms. She said if residents were not able to sign the arbitration agreement electronically, she would print out the agreement and have them sign the hard paper copy. AC #1 said she usually had the residents sign all the paperwork right when they walked in the door. She said the admission process could be hectic at times. She said sometimes she might have the residents finish the paperwork on the second or third day after they were admitted to the facility, but she liked having them complete it as soon as they could. She said she told residents she could print off a copy of the arbitration agreement during the admission paperwork process or the resident could request a copy from medical records. She said she was now going to offer to send out the arbitration agreements to the residents and/or the residents' representative. The NHA was interviewed on 4/30/24 at 11:50 a.m. The NHA said the arbitration agreement was part of the facility' s admission packet. He said the arbitration agreement was not binding and the agreement was voluntary for signing. He said the residents who signed the non binding arbitration agreement could revoke the agreement at any time. The NHA reviewed the arbitration agreement and identified the agreement was binding after 90 days if the resident did not rescind the agreement. The NHA said she did to know some of the residents were not aware they signed the agreement and had not been informed of key components of the agreements by AC #1 and AC #2. She said she did not know some of the residents felt they had signed the agreement at a time they were not in an appropriate state of mind to make the decision to sign the agreement and/or retain the information contained in the agreement.The NHA said the HR director was more familiar with the arbitration process and used to be the staff member who reviewed the agreements with residents and/or their representatives. The HRD joined the interview at 12:05 p.m. The HRD said she had previously been responsible for presenting the arbitration agreement to the residents and/or the residents' representatives for the past five years. She said in October 2023, the admissions department started taking on more of that role. The HRD said when she would review the agreement with the residents she would ask the residents if they were willing to enter into an arbitration agreement. She said she would explain to the residents that if the facility was not able to make things right for them or meet their needs, the arbitration process was available to help resolve concerns outside of court. The HRD said she would tell the residents they were able to rescind the agreement at any point. She said if the residents asked about a timeline, she would get more clarification. The HRD said the facility started an education on arbitration after AC #1 was interviewed about the arbitration agreement and she wanted to have a better understanding of the agreement. The HRD was interviewed again on 4/30/24 at 12:24 p.m. The HRD said the facility would create additional education on the arbitration agreement in addition to the below Take Five education. V. Facility follow up A Take Five Quality Assurance Performance Improvement education was provided by the HRD on 4/30/24 at 12:24 p.m. The education was provided to AC #1, AC #2, the HRD and the medical records director on 4/29/24. The education topic was the arbitration agreement. The education highlighted the portion of the agreement that read: Note: By signing this agreement you are agreeing to have any issue of medical malpractice decided by a neutral binding arbitration rather than by a jury or court trial. You have the right to seek legal counsel and you have the right to rescind this agreement within 90 days from the date of signature by both parties unless the agreement was signed in contemplation of hospitalization in which you have 90 days after discharge or released from the hospital to rescind the agreement. No healthcare provider shall withhold the provision of emergency medical services to any person because of that person's failure or refusal to sign an agreement containing a provision for binding arbitration of any dispute arising as to professional negligence of the provider. No healthcare provider shall refuse to provide medical care services to any patient solely because such patient refused to sign such an agreement or exercise the 90 day right of rescission.

Based on observation and interviews, the facility failed to ensure residents received professional standards of care for one (#18) of one resident reviewed for edema care out of 28 sample residents. Specifically, the facility failed to appropriately notify the provider of significant weight changes for Resident #18. Findings include: I. Facility policy The Edema policy, revised March 2024, was provided by the nursing home administrator (NHA). on 4/30/24 at 1:54 p.m It documented in pertinent part, Nurses are to obtain daily weights if ordered by the provider, and nurses are to notify the provider with any changes in edema. The Weight Loss and Interventions policy, revised March 2024,was provided by the NHA on 4/30/24 at 1:54 p.m. It documented in pertinent part, Nursing staff measures residents' weights on admission and then the next day or as ordered by physician, nurse practitioner, or dietician. III. Resident #18 A. Resident Status Resident #18, over the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician order (CPO), diagnoses included takotsubo' s syndrome (a temporary irregular heart shape and function), heart failure, and lymphedema (a swelling of a portion of the body). According to the 2/9/24 minimum data set (MDS) assessment, Resident #18 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented the resident was 63 inches (five feet three inches) and 297 pounds (lbs). The MDS assessment did not indicate the resident had any weight changes. B. Record review The 2/26/24 care plan failed to document the resident's edema. The care plan identified interventions for fluid imbalance deficit risk because the resident was receiving diuretics. -However, daily weights were not included in these documented interventions. According to the April 2024 CPO, Resident #18 had an order to weigh the resident daily, and to notify the provider if the resident had a three lb weight change in 24 hours or a five pound weight change in seven days, ordered 2/3/24. Resident #18' s weights were documented in the electronic medical record (EMR) as follows: On 2/7/24, the resident weighed 298.6 lbs, which indicated she had lost 3.0 lbs in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 2/7/24. On 2/11/24, the resident weighed 301.4 lbs, which indicated she had gained 3.4 lbs in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 2/11/24. On 2/13/24 the resident weighed 298.6 lbs, which indicated she had gained 4.0 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 2/13/24. On 2/15/24, the resident weighed 299.8 lbs, which indicated she had lost 6.0 pounds in two days. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 2/15/24. On 3/5/24, the resident weighed 301.6 lbs, which indicated she had gained 11.2 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 3/5/24. On 3/6/24, the resident weighed 290.6 lbs, which indicated she had lost 11.0 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 3/6/24. On 3/20/24, the resident weighed 298.2 lbs, which indicated she had gained 6.8 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 3/20/24. On 3/30/24, the resident weighed 291.9 lbs, which indicated she had lost 5.7 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 3/30/24 On 4/2/24, the resident weighed 299.4 lbs, which indicated she had gained 7.5 pounds in three days. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 4/2/24. On 4/3/24, the resident weighed 296.4 lbs, which indicated she had lost 3.0 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 4/3/24. On 4/28/24, the resident weighed 299.4 lbs, which indicated she had gained 4.2 pounds in one day. -A review of the resident' s EMR did not reveal documentation indicating the physician was notified of the weight change on 4/28/24. IV. Staff interviews Certified nursing aide (CNA) #1 was interviewed on 4/29/24 at 11:12 a.m. CNA #1 said Resident #18 needed to be weighed daily. CNA #1 said obtaining a consistent weight for Resident #18 had been difficult for the nursing team because of variations in the process of weighing residents among nursing staff. CNA #1 said if the nursing staff believed a weight was inaccurate the resident would be re-weighed that day or the next day. Registered nurse (RN) #2 was interviewed on 4/29/24 at 11:28 a.m. RN #2 said when a provider was notified of a weight change it was documented in the resident' s EMR. The registered dietitian (RD) was interviewed on 4/29/24 at 1:31 p.m. The RD said she was responsible for monitoring residents' weights. The RD said it was normal to weigh residents with edema daily. The RD said she was not aware Resident #18 had significant weight fluctuations in February 2024, March 2024 and April 2024. The RD said all provider orders should be followed. The RD did not know if a provider was notified for any of the significant weight changes documented in February 2024, March 2024 and April 2024. The RD said provider notification of weight changes should be documented in the progress notes section of the EMR. The director of nursing (DON) was interviewed on 4/30/24 at 3:38 p.m. The DON said all provider orders should be followed. The DON said she reviewed the documented weight changes for Resident #18 and the provider orders for Resident #18 for February 2024, March 2024 and April 2024. The DON said the provider should have been notified many times because the resident had significant weight changes in February 2024, March 2024 and April 2024. She said did not know if the provider had been notified for the significant weight changes The DON said she was unable to find documentation indicating the provider had been notified of the resident's weight changes.

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchens during meal services. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; and, -Ensure beverages were served at the appropriate temperature. Findings include: I. Professional standards The Centers for Disease Control and Prevention (CDC), reviewed 8/5/22, retrieved on 1/17/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under Four Steps to Food Safety read bacteria could multiply rapidly if left at room temperature or in the Danger Zone between 40 F and 140 F. II. Facility policy The Handwashing for Dietary Staff policy, revised 2/8/21, was provided by the dietary manager (DM) on 1/13/23 via email. The policy indicated staff should wash their hands as frequently as needed throughout the day using proper hand washing procedures. According to the policy, staff should wash their hands and exposed portions of the arms immediately before engaging in food preparation and as often as necessary to remove soil or contamination in efforts to prevent cross contamination. The policy hand hygiene should also occur when changing tasks during food preparation and other activities that could contaminate staff's hands. III. Observations A continuous observation of the lunch meal preparation and service was completed on 1/11/23 between 11:17 a.m. to 12:29 p.m. A. Cross-contamination During plating of the 1/11/23 lunch, the cook placed a plate of ready-to-eat food on the steamline shelf. Dietary aide (DA) #1 placed an empty tray on the back side of the steam table and set a covered dessert, paper napkin rolled silverware, and a pre-poured beverage on the tray with his bare hands. The DA then collected the plate off the shelf, covered it, and placed it on the prepared meal tray. DA #2 then placed a hot beverage (if ordered) on the tray and placed the completed meal tray inside a covered mobile unit for room delivery. Between 11:20 p.m. and 12:23 p.m. DA #1 placed his hands inside his pants pockets while he waited for the cook to place the plated meal on the shelf. The DA would then remove his hands from his pockets, place the plate of the tray, passing it to DA #2, and prepared the next tray. DA #1 did not perform hand hygiene after the removal of his hands in his pockets, and touching the outside surfaces of the paper napkin, plate holder, dessert bowl or beverage glass. Throughout the observation, DA #1 frequently retrieved the covered beverage glass of a cart by placing his hand over the top of the glass with his fingers, touching the drinking surface of glass, his fingers exceeding the surface of the thin covered lip of the glass. -At 11:57 a.m. DA #2 placed his right forearm across the prepared tray, resting the bare portion of his arm on the rolled napkin as he waited for the plated meals. DA #2 was not observed to wash his forearm prior to placing it across the tray. -At 12:04 p.m. DA #1 collected a plate from the shelf, touching the overhanging lettuce with his thumb before he placed a cover over the plate and set it on the tray. -At 12:09 p.m. DA #1 left the tray line and entered the dry storage room. The DA did not perform hand hygiene before returning to the tray line. -At 12:14 p.m. DA #2 touched the outside of his surgical mask and then proceeded to pour hot beverages in cups and place completed trays in the mobile unit. DA #2 did not perform hand hygiene after touching his mask. -Throughout the observation, DA #1 and DA #2 did not perform hand hygiene while preparing trays for resident delivery. B. Above temperature milk for resident consumption. On 1/11/23 between 11:20 a.m. and 12:23 p.m., pre-poured beverages in covered glasses were observed sitting out on a cart behind the steamline in the kitchen. The pre-poured beverages included several glasses of milk. On the bottom shelf on the cart was half of a gallon of milk. The pre poured glasses of milk and the milk container were not stored/held on ice or with another other system designed to keep the milk cold prior resident delivery. During observations, the dietary aides would retrieve an ordered an glass of milk from the cart, place the milk on a meal tray next to the covered hot food, and then place the tray with the milk in the covered mobile unit designed to keep meals warm.The mobile units would then be sent to the hallways for resident room delivery. -At 12:23 p.m. a test tray with a glass of pre-pour milk was placed in the mobile unit and sent to the second floor west hall. -At 12:27 p.m. the test tray arrived on the unit, along with resident meals, some of which included milk. -At 12:29 p.m. the test tray was removed from the mobile unit. -At 12:32 p.m. the temperature of the pre-pour glass of milk on the tray was collected. The temperature of the milk was 52.7 degrees Fahrenheit (F). IV. Staff interview The infection preventionist registered nurse (IPRN) and the corporate clinical consultant (CCC) was interviewed on 1/11/23 at 2:42 p.m. The IPRN said her infection control involvement with dietary, primarily consisted of Monday through Friday glance around to check if infection control practices were conducted as she placed her lunch order. The IPRN said she had also conducted a recent dietary audit and identified areas for dietary follow up. The DM was interviewed on 1/12/23 at 3:38 p.m. The DM said the dietary staff have had past in-services on appropriate infection control practices when handling food. She said infection control was an ongoing process. The above observations were reviewed with the DM. She said hands in the pocket, mask touching, and appropriate handling of resident drinking glasses/cups were all identified in the past and reviewed with the staff, due to the risk for cross-contamination. The DM said 52.7 F was not an acceptable temperature of milk to be served to the residents. The DM said the high temperature of milk could create a food borne illness. She said the milk should have been on ice to maintain an acceptable temperature. She said she would work on a different way to serve cold beverages. V. Facility follow-up The DM provided facility follow up to ensure infection control practice improvement according to a 1/13/23 provided email with an attached education checklist (Skills Check-Off Hand Washing form.) According to the email, the dietary department would be reviewing the below handwashing skill checklist on 1/16/23 through 1/21/23. In addition, and according to the provided email, the dietary department immediately corrected the beverage holding temperatures for meal delivery, starting with the evening meal service on 1/12/23. The beverages were placed in tubs containing ice to make sure they were within appropriate serving temperatures. The 1/13/22 DM provided Skills Check-Off Hand Washing form, identified the staff were instructed on how to wash their hands properly with a competency review.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for one (#8) out of 27 sample residents. Specifically, the facility failed to: -Promptly and thoroughly investigate a grievance and provide resident follow-up for resolution regarding potential mistreatment by a staff member; and, -Have a system in place to promptly identify and seek grievance resolution, when a resident reported missing items. Findings include: I. Facility Policy The Grievance policy, revised 2/8/21, was provided by the minimum data set coordinator (MDSC) on 1/12/23. According to the policy, residents had the right to voice complaints and/or grievances regarding respect, care, treatment or any other matters related to quality of care or quality of life. Grievances could be communicated to a staff member either verbally or in writing. The facility would make every effort to promptly investigate and resolve any grievances. The policy procedure read in pertinent part: If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The completed form must be provided to the executive director (nursing home administrator) or designee immediately. The grievance will be given to the appropriate department manager for follow-up and resolution. All grievances will be reviewed in morning meetings with the IDT (interdisciplinary team) members. Department managers are responsible for resolution of all complaints within his/her department. Department managers will note the disposition of the grievance in writing to the executive director or designee as soon as possible, but no later than 72 hours of the receipt. It is the responsibility of the department manager in coordination with the executive director, when appropriate, to develop a process/plan for resolution of the grievance and notify the complainant about the plan for resolution. All actions taken on the grievance included meetings with the patient, telephone calls, action plans, revision of care plans, ect. must be documented on the grievance form. The Quality of Life - Dignity policy, undated, was provided by the facility on 1/12/23. According to the policy, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy identified residents shall be treated with dignity and respect at all times. The policy indicated that treating with dignity meant the resident would be assisted in maintaining enhancing his or her self-esteem and self-worth. II. Resident #8 status Resident #8, age 77, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, Alzheimer's disease late onset, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, depression, and anxiety disorder. The 10/15/22 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment identified the resident did not have inattention or disorganized thinking. According to the MDS assessment, the resident required extensive one person physical assistance for transferring, locomotion on the unit, and toileting. Resident #8 required limited one person physical assistance for dressing, bed mobility and personal hygiene. The MDS assessment identified the resident had corrective lenses. III. Failed to promptly and thoroughly investigate a grievance and resident follow up for resolution regarding mistreatment by a staff member. A. Resident interview Resident #8 was interviewed on 1/10/23 at 8:41 a.m. She said she had not been treated with respect and dignity by one certified nurse aide (CNA). She said she did not know the name of the CNA but she was usually rude, pushy, and gruff with her. She said the CNA had also touched her after wiping her nose with hands and then touched the resident without performing hand hygiene. The resident said the CNA refused to wash her hands after the resident asked her too and said she would perform hand hygiene when she left the room. Resident #8 said she had reported her concerns to her nurse. B. Staff interviews Registered nurse (RN) #1 was interviewed on 1/12/23 at 1:06 p.m. She identified herself as a routine nurse for Resident #8. The RN said Resident #8 was very pleasant and did not usually complain. She said Resident #8 reported to her that CNA #2 was mean to her. The RN #1 clarified and said the resident reported the CNA was mean to her in a verbal tone and was not patient with her. RN #1 said she had seen CNA #2 impatient with other residents. The RN said she reported the concern to the infection preventionist registered nurse (IPRN) and then the CNA lead. RN #1 said she interviewed CNA #2 and identified that the CNA had personal concerns she was dealing with. The RN said she reminded CNA #2 to leave her personal issues at home. The CNA lead was interviewed on 1/12/23 at 1:16 p.m. The CNA lead said she talked to Resident #8 almost every day and she had not expressed her concerns to her regarding any staff members. The CNA lead said she was recently on vacation but when she returned on 1/5/23, she was informed Resident #8 did not want to have CNA #2 as her CNA. The CNA lead said Resident #8 felt the CNA did not want to help her and was impatient with her. She said she thought the concern occurred on the previous weekend shift (1/1/23) because the CNA worked weekends but was not sure exactly when. The CNA lead said she reported the concern to the NHA on 1/5/23. She said a grievance form was not generated. The CNA lead said the CNA was moved off the hall of Resident #8 and she completed an education with CNA #2. The assistant director of nursing (ADON) was interviewed on 1/12/23 at 10:02 a.m. She said she was not aware of any grievances or investigations regarding Resident #8 but would look. The social services director (SS) was interviewed on 1/12/23 at 10:07 a.m. She said she was not aware of any concern or grievances regarding Resident #8. The MDS coordinator (MDSC) who was identified as the former director of nursing (DON), the new DON, the assistant director of nursing (ADON) and the corporate clinical consultant (CCC) was interviewed on 1/12/23 at 6:26 p.m. The MDSC said in morning meetings the interdisciplinary team reviewed resident grievances. The grievance resolution would then be signed off by the nursing home administrator (NHA). The ADON and the MDSC said they did not review grievances or any heard information related to Resident #8 reporting a CNA was rude or mean. The ADON said she believed Resident #8 had a preference not to work with a CNA as reported by the CNA lead. She said she did not know which CNA. The ADON said she would have to follow up with the CNA lead. She said the CNA lead was in charge of CNA concern follow ups. The MDSC said she remembered the resident had an interaction with a staff member. The MDSC said she did not remember more regarding the concern discussed. She said when a resident reports a staff member being mean to them, the facility should make sure the person being accused was removed from the environment and immediately interview the resident. She said nursing management would then check with other staff on the same shift, family, and other residents about it. She said concerns should be reported right away. She said education would need to be completed with staff members. The ADON said education was completed with CNA #2 but she was not sure when. The MDSC said they were not made aware of the resident's concern until after the fact. The ADON said they were made aware when it was later reported to the CNA lead. The MDSC and ADON said the CNA had not worked with the resident since her concerns were reported. The ADON said the facility had done multiple training of abuse in the past and did a CNA skills training in October 2022. She said abuse education was conducted across the board with nursing shortly after management became aware of the resident's reports. The MDSC said the last education was specific about if they see something, report it right away. The MDSC said staff education was the first starting point in prevention. The education should include self identification of tone of voice, reminder to leave attitudes at the door, and present happy demeanor. She said the facility needed to continue coaching, continued follow up, working with our nurses, and coaching CNAs by example such as tone of voice and modeling appropriate behavior to others. The CCC identified the facility could benefit from outside education resources related to resident rights, dignity/respect, appropriate communication/interactions with residents. The CCC suggested potential available community education resources that could be obtained for additional staff training. The MDSC said the facility needed to improve their investigation process, including root cause analysis, when resident concerns are identified. The DON said they would immediately start reviewing their grievance processes and staff training. They said they would have something in process within next week, an ongoing thing, refreshing, and continuous and would probably start tomorrow (1/13/23). They said their actions would be in addition to already occurring patient advocate room rounds which were done daily by managers. The MDSC said she was not sure if there was follow up with Resident #8 after she reported her concerns with CNA #2. The MDSC said she would have to pull the room rounds. C. Record review The records did not identify a grievance was generated and the resident was followed up with to ensure her concern was resolved. The records did identify and investigation was conducted, identifying resident concerns, facility response and action, including interviews with the resident, staff, or other residents who have worked with CNA #2 to identify if they had additional concerns related to CNA #2 inappropriate treatment/behaviors. The review of Resident #8's progress notes did not identify her dignity, grievance was not documented or readdressed/followed up with her. A 1/5/23 abuse and mistreatment education was provided by the ADON via email on 1/13/23. The education was labeled Take 5 and instructed staff the read the following information: The (facility) has a zero tolerance for any abuse or mistreatment of our patients. we take pride and treating our patients with respect, dignity, kindness and compassion if you see or hear mistreatment remember your training brief reminder below: -Intervene if you witness the mistreatment ( make sure patient is safe) -Report immediately to your supervisor and administrator we comply with strict reporting to authorities as mandated by the state. -Always ask for help or ask questions when needed -When in doubt ask -You're supervisor, social services, d o n, and administrator always available- if not in-house they're available by phone -Remember our patients are here because they need our care, compassion and understanding. Making the patients feel safe and comfortable is our top priority. The 1/6/23 CNA #2 on the spot training related to patient complaints/concerns was provided by the facility on 1/12/22. The training identified the CNA lead conducted the education. The plan of correction/education read: Need to watch your tone of voice with patient. Perception is everything. The tone of your voice can come across as being rude and or aggressive. Also need to slow down while providing care so patients do not feel rushed, or feel that you're being impatient with them. -However, the facility did not follow up with the resident on her grievance with CNA #2 she reported. IV. Failed to timely follow up on Resident #8 concern of a missing pair of glasses A. Resident interview Resident #8 was interviewed on 1/10/23 at 8:41 a.m. She said she was not happy that she was still missing her glasses. She said she told everyone. The resident said they told her they would tell everyone else. She said not having her glasses, she was having a difficult time reading the menu, and reading the communication board located on the wall across from her bed. She said because she could not read the communication board, she did not know which staff members she would be working with that day or when therapy was scheduled that day. Resident #8 was interviewed again on 1/12/23 at 10:15 a.m. She knew her daughter did not have her glasses because she was the first one checked with. She said staff looked in her room for the glasses but that was all she knew about the follow up. B. Record review The vision care plan, initiated on 10/14/22 identified the resident had impaired vision. The care plan read the resident's needs would be met and not affected by her vision impairment. The care plan directed staff to assist her with glasses as needed. Records did not identify Resident #8 reported she was missing her glasses or what steps the facility took to find her glasses, and seek resolution. C. Staff interview CNA #1 was interviewed on 1/11/23 at 9:54 a.m. She said she was the resident's bath aide and also provided care. She said she knew Resident #8 had been missing her glasses for the past couple of weeks. She said she believed the glasses had been around since her last hospital appointment (12/23/22). She said the resident's nurse and her daughter were aware the glasses were missing. The SS was interviewed on 1/11/23 at 1:36 p.m. She said there was not a tracking process that she was aware of for missing items. She said if a resident reported a missing item, then nursing or the CNA lead would look for the item and check with the family. The SS said she was not usually involved in the process and not sure of the procedure. She said known missing items would be reported in the morning meeting. The ADON was interviewed on 1/12/23 at 9:53 a.m. She said if a resident was missing an item, the DON and the ADON and possibly the CNA lead. The ADON said the family would be contacted. She said if appropriate, laundry would be notified. She said they would also sometimes check with admissions to determine if the resident admitted with the identified missing item. The ADON said the IDT would also talk about the missing item in the morning meeting. She said there was no paper trail for missing items and follow-up, just verbal communication. She said she was not aware Resident #8 were missing glasses prior to 1/12/23. The SS was interviewed again on 1/12/23 at 10:05 a.m. She said she was not aware Resident #8 was missing her glasses. She said the CNA nor the resident's family reported the missing item to her. The CNA lead was interviewed on 1/12/23 at 10:09 a.m. She said if a concern of a missing item was reported to her, the concern would be flagged till the item was replaced or closed/resolved. She said it would be good to generate a grievance form for tracking. The CNA lead said she was not aware of Resident #8 missing glasses. She said she knew the resident had an outpatient patient hospital appointment she went to with her daughter in December 2022. She said she would follow up with her daughter. RN #1 was interviewed on 1/12/23 at 12:58 p.m. She said the resident and daughter reported to her that she was missing her glasses. She said she thought she heard that the glasses were missing since Christmas. The RN said she checked if the facility had a lost and found, but they did not have one. She said she asked the kitchen if they found any glasses that were left on the tray after meals. She said she had not heard back but assumed they did not find them. She said she found out today (1/12/23) that she should have filled out a grievance form for missing items. She said she brought the resident reading glasses but did not know the resident was still having difficulty seeing without her original glasses. The CNA lead was interviewed on 1/12/23 at 1:22 p.m. She said she followed up with missing glasses and identified they had been missing since 12/25/22 and not lost when she went out to her (12/23/22) appointment. She said the glasses were not reported to her or a grievance was completed. She said she educated staff today (1/12/23) to start using the grievance form to identify when a resident reports a concern with missing items. She said the facility used to use the grievance forms to report and track missing resident items but for the last couple of years, the process went away. She said up till 1/12/23, the facility just relied on verbal communication as their missing item process. She said the grievance form would provide a paper trail for notification, actions taken, and attempts for resolution. She said she would be the designated person to follow up and track missing items identified on the grievance forms. The CNA lead said having a set system in place would help address the missing items concern right away, increasing the probability of finding the item. The MDSC, the new DON, the ADON and the CCC was interviewed on 1/12/23 at 6:26 p.m. The MDSC said the facility had reached out to the resident's family but had not heard back. She said the CNA lead was reimplementing the grievances for missing items and would use the grievance forms as a tracking tool. The MDSC said it was within their policy to replace missing items if needed and the facility had replaced items in the past. D. Facility follow-up The Quality Education Performance Improvement attendance sheet, dated 1/12/23, was provided by the CNA lead on 1/12/23 4:04 p.m. According to the Performance Improvement attendance sheet, staff were educated on 1/12/23 regarding the new missing item process. The education read: If something is reported to you as missing, you need to check the patient's room for the item. If the item is not found, you are to write it up on the orange grievance forms located at the nurses station on both floors and give it to (CNA lead) as soon as possible. A grievance form, on behalf of Resident #8 was dated 1/12/23 and provided on 1/12/23 at 4:04 p.m. The grievance form read the resident was missing glasses. The grievance form identified missing glasses were reported to RN #1 on 1/5/23. The RN looked through the resident's room and called the front desk to check lost and found. The RN brought the resident a pair of reading glasses on 1/12/23.

Based on observation, record review and interview the facility failed to ensure that a resident, one (#26) of one reviewed for pressure ulcers, did not sustain an unstageable pressure injury out of 27 sample residents. Resident #26 was admitted to the facility for rehabilitation following a fall with a right [CONDITION(S)] requiring surgery on 8/20/21. She was identified during her admission assessment to be at risk for developing pressure ulcers and the admission skin assessment identified a surgical wound only. The resident developed an avoidable unstageable wound to her coccyx 16 days after admission. The facility was aware she was at risk for pressure ulcer development and failed to ensure all potential preventative interventions to help prevent an avoidable pressure ulcer from developing on her coccyx were implemented in a timely manner. According to her skin care plan, an air mattress was to be in place and she was to be monitored for and assisted to be turned and repositioned frequently. Observations revealed she did not have an air mattress in place. There was no evidence found to demonstrate she was on a formal turning and repositioning schedule. She required extensive assistance with her mobility. In addition, the facility failed to investigate or conduct a root-cause analysis to determine how the pressure ulcer was acquired to prevent any further pressure injuries from occurring. Findings include: I. Professional reference National Pressure Ulcer Advisory Panel (2016) Pressure Injury Stages. Retrieved on 9/24/21 from: https://npiap.com/page/PressureInjuryStages. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedure A Pressure Ulcer policy, revised 7/21/21, provided by the director of nursing (DON) on 9/20/21 at 2:20 p.m. documented in part, The Centers will provide the necessary requirements to ensure that a patient receives treatment and care in accordance with professional standards of practice. Procedure: Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin; In addition the (facility) shall describe and document the following: full evaluation of pressure sore including description of the wound, pain evaluation, the patient's mobility status, current treatments if applicable and MD and family notification. When a new skin concern is found, staff will: complete an incident report inside of risk management to include notifications to the physician, complete an SBAR (situation, background assessment and recommendation), place the patient on the 24-hour report and notify the director of nursing and wound specialist as needed. III. Resident status Resident #26, age 93, was admitted on [DATE]. According to the September 2021 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 8/27/21 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance from two staff for bed mobility, transfers and toileting. She was mobile per walker and wheelchair. She was coded at risk for developing pressure ulcers and had no pressure ulcers upon admission. Treatments included a pressure reducing device in her chair and bed, surgical wound care and application of ointments and medications other than to the feet. Her treatment did not include a turning or repositioning program. IV. Resident interview Resident #26 was interviewed on 9/14/21 at 9:05 a.m. She was sitting in her recliner at her bedside. The recliner was not upholstered and had a firm surface on the seat and back area. There was no supportive, offloading pad or cushion in the chair. The resident said that she had a sore on her bottom that was open. She said it happened after she arrived at the facility. She said the nurses were treating it with a bandage. She said she did not know how it happened but that she had been in bed for a long time due to her hip surgery. She said the sore caused her discomfort sometimes but she just shifted her weight and it helped. She said no staff reminded her or helped her change positions because she could reposition herself. V. Record review A nursing comprehensive admission data collection dated 8/20/21 documented the resident's skin condition as follows: -Right trochanter hip surgical wound. -There were no other identified skin issues. The Braden scale (part of the admission assessment) identified her as at risk for skin breakdown related to deficits in sensory perception, moisture, activity level, mobility, nutrition and friction and shear. A skin care plan initiated 8/23/21 identified the resident as at potential risk for skin breakdown due to decreased mobility and a surgical wound to the right hip. Interventions included: -Air mattress to bed per facility guidelines; however the resident only had a standard pressure relieving mattress and not an air mattress (see DON interview below). -Apply moisturizer to skin. Do not massage over bony prominence and use mild cleanser for peri-care/washing. -Braden scale every week per protocol, and skin evaluation as ordered and as needed. -Monitor/remind/assist to turn/reposition frequently as needed or requested (was no consistently implemented per resident interview, see above). -Skin treatment per physician order. A nutritional assessment dated [DATE] revealed under the other nutritional risk factors that the resident had no nutritional factors and that she did not have a pressure injury. A Braden scale for predicting pressure sore risk dated 9/2/21 documented the resident with a score of 13 meaning she was at moderate risk. A nurse note dated 9/6/21 and time-stamped at 5:04 p.m. documented in part that a certified nurse aide (CNA) alerted the nurse about an open area on the resident's coccyx. The wound was open with slough present and red skin surrounding the wound. A wound initial evaluation dated 9/6/21 documented in part the resident was found to have an acquired pressure ulcer to the coccyx measuring 0.4cm (centimeters) x 0.3cm with no depth, described as unstageable. The wound summary documented the wound had slough and the surrounding tissue had slight blanchable redness. The resident was making progress with therapy but did fatigue easily. The resident verbalized understanding and performed a return demonstration for frequent offloading and repositioning. A care plan initiated 9/6/21 identified the resident with an unstageable pressure injury to the coccyx area. Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate and any other notable changes or observations. A Braden scale for predicting pressure sore risk dated 9/9/21 documented the resident with a score of 14 meaning she was at moderate risk. -Although the resident was discovered to have an acquired pressure ulcer on 9/6/21. A wound progress review dated 9/10/21 documented in pertinent part the wound measured 0.3cm x 0.3 cm with no depth. The wound was documented as improving and documented as unstageable. A physician's telehealth progress note dated 9/13/21 documented in part the resident had a new stage 2 pressure ulcer to her coccyx. -However, it was previously documented as unstageable on 9/6/21. The physician did not document any new order changes or mention any other interventions. The September 2021 CPO revealed in part the following order: -Cleanse coccyx wound with normal saline, pat dry, apply medi-honey to wound bed, cover with a foam dressing. Change M-W-F and PRN (as needed) for soiling/dislodgement. Start date 9/6/21. -Barrier cream to coccyx/buttock/peri area/reddened area for prevention, q (every) shift and PRN. Start date 8/20/21. -Review of the September 2021 treatment administration record (TAR) revealed that on 9/17/21 and 9/20/21 there was no signature to demonstrate that the treatment (above) had been completed. In addition, there was no documentation found the resident received a PRN dressing change any time between 9/6/21 and 9/16/21 (see wound observation below). -Review of daily skilled notes and progress notes from 8/20/21 through 9/5/21 revealed the resident's skin was intact other than her surgical wound to her right hip until the discovery of the unstageable coccyx wound found on 9/6/21. In addition, documentation failed to demonstrate the resident was provided education and encouragement to change positions or off load to decrease pressure to her bottom. The resident's daily care record for September 2021 and the Kardex (record of specific care needs) failed to demonstrate the resident was on a turning or repositioning program. VI. Wound care observation and interview On 9/16/21 at 2:08 p.m. wound care was observed with registered nurse (RN) #2. He said that the last time he took care of the resident she did not have a wound on her coccyx. He said it was not reported to him during report that she had a wound on her coccyx. RN #2 reviewed the resident's daily assessments and said that she did not have any documented coccyx wound prior to 9/6/21. Next RN #2 gathered his supplies and took them into the resident's room and placed them on her over the bed table. He then assisted the resident from her recliner to her bed. He washed his hands with soap and water and then donned a clean pair of gloves. He then assisted the resident to pull her pants and underpants down below her buttocks. The resident did not have a dressing in place over her coccyx. The RN then doffed his gloves, washed his hands again and donned a clean pair of gloves. Next he cleansed the wound and measured it. The wound measured 0.5 cm x 0.75 cm x 0.25 cm. There was no drainage from the wound and in the center there was white to slightly yellow slough. The peri-wound was pink and intact. RN #2 said the wound was unstageable and that when he spoke to the DON earlier she said that it was looking better and had decreased in size. -However, according to the previous wound documentation on 9/10/21, the wound had increased in size. The RN then dressed the wound with the prescribed treatment (see above), placed the protective dressing over the wound and dated it. The resident said she wanted to go back into the recliner and the RN assisted her to the recliner. The RN said the resident liked to stay in her recliner and that nursing encouraged her to shift positions often. VII. Staff interviews RN #3 was interviewed on 9/16/21 at 2:40 p.m. She said she was helping on the floor as a CNA today and was taking care of Resident #26 today. She said the resident was a one person assist for transfers and used her walker and a gait belt for stability. She said she helped the resident to the bathroom today and helped her clean up. She said she did not see a wound on her coccyx and did not see a dressing. RN #4 was interviewed on 9/16/21 at 4:13 p.m. She said on 9/6/21 she had received report from the day nurse that Resident #26 had a pressure injury on her bottom. She said the resident did not have one before then. She said she assessed the area and then reported it to the DON. She said when the resident first admitted to the facility she was chair and bed bound due to her right hip surgery. She said she required a lift at that time up until about a week ago. She said the resident had some urinary incontinence and was at risk for shearing until recently. She said she felt the wound had improved. -However, according to the previous wound documentation on 9/10/21, the wound had increased in size. The DON was interviewed on 9/16/21 at 3:44 p.m. She said Resident #26's wound was acquired in the facility and she saw it last week when it was brought to her attention on 9/6/21. She said she did not know how the resident had acquired it. She said she did the resident's skin assessment along with her DON consultant that was in the building at the time. She said she had seen it since then and it was improving. -However, according to the previous wound documentation on 9/10/21, the wound had increased in size. She said she remembered discussing the resident's wound in the IDT (interdisciplinary team) meeting the next morning and that it was discussed that the resident had decreased mobility and was thin. She said they may have discussed her nutritional status as well. She said there were no formal notes taken or kept from that meeting that she was aware of. She said that a risk management report should have been completed which would have triggered an investigation. She reviewed the resident's record during the interview and said that she could not find an investigation. She said she would look into it further and provide follow up. The nursing home administrator (NHA) was interviewed during an administrative meeting on 9/16/21 at 5:23 p.m. She said the facility watched residents with high risk for pressure ulcers closely. She said the IDT reviewed skin integrity for residents at risk and or with current skin concerns. She said residents ' identified with a concern or potential concern were reviewed for nutritional needs. The NHA said the IDT received feedback from therapy on residents ' mobility and positioning to identify potential risk or causation. She said resident skin was reviewed daily and documented under daily skilled nurse notes. She said when a facility acquired pressure ulcer was identified with a resident, the facility would identify a plan for off-loading/repositioning. The NHA said the resident would be placed on two hour rounds and therapy would also watch for lack of movement of the resident during the day. She said the facility would also conduct random audits and at times, full house audits reviewing residents ' skin risk for or current pressure ulcer development. She said Resident #26 had a Braden assessment completed to identify risk. She said the resident may have had a deep trauma issue to the area that was not identified during admission or through daily nurse observations between 8/20/21 (admission) and 9/6/21 (on set). She said she believed the skin checks were not thorough enough to identify the concern prior to the finding of an unstageable pressure ulcer. VIII. Facility follow-up The DON was interviewed a second time on 9/16/21 at 5:52 p.m. She said she found out Resident #26 did have a pressure relieving mattress in place upon admission and that they would not have an air mattress in place for an unstageable wound. She said the resident also had a pressure relieving cushion in her wheelchair. She said she also followed up with the registered dietician (RD) and she did not feel the resident was nutritionally compromised and that supplements were already in place. She said there was not an additional nutritional assessment done when it was identified the resident had a change of condition (wound). She said she did not find a risk assessment or an investigation for Resident #26's wound.

Based on record review and staff interviews, the facility failed to ensure behavior monitoring was conducted for target behaviors related to the use of [CONDITION(S)] medications for one (#34) of five residents reviewed for medications of 27 sample residents. Specifically, the facility failed to ensure: -Target behaviors were being tracked for the use of [MEDICATION(S)] (an antidepressant medication) for Resident #34; -Hours of sleep were being tracked for the use of [MEDICATION(S)] (an antidepressant medication being used for [CONDITION(S)]) for Resident #34; and, -Consents for the above medications were obtained from Resident #34. Findings include: I. Facility policy and procedure The [CONDITION(S)] Medication Use policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 9/15/21 at 12:17 p.m. It documented residents who had not used [CONDITION(S)] drugs were not given these medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. II. Resident #34 A. Resident status Resident #34, age 74, was admitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included fusion of lumbar spine, [CONDITION(S)] and dementia without behavioral disturbance. -The resident did not have a diagnosis of depression or [CONDITION(S)]. The minimum data set (MDS) assessment dated [DATE] documented Resident #34 was cognitively intact for daily decision making with a brief interview for mental status (BIMS) score of 14 out of 15. It documented the resident had sleep disturbance and trouble concentrating two to six days during the 14-day lookback period. It documented he had little energy and an appetite disturbance 12 to 14 days during this lookback period. The MDS documented that this resident displayed no [CONDITION(S)] or behavioral symptoms. It documented three days of antidepressant usage during the seven-day lookback period. B. Record review The care plan related to [CONDITION(S)] medication, dated 9/8/21, documented the facility should be recording the number of episodes of Resident #34's mood disturbance and documented interventions should be attempted prior to medication administration. -There was no care plan created for the use of [MEDICATION(S)] or the resident had [CONDITION(S)]. The September 2021 CPO documented the following: -[MEDICATION(S)] (an antidepressant being used for [CONDITION(S)]), 100 mg prn (as needed) was ordered on 9/10/21. -[MEDICATION(S)], 200 mg QAM (every morning) for depression was ordered on 8/28/21 -Review of the resident's electronic medical record revealed there was no consent seen in Resident #34's chart for the use of [MEDICATION(S)]. -There was a consent obtained on 9/14/21 for the use of [MEDICATION(S)], but it was not completed until 9/14/21 (during the survey. -No behavior monitoring documentation was seen in the resident's chart under either the medication administration record (MAR) or treatment administration record (TAR). -The facility was not tracking hours of sleep for the resident, even though the sleep tracking was added to the resident's TAR on 9/10/21. C. Staff interviews Registered nurse (RN) #1 was interviewed on 9/14/21 at 11:21 p.m. She said she had not been tracking hours of sleep for the use of [MEDICATION(S)] or the target behaviors of depression for the use of [MEDICATION(S)] for Resident #34. The regional director of operations (RDO) was interviewed on 9/14/21 at 5:45 p.m. He said he could not find any behavior monitoring in the resident's chart at all. He said the facility should have been monitoring target behaviors for the use of the anti-depressant medication. He said he would have the facility create behavior monitoring sheets for this resident. The RDO was interviewed on 9/15/21 at 8:41 a.m. He said the facility created behavior monitoring in the resident's treatment administration record (TAR) the evening of 9/14/21. He provided documentation that the facility started tracking for signs and symptoms of the anti-depressant medication. -However, the facility still failed to track target behaviors for the use of the anti-depressant medication. The facility was not tracking hours of sleep for the use of [MEDICATION(S)] for Resident #34. The NHA was interviewed on 9/15/21 at 10:40 a.m. She said the facility should have been tracking behaviors for the use of [MEDICATION(S)] and hours of sleep for the use of [MEDICATION(S)] from the time they were ordered and ongoing. She said there should have been consents for the use of every [CONDITION(S)] medication ordered for this resident. She said the facility had been going to a new automated system for consents in their electronic records, but the [CONDITION(S)] consents for Resident #34 must have been missed somehow.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19 in three of four hallways. Specifically, the facility failed to ensure: -Staff followed proper infection control practices regarding donning and doffing of personal protective equipment (PPE) during resident cares; -Staff were performing proper hand hygiene after touching the outside of their mask to ensure cross-contamination did not occur; -Staff were offering and/or assisting residents to perform hand-hygiene prior to eating their lunch meal; and, -Housekeeping staff followed proper infection control practices while moving from one task to the next during room cleaning. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) guidance, How to protect yourself and others, updated 12/31/2020; retrieved 1/11/21 from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html Wash your hands often, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing. It is especially important to wash: Before eating or preparing food. Before touching your face. After using the restroom. After leaving a public place. After blowing your nose, coughing, or sneezing. After handling your mask. If soap and water are not readily available, use a hand sanitizer that contains at least 60 percent alcohol. Cover all surfaces of your hands and rub them together until they feel dry. Clean and disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks. If surfaces are dirty, clean them. Use detergent or soap and water prior to disinfection. se products from EPA's List N: Disinfectants for Coronavirus (COVID-19)external icon according to manufacturer's labeled directions. According to CDC guidance, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated July 2019, retrieved 1/14/21 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf Remove PPE at doorway before leaving patient room or in anteroom. GLOVES- Outside of gloves are contaminated. Grasp outside of glove with opposite gloved hand; peel off. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. GOGGLES/FACE SHIELD- Outside of goggles or face shield are contaminated! To remove, handle by clean headband or ear pieces. Place in designated receptacle for reprocessing or in waste container gown. Gown front and sleeves are contaminated! Unfasten neck, then waist ties. Remove gown using a peeling motion; pull gown from each shoulder toward the same hand. Gown will turn inside out. Hold removed gown away from body, roll into a bundle and discard into waste or linen receptacle MASK OR RESPIRATOR- Front of mask/respirator is contaminated, do not touch! Grasp only bottom then top ties/elastics and remove. Discard in waste container. Perform hand hygiene immediately after removing all PPE. II. Facility policies and procedures The Infection Control Precautions policy and procedure, revised December 2019, was provided by the director of nursing (DON) on 1/12/21 at 10:17 a.m. The policy documented in part, Purpose: (Facility corporation) are dedicated to providing the best care possible to patients who entrust their care to us. All employees must do everything possible to keep infection down. Policy: These infection control precautions must be used for all residents, regardless of [DIAGNOSES REDACTED]. The Hand Hygiene policy, revised May 2020, was provided by the DON on 1/7/21at 1:38 p.m. documented in part that hand sanitizer should be applied every time staff enter and leave a patient's room and hands must be rubbed together until hands feel dry (about twenty seconds). Hands should be sanitized or washed every time staff touch or remove their mask, goggles or face shield. III. Observations and interviews On 1/5/21 at 9:50 a.m., a physical therapy assistant (PTA #1) was observed stepping outside a non-covid, quarantine resident room in the hall with his isolation gown on. He removed the gown, rolled it up, carried it in his bare hands and walked to the opposite hallway to the soiled utility room. PTA #1 was interviewed at 9:52 a.m. as he exited the soiled utility room. He said staff were required to don full PPE when going into any resident room in the facility due to their current outbreak. He said when he finished with the resident he would remove his gown outside the resident room and take it to the soiled utility room. He said he knew he could not walk in the hall with the gown on. He said he did not know he had to place the gown in a bag before leaving the room. On 1/5/21 at 10:19 a.m. PTA #2 was observed exiting a non-covid, quarantine resident room with his gown held under his left arm while he sanitized his hands. He then placed the gown in his hands and continued down the hallway into the soiled utility room. PTA #2 was immediately interviewed as he exited the soiled utility room. He said he had received training on the proper use of PPE and masks. He said when he removed the gown inside the resident's room, he knew he was supposed to place it in a bag, tie off the bag and bring it out and place it in the laundry bin. He said plastic bags were hard to find inside the rooms and because he was in a hurry, he did not have the time to look for one. On 1/5/21 at 10:40 a.m. certified nurse aide (CNA #1) was observed sitting at the nurses station and charting at the computer. She had a KN95 mask on that fit her face loosely and sliding down her nose. She adjusted it several times with her right hand. She did not perform hand hygiene each time she touched her mask creating a potential for cross-contamination. On 1/5/21 at 11:00 a.m. CNA #1 was observed going into a non-covid, quarantine room to answer the call light without any PPE on except for her mask and face shield. Isolation carts, supplied with PPE were available in the hallway. On 1/5/21 at 11:45 a.m. PTA #2 was observed a second time coming out of a non-covid, quarantine resident room carrying an unbagged gown underneath his arm. PTA #2 said aloud as he passed by on his way to the soiled utility room across the hall the problem is there are no bags in the rooms. On 1/5/21 at 12:00 p.m. CNA #1 and CNA #2 were observed coming out of room [ROOM NUMBER], a non-covid, and quarantine resident room without isolation gowns on. CNA #1 went back into the same room without a gown, got the resident's plastic water pitcher, came out to the ice machine and filled it with ice. Then as she was returning to the room, she was stopped by the DON and told she had to wear full PPE each time she went into a resident room. CNA #1 said that someone should have told her when she came on duty in the morning. The DON then told her she needed to go home, shower and come back to work. At 12:05 p.m., CNA #1 was interviewed. She said that she had received training on how and when to don and doff PPE. She said today was her first day back after being off for four days. She said no one had told her she had to wear gowns for every resident on the third floor, where she was working. She said she thought that gowns only needed to be worn on the COVID-19 unit (located on the third floor, west hallway). She said usually signs were posted on the doors to let staff know they were supposed to gown up and she did not see any. She said she had gone into room [ROOM NUMBER] because the resident needed to be transferred and that CNA #2 came in to help her. On 1/5/21 at 12:12 p.m. CNA #2 was interviewed. He said he and CNA #1 were not wearing gowns when they transferred the resident in room [ROOM NUMBER] back to bed. He said CNA #1 called for help from the room because the resident was sitting very close to the edge of the bed ready to slip out. On 1/5/21 beginning at 12:30 p.m. the tray cart arrived on the third floor. Five staff assisted in passing trays out to six resident rooms. The staff did not offer, remind or assist these residents to perform hand hygiene when their food was delivered. On 1/7/21 beginning at 11:15 a.m. housekeeper (HSK #1) was observed cleaning a non-covid, quarantine resident room. She first sanitized her hands and then donned a gown and gloves to enter the room. She collected the trash first and came and placed it in the trash bin on her cart. She then took a dry mop, entered the room and began to dry mop the bathroom floor and then she dry mopped out of the bathroom into the living area and then pushed the debris to the doorway. She then swept up the debris into the dustpan and threw it in the trash bin on the cart. Then, without changing or sanitizing her hands she took a cleaning rag from the bucket containing disinfecting solution and began wiping down the high touch surfaces inside the room. She then took a used sheet from the seat of a chair inside the room and brought it out to the cart and placed it in a plastic bag containing dirty rags. She did not doff her gloves or sanitize her hands and went back into the room with the same cleaning rag to continue cleaning the high touch surfaces. She then came back to the cart, discarded the rag and without doffing her gloves or disinfecting her hands, she picked up a spray bottle disinfecting solution to spray on the toilet. She also took a second rag from the disinfecting solution in the bucket and went in and began cleaning the bathroom area. She then took a cloth gown hanging in the bathroom and brought it to the cart and placed it in the dirty rag bag. She did not doff or sanitize her hands and returned to cleaning the bathroom. After finishing the bathroom, she brought her dirty rag and toilet brush canister back to the cart. She did not doff her gloves or sanitize her hands. She then took a wet mop head from a bucket, placed it on the mop handle, entered the room and began wet mopping the main living area. She then came back to the cart, discarded the used mop head, placed a new one on the handle and wet mopped the bathroom floor. After she finished mopping the floor, she came to the cart, doffed her gown and gloves and sanitized her hands with alcohol based hand rub (ABHR) for three seconds. She did not let the it dry or rub her hands and cover all surface of her hands. HSK #1 was interviewed immediately after the observation. She said she had received education on infection control and donning and doffing of PPE and hand hygiene. She said that when using the ABHR she placed two pumps of it into the palm of her hand and rubbed hands together until it dried. She said the only time she would change her gloves was when she went in to clean the bathroom. IV. Record review Staff education material was provided for review on 1/5/21 by the DON. The content of the education contained information related to COVID-19 positive facility protocol. The protocol documented in part that due to the current COVID-19 outbreak in the building, all patients were on quarantine until further notice. This included in part, full PPE must be worn for every patient interaction. When entering a non-covid patient room in addition to mask and face shield, apply hand sanitizer, don gown, don gloves and provide patient care. When done with care: obtain a new trash bag from the trash can, remove gown and place it in trash bag and tie. Remove gloves, perform hand hygiene and take dirty linen (gown) to the dirty linen room designated gown bin. Review of the facility COVID-19 plan and focus on infection control education, provided to all staff in 3/2020, documented in part the following regarding mask use: do not touch your mask except to don/doff. If you touch your mask you must perform hand hygiene immediately. In addition the training documented that all patients must have (be offered) hand sanitizer or wash with soap and water prior to eating. V. Additional interviews The maintenance director (MD) was interviewed on 1/7/21 at 1:50 p.m. He said that all of the housekeepers had been trained on proper PPE use and sanitation. He said they should be changing gloves and sanitizing their hands in between going from one cleaning task to the next. He said that the bathroom floor and the main living area floor should be dry mopped and wet mopped separately with different mop heads and not going from one to the other with the same mop head due to possible cross contamination. The DON was interviewed on 1/7/21 at 4:10 p.m. She said when their outbreak happened the facility decided to treat all residents on the open units as if they were on quarantine to try and stop the spread. She said staff were to begin wearing full PPE (gowns, gloves) each time they went into a resident room. She said that they had been using reusable gowns to save their supply of disposable gowns. She said that the gowns needed to be removed inside the resident room then they needed to be placed in a plastic bag and taken out of the room to the soiled utility room and placed in a bin to be washed. She said that staff had been trained on proper use of PPE and were kept updated of all changes as they happened. She expected staff to follow the current protocol to prevent the spread of illness. She said that staff had been educated on proper hand hygiene technique and when to sanitize. She said that residents should be offered hand hygiene or assisted as needed to perform hand hygiene at each meal time. She said sanitizing products such as wet wipes were readily available and were usually provided on the residents trays. She said that housekeeping staff should be following proper infection control practices by frequently changing gloves and sanitizing hands. She said staff would be educated immediately regarding the concerns that were found. VI. COVID-19 status The DON reported upon entrance to the facility on [DATE] that they were currently experiencing their first resident COVID-19 outbreak with five residents positive for COVID-19 and one staff member positive for COVID-19.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 10.81%, or four errors out of 37 opportunities for error. Findings include: I. Facility policy and procedure The Medication Administration policy and procedure, undated, was provided by the medical records assistant (MRA) on 11/13/19 at 11:43 a.m. It was the policy of the facility that medications were to be administered in accordance with the written orders of the attending physician. Medications could not be set up in advance and must be administered within one hour before or after their prescribed time. The Medication Time Frames, undated, were provided by the director of nurses (DON) on the morning of 11/11/19. Morning medications were to be administered on arising, between 6:30 a.m. and 10:00 a.m. II. Medication error observations and interviews [NAME] Registered nurse (RN) #2 was observed preparing and administering medications to Resident #91 on 11/12/19 at 8:14 a.m. The resident's order was for Atrovent ([MEDICATION NAME][MEDICATION NAME]) one spray in both nostrils three times a day for allergies [REDACTED]. The RN handed the inhaler to the resident who administered the medication herself, and instilled three sprays in her right nostril and two in her left nostril. The RN did not provide the resident with any instructions or guidance prior to handing her the inhaler. The RN was interviewed later that morning at 8:42 a.m., and asked to clarify how many sprays of Atrovent she was supposed to receive. The RN said she was supposed to get two sprays in each nostril, then looked at the Medication Administration Record [REDACTED]. She explained another resident she took care of received two puffs, and she got them confused. B. RN #4 was observed preparing and administering medications to Resident #150 on 11/13/19 at 8:36 a.m., and the following errors were made: 1. The resident's order was for [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) one puff, inhale orally four times a day for [MEDICAL CONDITIONS]. The order was started 11/12/19. The RN handed the inhaler to the resident to administer herself without providing any guidance or instruction. The RN then went into the resident's bathroom, donned a pair of gloves and had her back turned to the resident. Resident #150 took three quick administrations in a row of the medication without any time in between. The RN realized what the resident did and provided her with education on how to take the medication properly after she had already taken it. 2. The resident's order was for [MEDICATION NAME] (corticosteroid), one spray in both nostrils every morning and at bedtime for allergies [REDACTED]. The RN handed the bottle to the resident to administer herself without providing any guidance or instruction. The resident sprayed one spray in the left nostril and two sprays in the right nostril. 3. The resident's order was for Rhinocort (corticosteroid) allergy suspension, one spray in both nostrils every morning and at bedtime for allergies [REDACTED]. The RN looked through the medication cart and was unable to locate the nasal spray. She said she did not have any to give to the resident at that time. The medication was administered at 3:34 p.m., which was five hours and 34 minutes late, after it arrived from the pharmacy. RN #4 was interviewed on 11/13/19 at 11:56 a.m., and she said she had worked as a nurse at the facility for almost two years, but normally worked on the night shift. She said nurses were supposed to explain to the residents how to administer nasal sprays and inhalers, what their medications were, what they were for, and if they were supposed to take one puff or two before giving them. She said when she handed Resident #150 her [MEDICATION NAME] inhaler, she did not have enough time to tell her how much she was supposed to receive before she took the medication, so she provided the resident with education afterwards as to how she was supposed to do it. She confirmed she noticed the resident administered two sprays of [MEDICATION NAME] instead of the ordered one spray and said, I didn't tell her. I thought about it and got side tracked. RN #4 said the Rhinocort would be delivered by the pharmacy later that day and the resident would receive her missed morning dose when it arrived. She said sometimes the pharmacy would need to get permission to dispense a medication to the facility if it was an over-the-counter drug, so sometimes the facility staff had to go to a drug store and purchase it themselves. III. DON interview The DON was interviewed on 11/13/19 at 1:00 p.m. She said as soon as medication orders were received from a provider they were faxed to their pharmacy, who provided routine deliveries daily before 2:30 p.m. or after 6:00 p.m. She said if a resident was admitted the previous day, the medications were typically available in the facility the following morning for administration. She said she had been made aware of the Rhinocort that was not available and a staff member was in the process of purchasing the medication at a drugstore. She said nurses should provide an explanation to the residents about inhalers and nasal sprays prior to administration that included what the medication was, how it was to be taken, how often it was needed, and if they needed to give themselves one spray or two sprays. The DON said the five rights of medication administration included to verify the dosage, and confirmed RN #2 and RN #4 did not do that prior to administering the medications. She said if a resident's dosage was different at home, they should ask the doctor to change it, and then educate the resident on what the doctor ordered.

Based on observations, record review, and interviews, the facility failed to provide medically related social services to attain or maintain the highest practicable mental and psychosocial well-being for one (#36) of one resident reviewed for mood and behavior of 23 sample residents. Specifically, the facility failed to ensure Resident #36 received appropriate and timely assessment, monitoring and support services following his statement that he would rather just end it all. Findings include: I. Facility policy and procedure The Suicide and Suicidal Ideation Recognition policy and procedure, dated 2/1/16, was provided by the medical records assistant (MRA) on 11/13/19 at 9:50 a.m. The purpose was to ensure all staff were familiar with the warning signs of suicidal behavior and it was to be used for residents who had expressed [MEDICAL CONDITION] or when a resident had made a suicide attempt. The policy defined suicidal ideation as a self-reported thought or behavior, which reasonably suggested thought of engaging in suicide-related behavior. The examples included but were not limited to statements or actions such as: -I wish I were dead. -Everyone would be better off if I were dead. -Life is not worth living. -If I had the means I would kill myself. A resident who made such a statement must be placed on 15-minute checks until they were evaluated by a licensed professional or physician and deemed in writing not to be a current danger to himself/herself. II. Resident #36 [NAME] Resident #36 status Resident #36, age 72, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/24/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive two-person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He used a walker and wheelchair for mobility, was frequently incontinent of urine, and always incontinent of bowel. Mood symptoms present included feeling down, depressed or hopeless, feeling tired or having little energy, and trouble concentrating on things such as reading the newspaper or watching television. He received an antidepressant medication seven of the last seven days, and frequently had pain that limited his day-to-day activities. B. Resident interview and observation Resident #36 was interviewed on 11/11/19 at 1:38 p.m. He was sitting in his wheelchair in his room next to the window. His legs were resting on the foot pedals and he was comfortable. He said he had problems with his swallowing at times and had a dish of green chilies in front of him that his wife had just brought him from home. His voice was scratchy and weak. He said he had intentionally lost weight recently and had gone from 181 pounds down to 158 pounds currently. He said, When I look in the mirror, I think I'm fat. He explained one of his hobbies at home was walking around his neighborhood, and now that he had broken his femur, he was unable to walk. He said it was frustrating to require so much assistance from staff to do the basic tasks he used to be able to do independently. C. Record review The care plan, initiated 11/10/19 and revised that same day, identified a decline in the resident's mood state as evidenced by negative statements about himself and his situation. The approaches included encouraging participation in activities of interest, encouraging him to verbalize and express his feelings and emotions, and encouraging visits and phone calls or letters from family and friends. He had declined psych services (undated). The Patient Health Questionnaire (PHQ-9) for depression was completed for Resident #36 on 10/20/19. It revealed he felt down, depressed or hopeless two to six days, felt tired/lethargic and had trouble concentrating seven to 11 days of the 14-day look back period. His overall score was five, which indicated mild depression. The Comments and Care Plans section of the form were void of documentation, and social worker (SW) #2 completed it. A progress note, dated 11/9/19 (Saturday) at 2:46 a.m., documented the following: Patient expressed his concerns with how embarrassing it is to have people have to take care of him. Patient expressing concerns that he is not getting better and that he would rather 'just end it all.' Nurse allowed patient to talk over his concerns, offered encouragement and support. Fax sent to (name of physician) requesting a psych consult. Registered nurse (RN) #4 signed the progress note. There were no additional progress notes documented until the Daily Skilled Nurse's Note on 11/10/19 at 10:23 p.m., which included no mood or behavior problems. There were no 15-minute checks initiated or one-on-one observations implemented. A fax was sent to Resident #36's primary care physician (PCP) on 11/9/19 (untimed), which included, Patient made the comment 'I just want to end it all.' Expressing his concerns with his difficult and slow recovery, concerned that he is not getting better and that he will need this higher level of care forever. (MONTH) we get a psych consult? RN #4 signed the fax. The fax was returned by the PCP on 11/11/19 with the response, Above request ok. III. Staff interviews Social services worker (SW) #1 was interviewed on 11/12/19 at 3:41 p.m., and she confirmed she was the director of social services. She said she was unaware of the comment Resident #36 made that he would rather just end it all, and explained that she was on vacation during that time. She said SW #2 usually covered for her when she was out of the facility, and had her on the schedule to cover for her during her vacation, but then she had an emergency and did not cover for SW #1 that week. She said, So I can't speak to what happened at that time. She looked in Resident #36's electronic medical record and said she did not see a psych consult or an order to obtain one. She said that if she had been informed of the resident's comment, she would have gone to talk to him first, then ask him if he wanted to see a psychiatrist. She said if he did, she would ask his physician for an order to contact the psychologist who followed residents at the facility. She said there were no additional interventions or safety measures she could think of that would need to be implemented for the resident in the meantime. RN #3 was interviewed on 11/12/19 at 3:47 p.m., and she said she was not very familiar with Resident #36 and did not usually work on his hall. She said she remembered vaguely hearing something about his comment to just end it all, and confirmed the facility did receive the approval from his PCP for a psych consult and thought the resident was agreeable to it. She said she thought he was getting stronger and doing better in therapy, which made that comment odd, and that was why they reached out and obtained the order for the psych consult. She said he had never made negative statements to her and said, It was never stated to me that precautions were put in place. She said the progress note written by RN #4 did not say what the resident's demeanor and mindset at the end of the conversation was, and she would have to know the rest of the conversation to know what line of thinking he had. Certified nurse aide (CNA) #2, who was assigned to Resident #36's hall, was interviewed on 11/12/19 at 3:56 p.m., and she said she routinely cared for him and knew him well. She said when she provided him with personal cares he would frequently say, Did I go and embarrass myself again? She said when he was incontinent it embarrassed him and she would try to make him feel comfortable by explaining that was why she was there. She said she had not received a report that there were frequent safety checks implemented and was not aware of any additional observations or cares he required. SW #1 provided an update on 11/12/19 at 4:02 p.m. She said she had spoken to Resident #36 and He is not suicidal. He told her he said things like that all the time when he got frustrated or upset, and would never act on it. She said she offered him counseling and he told her he had had it in the past and did not want it currently. She said when he made that comment to RN #4 on 11/9/19, the staff could always implement every 15 minute checks, and a local community mental health center could have been contacted. The activities director (AD) was interviewed on 11/12/19 at 4:47 p.m., and said, I have been his advocate since day one and knew from the get-go he has felt this way with frustration. She explained he had a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She said she met with him daily on Mondays through Fridays, and was aware he had refused counseling in the past. She stated, We can't force him to talk to her. The unit manager (UM) was interviewed on 11/13/19 at 2:35 p.m., and he confirmed he was the facility's weekend manager on duty. He said he was notified of Resident #36's comment either in the morning or later in the day, after the nurse was able to see all of her patients. He said the nurses did not report anything in regards to Resident #36 saying he might as well just end it all, or that there was any concern that he had any suicidal or depressive comments. He stated, Otherwise, I would have gone in there and assessed a little quicker or closer, but I had no reason to. He confirmed there were no five or 15 minute safety checks completed. RN #4 was interviewed on 11/13/19 at 11:56 a.m., and she said she worked night shifts at the facility for almost two years and was familiar with Resident #36. She said that night that he made the comment, she did not think to do anything beyond what she did, because she did not think suicide was an immediate threat for him. She said, It was something that was said when he was sad, expressing his frustration with where he was. He was not actively going to hurt himself. She said he did not verbally say that, but she said she felt confident just because of his overall behavior. She said he would say things like that and then turn around and still talk and be cheerful, and that made her think he was not in a mindset to hurt himself. She said she did not consider the statement that he might as well just end it all as a suicidal ideation, but he was just venting his frustration. She said in the past when she worked with him, he would express sadness and frustration, but not in those words. She said, I thought maybe he could use a psych evaluation. She did not feel 15 minute safety checks or a sitter were necessary. She did not notify the social services staff or the director of nurses (DON), and said, My professional opinion was that he was not a danger. She said when she left his room that night she had no concerns about his safety. The DON was interviewed on 11/13/19 at 1:00 p.m. She explained the facility had two dedicated social services staff, and one PRN (as needed) who filled in at times. She said SW #1 was the facility's main social worker and SW #2 was her back up. They did initial resident intake evaluations, care conferences, and communicated with the psychologist and other mental health professionals who worked with the facility. The DON said they also managed the discharge planning for all of the residents, which kept them busy. The DON confirmed RN #4 did not notify her on 11/9/19 when Resident #36 made the comment, but the UM was informed about it by the nurses. The UM informed her the resident was checked on frequently, and they just kind of watched things. The staff were instructed to watch him for behaviors, and nothing was documented because he did not have any behaviors that shift. She stated, I guess we talk more than we chart. The DON said she did not consider Resident #36's statement to just end it all a suicidal ideation and stated, It is so hard because of the context of it. She said she did not believe it was a suicidal ideation, but clarified she was not there when it was said. She said SW #1 went and talked to him the day before, and documented that Resident #36 was not going to hurt himself. However, she did not know if SW #1's licensing and credentials made her qualified to assess that. The DON confirmed Resident #36 was not placed on every 15 minute safety checks, was not placed on one-to-one (1:1) care with a sitter, did not create a behavioral contract with him, and he was not seen by a licensed professional or physician and deemed in writing not to be a current danger to himself. She said he did not currently have a plan to end his life and there was nothing he could easily access because he was non-weight bearing and was immobile, so he would be unable to physically carry anything out. The DON said she was concerned about his continual decision to decline psychiatric services. She said the resident had an appointment to see his PCP that day, and his brother was going with him. She said the resident's wife and daughter had been involved and spoken to at length regarding his negative statement. The DON said Resident #36 had been taking [MEDICATION NAME] (antidepressant) in the past and was recently changed to [MEDICATION NAME] (antidepressant), and she did not think it was working as well. IV. Additional record review A late entry progress note for the night of 11/9/19, dated 11/12/19 at 5:21 p.m. was written by RN #4 and included the following: After lengthy conversation with (Resident #36), patient had no specific plan on how to proceed or real intent to injure himself. At that time and with my evaluation of no plan or intent I determined the patient to not be a current danger to himself. Patient had no further expressions of negative self-thoughts or expressing his feelings through the remainder of the shift. Patient made this comment out of frustration and feelings of helplessness. CNA/nursing continued to check on patient frequently throughout the night. The DON provided an untitled, typed document that read: (SW #1's) credentials: Bachelor's degree, psych unit therapist at (local hospital) for [AGE] years, case manager for [AGE] years. The Director of Social Services job description was provided by the DON on 11/13/19 at 3:46 p.m. The purpose was to assure that the medically related emotional and social needs of the residents were met/maintained on an individual basis. The duties and responsibilities included the following: -Provide consultation to members of our staff, community agencies, etc. in efforts to solve the needs and problems of the resident through the development of social service programs. -Meet with administration, medical and nursing staff, as well as other related departments in planning social service programs and activities, -Make daily rounds to assure that social services personnel are performing required duties, and to assure that appropriate social service procedures are being rendered to meet the needs of the facility. -Review nurses' notes to determine if the care plan is being followed. Report problem areas to the DON. -Develop and maintain a good rapport with all services involved with the care plan to ensure that a team effort is achieved in developing a comprehensive plan of care. -Be prepared to handle emergencies as they come up. A Suicide Watch Log for One on One Observations was provided by the DON on 11/13/19 at 3:46 p.m. The frequent checks had been started that day at 1:45 p.m. The document revealed a local community mental health center employee met with the resident and his daughter at 2:50 p.m. A Safety Plan for Resident #36 was created by the mental health center employee that day and documented, Client is not a harm to self or others and is not in need of inpatient psychiatric hospitalization . It was signed by the resident and mental health center employee and dated incorrectly as 11/12/19, rather than the current date of 11/13/19. V. Facility follow-up On 11/14/19, after survey exit, the DON provided an encounter report from Resident #36's PCP on 11/13/19. The assessment documented the resident had a history of [REDACTED]. The plan was to switch the resident's antidepressant from [MEDICATION NAME] to [MEDICATION NAME], and to encourage him to continue participating in therapy as prescribed.