Every finding on record at City Creek Post Acute

Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 43 sampled residents, one resident sustained a third-degree burn to his left wrist from spilling a prepackaged soup prepared and served by facility staff. Resident identifier: 3.It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents, F689, at a scope and severity of G. However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance.The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by 3/11/26 included the following measures: 1. The resident was assessed and a new order obtained for treatment of the burn wound.2. Removed microwave and coffee pots from nutrition rooms.3. Director of Nursing (DON) reviewed the food and beverage process to determine where lapse in process occurred.4. Identified others at risk as all residents who requested food or fluids be warmed in the microwave.5. DON/designee re-educated facility staff on the facility process for reheating food and liquids.6. DON/designee ordered food grade thermometers for staff to use to verify temperature of food/liquids prior to serving residents.7. Microwaves returned to nutrition rooms after staff education completed. Process posted above microwaves.8. Temperature logs posted with microwaves for additional monitoring.9. DON/designee audited 5 resident foods/liquids temperatures bi-weekly x 4 weeks, weekly x 4 weeks or until substantial compliance was achieved. Audits were reviewed with the Interdisciplinary Team (IDT) team during Quality Assurance and Performance Improvement (QAPI).10. Plan of correction reviewed with QAPI team and resident council President and [NAME] President.The survey team verified all interventions were completed before the survey start date (3/23/26).Findings included:Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and acquired absence of left leg above knee.On 3/6/26 at 10:46 AM, the facility reported to the State Survey Agency that the Resident asked a staff member (RNA [Restorative Nurse Aide]) to cook his top ramen for him to take into his room. The food was heated in the microwave in the nutrition station behind the nurse's station as per the packaging directions and returned to the resident by a nurse. Resident turned in his power wheelchair causing the ramen to spill out and the liquid created a burn to the palmar side of his left wrist. Nurse immediately assessed the skin and began applying wound care application.On 3/5/26 at 5:35 PM, a progress note documented Notified that resident received a burn to his left wrist after spilling hot soup. Wound was assessed, wound care provided and new orders placed per consult with wound provider. Resident tolerated treatment well and denies any pain or other concerns at this time.On 3/10/26, a wound provider progress note classified the severity of the burn to resident 3's left wrist as third-degree. On 3/26/26 at 3:02 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3, who stated resident 3 would ask CNAs to heat up food for him in the microwave, and that he insisted on carrying food himself, saying that he did not want to be treated like a child. CNA 3 stated they would not heat Resident 3's food due to the resident's refusal to allow staff to safely carry it to his room, because it was dangerous for resident 3 to carry it himself. CNA 3 stated they were unable to recall if thermometers were available for use before resident 3 sustained the burn, because they did not search for a thermometer. CNA 3 stated after resident 3 sustained the burn, thermometers were available for use, a temperature log was used, and they were educated to not give residents food or drinks that had a temperature reading higher than 140 Fahrenheit (F). On 3/26/26 at 3:09 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 3 utilized a motorized wheelchair, was very independent, and did not want staff to carry items for him. LPN 2 stated before resident 3 sustained the burn, thermometers were not available for use. LPN 2 stated they would heat food up in 30 second increments until it was adequately heated, and touched the dinnerware to determine if the temperature was safe to return to the resident. LPN 2 stated after resident 3 sustained the burn the microwaves were removed from the nutrition stations until staff received training on how to use the thermometers and knew to not return food to residents until it measured below 140 F. LPN 2 stated thermometers were available for use when the microwave was returned to the nutrition station. On 3/26/26 at 3:23 PM, an interview was conducted with the Director of Nursing (DON), who stated that before resident 3 sustained the burn, staff heated food according to package directions and determined if it was safe to return food based on touch. The DON stated that when they were notified of the burn all microwaves and coffee pots were removed from the nutrition stations, resident 3 was provided wound care, and a 4-Step Action Plan was begun to ensure resident safety. The DON stated that microwaves were returned on 3/10/26, after all staff had completed education and were trained on appropriate reheating of resident foods and thermometer use. The DON stated that thermometers and coffee thermoses with pumps, instead of coffee brewers, were placed in nutrition stations when the microwaves were returned.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a Bluetooth speaker was stored on a shelf used to store items used in food preparation and a male staff member with a beard was observed to be preparing food without wearing a beardnet. Findings included:On 3/23/26 at 8:02am an initial observation was conducted of the facility kitchen. There was a Bluetooth speaker sitting on a shelf used to store hotel pans used for meal preparation.On 3/25/25 at 11:31am a follow up observation was conducted of the facility kitchen. [NAME] 1 was observed to have a beard. [NAME] 1 was not wearing a beard net while preparing enchiladas that were to be served to residents at lunch. On 3/26/26 at 8:36am, an interview was conducted with the Dietary Manager (DM). The DM stated that she would purchase beard nets for the male staff member that was not wearing a beard net while preparing food. The DM also stated that she would move the bluetooth speaker to an area of the kitchen not used for food preparation.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 43 sampled residents, staff did not wear personal protective equipment (PPE) when residents were on Enhanced Barrier Precautions (EBP) and hand hygiene was not performed during wound care. Resident identifiers: 14, 73, and 74.Findings included:1. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encephalopathy. On 3/23/26 at 2:21 PM, EBP signage was observed on the door frame and a PPE cart was observed outside of resident 14's room. A care plan Focus documented [name redacted] has potential for pressure ulcer development r/t [related to] Limited mobility d/t [due to] Parkinson's, Encephalopathy and Neurocognitive DO [disorder] 3/17/26 - Stage 3 Left buttock. There was no date to determine when the care plan was initiated. The interventions included, but were not limited to, use Enhanced Barrier Precautions. On 3/24/26 at 1:47 PM, the Skin/Wound Note documented . Wound assessment completed. Wound type: Stage 3 pressure Wound Location: Left Buttock Measurements: 0.6x0.5x0.2 [centimeters] Odor and Drainage if noted: No odor withsmall [sic] serosanguineous drainage Surrounding tissue: Thin and fragile . On 3/24/26 at 8:40 AM, a wound care observation was conducted with the Unit Manager (UM)/Wound care nurse and the Nurse Practitioner (NP). EBP signage was observed on resident 14's door frame and a PPE cart was observed outside of resident 14's room. The NP was observed to use an alcohol based hand rub on her hands prior to donning gloves. The UM and the NP did not don gowns at any time during the wound care. An immediate interview was conducted with the NP. The NP stated that she would wear a gown if the resident was on precautions. The NP stated that she was not sure what precautions were required for residents on EBP and the facility would set up the precautions. On 3/26/26 at 10:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 14 was on EBP for a wound to the right buttock and resident 14 had a Foley catheter. 2. Resident 74 was admitted to the facility on [DATE] with diagnoses which included encounter for orthopedic aftercare, right below the knee amputation, fusion of spine, displacement of internal fixation device, spinal stenosis, muscle weakness, radiculopathy lumbar region, and chronic pain. On 3/10/26, resident 74 had an order initiated for EBP and the indication was for a surgical wound. The order documented PPE required for high resident contact care activities. On 3/23/26 at 2:08 PM, an observation was made of resident 74's room. A sign for EBP was posted on the door. A PPE cart was not located outside of resident 74's room. An observation was made of Occupational Therapist (OT) 1 assisting resident 74. OT 1 was observed assisting resident 74 with pulling up the resident's trousers while lying in bed, repositioning from a lying to a sitting position at the bedside, and then a one person assisted transfer from the bed to the wheelchair. OT 1 was observed kneeling on resident 74's bed during repositioning. OT 1 wore gloves during the care but no gown was worn. On 3/26/26 at 9:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that EBP was for catheter or ostomy care. CNA 2 stated that if a resident had an exposed wound and they were assisting with wound care she would wear a gown and gloves. CNA 2 stated if she was changing bed linens, toileting a resident, or if a wound was protected by a dressing she would not wear PPE. On 3/26/26 at 9:17 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that EBP was for any catheter care, wound care, or perineal care and they needed to wear a gown and gloves. RN 1 stated she was not sure if it was just for wound care or if they needed PPE for any other care for residents who had wounds. On 3/26/26 at 10:10 AM, an interview was conducted with the DON. The DON stated that EBP was for any indwelling medical device, wounds, or anything that puts the resident at risk for infection. The DON stated that staff should don a gown and gloves for direct patient care in EBP rooms. The DON stated that PPE should be donned for any care in a EBP room when care was for an extended period of time. The DON stated that resident 74 was on EBP for his surgical wound to his right leg and that the resident had a total of five wounds. The DON stated that the best case scenario was that staff wore PPE for any resident on EBP when providing direct patient care. 3. Resident 73 was admitted to the facility on [DATE] with diagnoses which included general anxiety disorder, major depressive disorder, obstructive sleep apnea, type 2 diabetes mellitus, and left below the knee amputation. On 3/23/26 at 10:52 AM, an interview was conducted with resident 73. Resident 73 stated he had a sore on his buttocks and the dressing was changed every other day. Resident 73 stated he had sores on his right foot that were healing and that the dressing was also changed every other day. On 3/12/26, resident 73 had an order initiated for EBP and the indication was for an indwelling medical device (foley catheter). On 3/19/26, resident 73 had an order for wound care to the right foot to be completed every day shift. The order documented to cleanse the wound with wound cleaner, pack with collagen (Alginate), apply a foam dressing to the wound, and secure with tape or gauze. On 3/26/26 at 1:58 PM, a wound care observation was conducted with RN 1. RN 1 stated that resident 73's wound order was to irrigate the wound with normal saline or wound cleanser, apply alginate to the wound bed, cover with a foam dressing, and wrap in Kerlix and Coban. RN 1 was observed to don a gown and gloves prior to wound care. RN 1 propped resident 73's right foot on a pillow and removed the resident's sock and old dressing. RN 1 doffed her dirty gloves and new gloves were donned. RN 1 did not perform hand hygiene prior to applying new gloves. RN 1 proceeded to irrigate resident 73's wound bed with normal saline. RN 1 then obtained a gauze soaked in wound cleaner and cleaned the wound bed working from the inside outward. RN 1 doffed her gloves and new gloves were donned. RN 1 did not perform hand hygiene prior to applying new gloves. RN 1 applied skin prep to the surrounding wound bed. RN 1 tore a piece of calcium alginate into two pieces and applied them to two separate wound beds. RN 1 doffed her gloves, performed hand hygiene and then applied new gloves. RN 1 then applied a bordered foam dressing over the alginate. RN 1 doffed her gloves, performed hand hygiene and donned new gloves. RN 1 applied a gauze roll over top of the foam dressing, covering the entire foot and ankle. RN 1 then applied Coban on top of the gauze dressing. An immediate interview was conducted with RN 1. RN 1 stated that hand hygiene should be performed after changing the dressing and prior to the application of a new dressing. RN 1 stated that when going from a dirty to clean area hand hygiene should be performed. RN 1 stated that she forgot to do this during the wound care because she was nervous. On 3/26/26 at approximately 2:30 PM, an interview was conducted with the UM/Wound care nurse. The UM stated that anytime staff went from a dirty area to a clean area during wound care they should doff their gloves, perform hand hygiene, and then put on clean gloves. The UM stated pretty much with each step during wound care gloves should be changed and hand hygiene should be performed.

Based on interview and record review, the facility did not ensure that when they transferred or discharged a resident that it was documented in the resident's medical record and that the information contained the contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 1 of 43 sampled residents, the facility did not document in the residents' medical record the information that was given to the receiving provider when the resident was transferred to the hospital. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included calculus of bile duct, urinary tract infection (UTI), pneumonia, type 2 diabetes mellitus, systemic inflammatory response syndrome, hypertension, chronic pancreatitis, emphysema, dysphagia, obstructive reflux uropathy, history of malignant neoplasm of prostate, anemia, benign prostatic hypertrophy, and generalized anxiety disorder. On 3/23/26 at 1:10 PM, an interview was conducted with resident 9. Resident 9 stated that he went to the hospital for a UTI and was treated with antibiotics for three days afterwards. On 3/8/26 at 2:48 PM, a nursing progress note documented, Resident not arousable with verbal stimuli or sternal rub, resident vitals bp [blood pressure]: 110/50, hr [heart rate]: 103, rr [respiratory rate]: 19, temp [temperature] : 98.8. Resident sent to [name omitted] hospital, son [name omitted] notified. It should be noted that no documentation could be found of a hospital transfer sheet or any documentation of what information was sent to the hospital with resident 9. On 3/25/26 at 1:56 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when they transferred a resident to the hospital they sent a face sheet, a copy of the bed hold, and a medication list. RN 1 stated that it should be documented in a progress note what was sent with the resident to the hospital. On 3/25/26 at 3:14 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that for transfers the nurse should obtain an order from the provider, fill out a hospital transfer agreement, and go over the bed hold policy. The DON stated that they printed out a face sheet, medication list, physician order for life sustaining treatment (POLST), and the transfer sheet which contained the reason for the transfer. The DON stated that if the transfer form was not found in the resident's medical record then it probably did not get done. The DON stated that he was not able to tell from resident 9's medical record what information was sent to the receiving provider for the transfer on 3/8/26.

Based on observation, interview, and record review, the facility did not ensure that when a bed rail was utilized that the resident was assessed for the risk of entrapment from the bed rail prior to installation. Specifically, for 1 out of 43 sampled residents, the facility did not evaluate a resident for entrapment from the bed rail prior to use and the resident reported that her hand was caught in the bar. Resident identifier: 65. Findings included: Resident 65 was admitted to the facility on [DATE] with diagnoses which included secondary malignant neoplasm of the brain, malignant neoplasm of the left breast, disorders of bone density, hemiplegia and hemiparesis following a cerebrovascular accident, seizures, weakness, thyrotoxicosis, adjustment disorder with anxiety, and depressed mood. On 3/23/26 at 11:13 AM, an interview was conducted with resident 65 and their representative. Resident 65 stated that she fell off the bed and her hand was caught in the side bar. Resident 65's representative stated that he reported the incident but was unable to recall who he told. Resident 65 was observed with a sling on her left arm and left hand. Resident 65 was observed to adjust her left hand in the sling with the use of her right hand. Resident 65's bed was observed with bilateral upper side rails. The rails were observed with a gap between the mattress frame and the side rail and the rails were not stationary but shifted when touched. On 3/24/26 at 1:18 PM, a follow-up interview was conducted with resident 65. Resident 65 stated that her hand got caught in the side rail and that this happened approximately two weeks ago on a Saturday. Resident 65 did not have an assessment of the side rail for entrapment in her medical record. On 3/24/26 at 12:18 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 65 required a two person assist for transfers and bed mobility. On 3/24/26 at 12:49 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that they evaluated the resident for entrapment with bedrails on admission. LPN 1 stated that the nurse did the initial assessment for the resident's bed mobility and if they saw an issue they would contact physical therapy to evaluate the resident as well. LPN 1 stated that the functional abilities assessment conducted on 3/5/26, assessed resident 65's mobility status but did not assess the resident for positioning bars or entrapment. On 3/24/26 at 1:07 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that on admission the beds did not have any side rails. The RNC stated that if therapy recommended side rails then an assessment would be conducted for that mobility device to determine if it was a restraint vs. an enabler device. The RNC stated that therapy did the assessment and then obtained consent from the responsible party. The RNC stated that resident 65 did not have the assessment completed in their medical record. At 2:28 PM, the RNC followed up and stated that physical therapy evaluated resident 65 for the bedrail but they did not enter an assessment in the medical record. On 3/24/26 at 3:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they assessed resident 65 for a restraint vs. enabler and they should have assessed her for the bedrail as well. The DON stated that therapy should have initiated the assessment and then once completed put the assessment in the resident's medical record. The DON stated that therapy would also put the order in the chart, update the resident care plan, and obtain a written consent for the device.

Based on observation, interview, and record review, the facility did not ensure that each resident received food that accommodated the resident allergies, intolerances, and preferences. Specifically, for 1 out of 43 sampled residents, the facility did not provide the resident with the food preferences as outlined on their meal ticket. Resident identifier: 8. Finding included: Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition, cachexia, hypokalemia, hypotension, acute kidney failure, hypomagnesemia, depression, and pain. On 3/24/26 at 8:12 AM, an interview was conducted with resident 8. Resident 8 stated that he was on hospice for malnutrition and met with the Registered Dietician regularly. Resident 8 stated that the kitchen never followed the instructions for his meals. Resident 8 stated that last night's dinner was a salad and he could not digest any leafy green vegetables. Resident 8 stated that he had to order food out so much because he could not eat a lot of what the facility provided. Resident 8's breakfast meal tray was observed during the course of the interview and contained two plates of scrambled eggs, one English muffin, two tortillas, two glasses of milk, and two bowls of [NAME] Krispies. Resident 8 stated that the eggs were not hot and the muffin was not toasted or warm. Resident 8 stated that the kitchen knew he needed double protein. Resident 8 stated that he had a malabsorption issue, Irritable Bowel Syndrome, and had multiple surgeries on his stomach. Resident 8's meal ticket for breakfast was observed. The special instructions documented double portions with extra gravy/sauces. The likes documented double portions, add cold cereal, yogurt, two omelets with four salsa, two tortillas. No dislikes were documented on the meal ticket. On 10/6/25, resident 8's diet order was for a regular diet, regular texture, thin liquid consistency with double meal portions. On 11/20/24, the Nutrition admission Evaluation did not document any food likes or dislikes. The evaluation documented that the resident requested double portions due to malnutrition. On 7/18/25, the Nutrition - Quarterly Evaluation documented fortified double portions. Patient (Pt) requested extra sauces and gravies or butter with all meals I need to gain weight. Pt continues to have noted weight gain. Hospice services remain in place. Pt selective with meal preferences that are offered as possible. Pt continues to take a lot of outside foods and snacks as desired.Continue as set and honor requests. On 3/26/26 at 9:27 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that ideally she liked to meet with the residents within the first couple of days of admission to obtain their likes and dislikes for food items. The DM stated that the food preferences were printed on the resident meal tickets. The DM stated that she had spoken to resident 8 multiple times and he preferred double portions. The DM stated that resident 8 was at the facility for malnutrition. The DM stated that resident 8 also requested extra gravy and sauces with his meals. The DM stated that resident 8's breakfast requests included cold cereal, two omelets with cheese, two yogurts, and two tortillas. The DM stated that lunch and dinner were also double portions with extra gravy and sauces, and pudding.The DM stated that resident 8 did not have any documented dislikes on his meal ticket. The DM stated that resident 8 was included in a list of residents that did not want any lettuce or fish. The DM stated that last night resident 8 had a meal substitution of chicken tenders instead of the fried fish. The DM stated that any time they had a side salad or a side of lettuce resident 8 should have a substitution of cooked vegetables instead. The DM was informed that resident 8 did not have cheese omelets or yogurt on his breakfast tray on 3/24/26, and that the resident received a side salad on 3/23/26, instead of cooked vegetables.

Based on interview and observation, the facility did not ensure that the resident environment remained as free of accidents as possible. Specifically, the laundry room was left open with no staff present; the laundry room was observed to have various chemicals inside. Findings include: On 1/29/24 at 10:43 AM, an observation was made of the first floor laundry room. The laundry room door was cracked open and no staff were located inside the laundry room. An observation was made of several chemicals located on the clean side of the laundry room which included: 4 containers of Febreeze fabric refresher, 7 containers of Comet disinfecting sanitizing bathroom cleaner, 2 bottles of broad range quaternary sanitizer and 2 containers of disinfecting all purpose spray and glass cleaner. Several of the warning labels located on the containers stated to keep out of reach of children and may be harmful if swallowed. Another observation of the door between the clean and dirty laundry room was made. The door had a sign which read this door must not be propped open. That door was found to be propped open and more chemicals were located inside the dirty side of the laundry. Those chemicals consisted of a 5 gallon container of tide whiteness enhancer, 5 gallon container of Tide laundry detergent, 5 gallon container of Clorox bleach, 9 boxes of tide stain removal treatment powder, 6 bottles of tide rust stain remover, and 5 one gallon containers of germicidal ultra bleach. On 1/29/24 at 10:53 AM, an interview was conducted with Housekeeping (HK). The HK stated the laundry room door was always closed when no one was in there. The HK stated the door remained closed so residents were not able to come in unattended. The HK stated residents knocked on the door when they needed to look through the lost and found. The HK stated only staff had access to the laundry room when they were not in here. The HK stated residents were not allowed to be in the laundry room unattended. On 1/29/24 at 12:17 PM, an interview was conducted with the Maintenance Director (MD). The MD stated residents were not allowed in the laundry room by themselves due to the chemicals located inside. The MD stated due to resident safety, the laundry door was always kept shut to prevent residents from having access to the chemicals.

Based on interview and record review it was determined, for 1 of 37 sampled residents, that the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment received appropriate treatment and services to restore continence to the extent possible. Specifically, a resident who was incontinent of bladder and was assessed to be a likely candidate for a toileting program was not provided treatment and services to achieve as much normal bladder function as possible. Resident identifier: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included diabetes mellitus type 2, congestive heart failure, chronic kidney disease, respiratory failure with hypoxia, atrial flutter, major depressive disorder, and right leg below the knee amputation. On 1/23/24 at 10:16 AM, an interview was conducted with resident 10. Resident 10 stated she used a brief for bladder incontinence and that she wished she was on a bladder training program. Resident 10 stated she was on dialysis but that she did make urine and had urine frequency. Resident 10 stated the facility had done nothing for bladder training and that the facility had not talked with her about bladder training. Resident 10's medical record was reviewed from 1/22/24 through 1/29/24. The MDS (Minimum Date Set) Quarterly assessment dated [DATE] revealed resident 10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated a cognitive status of an intact cognition. The MDS quarterly assessment dated [DATE], indicated that a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility. It further indicated that resident 10 was always incontinent of urine. The Bowel and Bladder Evaluation dated 1/2/24 at 10:18 AM indicated that resident 10 was a likely candidate with a score of 8. A score of 8 indicated, Likely candidate for Bowel and Bladder re-training (LC). It further indicated resident 10 was evaluated to have, Behavior/Attitude. Shows initiative and Willingness. On 1/25/24 at 2:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the bowel and bladder evaluation was completed when a resident was first admitted , quarterly, and when a change of condition occurred. LPN 1 stated she did not think resident 10 was on a bowel and bladder program. On 1/29/24 at 11:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the bowel and bladder assessment was to be completed every quarter. The DON stated resident 10 had episodes of urinary incontinence and was on a check and change program. The DON stated that if a resident was a likely candidate for the bowel and bladder program that they would have been added to a bathroom upon rise program. The DON further stated that based on how a resident responded to the bathroom upon rise program, along with being cognitively able, the resident would then be a candidate for a prompt and void program. The DON stated resident 10 was cognitively capable and that she would have been a likely candidate for the bowel and bladder program. On 1/8/24 at 9:07 AM, an interview was conducted with resident 5 who stated she had a concern that one of the providers had changed her medication without

Based on interview and record review it was determined, for 2 of 23 sample residents, that each resident did not have the right to be free from abuse. Specifically, a resident was threatened by a roommate and there was no investigation to rule out abuse. Resident identifier: 33 and 89. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated her roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 33 had a Brief Interview of Mental Status (BIMS) score of 12. A score of 12 revealed that resident 33 had mild impairment. The MDS further revealed that resident 33 did not have evidence of acute change in mental status from baseline, no inattention, no disorganized thinking, and no altered level of consciousness. In addition, resident 33 required 1 person limited assistance for transfers and to walk in room. Resident 33 was not steady and was only able to stabilize with human assistance when moving from a seated to standing position. There were no progress notes located in resident 33's medical record regarding any concerns with her roommate. Resident 89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 89's medical record was reviewed on 5/3/22. An entry MDS dated [DATE] revealed revealed resident 89 had a BIMS score of 11 which indicated resident 89 had mild cognitive impairment. Resident 89 required 1 person extensive assistance with transfers. Resident 89 was able to walk in her room with 1 person supervision. The MDS further revealed that resident 89 was able to move from a seated to standing position only with human assistance to stabilize. Resident 89's History and Physical prior to admitted d 3/24/22 revealed She becomes agitated and may hit, kick, scream or grab. The form further revealed Familiar people are not recognized or misidentified. Resident 89's progress notes revealed the following entries: a. On 4/14/22 at 5:12 PM, Registered Nurse (RN) 3 documented Staff member went into patients room to get the covid test done. Patient told her that she would not let her do that. Staff member asked her why and patient told her that she was thinking about murder and that she was thinking about doing this to the staff member. Staff member left the room and did not perform the test. Will notify social services. b. On 4/15/22 at 10:54 AM, RN 3 documented Resident has been having increased behaviors, medical provider ordered a STAT CBC (complete blood count), CMP (comprehensive metabolic panel) and urine. c. On 4/15/22 at 2:49 PM, the MDS coordinator documented Labs reviewed by provider and sent to [mental health facility] for review and possible readmission. d. On 4/15/22 the Nurse Practitioner (NP) documented Seen due to agitation and aggression. Threatened to stab roommate last night. When laboratory analysis without acute normalizites. Coordinate transfer back to [mental health facility]. e. On 4/15/22 at 8:35 PM, resident 89 was picked up and transported to the mental health facility about 8:35 PM. A review of facility reported incidents to the State Survey Agency revealed no reported information regarding the incident. On 5/5/22 at 9:52 AM, a follow up interview was conducted with resident 33. Resident 33 stated that her roommate kept talking about killing. Resident 33 stated that her roommate told resident 33 to call the cops because she had already hurt someone. Resident 33 stated she told a nurse and a couple of Certified Nursing Assistant's (CNA) about resident 89's comments. Resident 33 stated that after the roommate told her that she already hurt someone, resident 33 stated that she was afraid that the resident would stab her. Resident 33 stated she was concerned the roommate was a threat to other people if she came back to the facility. Resident 33 stated she did not feel safe with resident 89 in her room. Resident 33 stated she did not remember if the NP, doctor or Administrator talked to her about feeling safe. Resident 33 stated if she had been asked if she felt safe, she would have said no. Resident 33 stated I just felt like she was crazy. Resident 33 stated she was unable to sleep for about 4 night because she was scared of her roommate. Resident 33 stated her roommate did not talk much but was able to get herself up and walk to the bathroom and walk to the door. Resident 33 stated as soon as the roommate left, she was not scared anymore. Resident 33 stated she would be afraid if resident 89 was readmitted to the facility. On 5/5/22 at 10:24 AM, an interview was conducted with CNA 2. CNA 2 stated she worked with residents on the 3rd floor three days a week. CNA 2 stated there was a incident with resident 33 who had a roommate, resident 89. CNA 2 sated when she went in to help resident 33, resident 89 told CNA 2 that she committed a murder and she asked who she had murdered and resident 89 stated she had not done it yet but was going to and pointed to resident 33. CNA 2 stated she reported the incident to the nurse but could not remember who the nurse was because it might have been a agency nurse. CNA 2 stated she asked resident 33 if she was afraid and she said no, but her roommate was just crazy. CNA 2 stated she thought resident 89 was transported to a mental health facility the same day. CNA 2 stated she was not aware of comments made to the nurse on 4/14/22. CNA 2 stated she heard from another CNA that resident 89 was thinking about murdering that CNA too. CNA 2 stated she reported the threat to the nurse because it was a form of abuse and did not think resident 33 should be in the same room with resident 89 because she could use utensils or something to hurt resident 33. CNA 2 stated she looked in room to make sure that resident 89 did not have anything she could hurt resident 33 with. CNA 2 stated she felt like it could be a threat or abuse that's why she reported it to the agency nurse. On 5/4/22 at 3:12 PM, an interview was conducted with CNA 3. CNA 3 stated resident 33's roommate was here for a short time. CNA 3 stated that resident 89 said some not so nice things to her. CNA 3 stated she was helping resident 33 and resident 89 looked at CNA 3 and said that B gets all the help and she wanted to kill her. CNA 3 stated she helped resident 33 back to bed to get her safe. CNA 3 stated then she went to resident 89 and asked her what she needed. CNA 3 stated that resident 89 stated she was fine.CNA 3 stated other staff heard resident 89 say she wanted to kill resident 33 at different times. CNA 3 stated it happened about the middle of April 2022. CNA 3 stated that she reported it to an agency nurse. CNA 3 stated she hoped that the nurse documented something about it. CNA 3 stated she randomly check in there (the room) for safety reasons. CNA 3 stated resident 89 was transferred out of the facility the same day CNA 3 heard the threat. CNA 3 stated staff were randomly checking the room through out the day. CNA 3 stated resident 33 did not say anything about feeling unsafe. On 5/4/22 at 3:28 pm, an interview was conducted with RN 3. RN 3 stated resident 33's roommate was paranoid and was having some issues. RN 3 stated resident 89 threatened staff and then threatened her roommate because she was not in her right mind. RN 3 stated resident 33 sat out with the staff at the nurses station because the roommate was not coming out of her room. RN 3 stated she was told from a staff member that resident 89 had threatened resident 33. RN 3 stated she did not remember the exact words. RN 3 stated that she talked to resident 33 after the incident and she told the nurse that her roommate was crazy and did not want another roommate. RN 3 stated Yes, absolutely it would be reported as possible abuse. RN 3 stated she talked to the Director of Nursing (DON) and the Administrator about it being abuse. RN 3 stated that she was educated that a threat needed to be handled the same as an abuse case. RN 3 stated that the DON educated everyone about that. RN 3 stated that the note on 4/14/22 that she wrote, it was something about not letting resident 89 get the COVID test and resident 89 stated that she was thinking about murder. RN 3 stated she notified people and let them know resident 89 was unstable and that's when management started to get her transferred. RN 3 stated resident 89 had threatened the staff member not the roommate on 4/14/22. RN 3 stated that resident 89 just told her that she was thinking about murder. RN 3 stated on 4/15/22 resident 89 threatened resident 33 and a CNA reported it to her. RN 3 stated she should have taken it more seriously on 4/14/22 but did not and had since been education about it. RN 3 stated she was educated by 4/16/22 about it being possible abuse. On 5/5/22 at 10:18 AM, a follow up interview was conducted with CNA 3. CNA 3 stated later that evening when doing the shift change, she told the next shift CNA that resident 89 was being verbal and to watch it and keep resident 33 safe. CNA 3 stated that Corporate Resource Nurse (CRN) 1 did an in-service about abuse and there was a thing on their website training that needed to be done by the following Monday after the resident had been discharged . CNA 3 stated she was told it needed to be done to get more education on abuse. On 5/4/22 at 3:41 PM, an interview was conducted with the DON. The DON stated that she did not remember an incident between resident 33 and resident 89. The DON stated that resident 89 discharged to a mental health facility and returned to the facility on [DATE]. The DON stated she was gone when the incident happened and the Assistant Director of Nursing (ADON) and Corporate Resource Nurse (CRN) 1 took care of it. On 5/4/22 at 3:45 PM, an interview was conducted with the ADON. The ADON stated resident 89 was was not at the facility very long. The ADON stated she discharged to a mental health facility on 4/15/22 at about 8:35 PM. The ADON stated she did not remember any additional information about why resident 89 was admitted to the mental health facility. The ADON stated resident 89 was discussed in the morning meeting but did not recall what day or what was discussed. On 5/4/22 at 3:45 PM, an interview was conducted with CRN 1. CRN 1 stated the NP caught him in the parking lot on the way into work on 4/15/22. CRN 1 stated resident 89 came from a mental health facility because of homicidal comments. CRN 1 stated resident 89 had homicidal comments toward staff so the NP had staff obtain labs. CRN 1 stated there was nothing acute wrong with resident 89, so resident 89 was sent back to the mental health facility. CRN 1 stated nothing had been reported about threats toward another resident. CRN 1 stated as far as he knew that staff member was told by resident 89 that she was going to kill her. On 5/5/22 at 10:36 AM, a follow up interview was conducted with CRN 1. CRN 1 stated there was a resident to resident incident reported to the state in the middle of April between 2 male residents. CRN 1 stated the resident to resident was not reported timely so that triggered abuse education with all staff. CRN 1 stated that the training would have been for staff employed at the facility. CRN 1 stated there was an education binder that had policy in there for agency staff. CRN 1 was observed to review the binders on the 2nd and 3rd floor. CRN 1 was unable to locate information regarding abuse in the binder titled Nurse Quick Guide Reference. On 5/4/22 at 3:58 PM, an interview was conducted with the Operations Manager (OM). The OM stated there was a resident that was making threats but not to a specific person. The OM stated he did not know if there was an investigation into it. The OM stated that he was the abuse coordinator. The OM stated if he had an allegation of abuse, he would try to get all of the initial information in the first hour or two. The OM stated that an investigation was started by interviewing the resident, staff involved, investigate and then get that all typed up and sent in within the 5 days to the State Survey Agency. The OM stated he reported to Adult Protective Services and or the police also. The OM stated the only thing he heard was that it was not a threat to a particular staff or resident. The OM stated the resident was homicidal but not to a specific person. The OM stated he did not write anything down, but did ask if anyone heard anything. On 5/5/22 at 9:03 AM, an interview was conducted with the NP. The NP stated he was notified about residents by staff through a secured texting system. The NP stated that he was able to text back to the staff and that the messages deleted within 5-7 days. The NP stated he cared for resident 89 at the mental health facility prior to her admission to the facility. The NP stated when he was made aware of the incident he contacted the mental health facility and readmitted resident 89 there. The NP stated the morning resident 89 was readmitted to the mental health facility he could not remember 100% of the details. The NP stated he knew resident 89 threatened to harm her roommate. The NP stated he had was notified and then transferred her out the same day. The NP stated he had not been notified of any other times resident 89 had made threatening statements. The NP stated resident 89 was ambulatory but needed a walker. The NP stated resident 89 was able to walk across her room but not much further. The NP stated resident 89 was not very independent or able to get around very far by herself. The NP stated it was safer to get her back to the mental health facility for a change in an environment and see if anything could be done with her medications. The NP stated he did not think resident 89 was going to really hurt anyone at the facility. The NP stated that resident 89 spent a majority of the time in her bed while she was at the facility. The NP stated he instructed staff to monitor her and get blood work. The NP stated he talked to CRN 1 and the ADON about the incident. The NP stated that the DON was moving residents around on the 3rd floor the same day resident 89 made the threatening statements. CRN 1 stated the DON was trying to separate multiple people that day. The NP stated he did not recall if resident 89 had specifically threatened a person. The NP stated he thought he talked to the roommate (resident 33) the morning of 4/15/22. The NP stated that he through resident 33 stated everything was fine. The NP stated that resident 33 was fairly mobile.

Based on interview and record review it was determined, for 1 of 23 sample residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. Specifically, a resident was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 38's medical record was reviewed on 5/4/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The urine analysis and culture were not located in resident 38's medical record. The Assistant Director of Nursing (ADON) provided the UA with reflux culture dated 4/7/22. The form was flagged as abnormal. Resident 38's protein was 300 miligrams per deciliter (mg/dL) and normal was negative. Resident 38 was 150 mg/dL for glucose and normal range was Negative, 30. The laboratory form further revealed small amound of blood and normal was negative. White blood cells were 6-10 high power field (hpf) with a normal range of 0-5, red blood cells were 16-25 with normal 0-5 hpf, and Epithelial Cell were greater than 15 with a normal range of 0-5 low power field (lpf). In addition, [MEDICATION(S)] threads were 1+/lpf with a normal of none and bacteria was rare/hpf which was flagged as abnormal. Resident 38's progress notes were reviewed and revealed the following: a. On 4/6/2022 at 6:22 PM, Received labs results on labs drawn 04/05/22. Sent abnormal lab values to the medical provider. No new orders have been given at this time. b. On 4/7/22 at 2:59 PM, Resident had foley catheter removed, noted to have 390 mLs (milliliters) urine post residual, RN (Registered Nurse) spoke with NP (Nurse Practitioner), received orders to replace foley catheter with dx (diagnoses) of [CONDITION(S)] and to refer resident to urology. Informed floor nurse, placed orders, resident educated, notified transportation. c. On 4/7/22 at 5:40 PM, Urine is yellow, clear, no odor. d. On 4/7/22 at 11:07 PM, . foley catheter inserted as per new order received for dx. of urinary obstruction. Procedure was without complication, cloudy dark yellow urine draining well into catheter drainage bag. Bag placed at lowest position of bed. Wctm (Will continue to monitor). e. On 4/8/22 at 4:26 PM, . Blood Glucose is not being monitored.Urine is cloudy, amber. Foley catheter inserted. f. On 4/8/22 at 4:44 PM, 300mls dark yellow/clear urine seen @ 0945 (9:45 AM). Foley care done. It should be noted that there was no progress note regarding the physician notification. g. On 4/10/22 at 10:08 AM, Patients BS (Blood sugar) was taken at breakfast time at approximately 0900 (9:00 AM) and was 441. Patient is A & O x 2 (Alert and oriented to person and place) which is within patient's baseline and is awake. On call medical provider contacted. [MEDICATION(S)] insulin 10 unites order one time now and then with meals, BS to be rechecked before lunch. Nurse administered insulin as ordered. Patient tolerated well. Will continue to monitor. h. On 4/10/22 at 12:36 PM, No urine was observed that shift. i. On 4/10/22 at 3:44 PM, resident's left breast was firm with odd texturing. Patient denied pain or discomfort. j. On 4/11/22 at 2:15 AM, resident was found unresponsive with no vital signs. Do not recusetate between rounds. Family, Doctor on call, DON notified. Waiting for family to call back. k. On 4/11/22 at 2:50 AM, resident passed at 1:55 am. On 5/4/22 at 2:03 PM, an interview was conducted with RN 3. RN 4 stated resident 38's death was a surprise. RN 4 stated that between CNA rounds resident 38 passed away. RN 4 stated a CNA came to get her and stated resident 38 was not breathing. RN 4 stated that she could not remember who the was CNA. RN 4 stated that resident 38 was not alive and she used her stethoscope to check. RN 4 stated another resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 4 stated CNA's repositioned resident 38 during the shift but RN 4 did not remember when that occured. RN 4 stated she was not aware that resident 38 had a urine analysis with culture. On 5/4/22 at 2:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility were in a transition with the laboratory draws and results. The DON stated that the process was currently for the (ADON) to look at the results, download the results and then send the results to the physician. The DON stated the ADON then wrote a progress notes in the medical record that results were received and that the physician had been notified. The DON stated then laboratory results were placed in the results tab of the electronic medical record. The DON stated resident 38 had retention so a urine analysis was obtained. The DON stated that the process just shifted and nurses were taking over the laboratory draws and notification to the physician. The DON was observed to review resident 38's urine analysis and culture. The DON stated resident 38 should have been treated because the urine was dark, had blood and some bacteria according to the UA. On 5/5/22 at 9:03 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that staff notified him through phone calls or a secured text messaging system that automatically delete after 7 days. The NP stated he was able to respond back to nursing staff through the messaging system. The NP stated the messaging can be sent through a specific resident. The NP stated he was able to obtain laboratory results that way as well. The NP stated he can access laboratory results on his phone through the messaging system.

Based on observation, interview and record review it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Specifically, appropriated signage was not placed outside resident rooms identifying the need for transmission-based precautions (TBP), staff were observed in a patient's isolation room without personal protective equipment (PPE) and unvaccinated COVID-19 newly admitted residents were not put on TBP. In addition, staff did not wear appropriate eye protection (goggles or face shields) when interacting with residents and visitors were observed to enter the facility through a back entrance on the second floor and walk down a hallway past residents prior to performing the COVID-19 screening process. Resident Identifiers: 88, 138 and 193. Findings include: 1. Resident 193 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 9:30 AM, resident 193's room was observed. Located outside the room in the hallway was a cart containing PPE. A white sign stating stop and the resident's name was located on the door. The stop sign had a date 5/6/22. On 5/3/22 at 8:49 AM, Certified nursing assistant (CNA) 1 was observed to enter resident 193 without the appropriate PPE. An interview was immediately conducted with CNA 1 when they exited resident 193's room. CNA 1 stated that PPE must be worn at all times when going into resident 193's room. Resident 193's medical record was reviewed on 5/3/22. Resident 193 developed c-diff in the hospital prior to arriving to the facility. Resident 193 had been on antibiotics to treat his infection and the course of treatment ended on 5/6/22. On 5/2/22 at 9:32 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated they normally he did not work here and needed to look a report sheet to see why there was a sign on resident 193's door. RN 1 then stated that resident 193 had the sign outside their door due to being on intravenous (IV) fluids and receiving a bag of normal saline. [Note: RN 1 did not know resident 193 was on contact precautions due to c-diff.] On 5/2/22 at 12:11 PM, an interview and observation was made of RN 1. RN 1 stated that resident 193 had a stop sign on his door because he was getting IV fluids. RN 1 was observed to enter resident 193's room without PPE. RN 1 was observed to walk next to resident 193 and touch his IV fluid bag. RN 1 was observed to exit the room and hand hygiene was not performed. On 5/3/22 at 8:47 AM, RN 2 was interviewed. RN 2 stated that resident 193 was precautions for either two reasons, c-diff or because he was a new admit and probably was not vaccinated for COVID-19. RN 2 stated that it was most likely because of the vaccination that resident 193 was on precautions. On 5/4/22 at 12:15 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that resident 193 was on standard contact precautions due to c-diff. LPN 1 stated that PPE must be worn when coming in contact with the resident. 2. Resident 88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 9:00 AM, an observation was made of a 3 drawer container outside resident 88's room. There was no signage on the door. Resident 88's medical record was reviewed on 5/3/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . droplet. May resolved associated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no end date. It should be noted day 10 since admission was 5/2/22. On 5/2/22 at 11:53 AM, an observation was made of RN 5. RN 5 was observed to enter resident 88's room with surgical mask and eye protection. RN 5 was interviewed. RN 5 stated he was called in to help out and was not aware of any residents that required isolation precautions on the 200 hallway. RN 5 stated that RN 1 was the nurse for the hall and he knew who was on isolation precautions. On 5/2/22 at 12:11 PM, RN 1 was interviewed. RN 1 stated that there was one resident on isolation precautions in the 200 hallway. RN 1 stated that resident 88 was not on isolation precautions. On 5/2/22 at 12:19 PM, an observation was made of CNA 5. CNA 5 was observed to enter resident 88's room. CNA 5 was observed to wear a surgical mask and eye protection into resident 88's room. CNA 5 was not observed to change her mask or eye protection and did not add additional PPE. On 5/2/22 at 12:21 PM, CNA 4 was interviewed. CNA 4 stated if a resident was on isolation precautions there was usually a 3 drawer compartment outside their room. CNA 4 stated resident 88 did not have a stop sign. On 5/3/22 at 8:16 AM, an interview was conducted with resident 88. Resident 88 stated she was not vaccinated for COVID-19. Resident 88 stated that staff wore yellow gowns, gloves, eye protection and masks into her room. Resident 88 stated she was told her isolation was discontinued yesterday. On 5/5/22 at 2:00 PM, the Director of Nursing (DON) was interviewed. The DON stated that residents unvaccinated for COVID-19 required isolation precautions for 10 days after admission. The DON stated if a resident tested negative for COVID-19 on day 7, then isolation precautions were discontinued. The DON stated that resident 29 had been in isolation but there was no signage to notify staff until 5/5/22. The DON stated she removed resident 29 from the dining room on 5/2/22 and told resident 29 she was on isolation and not allowed in the dining room. The DON stated there were orders in resident's electronic medical record for staff, Sadly who knows with agency (staff where they) look regarding isolation. 3. Resident 138 was admitted to the facility on [DATE] no medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 138 was not vaccinated against COVID-19. On 5/2/22 at 9:00 AM, an observation was made of room [ROOM NUMBER] door open, no signage or isolation cart outside of room. On 5/3/22 at 7:10 AM, an observation was made of room [ROOM NUMBER] door open, no signage or isolation cart outside of room. On 5/04/22 at 11:22 AM, an interview was conducted with RN 3. RN 3 stated for those residents who are not vaccinated, they are isolated for 14 days, the facility could administer the COVID-19 vaccination if they want it. RN 3 stated there should be a sign that said to see the nurse before entering and a cart with PPE outside the residents door. On 5/5/22 at 2:49 PM, an interview was conducted with the DON. The DON stated resident 138 was not COVID-19 vaccinated and isolation was to continue until 5/10/22. The DON stated resident 138 was able to test for COVID-19 on 5/6/22 and if it was negative was able to discontinue isolation. On 5/05/22 at 10:09 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated when a resident was in isolation staff must wear gown goggles, mask, and gloves. The NP stated unvaccinated residents should be in isolation for 5-10 days then they can be retested at 7 days to see if they were positive or if isolation could be discontinued. The NP stated vaccinated residents did not need to be isolated. 4. PPE usage On 5/3/22 at 7:38 AM, an observation was made of RN 2 not wearing eye protection during morning medication pass. On 5/03/22 at 7:35 AM, an observation was made of the Maintenance Director (MD). The MD wore his eye protection on top of his head while on the 3rd floor. On 5/03/22 at 8:11 AM, an observation was made of the MD. The MD wore his eye protection on top of his head while on the 3rd floor. On 5/03/22 at 8:30 AM, an observation was made of the MD. The MD wore his eye protection on top of his head while on the 3rd floor. On 5/2/22 at 12:57 PM, an observation was made of CNA 4. CNA 4 was observed with his nose and mouth exposed in the hallway outside room [ROOM NUMBER]. CNA 4 was observed to enter room [ROOM NUMBER] with his nose and mouth exposed. On 5/4/22 at 10:47 AM, an observation was made in the 300 hallway. A Dentist and Dental Assistant were observed with residents without eye protection. An observation was made of the Dentist and Dental assisting within 6 feet of residents without eye protection. According to the Utah Department of Health Personal Protective Equipment (PPE) Requirements for Long-Term Care Facility Staff updated 3/21/22 surgical masks and eye protection were to be worn by staff in resident rooms and resident common areas by staff when the community transmission rate was high. 5. Visitor Screening: On 5/3/22 at 8:00 AM, an observation was made of the Corporate Resource Nurse (CRN) 1 and CRN 2 standing next to the North outside entrance on the 2nd floor. A visitor was observed to come to the door. CRN 2 opened the door and asked what the visitor needed. The visitor stated she was there to see her son. CRN 2 asked the visitor if she had a mask, the visitor reached into her bag and placed a surgical mask on her face. The visitor then entered the facility and walked directly to her son's room. On 5/3/22 at 8:10 AM, an interview was conducted with the visitor. The visitor stated she came in the front entrance a couple of times at the beginning of her son's stay at the facility, but since being there for a while they know me and I come in the side entrance. The visitor stated she was vaccinated and wore a mask. The visitor stated she did not screen today at the front entrance. On 5/03/22 at 8:10 AM, an interview was conducted with CRN 1 and CRN 2 who stated they did let the visitor in through the 2nd floor side entrance. CRN 2 stated the visitor screened at the nurses pod on the 2nd floor. The visitor was not observed to come to the nurses station as this surveyor was standing there doing medication pass with the nurse on duty. CRN 1 stated the visitor would have had to walk down the 2nd floor resident hallway, past residents to screen in at the nurses pod on the 2nd floor. On 5/3/22 at 8:15 AM, an interview conducted with DON. The DON stated screening was done at the front entrance. The DON stated all visitors screened at the front entrance. The DON stated they came in on the second floor but there was no screening done on the second floor. The DON stated there was a sign on the 2nd floor entrance that directed all visitors to come to the first floor for them to screen. The DON stated the doors on 2nd floor were locked. The DON stated if a visitor entered through the 2nd floor entrance they were directed to the 1st floor to screen in at the front of the building to screen. The DON stated the staff were to wear goggles and masks and visitors were to wear masks.

Based on interview and record review it was determined, for 5 out of 6 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed. Findings include: On 5/5/22, the Operations Manager (OM) provided the vaccination status of facility staff. Staff member (SM) 1, SM 2, SM 3, SM 4, SM 5 and SM 6. SM 1, SM 3, SM 4, SM 5, and SM 6 had Religious Objections to the COVID-19 vaccination. SM 2 did not have an exemption. The county transmission rate provided by the facility revealed the following: a. 4/4/22 rate was 3.27% indicating weekly COVID-19 testing, b. 4/11/22 rate was 4.07% indicating weekly COVID-19 testing, c. 4/18/22 rate was 5.36% indicating weekly COVID-19 testing, d. 4/25/22 rate was 6.63% indicating twice weekly COVID-19 testing, e. 5/2/22 rate was 11.28% indicating twice weekly COVID-19 testing. COVID-19 testing was reviewed and SM 1 was tested on [DATE], 4/13/22, 4/22/22, 4/29/22, 4/26/22 and 5/3/22. There were no COVID-19 testing results for SM 2, SM 3, SM 4, SM 5 and SM 6 from 4/4/22 through 5/5/22. The facility COVID-19 Vaccine Policies and Procedures with no date, stated additional precautions and contingency plans for unvaccinated staff included, requiring at least weekly testing for exempt staff, and staff who have not completed their primary vaccination series . On 5/5/22 at 2:19 PM, an interview was done with the Director of nursing (DON). The DON stated that the Human Resource (HR) staff member had COVID-19 testing and documentation. The DON stated that the (HR) staff member was unavailable. On 5/5/22 at 2:49 PM, a follow up interview was conducted with the DON. The DON stated SM 2 was a fairly new employee and she was not sure if SM 2 was vaccinated or not. On 5/24/22 at 2:26 PM, a follow up interview was conducted the OM. The OM stated that not all COVID-19 testing was being completed for unvaccinated staff.

Based on observation, interview and record review, it was determined the facility did not develop and implement policies and procedures to ensure that all staff were fully vaccinated for Coronavirus Disease-2019 (COVID-19). The facility did not ensure that the policies and procedures applied to individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Also, the facility did not implement policies and procedures that included, at a minimum, a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. Specifically, the facility was unaware and did not keep documentation of the vaccination status for their contracted staff. In addition, an unvaccinated staff member was not wearing the appropriate personal protective equipment according to the facility's policy and procedures. Findings include: On 5/4/22 at 3:04 PM, an observation was made of Staff member (SM) 3. SM 3 was observed to be wearing a surgical mask with eye protection in resident care areas. On 5/5/22 Operations Manager (OM) provided 3 agency staff vaccination records. The facility COVID-19 Vaccine Policies and Procedures with no date, stated additional precautions and contingency plans for unvaccinated staff included, requiring at least weekly testing for exempt staff, and staff who have not completed their primary vaccination series . Requiring staff who have not completed their primary vaccination series to use a NIOSH approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients. The facility staff vaccination matrix revealed staff members (SM) 1, SM 2, SM 3, SM 4, SM 5, and SM 6 had religious objections for the COVID-19 vaccination. On 5/24/22 the facility's COVID-19 testing plan implementation and documentation was reviewed and revealed that only staff member 1 had been doing the required weekly testing as per facility policy and guidelines. No documentation regarding COVID-19 testing was found regarding staff members 2,3,4,5,6 through the month of March and April. On 5/5/22 at 1:16 PM, an interview was done with the Operations Manager (OM). The OM stated that the facility did not have contracted employee vaccine status including hospice and agency staff. On 5/5/22 at 2:19 PM, an interview was done with the Director of Nursing (DON). The DON stated that Human Resource (HR) staff member had COVID-19 testing and documenting for staff. The DON stated the HR staff member was unavailable and other staff were unable to locate the testing. It should be noted testing was sent to surveyors on 5/23/22. On 5/24/22 at 2:26 PM, a follow up interview was conducted the OM. The OM stated that not all COVID-19 testing was being completed for unvaccinated staff.

Based on observation, interview, and record review it was determined, for 2 of 23 sample resident, the facility did not provide the right for residents to choose medical treatment. Specifically, residents Physicians Orders for Life Sustaining Treatment (POLST) forms were not filled out timely after the residents were admitted to the facility. Resident identifiers: 8 and 30. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] a review of resident 8's medical record was conducted. Resident 8's POLST was not signed by the resident until [DATE] and signed by a medical provider on [DATE]. This was 84 days after admission. 2. Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] a review of resident 30's medical record was conducted. Resident 30's POLST was not signed by the resident until [DATE] and signed by a medical provider on [DATE]. This was 61 days after admission. On [DATE] at 2:16 PM, an interview with Registered Nurse (RN) 3. RN 3 stated if a resident had an emergency she would find the information for treatment on her shift sheet, if it was there, if not RN 3 stated she would look in the POLST book. If no information was found the resident would be considered a Full Code. On [DATE] at 10:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the POLST needed to be signed within 24 hours of resident's admission to the facility. The DON stated if the POLST was not completed we would assume the resident was a full code and do cardiorespiratory resuscitation (CPR). The DON stated if that resident was a Do Not Resuscitate (DNR) and CPR was performed that would be a big problem. The DON stated the system on how the POLST forms had been completed was ineffective and was on the forefront of the facilities recovery effort for ineffective systems.

Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the two showers in the third floor shower room were in disrepair. Findings included: On 5/2/22 at 10:27 AM, an interview was conducted with resident 19. Resident 19 stated the showers had black stuff in the corners, the Certified Nursing Assistant's (CNA) went in after each person and washed it down after each person showered. On 5/4/22 at 3:07 PM, an observation was made of the shower room on the third floor. The following observations were made: a. Shower A had orange rust stains that ran down the tiled wall to the floor. b. Shower A faucet continuously dripped from the end of the hand held shower nozzle. c. Shower A paint peeled along the top of the shower, where the tile met the pain in two locations. d. Shower A had caulk missing around the base of the shower. e. Shower A had multiple tiles with reminents of adhesive residue on the walls. f. Shower A had fauset base pulled out from wall. g. Shower A had multiple quarter sized rust stains on the tile floor. h. Shower B had missing caulk around the base of the tiled shower, there was a black substance around the bottom of the shower. i. Shower B soap holder with corrosion on the side and top of the holder. j. Shower B had the tip of a latex glove, in the same location on the tiled floor on 5/4/22 and 5/5/22. k. Shower B had a plastic razor cap, in the same location on the tiled floor on 5/4/22 and 5/5/22. On 5/4/22 at 3:20 PM, an interview was conducted with Certified Nurses Assistant (CNA) 3. CNA 3 stated the showers were cleaned in between each shower. CNA 3 stated the showers were sprayed with disinfectant, then wiped down after the disinfectant sat for one minute then, we can shower another resident. CNA 3 stated we try to keep the showers clean for the residents. On 5/5/22 at 10:15 AM an interview was conducted with Maintenance Director (MD). The MD stated housekeeping cleaned the showers everyday, they wash them and clean the floors. The MD stated before he came they changed the caulk in the showers and put in the wrong caulk. The MD stated the black on the caulk was from the paint. The MD was observed pointing to the wall that was painted white in color. The MD stated the metal soap dispenser was placed over a metal screw and there was a leak behind that caused the rust to run down the wall and the faucet to leak. The MD stated the showers needed to have some things fixed in them so they were better for the residents.

Based on interview and record review it was determined, for 4 of 23 sample residents, that in response to an allegation of abuse, neglect, exploitation or mistreatment, the facility did not ensure that all alleged violations were report no later than 2 hours after the allegation was made and the results of all investigations were reported within 5 working days of the incident. Specifically, two resident to resident altercations were not reported within 2 hours to the state survey agency. Resident identifiers: 9, 31, 33 and 89. Findings include: 1. Resident 33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated the roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. There were no progress notes located in resident 33's medical record regarding any concerns with her roommate. Resident 89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 89's medical record was reviewed on 5/3/22. Resident 89's History and Physical prior to admitted d 3/24/22 revealed She becomes agitated and may hit, kick, scream or grab. The form further revealed Familiar people are not recognized or misidentified. Resident 89's progress notes revealed the following entries: a. On 4/14/22 at 5:12 PM, Registered Nurse (RN) 3 documented Staff member went into patients room to get the covid test done. Patient told her that she would not let her do that. Staff member asked her why and patient told her that she was thinking about murder and that she was thinking about doing this to the staff member. Staff member left the room and did not perform the test. Will notify social services. b. On 4/15/22 the Nurse Practitioner (NP) documented Seen due to agitation and aggression. Threatened to stab roommate last night. When laboratory analysis without acute normalizites. Coordinate transfer back to [mental health facility]. c. On 4/15/22 at 8:35 PM, resident 89 was picked up and transported to the mental health facility about 8:35 PM. A review of facility reported incidents to the State Survey agency revealed no reported information regarding the incident. On 5/5/22 at 9:52 AM, a follow up interview was conducted with resident 33. Resident 33 stated that her roommate kept talking about killing. Resident 33 stated that her roommate told resident 33 to call the cops because she had already hurt someone. Resident 33 stated she told a nurse and a couple of Certified Nursing Assistant's (CNA) about resident 89's comments. Resident 33 stated that after the roommate told her that she already hurt someone, resident 33 stated that she was afraid that the resident would stab her. Resident 33 stated she was concerned the roommate was a threat to other people if she came back to the facility. Resident 33 stated she did not feel safe with the roommate in her room. Resident 33 stated she did not remember if the NP, doctor or Administrator talked to her about feeling safe. Resident 33 stated if she had been asked if she felt safe would have said no. Resident 33 stated I just felt like she was crazy. Resident 33 stated she was unable to sleep about 4 night because she was scared of her roommate. Resident 33 stated her roommate did not talk much but was able to get herself up and walk to the bathroom and walk to the door. Resident 33 stated as soon as the roommate left, she was not scared anymore. Resident 33 stated she would be afraid if her roommate was readmitted to the facility. On 5/5/22 at 10:24 AM, an interview was conducted with CNA 2. CNA 2 stated she worked with residents on the 3rd floor three days a week where resident 33 and resident 89 resided. CNA 2 stated there was a incident with resident 33 who had a roommate, resident 89. CNA 2 stated when went in to help resident 33, resident 89 told CNA 2 that she committed a murder and she asked who she had murdered and she said she had not done it yet but was going to and pointed to resident 33. CNA 2 stated she reported the incident to the nurse but could not remember who the nurse was and might have been a agency nurse. CNA 2 stated she talked to resident 33 and asked her how she felt. CNA 2 stated she asked resident 33 if she was afraid and she said no, but her roommate was just crazy. CNA 2 stated she thought resident 89 was transported to a mental health facility the same day. CNA 2 stated she heard from another CNA that resident 89 was thinking about murdering that CNA too. CNA 2 stated she reported the threat to the nurse because it was a form of abuse and did not think resident 33 should be in the same room with resident 89 because she could use utensils or something to hurt resident 33. CNA 2 stated she looked in the room to make sure that resident 89 did not have anything she could hurt resident 33 with. CNA 2 stated she felt like it could be a threat or abuse that's why she reported it to the agency nurse. On 5/4/22 at 3:12 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 89 said some not so nice things to her. CNA 3 stated she was helping resident 33 and resident 89 looked at CNA 3 and said that B gets all the help and she wanted to kill her. CNA 3 stated she helped resident 33 back to bed to get her safe. CNA 3 stated then she went to resident 89 and asked her what she needed. CNA 3 stated that resident 89 stated she was fine. CNA 3 stated other staff heard resident 89 say she wanted to kill resident 33 at different times. CNA 3 stated it happened about the middle of April 2022. CNA 3 stated that she reported it to an agency nurse. CNA 3 stated she hoped that the nurse documented something. CNA 3 stated she randomly check in there for safety reasons. CNA 3 stated the same day resident 89 was transferred out of the facility. CNA 3 stated staff were randomly checking the room through out the day. CNA 3 stated resident 33 did not say anything about feeling unsafe. On 5/4/11 at 3:28 pm, an interview was conducted with RN 3. RN 3 stated resident 33's roommate was paranoid and was having some issues. RN 3 stated resident 89 threatened staff and then threatened her roommate because she was not in her right mind. RN 3 stated resident 33 sat out with us at the nurses station because the roommate was not coming out of her room. RN 3 stated she was told from a staff member that roommate had threatened resident 33. RN 3 stated she did not remember the exact words. RN 3 stated that she talked to resident 33 after the incident and she told the nurse that her roommate was crazy and did not want another roommate. RN 3 stated Yes, absolutely it would be reported as possible abuse. RN 3 stated she talked to the Director of Nursing and the Administrator about it being abuse. RN 3 stated that she was educated that a threat needed to be handled the same as an abuse case. RN 3 stated that the DON educated everyone about that. RN 3 stated that the note on 4/14/22 that she wrote, it was something about not letting resident 89 get the COVID test and resident 89 stated that she was thinking about murder. RN 3 stated she notified people and let them know resident 89 was unstable and that's when management started to get her transferred. RN 3 resident 89 had threatened the staff member not the roommate on 4/14/22. RN 3 stated that resident 89 just told her that she was thinking about murder. RN 3 stated on 4/15/22 resident 89 threatened resident 33 and a CNA reported it to her. RN 3 stated she should have taken it more seriously on 4/14/22 but did not and had since been education about it. RN 3 stated she was educated by 4/16/22 about it being abuse possibly. On 5/4/22 at 3:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 89 was was not at the facility very long. The ADON stated she discharged to a mental health facility on 4/15/22 at about 8:35 PM. The ADON stated she did not remember any additional information about why resident 89 was admitted to the mental health facility. The ADON stated resident 89 was discussed in the morning meeting but did not recall what day or what was discussed. On 5/4/22 at 3:45 PM, an interview was conducted with CRN 1. CRN 1 stated the NP caught him in the parking lot on the way into work on 4/15/22. CRN 1 stated resident 89 came from a mental health facility because of homicidal comments. CRN 1 stated resident 89 had homicidal comments toward staff so the NP had staff obtain labs. CRN 1 stated there was nothing acute wrong with resident 89, so resident 89 was sent back to the mental health facility. CRN 1 stated nothing had been reported about threats toward another resident. CRN 1 stated as far as he knew that staff member was told by resident 89 that she was going to kill her. On 5/4/22 at 3:58 PM, an interview was conducted with the Operations Manager (OM). The OM stated there was a resident that was making threats but not to a specific person. The OM stated he did not know if there was an investigation into it. The OM stated that he was the abuse coordinator. The OM stated he tried to get all of the initial information in the first hour or 2. The OM stated that an investigation was started by interviewing the resident, staff involved, investigate and then get that all typed up and sent in within the 5 days to the State Survey Agency. The OM stated he reported to Adult Protective Services (APS) and or the police also. The OM stated the only thing he heard was that it was not a threat to a particular staff or resident. The OM stated the resident was homicidal but not to a specific person. The OM stated he did not write anything down, but did ask if anyone heard anything. On 5/5/22 at 9:03 AM, an interview was conducted with the NP. The NP stated he was notified about residents by staff through a secured texting system. The NP stated that he was able to text back to the staff and that the messages deleted within 5-7 days. The NP stated he cared for resident 89 at the mental health facility prior to her admission to the facility. The NP stated when he was made aware of the incident he contacted the mental health facility and readmitted resident 89 there. The NP stated the morning resident 89 was readmitted to the mental health facility he could not remember 100% of the details. The NP stated he knew resident 89 threatened to harm her roommate. The NP stated he had was notified and then transferred her out the same day. The NP stated he had not been notified of any other times resident 89 had made threatening statements. The NP stated resident 89 was ambulatory but needed a walker. The NP stated resident 89 was able to walk across her room but not much further. The NP stated resident 89 was not very independent or able to get around very far by herself. The NP stated it was safer to get her back to the mental health facility for a change in an environment and see if anything could be done with her medications. The NP stated he did not think resident 89 was going to really hurt anyone at the facility. The NP stated that resident 89 spent a majority of the time in her bed while she was at the facility. The NP stated he instructed staff to monitor her and get blood work. The NP stated he talked to CRN 1 and the ADON about the incident. The NP stated that the DON was moving residents around on the 3rd floor the same day resident 89 made the threatening statements. CRN 1 stated the DON was trying to separate multiple people that day. The NP stated he did not recall if resident 89 had specifically threatened a person. The NP stated he thought he talked to the roommate (resident 33) the morning of 4/15/22. The NP stated that he through resident 33 stated everything was fine. The NP stated that resident 33 was fairly mobile. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9's progress notes were reviewed and revealed on 4/15/22 at 4:32 AM, Staffing heard screaming, abusive language and resident 9's roommate screaming, 'why did you hit me in the arm!' CNA intervened and separated resident 9, after he was threatening roommate that he will kill him. Resident 31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31's progress notes were reviewed and revealed On 4/15/22 at 4:40 AM, Staff heard loud voices fighting, abusive language, and verbal threats coming from residents room. Staffing intervened and resident stated roommate had hit him in the arm for no reason. CNA separated roommate and redirected. No injuries to resident upon assessment shall continue to monitor. A Facility Reported Incident (FRI) revealed the State Survey Agency was contacted on 4/15/22 at 11:04 AM. The report revealed on 4/15/22 at 4:30 AM resident 31 reported that resident 9 hit his arm. The residents were separated and assessments of resident 31 was completed. Labs were also ordered for resident 9. APS and Physician were notified. On 5/4/22 at 3:41 PM, an interview was conducted with the DON. The DON stated there had been one incident and she was not the one that reported it. The DON stated the incident was between resident 9 and resident 11. The DON stated she was not at the facility when the incident occurred. On 5/5/22 at 10:36 AM, an interview was conducted with CRN 1. CRN 1 stated there was a resident to resident incident that was reported to the state. CRN 1 stated it was between resident 9 and resident 31. CRN 1 stated from what he remembered one resident was struck another resident on the arm. CRN 1 stated it was reported up the chain of command but it was reported late. CRN 1 stated since the incident was not immediately reported it triggered management to to do abuse education with all staff. CRN 1 stated that agency staff had a binder at each nurses station with the abuse policy and procedure. CRN 1 was observed to look through the binders titled Nurse Quick Guide Reference and was unable to find information on abuse. On 5/5/22 at 1:45 PM, an interview was conducted with the Operations Manager (OM). The OM stated the incident between resident 31 and resident 9, took place early into the day, like early in the morning. The OM stated that he was informed about it between 8:00 to 9:00 AM. The OM stated the incident needed to be reported within 2 hours to the State Survey Agency and was not. A review of the facility Abuse policy and procedure revealed, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Mental Abuse - This includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Procedures: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Not later than two (2) hours after the allegation is made if the events that cause the allegation involved abuse or results in serious bodily injury. Not later than twenty-four (24) hours if the events that cause the allegation does not involved abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: The Administrator of the Facility The State Survey Agency Adult Protective Services (as appropriate) Ensures that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident (s). Ensure that the results of all investigations are reported within five (5) working days of the incident: The Administrator The State Survey Agency .

Based on interview and record review it was determined, for 2 of 23 sample residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, a resident threatened another resident and there was no investigation. Resident identifiers: 33 and 89. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated the roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. There were no progress notes located in resident 33's medical record regarding any concerns with her roommate. Resident 89 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 89's medical record was reviewed on 5/3/22. A History and Physical from 3/24/22 revealed She becomes agitated and may hit, kick, scream or grab. The form further revealed Familiar people are not recognized or misidentified. Resident 89's progress notes revealed the following entries: a. On 4/14/22 at 5:12 PM, Registered Nurse (RN) 3 documented Staff member went into patients room to get the covid test done. Patient told her that she would not let her do that. Staff member asked her why and patient told her that she was thinking about murder and that she was thinking about doing this to the staff member. Staff member left the room and did not perform the test. Will notify social services. b. On 4/15/22 the Nurse Practitioner (NP) documented Seen due to agitation and aggression. Threatened to stab roommate last night. When laboratory analysis without acute normalizites. Coordinate transfer back to [mental health facility]. c. On 4/15/22 at 8:35 PM, resident 89 was picked up and transported to the mental health facility about 8:35 PM. A review of facility reported incidents to the State Survey agency revealed no reported information regarding the incident. On 5/5/22 at 9:52 AM, a follow up interview was conducted with resident 33. Resident 33 stated that her roommate kept talking about killing. Resident 33 stated that her roommate told resident 33 to call the cops because she had already hurt someone. Resident 33 stated she told a nurse and a couple of Certified Nursing Assistant's (CNA). Resident 33 stated that after the roommate told her that she already hurt someone, resident 33 stated that she was afraid that the resident would stab her. Resident 33 stated she was concerned the roommate was a threat to other people if she came back to the facility. Resident 33 stated she did not feel safe with the roommate in her room. Resident 33 stated she did not if the NP, doctor or Administrator talked to her about feeling safe. Resident 33 stated if had been asked if she felt safe would have said no. Resident 33 stated I just felt like she was crazy. Resident 33 stated she was unable to sleep about 4 night because she was scared of her roommate. Resident 33 stated her roommate did not talk much but was able to get herself up and walk to the bathroom and walk to the door. Resident 33 stated as soon as the roommate left, she was not scared anymore. Resident 33 stated she would be afraid if her roommate was readmitted to the facility. On 5/5/22 at 10:24 AM, an interview was conducted with CNA 2. CNA 2 stated she worked with residents on the 3rd floor three days a week. CNA 2 stated there was a incident with resident 33 who had a roommate resident 89. CNA 2 sated when went in to help resident 33, resident 89 told CNA 2 that she committed a murder and she asked who she had murdered and she said she had not done it yet but was going to and pointed to resident 33. CNA 2 stated she reported the incident to the nurse but could not remember who the nurse was and might have been a agency nurse. CNA 2 stated she talked to resident 33 and asked her how she felt. CNA 2 stated she asked resident 33 if she was afraid and she said no, but her roommate was just crazy. CNA 2 stated she though resident 89 was transported to a mental health facility the same day. CNA 2 stated she was not aware of comments made prior to that day. CNA 2 stated she heard from another CNA that resident 89 was thinking about murdering that CNA too. CNA 2 stated she reported to the treat to the nurse because it was a form of abuse and did not think resident 33 should be in the same room with resident 89 because she could use utensils or something to hurt resident 33. CNA 2 stated she looked in room to make sure that she did not have anything she could hurt resident 33 with. CNA 2 stated she felt like it could be a threat or abuse that's why she reported it to the agency nurse. On 5/4/22 at 3:12 PM, an interview was conducted with CNA 3. CNA 3 stated resident 33's roommate was here for a short time. CNA 3 stated that resident 89 said some not so nice things to her. CNA 3 stated she was helping resident 33 and resident 89 looked at CNA 3 and said that B gets all the help and she wanted to kill her. CNA 3 stated she helped resident 33 back to bed to get her safe. CNA 3 stated then she went to resident 89 and asked her what she needed. CNA 3 stated that resident 89 stated she was fine. CNA 3 stated other staff heard resident 89 say she wanted to kill resident 33 at different times. CNA 3 stated it happened about the middle of April 2022. CNA 3 stated that she reported it to an agency nurse. CNA 3 stated she hoped that the nurse documented something. CNA 3 stated she randomly check in there for safety reasons. CNA 3 stated the same day resident 89 was transferred out of the facility. CNA 3 stated staff were randomly checking the room through out the day. CNA 3 stated resident 33 did not say anything about feeling unsafe. On 5/4/11 at 3:28 pm, an interview was conducted with RN 3. RN 3 stated resident 33's roommate was paranoid and was having some issues. RN 3 stated resident 89 threatened staff and then threatened her roommate because she was not in her right mind. RN 3 stated resident 33 sat out with us at the nurses station because the roommate was not coming out of her room. RN 3 stated she was told from a staff member that resident 89 had threatened resident 33. RN 3 stated she did not remember the exact words. RN 3 stated that she talked to resident 33 after the incident and she told the nurse that her roommate was crazy and did not want another roommate. RN 3 stated Yes, absolutely it would be reported as possible abuse. RN 3 stated she talked to the Director of Nursing (DON) and the Operations Manager (OM) about it being abuse. RN 3 stated that she was educated that a threat needed to be handled the same as an abuse case. RN 3 stated that the DON educated everyone about that. RN 3 stated that the note on 4/14/22 that she wrote, it was something about not letting resident 89 get the COVID-19 test and resident 89 stated that she was thinking about murder. RN 3 stated she notified people and let them know resident 89 was unstable and that's when management started to get her transferred. RN 3 resident 89 had threatened the staff member not the roommate on 4/14/22. RN 3 stated that resident 89 just told her that she was thinking about murder. RN 3 stated on 4/15/22 resident 89 threatened resident 33 and a CNA reported it to her. RN 3 stated she should have taken it more seriously on 4/14/22 but did not and had since been education about it. RN 3 stated she was educated by 4/16/22 about it being possible abuse. On 5/4/22 at 3:41 PM, an interview was conducted with the DON. The DON stated that she did not remember an incident between resident 33 and resident 89. The DON stated that resident 89 discharged to a mental health facility and returned to the facility on [DATE]. The DON stated she was gone when the incident happened and the Assistant Director of Nursing (ADON) and Corporate Resource Nurse (CRN) 1 took care of it. On 5/4/22 at 3:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 89 was was not at the facility very long. The ADON stated she discharged to a mental health facility on 4/15/22 at about 8:35 PM. The ADON stated she did not remember any additional information about why resident 89 was admitted to the mental health facility. The ADON stated resident 89 was discussed in the morning meeting but did not recall what day or what was discussed. On 5/4/22 at 3:45 PM, an interview was conducted with CRN 1. CRN 1 stated the NP caught him in the parking lot on the way into work on 4/15/22. CRN 1 stated resident 89 came from a mental health facility because of homicidal comments. CRN 1 stated nothing had been reported about threats toward another resident. CRN 1 stated as far as he knew that staff member was told by resident 89 that she was going to kill her. On 5/4/22 at 3:58 PM, an interview was conducted with the Operations Manager (OM). The OM stated there was a resident that was making threats but not to a specific person. The OM stated he did not know if there was an investigation into it. The OM stated that he was the abuse coordinator. The OM stated if there was an allegation of abuse, he tried to get all of the initial information in the first hour or 2. The OM stated that an investigation was started by interviewing the resident, staff involved, investigate and then get that all typed up and sent to the State Survey Agency within the 5 days. The OM stated he reported to Adult Protective Services and or the police. The OM stated the only thing he heard was that it was not any threat to a particular staff or resident. The OM stated the resident was homicidal but not to a specific person. The OM stated he did not write anything down, but did ask if anyone heard anything. A review of the facility Abuse policy and procedure revealed, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Mental Abuse - This includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Procedures: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Not later than 23 hours if the events that cause the allegation does not involved abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to : The Administrator of the Facility The State Survey Agency Adult Protective Services (as appropriate) Ensures that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident (s). Ensure that the results of all investigations are reported within five (5) working days of the incident: The Administrator The State Survey Agency .

Based on observation, interview, and record review it was determined, for 1 of 23 sample residents, the facility did not ensure that the residents' environment remained as free of accident hazards as was possible or that each resident received adequate supervision to prevent accidents. Specifically, a resident had access to hazardous chemicals and there was a hallway rug outside of a resident's room which a resident tripped over when using a walker. Resident identifier: 194 Findings include: Resident 194 was admitted to the facility on [DATE] with diagnoses which included left knee derangement of patella, [CONDITION(S)], current episode manic without psychotic features, borderline personality disorder, muscle weakness and unsteadiness on feet. 1. On 5/2/22 at 12:08 PM, an observation was made of resident 194. Resident 194 was observed to ask house keeping for a broom and dust pan so resident could clean behind the door. House keeper was observed to give resident 194 the supplies requested and proceeded to tell the resident to return the broom and pan back to the house keeping closet and gave resident 194 the code to the closest. On 5/4/22 at 10:49 AM, an observation of the housekeeping closet was conducted. Several hazardous containers were located including Clorox, Peroxide multi surface cleaner, liquid hand sanitizer, Multiple bags of keystone multi-quat sanitizer and glass cleaners. Warning labels on the containers stated hazardous to humans and domestic animals. Resident's 194 medical record was reviewed on 5/4/22 Care plan dated 4/14/22 revealed a Focus of The resident is at risk for falls r/t (related to) L (left) patellar fx (fixture) / hardware removal, WBAT (weight bearing as tolerated) to LLE (left lower extremity). The goal developed was The resident will not sustain serious injury through the next review date. Interventions developed were, Therapy evaluation and treatment per physician orders, educate resident/family/caregivers about safety reminders and what to do if a fall occurs. On 5/4/22 at 10:54 AM, an interview was conducted with Housekeeper 1. Housekeeper 1 stated housekeeping were the only ones aware what the code was to the housekeeping closet and residents were not allowed to borrow any kind of supplies from them nor were residents allowed in the housekeeping closest. Housekeeper 1 stated if a resident needs something cleaned or picked up house keeping did it. On 5/5/22 at 10:14 AM, an interview was conducted with the Director of Nursing (DON). The DON stated hazardous chemicals were stored in the maintenance closet and they had a biohazard room (housekeeping closet) with some sprays in it that was locked. The DON stated the only staff that was aware of the code and who had access to the closets were the maintenance worker and housekeeping. The DON stated the codes were not given out to residents. The DON then stated if a resident did have access to any of the closets, they would be concerned about ingestion of the hazardous material, especially pertaining to resident 194. The DON stated that resident 194 was not mentally stable to be around hazardous material and worried that resident 194 may ingest the chemicals or spray another resident/staff since resident 194 was vindictive. The DON since resident 194 knew the code, they were immediately changing the code. 2. On 5/3/22 at 09:02 AM, an observation was made of resident 194. Resident 194 was observed to get the left front end of their walker stuck on an entry rug located outside resident's 194 room. Resident 194's medical record was reviewed on 5/4/22. Care plan dated 4/19/22 revealed a Focus of The resident has potential to demonstrate verbally abusive behaviors r/t (related to) Mental/ Emotional illness. The goal developed was The resident will demonstrate effective coping skills through the review date. Intervention developed were, Assess and anticipate resident's needs, assess resident's coping skills and support system, assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation. Give as many choices as possible about care and activities. Progress notes revealed the following entries: a. Nursing note on 4/16 at 14:54 revealed resident 194 was put on a behavior contract due to aggression. b. Behavior note on 4/19 at 12:46 revealed that resident 194 was identified as a fall risk by staff. Behavior note stated Res did not have brace applied to leg. Res ambulates without socks placed to feet. c. Daily skilled nursing note on 4/23 revealed resident 194 was independent with walker and knee brace d. Daily skilled note on 5/2 at 14:58 signed by DON, read, Discussed with resident the importance of wearing non-skid footwear while ambulating in the halls to prevent skipping or falls. Resident has been non-compliant with footwear and when redirected, has melt-downs. Staff and the resident have been educated on proper communication and presentation. Resident was admitted to the facility for rehab stay post-surgery on her Left Knee. Physical therapy discharge summary on 5/2/22 revealed resident 194 was discharged due to achieving the highest practical level. Interventions reviewed by PT included safety precautions and use of assistive device(s) in order to improve safety and independence with functional mobility. On 5/4/22 at 11:18 AM, an interview was conducted with License Practical Nurse 1 (LPN). LPN 1 stated that resident 194 needed more help than she let on. LPN 1 stated resident 194 needed a walker to get around but was unsure if resident was compliant with it at all times. On 5/4/22 at 11:57 AM, an interview was conducted with resident 194. Resident 194 stated they trip on the rug all the time but have not fallen yet. Resident 194 stated staff had not been notified but stated staff had witnessed them trip on the rug and had made comments about resident 194 tripping. On 5/4/22 at 3:07 PM, an interview was conducted with the DON. The DON stated they have not been made aware by staff about resident 194 tripping on the rug located outside resident 194's room. The DON agreed that the rug would be considered a tripping hazard especially since resident 194's walker continually got stuck on it. On 5/5/22 at 10:23 AM, an interview was conducted with the Physical Therapist (PT). PT stated they were working with resident 194 due to a left patellar fracture and they were working on increasing her strength on the left leg. Resident 194 was recently discharged from their care due to reaching their goal of being able to walk short house hold distances. PT stated while resident 194 was under the supervision of PT, resident 194 was instructed to wear a left leg immobilizer and use a walker anytime they were going to bear weight on the left leg. PT stated additionally at that time, rugs were not identified as a barrier for resident 194 while using a walker. Resident 194 had been instructed on how to use a walker properly per PT. PT stated that when a resident discharged to the community, PT reviewed safe at practices and safety hazards including how to correctly position their body within the walker, how to watch transitions around doorways to avoid falls and watch for throw rug as they could potentially be a fall hazard. PT stated that resident 194 has been compliant with PT instructions.

Based on observation and interview, it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and did not include appropriate accessory instructions and the expiration date when applicable. Specifically, insulins were not labeled with an open date and administered to residents. The medication cart was not locked when the nurse was not by it. Resident identifier: 8, 19, and 194. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/3/22 at 7:10 AM, an observation was made of Registered Nurse (RN) 6. RN 6 was observed to obtain a [MEDICATION(S)] 70/30 Kwikpen Insulin pen from the medication cart. The insulin pen did not have an open date written on the label. RN 6 stated, We don't know when it was opened because no one wrote the date on it. But insulin is good for 30 something days after it is opened, so it is fine to give. RN 6 was then observed to administer the insulin pen to resident 19. RN 6 then placed the insulin pen back in the medication cart, no date was written on the insulin pen. 2. Resident 8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/3/22 at 7:22 AM, an observation was made of RN 6 obtaining [MEDICATION(S)] 30/100 unit/ml vial for resident 8 from the medication cart. RN 6 stated resident 8 had received the insulin that morning. The vials of insulin in the medication cart had a yellow tag on them that stated when opened date no open dated was written on the vial of insulin for resident 8. An immediate interview was conducted, RN 6 stated, we probably messed up on that one, and yes we will give the insulin to the residents if the insulin is in the medication cart. 3. On 5/3/22 at 7:55 AM, an observation was made of a report sheet with resident information face up on the counter of the nurses desk with residents in hallway. On 5/3/22 at 7:40 AM, an observation was made of RN 2. RN 2 walked away from the medication cart and left a bottle of aspirin on the top. Residents were observed in the hallway. On 5/3/22 at 8:05 AM, an observation was made of RN 2. RN 2 walked away from the medication cart to go down the hallway into room [ROOM NUMBER] and left the medication cart unlocked. On 5/3/22 at 8:15 AM, an observation was made of RN 2. RN 2 left the medication cart unlocked to walk down the hallway. Resident 194 was sitting next to the medication cart. On 5/3/22 at 8:22 AM, an interview was conducted with RN 2. RN 2 stated the medication cart should always be locked and the medications be put away if the nurse was not directly by the cart. On 5/05/22 at 10:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses are to label the medications when they open them. The DON stated insulin is good for 28 days after being opened. The DON stated she would want the nurses to look at the date the pharmacy delivered the medication and use that date on the insulin as the opened date, if the date of the insulin being used is within a couple of days of the delivery date then the nurses are good to use the insulin. The DON stated the insulin should have been labeled. The DON stated if the insulin is not marked and the nurse does not check the pharmacy date then the resident could be given insulin that has gone past the 28 days and that is not appropriate. The DON stated the medication cart should be locked, and the screens should be locked and all information should be covered for the residents privacy.

Based on interview and record review it was determined, for 1 of 23 sampled residents, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, a resident had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 30. Findings included: Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/3/22 resident 30's medical record was reviewed. A Registered Dietitian Note dated 4/15/22 revealed a recommendation of follow up labs of A1C, Phos, CMP, CRP and prealbumin. A Nurse Practitioner/Physician Assistant (NP/PA) Progress note dated 4/18/22 revealed to monitor labs as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress note dated 4/28/22 revealed, Provider ordered to dc (discontinue) mvi (multivitamin) with minerals, start on renal mvi with minerals, juven 1 packet BID (twice daily), vit (Vitamin) c qd (daily), Zinc 220 mgqd x 14 days, [MEDICATION(S)] 100 mg x 10 days and A1c, Phos, CMP, CRP, prealbumin. Resident was educated on new orders. The April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No progress notes found in the medical record for lab draw being performed on 4/28/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress note dated 5/2/22 revealed, Attempted to draw labs with no success, will attempt again tomorrow. Lab results revealed labs were collected in 5/4/22 and reported to the facility on [DATE]. It should be noted this was 6 days after the original order to draw the labs. On 5/4/22 at 1:30 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated the order for labs was put in the book by the nurses, then a progress note was written in the medical record. RN 3 stated when the results came back the nurses reviewed them. RN 3 stated if we had not gotten the labs back the same day they were drawn, then it was passed on in report to the next shift. RN 3 stated when drawing labs it was customary to attempt the draw twice and then let management know if unsuccessful. RN 3 stated if we just can not get the labs draw then we make the provider aware and they can bring someone else in if needed. On 5/4/22 at 1:47 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she reviewed the orders, put a note in the medical record and notify the provider, then marked the labs as reviewed and follow through with any new orders. The ADON stated the nurses on the floor put a lab form in a binder for the physician and the physician reviewed them and gave orders based off of the labs. On 5/4/22 at 2:08 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that labs were the facilities weak spot. The DON stated these labs were not drawn by the staff on shift and management was not made aware of the unsuccessful attempt(s). The DON stated that herself and the ADON looked at the labs every day but we were unable to see all the messages in the medical record and it had been a very hard thing to clear up. The DON stated immediate (STAT) labs and the medical record were the main areas they were focused on fixing.

Based on interview and record review, it was determined the facility did not implement emergency procedures for 12 of 39 sample residents. Specifically, the Missing Resident Policy and Procedure was not implemented when residents left the facility and did not return. Resident 47 left the facility and did not return while experiencing delusions and appeared manic and resident 10 sustained a needle stick from used syringes that was reported to the licensed nursing staff. The licensed nursing staff did not act on the needle stick for six days. The deficient practice identified for resident 10 and 47 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for residents 34, 77, 89, 100, 103, 123, 132, 133, 134 and 135 was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. Resident identifiers: 10, 34, 47, 77, 89, 100, 103, 123, 132, 133, 134 and 135. NOTICE: Notice of Immediate Jeopardy was given verbally to the facility Administrator (ADM) on 7/31/17 at 4:00 PM. The facility Administrator (ADM) was asked to develop an immediate plan to ensure resident safety. PLAN: On 8/3/17, the ADM provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 8/3/17 stated the following: Mr. (Long Term Care Manager) Manager-Utah Department of Health Bureau of Health Facility Licensing and Certification and Resident Assessment PO Box 3 Salt Lake City, Utah -4103 Phone: [PHONE NUMBER] Dear Mr. (Long Term Care Manager), Please accept this letter and allegation of City Creek Post Acute abatement plan for the immediate jeopardy that was identified by the survey team on July 31, 2017. The facility believes the immediate jeopardy was fully abated on July 31, 2017, at 23:00. F 518- §483.75(m)(2) - Training Staff in Emergency Procedures Needle Stick- 1) Resident Specific: Resident 10 was seen by the provider after he was made aware of the reported needle stick on July 25, 2017. [MEDICAL CONDITION] panel,[MEDICAL CONDITION](human immunodeficiency virus) 1& (and) 2, and [MEDICAL CONDITION] were completed per CDC (Centers for Disease Control) guidelines on July 25, 2017. Upon discharge, doctors' orders will be sent with the resident to receive [MEDICAL CONDITION] panel,[MEDICAL CONDITION]&2, and [MEDICAL CONDITION] on November 25, 2017. PCP (Primary Care Physician) will be notified of the follow up orders for labs and vaccinations, and the facility will send the labs that were completed on July 25, 2017 for review. [MEDICAL CONDITION] and [MEDICATION NAME] (Tetanus, [MEDICATION NAME] and [MEDICATION NAME]) vaccines were given on July 25, 2017. Follow up vaccinations for resident 10's [MEDICAL CONDITION] series will be completed on August 25, 2017 and January 25, 2018. On July 25, 2017, a written policy was provided to the staff. All staff present and working on July 25, 2017, were educated on the needle stick procedures; staff were educated and provided with case scenarios to ensure understanding. The education and training has been completed and remains ongoing relative to new staff members or staff returning from leave. PRN (as needed) and agency staff are identified at the beginning of their shift, and receive the needle stick training and education before they start working on the floor. The room of Resident 10 was searched on July 20, 2017, following resident 10's roommates hospitalization r/t (related to) suspected drug use. No needles or other contraband were found. The room was searched again on July 25, 2017, for needles or other contraband, and none were found. Incident report was initiated on July 25, 2017, and all resident rooms were visually searched for additional needles or other contraband; none were found. The incident was reported to the Utah Department of Health, and assigned a case number of UT 603. The in-services and training initiated on July 25, 2017, included incident reporting and investigating requirements. Administrator will follow up on November 27, 2017 with resident 47's PCP to ensure that proper labs were drawn and immunizations were completed. 2) Identification of Others: All residents have the potential of being affected. 3) System and Measures: Implemented Substance Abuse policy on July 28, 2017. This policy was reviewed by the Ombudsman on July 28, 2017. Over 85% of staff received the in-service before July 31, 2017 and all other staff will be in-serviced before they begin their next shift (including all PRN staff members and agency). The policy states that If the facility has a reasonable belief or concern that a resident is in possession of alcohol or recreational drugs, it expressly reserves the right to inspect the resident's persons, room, and/or belongings to ensure that the safety and well-being of other residents are protected and respected. The policy further establishes that management will be notified and the police called if drugs are found on a resident or in a resident room. Training of staff on these policies included the identification of and response to the presence of drugs and/or alcohol, and the relationship between these issues and a possible emergency situation. All residents were reviewed to identify high risk residents. LCSW ((Licensed Clinical Social Worker)) evaluated residents identified, and residents were educated on the Substance Abuse Policy on July 28, 2017. Plans of care were reviewed and care plans were updated as appropriate on July 28, 2017. All new residents will be educated on the Substance Abuse Policy upon admission. 4) Monitoring: DON (Director of Nursing) or Designee to audit new admission chart for education and signature on Substance Abuse Policy 3 x a week on all new admissions for 4 weeks then monthly. Additionally, a minimum of 3 staff members a week will be given case scenarios regarding needle stick or the substance abuse policy for 4 weeks, and then monthly, to ensure understanding and compliance. All concerns will be brought to the quality assurance meeting for review. If areas for improvement are identified, the quality assurance committee will make recommendations for changes and/or additions to the protocols. Missing Resident- 1) Resident Specific: Resident discharged from facility 2) Identification of Others: All residents have the potential of being affected. 3) System and Measures: On July 25, 2017, the AMA (Against Medical Advice), LOA (Leave of Absence), and Missing Resident Policies were revised. All staff working and/or on the floor were educated on the new policy on July 25, 2017. The education and training has been completed and remains ongoing relative to new staff members or staff returning from leave. PRN and agency staff are identified at the beginning of their shift, and receive the AMA, LOA, and Missing Resident training and education before they start working on the floor. The LOA policy was updated to include actions of what to do if a resident has not returned by the expected time they stated they would be back. The actions will include call the contact number or the resident emergency contact to verify intent to return and If unable to contact the resident, refer to the Missing Person Policy. Our missing person policy was revised to state that, no matter the cognition level of the resident, the same actions will be followed of notifications to the DON, ED (Executive Director), MD (Medical Doctor) and police department. The LOA sign out form was updated to include destination, contact number, and expected time of return. All residents will have an elopement assessment upon admission and quarterly. Included in this assessment is the resident's mobility, history of wandering, predisposing diseases, history of elopement in the last 6 months, and days of residence in facility. If residents are determined to be at high risk for wandering, they will be care planned accordingly. Upon admission, all residents will also be care planned relative to discharge, to include their expected discharge location. If the staff are unable to locate a resident when they complete their 2 hours rounds the missing person policy will be initiated. 4) Monitoring: DON/designee will review any occurrence of a resident leaving and not returning to the facility to ensure policy and procedures were followed; education will be provided as necessary. Additionally, a minimum of 3 staff members a week will be given case scenarios regarding LOA, Missing Residents, or AMA for 4 weeks and then monthly to ensure understanding and compliance. All concerns will be brought to the quality assurance meeting for review. If areas for improvement are identified, the quality assurance committee will make recommendations for changes and/or additions to the protocols. IMMEDIATE JEOPARDY: 1. Resident 47 was admitted to the facility on [DATE], and readmitted on [DATE]. This resident's [DIAGNOSES REDACTED]. Resident 47's medical record was reviewed and included the following documentation: A hospital History and Physical, from February 2017 included documentation that resident 47 sustained a right ankle pilon fracture in August 2012. Subsequently, resident 47 was diagnosed with [REDACTED]. Per the History and Physical, resident 47 underwent partial debridement of the hardware on 2/17/17. The discharge [DIAGNOSES REDACTED]. Facility staff documented the following progress notes in resident 47's electronic health record: a. On 2/24/17 at 6:13 PM, .nurse came in and changed wound vac (vacuum) to R (right) ankle. Resident was focused on the fact that she is 'in with the feds and cops. They are my family.' She was eager to tell nursing staff that her son is 'In the government' but she is trying to 'get him out with me.' She states that she has a few different names and was unsure which one we would be using. Nurse oriented resident to legal name we have on file. Resident nodded in agreement. She was fixated on leaving this afternoon and visiting her cop friends she hasn't seen in a while. She stated 'If you see any new cop cars driving by they are just checking up on me.' Resident was very fixated on the 'Feds' and 'CIA (Central intelligence Agency), watching her and how she is 'A narc but sshhhh don't tell anyone here.' b. On 2/25/17 at 4:04 PM, Resident has been delusional this shift. She stated to nurse 'At the hospital they drained me of all my fluids and filled me back up with all new fluids.' c. On 2/28/17 at 9:30 PM, Pt. (patient) is seen for initial NP (Nurse Practitioner) visit.Pt endorses thoughts about being connected to CIA, FBI (Federal Bureau of Investigation), US (United States) marshals, Navy Seals. Pt's thoughts do appear delusional and grandiose at times. Pt. endorses auditory hallucinations at times. She reports them as voices of people she knows. When she hears these voices she would go and speak to them. Pt reports that these voices do not cause her any distress. d. On 3/2/17 at 12:08 PM, .Resident is Restless. Resident has been up in w/c (wheelchair) this shift. She is very energetic and mobile. Resident often is in w/c talking to no one specific while wheeling down the hallways. It was reports to nurse that resident slept maybe 2 hours last night. Resident has not slept this morning. e. On 3/2/17 at 6:15 PM, .Provider was asked to discuss with pt about her delusions and mania. Pt reports that she is aware that she may be manic at times. Pt reports that she is special and the navy, CIA, FBI, marshalls have been recruiting her. Pt's thought process is organized within her delusions. Pt. attributes her delusions to a TBI ([MEDICAL CONDITION]) when she was younger. Pt reports that she does not want to take any medications. Pt. is not suicidal, homicidal, or a danger to herself or others. Nursing staff reports that pt was up for part of the night talking in the hall really loud and waking up other residents. f. On 3/16/17 at 10:55 AM, Resident is having c/o (complaints of) of rash getting worse and burning. Dose of PRN [MEDICATION NAME] 50 mg (milligrams) given PO (orally) for the rash, but with no good effect. NP was notified of rash getting worse at this time and told this writer to send her out to be evaluated. (Local ambulance service) was called and picked her up safely to take her to the (local hospital) to be evaluated. Resident wanted mother informed and this writer tried calling the mother with no success. DON was notified of ER (emergency room ) transfer. g. On 3/16/17 at 5:43 PM, Resident returned safely from the (local hospital) safely via (ambulance). ED (Emergency Doctor) medical instructions to stop [MEDICATION NAME] IV (intravenously), [MEDICATION NAME] PO and [MEDICATION NAME] PO. They started her on [MEDICATION NAME] 8 mg/kg (milligrams per kilogram) daily to complete her treatment course. h. On 3/22/17 at 3:42 PM, Resident went out to wound clinic appointment. She was sent to the (local hospital). Nurse called ER and was notified that resident will be admitted to the floor. She has an elevated WBC (white blood count) and [MEDICAL CONDITION]. NP and DON notified. i. On 3/28/17 at 3:55 PM, Resident has arrived from hospital from (non-emergent) transportation. j. On 4/3/17 at 10:04 PM, .does present with manic behaviors, has been talking nearly non stop, has been talking to herself, speech is pressured and ideas expressed are delusions, involving government agencies and random connection. k. On 4/4/17 at 1:33 PM, Writer spoke with patient re: being seen by (mental health facility). Patient stated that she has seen a psychiatrist with NASA (National Aeronautical Space Administration) but is not able to get any state funded programs in her lifetime. l. On 4/4/17 at 9:43 PM, .Pt has been at nursing station most of shift, pressured speech and non-related subjects being covered in a single sentence. s/sx (signs and symptoms) of manic behavior. m. On 4/5/17 at 10:06 AM, .Resident has delusions. Resident has delusions, is on [MEDICATION NAME], is not disturbing to her. n. On 4/5/17 at 10:50 AM, MD (name redacted) documented .Alert and oriented X (times) 2 (person and place). Requires up to one person limited assistance with her ADL's (activities of daily living). Ambulates short distances, utilizes wheelchair for longer distance mobility.Mood and behavior are stable.Psych: alert, delusional. Poor insight and judgment. o. On 4/5/17 at 11:34 AM, Weekly Skilled Review .Barriers to Safe and Effective Discharge: Not safe for community mobility. Requires Min (minimal) A (assistance) for shoes management and cues for safety awareness. Has chronic ulcer to right ankle. Has increased delusional thoughts and manic episodes. p. On 4/7/17 at 4:23 PM, Resident returned from being LOA. She was very hyper and speaking rapidly and nonstop. Resident walked into her room and began talking as if to someone. There was no one present in her room and she was not on a phone. She was stating 'Ok we gotta go or they are going to get pissed off.' She was speaking to this person ass (sic) if they were making plans to do something in the upcoming week. She told the nurse that she invited 'ICE (Immigration and Customs Enforcement) police to come over so don't be worries (sic) of they show up.' Nurse tried asking who resident was talking with in the room. Resident did not answered (sic) and continues pacing and speaking in a loud fashion. Nurse tried to help resident calm down by instructing her in deep breathing. Resident was able to take a few deep breaths then sat quietly for a few moments. She then began to pace and speak again. q. On 4/9/17 at 9:28 AM, .Alert, Oriented X 2 Resident is Anxious/Agitation. Resident is Restless. Resident has delusions. Resident has delusions, receiving [MEDICATION NAME] qhs (at hour of sleep) for delusions; receives [MEDICATION NAME] PRN for anxiety; appears to be good effect. r. On 4/10/17 at 9:28 AM, Resident left facility yesterday around noon. She was overheard talking with another resident about 'going down to the block to get some beers.' RN (Registered Nurse) on duty had educated resident that it was not safe to drink on current medication regimen. Resident has not returned to facility. Resident is alert and oriented X 3 and is own POA (Power of Attorney). Spoke with provider and received orders to DC (discharge) resident AMA. Left voicemail for residents mother requesting returned phone call to inform her. s. On 4/10/17 at 11:37 AM, Residents (sic) mother called back, informed her resident had left AMA and would not be allowed to come back to facility. Resident 47's Medication Administration Records (MARs) for February, March and April 2017 were reviewed. The facility licensed nursing staff documented that resident 47 had delusional behaviors on 2/24/17, 2/25/17, 3/2/17, and 3/3/17. After resident 47 was readmitted to the facility on [DATE], resident 47's delusional episodes were documented as more than ten episodes daily from 4/1/17 through 4/8/17. Additionally, at the time the resident left the faciity on [DATE], resident 47's ankle ulcer measured 3.4 cm (centimeters) X 2.2 cm X 1 cm and the right medial ankle measures 2.0 cm X 0.9 cm X 0.9. On 7/26/17 at 9:21 AM, RN (Registered Nurse) 3 was interviewed. RN 3 stated she had been employed by the facility for 6 months and had not received training regarding resident elopement. RN 3 stated she was unaware of a facility policy regarding LOA for residents. RN 3 stated residents were typically permitted four hours of LOA at a time and that if a resident were to be gone longer than four hours, she would look at the LOA sign-out book and call the phone number provided by the resident on the LOA sign-out sheet. RN 3 stated if the resident could not be reached by phone, staff would typically sweep the block if the resident was ambulatory and call the police if the resident was impaired. On 7/26/17 at 9:38 AM, RN 3 approached a surveyor requesting to clarify some responses she had previously provided. RN 3 stated the facility did not have policies but did have procedures. RN 3 stated the procedure for elopement would be to call the DON, the Administrator, and the police if a resident were to be gone longer than four hours. On 7/26/17 at 9:25 AM, RN 4 was interviewed regarding how to respond when a resident was missing. RN 4 stated she was not aware of a policy regarding missing residents. RN 4 stated she would personally look for the resident and notify the DON and Administrator. RN 4 further stated she would call the police. RN 4 stated residents were allowed up to four hours of LOA before facility staff would become concerned. RN 4 stated if a resident were to be out of the facility for over four hours, she would call the phone number documented on the LOA sign-out sheet. RN 4 stated that the LOA sign-out book was recently revised and staff were in-serviced about the change. RN 4 stated the reason for the change to the LOA book was a problem over the last six months with residents being gone for over four hours with no way to contact them. On 7/27/17 at 11:12 AM, Certified Nurse Assistant (CNA) 3 was interviewed. CNA 3 stated the residents were not allowed to leave the facility without signing out. CNA 3 stated residents were supposed to record what time they estimated they would return to the facility on the sign-out sheet. CNA 3 stated the facility was not a hotel and that there were specific rules regarding LOA. CNA 3 further stated if a resident was gone longer than the time of return listed on the LOA sign-out sheet, facility staff should announce the resident was missing over the radio and report it to the Administrator. On 7/27/17 at 11:25 AM, CNA 4 was interviewed. CNA 4 stated if a resident wanted to leave the facility, the resident was supposed to record on the LOA sheet what time he/she were leaving and what time he/she estimated he/she would return. CNA 4 stated facility staff would not be concerned about a resident unless the resident had been gone more than four hours. CNA 4 explained that if a resident were to be gone more than four hours, she would report the missing resident to the resident's nurse. On 7/26/17 at 9:45 AM, RN 1 was interviewed about missing residents. RN 1 stated if a resident were to be missing, she would call the Administrator and Director of Nursing, call the police and give them a description of the resident, and call the family. RN 1 stated it would depend on the resident as to when she would be concerned that the resident had not returned. RN 1 stated some residents could be gone two to three hours before she would be concerned and that some residents could be gone 10 to 11 hours before she would be concerned. RN 1 stated most residents were mobile and walk around the unit. RN 1 stated the CNA's were to do rounds on each resident every one to one and a half hours. On 7/26/17 at 9:50 AM, CNA 1 was interviewed about missing residents. CNA 1 stated she would tell the Nurse and the Administrator if a resident was missing. CNA 1 also stated she would be concerned quickly if a resident was not back in the facility when they were supposed to be back. CNA 1 stated she would use the facility radio system to let all staff know if a resident was missing. CNA 1 stated she would check all the areas on the unit and outside the building. On 7/27/17 at 11:05 AM, Licensed Practical Nurse (LPN) 2 was interviewed about missing residents. LPN 2 stated residents were to be checked on at meals, with medication passes and every two hours. LPN 2 stated she would notify the DON, Administrator, call the resident's family, notify the police and send staff around the neighborhood to look for the missing resident. LPN 2 further stated the facility and the grounds of the facility were to be checked if a resident was missing. On 7/27/17 at 11:20 AM, RN 5 was interviewed about missing residents. RN 5 stated the facility CNA's do rounds every two hours. RN 5 stated facility residents were also observed during medication pass and wound treatments. RN 5 stated if a resident was missing, the facility and the facility grounds were to be searched. RN 5 stated she would notify the Administrator, the DON, proper authorities and the resident's family if a resident were to be missing. On 7/27/17 at 11:30 AM, CNA 5 was interviewed about missing residents. CNA 5 stated she completed a head count at the beginning of her shifts. CNA 5 stated if a resident was missing she would notify the charge nurse and search the building. On 7/26/17 at 10:21 AM, the Director of Nursing (DON) was interviewed. When asked about resident 47, the DON stated resident 47 was alert and oriented and was on an antipsychotic medication for treatment of [REDACTED]. The DON stated the facility policy and procedures for a missing resident were not initiated when resident 47 went missing because the resident was alert and oriented. When asked about resident elopement, the DON stated he would notify the Administrator, the police, local emergency room s, Adult Protective Services and the Ombudsman if a resident were to elope from the facility. On 7/26/17 at 12:15 PM and again on 7/27/17 at 12:50 PM, interviews were held with the Administrator. When asked about resident 47, the Administrator stated resident 47 was alert and oriented and decided to leave the facility and not come back. The Administrator stated since resident 47 was alert and oriented and had left the facility before, without incident, she was not considered a Missing Resident. The administrator stated resident 47's family and physician were notified. The Administrator stated facility staff have not documented incident reports in situations where a resident left the facility without signing out and subsequently discharged as leaving AMA. The Administrator stated there was no elopement policy for alert and oriented residents. The Administrator further stated an alert and oriented resident leaving the facility would not be considered an elopement and only residents, who are not alert and oriented, would be considered to have eloped if they left the facility. A review of the facility policy and procedure for a Missing Resident was conducted and included the following: It is the policy of this facility that facility staff will respond immediately and appropriately to any report of a resident missing from the facility to ensure the resident's safety and security. PR(NAME)EDURES: In order to establish whether or not a resident is, in fact, missing, the following procedure will be implemented when the location of a resident is unknown. 1. The nurse in charge will be immediately made aware of the fact that a resident appears to be missing. 2. The sign in/out book will be checked to determine if the resident has indicated plans to be out of the facility. 3. The nurse in charge of the shift will assign one aide from each hall to check each room, including toilet rooms and closets, on each hall. 4. The nurse in charge will assign one nurse to systematically check all other areas i.e., offices, tub rooms, activity rooms, kitchen, basements, etc 5. If the resident still has not been located, one aide from each hall and the nurse will search the facility grounds. 6. If the resident still has not been located, the facility shall initiate and conduct a search of the immediate neighborhood. a. If the above steps have been completed and the resident still has not been located, it will be assumed that the resident is missing and the following steps will be immediately taken by the nurse in charge. 7. The Police Department will be notified. 8. Be prepared to give a complete description of the resident (height, weight, hair color, etc.) and provide photo, if possible. 9. Follow the instructions given by the office in charge for a continued and coordinated search effort. 10. If there is a possibility that the resident may have left the area, you may need to consider notifying the Sheriff's Department and/or State Patrol. Consider using all available resources, i.e., Civil Defense, emergency room s of acute hospitals. Consider with the Policy Department regarding this. 11. The Administrator and Director of Nursing Services will be notified that a resident is missing. 12. Social Services - Notify only if Administrator or DNS (Director of Nursing Services) is unavailable. 13. Office Manager - Notify only if Administrator or DNS is unavailable. a. If it is deemed appropriate, either because of the length of time the resident has been missing or the jeopardy the resident is in by being away from the facility, consideration will be given to contacting the various news media available (radio, TV, newspaper, etc.). Each facility Administrator will determine at what level this decision will be made after contact with the appropriate service center staff. 14. The family member or responsible party indicated on the chart will be called to make them aware of the fact that the resident is missing and to inform them of what steps have been taken to locate the resident. 15. The attending physician is informed as condition warrants. 16. The Medical Director shall be notified. 17. The DHS (Department of Health Services) will be notified immediately, when a resident has eloped. 2. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/25/17 at 9:00 AM, an observation was made as resident 10 reported to the facility Nurse Practitioner (NP) that he had been stuck (resident 10 was observed to point to the middle of his left palm). Resident 10 was observed to report to the NP that he had been stuck by a needle that he had found on the floor in his room last week and wondered do I need a tetanus shot or something? Resident 10 stated that he had reported the needle stick to facility nurses and that nobody had gotten back to him. On 7/25/17 at 9:02 AM, an observation was made as Registered Nurse (RN) 1 informed the facility NP that resident 10 had reported finding a needle on his floor last week and that he had informed the nursing staff that he had been stuck by the needle as he placed the needle into a coke bottle. On 7/25/17 at 9:15 AM, an interview was conducted with RN 1. RN 1 stated that she had received report from Licensed Practical Nurse (LPN) 1 on the morning of 7/20/17. RN 1 stated that LPN 1 had asked her if she had heard that resident 10 had been stuck by a needle. RN 1 stated that she informed LPN 1 that she had not heard of the needle stick. RN 1 stated that she had not reported the needle stick to resident 10's physician nor to the facility Director of Nursing (DON) as she had assumed that LPN 1 had reported the needle stick to the DON and resident 10's physician. RN 1 stated that she really did not think anything of the needle stick because resident 10 has diabetes and we always stick him. On 7/25/17 at 9:30 AM, an interview was conducted with the facility DON. The facility DON stated that he had not been made aware of the needle stick until just now and because of that there was no incident report nor investigation into the needle stick or how it had occurred. The facility DON stated that facility staff had suspected that resident 70's wife had been bringing drugs into the facility for him. The facility DON stated that resident 70 was the current roommate to resident 10. (NOTE: Resident 70 had a history of [REDACTED]. On 7/25/17 at 10:00 AM, an interview was conducted with resident 10. Resident 10 stated that he had found two used needles on his floor near the bathroom. Resident 10 stated that he had worried that someone would accidentally kick the needles and stick themselves, so he picked the needles up and placed them into a coke bottle. Resident 10 stated that his eyesight was not good and thought he had placed the needle end into the coke bottle, then placed his left palm over the needle to push it into the coke bottle and stuck himself with the needle. On 7/25/17 at 10:30 AM, an interview was conducted with the facility NP. The facility NP stated that he had not been made aware of the needle stick and that he would order labs today and start resident 10 on the [MEDICAL CONDITION] vaccination series. The facility NP stated that his expectation would have been for facility staff to notify him or the physician about the needle stick. The facility NP stated that he would have called the CDC (Centers for Disease Control) and the State Health Department to notify them and to find out about treatment that would have been available to resident 10 within the first five days after a needle stick. The facility NP stated that the treatment was no longer The facility NP stated that he would order labs and the [MEDICAL CONDITION] vaccination series today for resident 10. On 7/25/17 at 1:16 PM, a telephone interview was conducted with LPN 1. LPN 1 stated that she had given report to RN 1 on the morning of 7/20/17 and had reported that resident 10 had been stuck by a needle. LPN 1 stated that she did not inform resident 10's physician nor the facility DON as she had assumed that RN 1 would report the incident. On 7/25/17 at 1:25 PM, a telephone interview was conducted with RN 5. RN 5 confir

Based on observation, interview, and record review, it was determined for 1 of 39 sample residents, that the facility did not ensure that residents received adequate supervision to prevent accidents. Specifically, a resident who had a history of [REDACTED]. The deficient practice identified for the resident was found to have occurred at a harm level. Resident identifier: 34. Findings include: Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/17 resident 34's medical record was reviewed. Nursing progress notes revealed the following entries: a. 2/25/17 at 6:09 PM, Resident came up to nurses station and stated 'I just fell and hit my head.' He states that he was getting into the closet when he was trying to get to his walker, missed and then fell . b. 2/25/17 at 8:18 PM, Pt (patient) had an unwitnessed fall earlier tonight. Pt c/o headache, nausea and reported emesis x (times) 2. Assessed pt and pt lethargic, pupils round and reactive to light, held up 2 fingers and pt reported seeing 3 fingers, pt reported blurred vision, pt was able to track fingers, right hand grip slightly weaker than left hand grip. Notified on call provider FNP (Family Nurse Practitioner) and new order to send to ER (emergency room ) for evaluation at this time. c. 2/26/17 at 2:28 PM, At 1330, resident returned from (name of hospital) ER (emergency room ) for observation r/t (related to) fall on 2/25/2017. Resident returned with paperwork to: 'follow up with faint clinic .' d. 2/27/17 at 5:27 PM, fell yesterday - seen at the ER with concussion and corneal abrasion . Uses a walker for mobility - it got stuck while he was using it and caused him to fall and hit his head. BP (blood pressure) running a bit low. Edema is well managed . (NOTE: This entry was authored by resident 34's physician.) e. 3/1/17 at 5:08 PM, Resident reviewed with IDT s/p (status [REDACTED]. Resident was getting something out of his closet and lost his balance . Educated resident on asking for assistance and what do (sic) if fall occurs . (NOTE: Resident 34 was sent to the ER and had sustained a concussion and corneal abrasion and was not without injury.) f. 3/2/17 at 12:42 PM, He has been slightly off balance this shift. He's been using the walker for mobility without difficulty but when he stands still for a few seconds he starts to lean backwards slightly and often has to catch himself before losing balance. Will notify MD if changes occur. Resident 34's 30 day MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 34's BIMS (Brief Interview for Mental Status) was scored at an 11. According to the scoring key for the BIMS, resident 34 had a moderate cognitive impairment. On 3/8/17, the progress notes from the (name of hospital) Faint & Fall Clinic revealed the following: a. (Resident) reports only one fall but notes he does stumble a great deal. His last fall occurred 2/27/17. He was standing when he turned around, and his walker caught on the side of a the (sic) closet causing him to lose his balance and fall . He reports a lot of trouble with losing his balance and falling, however he thinks overall he has improved since getting rehab. He notes he that (sic) he is continuing to do his exercises in his room on his own. b. I called and spoke with the Assistant Director of Nursing (ADON) (name of ADON) . The patient has had troubles with oversedation on medications . The thought was that polypharmacy was playing a role in some of (his) fall risk. c. BP at the facility frequently runs in the 90s-100s systolic. The BP taken at the clinic was measured to be 88/54, HR 72, standing at one minute 100/56, HR 79, standing at three mins 104/69 . His chronic fall risk factors include him being at risk for orthostatic hypotension, low physical activity level, .polypharmacy. (NOTE: DON interview of SBP < 110 Facility progress notes for resident 34 revealed the following: a. 3/10/17 at 2:09 PM, Residents (sic) ammonia level 61, results given to NP (Nurse Practitioner). Order to change lactulose to 45 mL (milliliters) PO (by mouth) six times a day. (NOTE: An ammonia test measures the amount of ammonia in the blood. Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis. An ammonia test is done to check how well the liver is working, especially when symptoms of confusion, excessive sleepiness, coma, or hand tremor are present.) b. 3/29/17 at 6:07 PM, Elevated ammonia level despite adequate dosing of lactulose and loose stools. Increased confusion and sleepiness . Add xifaxan. (Note: A physician's orders [REDACTED]. This note was authored by resident 34's NP.) c. 4/4/17 at 4:19 AM, Pt found on floor near bed @ 0400. States he rolled off bed. Pt a et o (alert and oriented) x (times) 2-3. d. 4/4/17 at 11:29 PM, Pt was educated to utilize call light for staff assistance. Pt was educated to utilizes (sic) staff assistance to reduce the likelihood of falls. (Note: A physician's orders [REDACTED]. This entry was authored by resident 34's NP.) e. 5/3/17 at 5:22 PM, Pt ammonia lvl (level) (sic) returned elevated 94 which is an increase compared to when he was on the rifaxmin (sic). Pt reports that he feels okay. Nursing staff reports that pt has not had any significant changes in mental status. (Note: A physician's orders [REDACTED]. This note was authored by the NP.) f. 6/2/17 at 11:25 AM, Pt is seen for monthly visit. he continues to utilize a walker for mobility and is a 1 person assist with ADL's including transfers. he has intermittent confusion. (NOTE: This note was authored by the NP.) g. 6/2/17 at 9:34 AM, Residents (sic) ammonia levels results received, 113, given to NP. no new orders at this time. Resident currently receiving 45 mL Lactulose Q (every) 4 hours, also 550 mg Rifaximin PO (by mouth) BID (twice daily). h. 6/5/17 at 1:05 PM, Pt is seen due to increased confusion over the weekend and last ammonia lvl (sic) continues to be high . Oriented to time, place, and person with confusion at times. (Note: This entry was authored by resident 34's NP.) i. 6/8/17 at 5:07 PM, Resident returned from liver clinic, orders to start non-selective beta blocker nadaolol 20 mg daily to prevent esophageal bleed. j. 6/8/17 at 7:05 PM, Pt cont (continues) to be unsteady on his feet, requiring assist when walking at times. Using walker as well . Encouraged pt to sit or lie down in his room due to unsteadiness. k. 6/9/17 at 1:10 PM, Contact GI (gastrointestinal physician) about changing to a different beta blocker due to insurance. (Note: This entry was authored by resident 34's NP. Resident 34's BP was documented as being 108/65 at 8:22 AM.) l. 6/13/17 at 12:18 PM, Received a call from (name of GI clinic staff member) at the GI clinic. They were responding to our call about change Nadolol to propranolol or a different similar medication. They stated we can change medication to Propranolol 20 mg PO BID to help prevent esophageal bleed. (NOTE: Resident 34's BP was documented as being 101/57 at 8:56 AM and 99/64 at 6:25 PM.) m. 6/14/17 at 11:25 AM, Pt very disoriented and confused this evening. Unsteady on his feet. Redirected back to room to lie down for pt safety. BP low for this pt, may possibly be a contributing factor. (NOTE: no BP documented for resident 34 on this day.) n. 6/15/17 at 7:11 PM, Pt still appears to be a little unsteady on his feet, encouraged to use walker and rest as needed. o. 6/16/17 at 7:18 PM, Pt very confused this evening, unsteady . encouraged pt to sit or lie down, pt resistant. Cont (sic) to want to stand and walk. p. 6/19/17 AT 6:36 PM, Writer was at nursing station speaking with staff member, when I heard a loud crashing noise come from his room. We ran into the residents (sic) room, resident was lying on his back, on the ground, next to his bad (sic), naked . Residents (sic) walker was at the foot of the bed. We assisted the resident to a sitting position and I asked the resident what happened. Resident stated 'I fell down'. I asked the resident why he was undressed, resident stated 'I was trying to change my clothes and I fell '. Resident stated that he 'hit my back and head and that table (pointing to the bedside table)' . Resident educated about the importance of using his call light for assistance. Resident acknowledged understanding. (Resident 34's BP was documented as being 97/56 at 8:58 AM.) q. 6/20/17 at 4:01 PM, Pt is seen for follow (up) on fall yesterday. Pt reports that he is not sure what happened. He reports that he thinks he might have tripped over his table but he is not really sure. (Resident 34) oriented to time, place, and person with confusion at times. Pt was educated to utilize call light for staff assistance. Pt was educated to utilizes (sic) staff assistance to reduce the likelihood of falls. (Note: This entry was authored by resident 34's NP. Resident 34's BP was documented at being 90/59 at 6:34 PM.) r. 6/21/17 at 3:29 PM, Resident reviewed with IDT s/p fall on 06/19/17 without injuries. Resident was attempting to change and lost his balance . Educated resident on asking for assistance and call light use with verbalized understanding.(Resident 34's BP was documented at 96/61 at 8:41 AM.) s. 6/22/17 at 9:56 PM, (Resident 34) continues to be encouraged to use his walker whenever walking in his room or the hallways, sometimes having to be reminded. t. 6/30/17 at 1:09 AM, Pt has been lethargic this shift. VS (vital signs) as charted, noted low BP et HR (heart rate). Able to wake pt easily, but he don't (sic) stay awake for very long. Compliant with medications. Will monitor and notify MD if changes occur. (Resident 34's BP was documented at 102/63 at 6:25 PM.) The following was documented in the ED report from (name of hospital) on 7/1/17. According to the report, resident 34 was brought to the ED at 1:55 PM: a. Patient was brought in by EMS (Emergency Medical Services). Patient states he was walking down the street and lost his balance while using his walker and fell forward and hit a tree. He is unsure if he was injured. EMS was called. They brought him in he states against his well (sic). He did not want to come in and just wanted to be taken back to place where he is living. He does complain of some slight increased head and neck pain and also right wrist pain. He states he has fallen numerous times in the past and does not believe he has been injured. He is not requesting any tests. b. Under the Exam heading, the resident was listed as having slow mentation and as being slow to respond. c. Patient does not exhibit any neurologic findings to be concerned about an intracranial bleed however due to his vague history and slow mentation I suggested he have a CT of his head and cervical spine. I have also suggested a right wrist x-ray . He is becomes (sic) frustrated and states these are not needed . The patient I believe he (sic) is alert enough and is oriented to person place and time and date of birth I think he can make an informed decision. The nursing progress notes revealed the following: a. On 7/1/17 at 5:41 PM, Resident has been out of the facility and unable to assess . b. On 7/1/17 at 7:43 PM, Pt returned to facility via (ambulance). Reported pt had fall in community, EMS (Emergency Medical Services) was contacted and ptwas (sic) seen at (name of hospital) ED (Emergency Department). They then released him. EMS then found him walking on the street, without his walker and disoriented. he was able to give his name and the name of facility. They contacted facility, and then transported him here. He is unable to remember where he was going, or where he left his walker, other than 'in some bushes.' .Stat ammonia level ordered. Current VS 104/59 . Pt does know where he is and recognized staff. Unable to state where he was going, confused about time and date. (Note: Ammonia level was measured to be 64 on 7/1/17 at 10:21 PM. Normal ammonia levels were reported by the lab company as being between 9 - 33.) c. On 7/3/17 at 1:08 AM, Pt cont (sic) to be lethargic. d. On 7/3/17 at 4:35 PM, RN spoke with resident about event on 07/01/17. Resident states, 'he went out for a walk and lost his footing causing him to fall'. He reports a bystander contacted EMS and had him taken to the ER. Resident was evaluated in the ER and released shortly after. Resident reports he got turned around leaving hospital and couldn't figure out how to get back. Resident is alert and oriented to person, place and time. Resident apologetic and states 'I will sign out so you guys know where I am'. On 7/25/17 at approximately 1:30 PM, Registered Nurse (RN) 6 was interviewed. RN 6 stated that the resident had sustained a fall earlier in the month while the resident was on a leave of absence (LOA). RN 6 further stated that the resident was found by Paramedics and that he had not sustained any injuries except for road rash on his buttocks. On 8/1/17 at 8:05 AM, RN 6 was interviewed. RN 6 stated that she did not consider resident 34 safe to be out of the facility by himself. RN 6 stated that the resident had left the facility alone before the incident on 7/1/17 and had become lost on his way back. RN 6 further stated that on these occasions, resident 34 was oriented to self but couldn't remember how to get back to the facility. On 8/1/17 at 8:09 AM, RN 5 was interviewed. RN 5 stated that the facility staff encouraged resident 34 to sign out before he would leave the facility, but that the staff can't keep anyone here. RN 5 stated the resident had a track phone that he could take with him, however, the phone did not always work. RN 5 stated that sometimes the resident called the facility staff when he was on LOA because he forgot why he wanted to leave the facility. RN 5 further stated that before his Oxycodone was changed to Tramadol during the last week of July, the resident was getting really unsteady and really loopy. Finally, RN 5 stated that facility staff would encourage him to take someone with him when he left the facility. On 8/1/17 at 8:16 AM, Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated that resident 34 had been known to leave the facility by himself before. CNA 1 stated that the resident needed help ambulating outside of the facility. CNA 1 stated that resident 34 needed limited assistance for ADLs and required the use of a walker to ambulate. CNA 1 stated that she was not aware of any recent falls and that no information regarding falls or fall prevention was communicated to her during shift report that morning. On 8/1/17 at 8:50 AM, RN 5 was interviewed. RN 5 stated that the resident needed stand-by assistance with transfers. RN 5 stated that she had seen resident 34 walk down the hall with his walker and sway in a way that required her to encourage him to sit down for his safety. RN 5 stated that staff had to remind the resident to ask for help. RN 5 further stated that resident 34 gets up by himself all of the time and goes to the bathroom and that staff try to ask him to call us to go to the bathroom. On 8/1/17 at approximately 8:55 AM, RN 6 was interviewed. RN 6 stated that resident 34 frequently walked to the nurse's station by himself. RN 6 stated she would remind the resident to ask for help whenever this happened. On 8/1/17 at 9:03 AM, CNA 3 was interviewed. CNA 3 stated that resident 34 needed supervision for ADLs. CNA 3 stated that the resident was not safe to go outside by himself. CNA 3 further stated that she was unaware of any instances when the resident left the facility alone. On 8/1/17 at 1:57 PM, the Director of Nursing (DON) was interviewed. The DON stated that the resident had been unsteady on several different occasions due to a high ammonia level. The DON further stated that the resident had left the facility twice in the month prior to the fall on 7/1/17 and the resident had been fine. On 8/1/17 at 2:30 PM, the DON was reinterviewed. The DON stated that the resident had experienced confusion when his ammonia levels were high. The DON stated he considered resident 34 safe for the most part to leave the facility by himself. The DON stated on days when the resident was confused, facility staff encouraged him to let them go with him. When questioned regarding the resident's fall in the community on 7/1/17, the DON confirmed that resident 34 did not sign out before he left and that he left the facility alone. The DON stated that the resident let them know he was leaving the facility. The DON stated there was no noted confusion before the resident left the building on 7/1/17. (Note: There was no documentation of the resident being encouraged by staff or of the resident's refusal to be accompanied by staff on 7/1/17.) On 8/2/17 at 9:34 AM, the DON was interviewed. The DON stated that he considered resident 34 to be alert and oriented if the resident could state his name, where he lived, and the date. (Note: There was no documentation that facility staff assessed his cognitive status before he left the faciity on [DATE].) On 8/3/17 at 12:43 PM, the NP was interviewed. The NP stated that he considered the resident safe to leave the facility alone on some days, but did not consider the resident safe to leave the facility alone when the resident was experiencing confusion. The NP stated that the safety of resident 34 leaving the facility alone should be assessed day by day. The NP stated that before the resident left the facility alone, he expected the staff to assess the resident to see if he was alert and oriented. The NP stated that when the resident's short-term memory goes, that's when he is in trouble. The NP stated that he considered the resident's falls to be related to high ammonia levels rather than to hypotension. The NP stated that he expected facility staff to measure resident 34's BP after he had been out of bed and had participated in some kind of physical activity. The NP further stated that due to the progressive nature of end-stage liver disease, episodes of high ammonia and confusion had been and would become more frequent for the resident. (NOTE: The facility NP had previously noted on 6/2/17 that resident 34 had intermittent confusion.)

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 28 sampled residents. Specifically, one sample resident did not receive wound care dressing changes as ordered by the physician. Resident identifier: 46. Findings include: Resident 46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/5/14, resident 46's closed medical record was reviewed. On 8/23/13, the Skin/Wound Note revealed that upon admission resident 46 had four wounds as follows: a. The right great toe, distal portion of nail had an old open area routine to diabetic ulcer. There was bloody drainage noted. The wound measured 1.3 x 1.5 x 0.4 centimeters (cm). b. The second toe on the right foot had a skin tear by the nail that was opened and measured 1.2 x 0.2 cm. The proximal phalange presents with an abrasion that measured 2.8 x 1.2 x 0.3 cm. The drainage was scant of serousanguineous fluid. c. The left dorsal foot presented an open area that measured approximately 4 x 2 x 0.1 cm. The area had [MEDICATION NAME] tissue in all areas and the drainage is scant. d. The left fourth toe presented an open diabetic ulcer that measured approximately 1 x 0.8 x 0.4 cm. The area had scant drainage of serosanguineous fluid. On 8/26/13, a culture of the wound on resident 46's right foot was obtained. On 8/29/13, the laboratory report revealed that resident 46 had [MEDICAL CONDITION] (MRSA). On 8/29/13, resident 46 had a consultation with the podiatrist. The podiatrist note revealed dressing orders and an order for [REDACTED]. On 9/10/13, resident 46 had a follow up appointment with the podiatrist. The podiatrist note revealed that the first and second toes on the right foot needed to be amputated. On 9/17/13, resident 46 had the first and second toes on the right foot amputated. The orders revealed to "leave the dressings clean, dry and intact. Reinforce dressings as needed". A review of the September 2013 Medication Administration Record [REDACTED]. Order date of 9/18/13. (Note: No physician order could be located in resident 46's chart regarding the change to the dressing orders.) On 9/24/13, resident 46 had a follow up appointment with the surgeon. The surgeon note revealed that resident 46's wound was healing very well and the sutures were intact. The surgeon's office "accomplished" a dry, sterile dressing change. The new dressing orders were to keep the dressing clean, dry and intact. On 10/7/13, the Nursing Progress Note revealed that resident 46's incision line in the right foot had a moderate amount of bloody drainage in the dressing. The incision was cleansed and it had been noticed that from the medial portion of the incision line that bloody drainage was coming out. The metatarsal area presented a hematoma and had been draining from the incision hole. The sutures were still in place and more old blood had come out from the affected area. No purulent fluid had been noticed and there were no signs and symptoms of infection at the time. The hematoma had been originated when resident 46 was transferred from the bed to the wheelchair. Resident 46 required total assistance with transfers and required two people assistance. The surgeon had been contacted and was informed regarding the findings. The surgeon ordered to "cleanse the area and remove as much fluid as possible, remove sutures, and apply calcium alginate with Silver (Ag) in open areas if any, and to call the office with further questions". Resident 46 had been medicated for pain. Resident 46's non-verbal signs were noted of pain including grimacing. The facility will continue to monitor. (Note: An incident report regarding resident 46 for the month of October 2013 could not be located by the Director of Nursing (DON).) On 10/11/13, the Nursing Progress Note revealed that the Registered Nurse (RN) had removed the dressings on the right foot and cleansed the area with normal saline. Large blood clots had come from the wound. There were two areas open along the incision line, but they are connected. The surgeons office had been contacted to set up an appointment to evaluate and treat resident 46's wound. The appointment was set up for 10/16/13. The wound was currently being dressed with calcium alginate with Ag and secured with rolled gauze and cohesive dressing. A review of resident 46's physician orders revealed orders for, "Right foot incision line. Cleanse and irrigate open areas with normal saline. Pad (sic) dry and apply calcium alginate with Ag. Cover the area with non-adherent foam and secure with rolled gauze and wrap with cohesive dressing. Change daily and prn." A review of the October 2013 MAR, revealed that resident 46 had not received 7 of the 12 scheduled dressing changes. No documentation could be located indicating why the dressing changes were not received by resident 46. On 10/22/13, the Nursing Progress Note revealed that resident 46's blood sugars had been elevated for the past few days. The staff had obtained an order for [REDACTED]. Resident 46's right foot had light pink, milky drainage. An order was obtained to culture the open areas on right foot. The surgeon was notified. On 10/22/13. the Nursing Progress Note revealed that at approximately 8:15 PM, resident 46 was assessed. Resident 46 had a blood pressure of 124/62, pulse 113, respirations 23 and a temperature of 101.3. Resident 46 had sporadic and labored respirations upon exertion. Resident 46 appeared to be in discomfort and had a decreased level of consciousness. The Medical Director (MD) was notified and ordered to have resident 46 sent to the local hospital emergency room for evaluation and treatment. (Note: Resident 46 was admitted to the local hospital for a possible infection.) On 2/6/14 at 8:30 AM, an interview was conducted with the DON. The DON stated that the nursing staff should chart all treatments on the Treatment Administration Record (TAR). If there were a change in wound care orders the order would be put into the electronic medical record and then printed out on the TAR. The DON stated that the incident on 10/7/13 with resident 46 should have been reported to the DON and documented on an incident report. On 2/6/14 at 10:30 AM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 stated that the surgeons office had not seen resident 46 since 9/24/13. Resident 46 had a visit scheduled for 10/16/13 but the office had canceled the visit and rescheduled for 10/22/13. The surgeon did not see resident 46 on 10/22/13 because he was admitted to the hospital. On 2/6/14 at 1:15 PM, an interview was conducted with the facility MD. The MD recalled resident 46. The MD stated that the wound care nurse had called to have the wound care orders changed. The MD was not aware that the orders were not being followed by the nursing staff. According to the professional opinion of the MD if the wound care was not being done daily for resident 46, then "yes it could lead to an infection". The MD was not informed of the incident on 10/7/13 with resident 46. The MD did see resident 46 for a recertification visit on 10/14/13, but was under the impression that resident 46 would be seeing the surgeon in the next few days. It was also noted in the physician progress notes [REDACTED]. The admitting hospital records were obtained and reviewed. The local hospital transfer summary dated 10/22/13, revealed that resident 46 was admitted for [MEDICAL CONDITIONS], diabetic foot infection to the right foot . A further review of the hospital records revealed that a right lower extremity [MEDICAL CONDITION] was performed on resident 46.. (Cross refer to F 329, and F 333)

Based on interview, observation, and record review it was determined that the facility failed to properly provide supervision to residents while the residents left the building, provide interventions for residents who have had falls and been identified as a fall risk, and ensure that hot water temperatures throughout the building did not exceed 120 degrees Fahrenheit. (Residents 10, 20, 44, 50, 77, and 81). The deficient practice identified for resident 44 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 10 was found to have occurred at a harm level and will not be included in the Immediate Jeopardy. The deficient practice identified for residents 20, 50, 77, and 81, in addition to the hot water temperatures, was found to have occurred at a potential for harm and will also not be included in the Immediate Jeopardy. Resident 44 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], following an inpatient psychiatric admission. Upon admission, resident 44's [DIAGNOSES REDACTED]. On 2/19/13, between 10:00 AM and 10:20 AM, resident 44 was observed to be outside of the facility's first floor rear exit, near the facility parking lot. This area was not secured. At the time of the observation, resident 44 was smoking. There were no staff or other residents with resident 44. At 10:20 AM, a facility nurse accompanied a surveyor to meet with resident 44 to assess the resident's hands for cigarette burns. As the facility nurse returned inside the building, resident 44 remained outside, with no staff supervision. On 2/19/13 at 12:30 PM, resident 44 was interviewed. Resident 44 stated that in the past few weeks she had left the facility, on her own, and purchased Sudafed and Benadryl at a local pharmacy. The resident stated, "the more pills I took, the more I wanted." Resident 44 stated that on 2/18/13 she began to have chest heaviness and her first thought was, "Great, this is the end!" Resident 44 stated that she has had thoughts of suicide on almost a daily basis but was not thinking about suicide when she took the pills. During the interview, resident 44 became tearful and expressed that she did not feel facility staff listened to her. Resident 44 stated that she had not been seen by a mental health professional since her readmission from the inpatient psychiatric facility except for someone who, "pops their head into my room and tells me my medications are fine". Resident 44 expressed that it would be helpful for her to discuss her thoughts of harming herself to a counselor. A review of resident 44's medical record was completed on 2/19/13. On 2/18/13 at 7:22 PM, a facility nurse documented that resident 44 came to the nursing station at 6:40 PM and stated she had taken medications she had purchased from a local grocery store. The nurse documented that resident 44 reported she had taken 48 tablets of pseudoephedrine in the past three days and wanted to be sent to the emergency room for evaluation. The nurse documented that resident 44 had complaints of chest pain and was not able to sleep for the past three days. The nurse documented that resident 44 had shown the nurse two empty boxes of pseudoephedrine and three empty boxes of Benadryl. The nurse documented that resident 44's physician was notified and ordered that the resident be sent to the emergency room for evaluation and treatment. The nurse documented resident 44's vital signs as temperature at 98.4 degrees Fahrenheit, pulse at 107, respirations at 20, blood pressure at 171/84 and oxygen saturations at 92 percent. On 2/18/13 at 7:28 PM, a facility nurse documented that per physician orders, resident 44 was sent to a local acute care hospital for evaluation and treatment related to the resident's report that she had over-dosed on pseudoephedrine and Benadryl. On 2/18/13 at 11:23 PM, a facility nurse documented that resident 44 had returned from the emergency room at 11:15 PM with a [DIAGNOSES REDACTED]. The note also included documentation that resident 44's attending physician was notified and "Will monitor". A review of the Discharge Instructions from the local acute care hospital, dated 2/18/13, revealed Discharge [DIAGNOSES REDACTED]. A review of a Pre-Admission Screening and Resident Review (PASRR) level II dated 1/10/13, revealed a recommendation that resident 44 would benefit from mental health treatment due to her [DIAGNOSES REDACTED]. The PASRR also included documentation that resident 44's admission to the facility in 2009 followed a hospitalization secondary to an accidental overdose of Lortab. An interview was held with the facility's Resident Advocate (RA) on 2/19/13 at 12:35 PM. The RA stated that PASRR had no current recommendations for resident 44. She stated that the facility should have been following the recommendations from 2010. A review of the Comprehensive Resident Admission Assessment, dated 1/10/13, revealed that facility staff had assessed resident 44 as not desiring to self administer drugs, received psychotropic medications, was independently mobile, was cognitively intact, but that the resident did not have competent decision making capability, and that the resident exhibited wandering behaviors. A review of resident 44's care plan revealed a plan for problem of ineffective individual coping. The plan was dated 1/10/13 and was updated 1/24/13. The identified problem was related to resident 44's history of hurting herself, cutting herself, suicide attempts, suicidal comments, and a history of suicidal ideation. The goals for this identified problem were that resident 44 would not harm herself, would not make any suicidal gestures, would not make any suicidal comments, would not verbalize an intent to harm herself and that she would participate in mental health visits as scheduled. Interventions for this identified problem included as a measure to prevent harming herself, staff were to encourage resident 44 to be out of her room much of the day, to ensure the resident swallowed her pills, to attempt to identify the residents emotional triggers for self-harm and to offer support. Interventions also included that staff were to evaluate the effectiveness of the resident's psychoactive medications every 90 days and as needed and that if the resident verbalized suicidal ideations without a plan, staff were to monitor the resident every 15 minutes for 24 hours or until the danger passed and that staff were to review the care plan with the resident. If resident 44 were to attempt to harm herself, staff were to monitor closely, 1:1, until the resident could be transferred to the emergency room and that staff were to notify the facility Social Worker, Medical Director, and Director of Nursing (DON). An additional care plan was developed for the problem of, "I have times when I feel down or depressed". The goal for this identified problem was for the resident to say something positive everyday and that the resident did not want to feel hopeless and sad, and that the resident did not want to hurt herself because she felt down. Interventions for this identified problem were for staff to offer the resident frequent visits with her friends, to invite the resident to activities staff believed she would enjoy, for staff to listen to what the resident had to say, and allow the resident to express her feelings, for staff to refer the resident to the local mental health provider as needed, and for the psychotropic drug committee to review the resident's anti-depressant therapy. A review of Social Service Progress notes for resident 44 revealed the resident was being followed by the local mental health provider and that resident 44 had Schizophrenia, paranoid type, Substance abuse (Valium and Lortab abuse) and that resident 44 had a history of [REDACTED]. On 2/19/13 at 9:18 AM, the following social service note was documented regarding resident 44: "talked with resident about creating a care plan to check for outside medications on her person when she goes out in the community. Resident agreed. Educated resident about outside medications are not allowed in facility, res (resident) agreed." 2/19/13 7:21 AM, the following social service note was documented regarding resident 44: "talked with resident about incident reported for (sic) staff regarding taking medications she bought at the store. She stated she had a cold and wanted to breathe again, so she went to the store and got some benadryl to help with her cold. She stated she has been taking it for the past two weeks, but noticed she started to shake and get the sweats and decided to tell the nurse. Discussed mental health, denies any hallucination or delusions, States she was feeling a little depressed because of her cold. She denies any suicidal thoughts or ideations at this time. She told (facility staff member) that she was very tired and has not been sleeping at night. Discussed communicating this to nursing management, res agreed. Also Discussed communicating when she is feeling depressed or frustrated and coming to talk to (facility staff member) resident agreed. (Facility staff member) communicated finding to DON and administrator." A review of the facility's Elopement Risk Assessment for resident 44 revealed that the facility staff assessed resident 44 on 1/11/13 and 2/13/13 as being a low risk for elopement. A review of an Assessment for Self-Administration of Medications, dated 1/11/13, revealed that facility staff assessed resident 44 as not being able to self administer medications. A review of the facility's "Leave Signing Resident Out" Policy revealed the following: "It is the policy of this facility that all residents leaving the premises must be signed out." "Procedures: 1. Each resident leaving the premises must be signed out. 2. The sign out register must indicate the resident's expected time of return. (See LOA (Leave of Absence) release form). 3. Medications that must be administered while the resident is out will be given to the resident or to the person signing the resident out. 4. Written and or oral instructions on when and how to administer the medication will be provided to the resident or to the person signing the resident out. Only medications that must be administered while the resident is out will be issued. 5. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. 6. Should the above policy be challenged, the charge nurse should contact the legal representative (sponsor) to determine if changes have been made. Should there be further disagreements, the Director of Nursing Services should be contacted and informed of the situation. 7. Residents must be signed in upon return to the facility. 8. Inquiries concerning the signing out of residents should be referred to the Director of Nursing Services or to the Executive Director." A review of the "Release of Responsibility for Leave of Absence" for resident 44 revealed the following: "I, the undersigned, do hereby request the privilege of taking the resident, whose name appears below, away from the premises of this facility. I hereby specify the date and time of departure, destination and the approximate date and time of return. By affixing my signature where provided, I guarantee to assume all responsibility, and promise and agree not to hold the facility in any way responsible or liable in case of accident or any other incident involving the resident while away from this facility. The below named resident may be granted Leave of Absence for the purpose of: . . " Resident 44's "Leave of Absence" form was blank except for an entry dated the "14th Going to Wal Mart." No other entries were listed on resident 44's LOA form. An interview was held with the Assistant Director of Nursing (ADON) on 2/19/13 at 9:50 AM. The ADON stated that all mental health patients should be supervised when leaving the building LOA. She further stated that the facility was going to assess resident 44's safety to be in the community. She stated that the incident with resident 44 should not have occurred. An interview was held with a facility charge nurse on 2/19/13 at 10:00 AM. The nurse confirmed that resident 44 was alert and oriented. The nurse stated that he was not aware of any episodes of elopement involving resident 44 and that the resident did not require increased supervision. The nurse stated resident 44 was able to sign herself out and was assessed to be safe in the community, but that resident 44 did not typically leave the premises. The nurse stated that resident 44 had suffered a psychotic break a couple of months ago and spent time at the hospital on the inpatient psychiatric unit. An interview was held with the Administrator on 2/19/13 at 10:10 AM. The Administrator stated that nursing staff have assessed residents, on admission, for safety in the community. He stated that staff would review information from the hospital and previous behaviors and would involve Social Services in determining a resident's safety to be in the community alone. He stated that if a resident had mental health concerns, Social Services would definitely be involved and an interdisciplinary team meeting would be held to determine if a resident were safe to be alone in the community. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/13/13 resident 10's medical record was reviewed. Through interviews with facility staff, it was determined that facility staff were using a restraint device to strap resident 10's legs onto the foot pedals of a wheel chair. Review of the medical record revealed that resident 10 sustained a fall from the wheel chair on 2/4/13 with the wheel chair landing on top of resident 10's back due to resident 10's legs being strapped onto the wheel chair. Incident reports revealed that resident 10 sustained an additional fall from the wheel chair on 2/5/13 with the wheel chair landing on top of resident 10's back due to resident 10's legs being strapped onto the wheel chair. Subsequently, resident 10 was diagnosed at a local acute care hospital on [DATE] with a fractured patella. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 2/20/13 at 1:15 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to accidents and supervision to prevent accidents. PLAN: On 2/21/13 at 1:00 PM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 2/21/13 stated the following: "Please accept this letter as evidence of Arlington Hills' credible allegation of compliance in support of the Facility's request that the Department abate the immediate jeopardy situation identified on the recertification survey (as more fully described in correspondence received from the Department on February 20th, 2013). It is the Facility's position that the conditions identified by the Department as constituting immediate jeopardy have been fully removed, effective February 20th 2013. .... F Tag 323 (S/S=J): 1. Resident #44 no longer resides in the Facility. 2. All residents present in the Facility will be assessed by the Interdisciplinary Team (IDT) and Facility Clinical Resources via a "BIMS" form and a "Evaluation for community Access" form to determine whether their mental status/capacity as assessed is consistent with community exposure by way of an unsupervised pass or leave of absence. 3. The IDT will identify, assess and monitor Facility residents on admission, quarterly, annually, and on change of condition to determine whether the resident is appropriate for an unsupervised pass away from the Facility; these observations and conclusions will be documented in the resident's medical record. 4. All residents deemed inappropriate for unsupervised pass will not be permitted to leave the Facility absent supervision. a. These residents will be clinically assessed for the placement of a Wander Guard device; when appropriate, the resident will receive a Wander Guard to assist with the prevention of elopements. b. Until all Wander Guards are in place, both the East and West entrances of the Facility will be supervised by staff and/or doors alarmed to prevent residents from taking unauthorized leaves and to ensure compliance with this Plan of Correction. 5. All residents and/or responsible party will receive education on the Facility's newly revised leave of absence policy and procedure at the time of admission, and as needed thereafter, and will be provided a copy of that policy for review and retention. 6. All residents deemed appropriate for a Leaves (sic) of Absence will be approved by a physician for appropriateness. A physician's orders [REDACTED]. 7. All residents with a Wander Guard device will be checked by nursing management for placement and functionality on a daily basis for two weeks; the results of each such check will be documented. Thereafter, the verification and documentation relative to Wander Guard placement will occur on a weekly basis. a. Any Wander Guard device that does not function as per manufacturer specifications will be repaired or replaced immediately. b. Residents and/or Responsible Parties will be educated on the Wander Guard process during Wander Guard device checks as deemed necessary by staff; this education will occur on a daily or weekly basis, depending on the frequency of checks then being performed. 8. The below-listed in-service training will be provided by Administrator/DNS (Director of Nursing Services)/Clinical Nurse Resources/Management Designee on the following issues to all current staff members as indicated below by the time of alleged abatement. No staff member will be allowed to work on shift until all below identified training has been completed: a. All staff members will receive education on the revised Facility Policy and Procedure regarding leaves of absence/resident pass process. b. All licensed nurses will be in-serviced on expectations related to assessment and documentation prior to a resident leaving on pass and at the time of the resident's return to the Facility. c. All staff members will receive education on the revised procedure for checking residents in and out relative to an approved leave of absence. d. All residents and/or responsible parties will be educated on the revised process for leave of absence within two weeks of the alleged abatement. e. Police, state agencies, physicians and responsible party will be notified as necessary and appropriate in the event of a resident's elopement or failure to return timely from an approved leave. f. All licensed nursing staff will be educated on the comprehensive clinical assessment required upon a resident's return from an approved leave of absence, and the documentation expectations associated with this assessment. 9. All staff will be in-serviced monthly for a period of three months on the Wander Guard system and the actions to take in the event of a resident's elopement. 10. Changes in building security will be made as follows: a. All doors will be locked after 10:00 p.m. and reopened after 6:00 a.m. b. Alarms will sound in the event a locked door is opened during off hours to alert staff on duty of a possible security compromise. c. Maintenance/Designee will check alarm systems weekly to verify they are properly functioning, and will log the results of these checks. 11. The Facility's Clinical Resources will, weekly for a period of three weeks, review up to five residents who have been identified as unsafe for an unsupervised Leave of Absence; these reviews will be conducted to validate compliance with the revised policies and procedures in this area. 12. The Facility's Clinical Resources will, weekly for a period of eight weeks, review the Wander Guard log to validate compliance with the revised requirements of checking the device and documenting results from these checks. 13. The above processes and policies will be reviewed and evaluated by the facility Quality Assurance Committee on a weekly basis for one month. The QA committee will thereafter adjust the frequency of the meetings and the monitoring as appropriate." Prior to leaving the facility on 2/21/13, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 2/21/13, the surveyors confirmed removal of the Immediate Jeopardy situation as of 2/20/13. Deficient practice with actual harm and potential for more than minimal harm remained for the risk of injury. Findings Include: Elopement: Immediate Jeopardy: A. Resident 44 Resident 44 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a recent admission for inpatient psychiatric treatment. Resident 44 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility Progress Notes revealed the following entries: A. "2/18/2013 18:59 (6:59 PM) Nursing Note Text: Pt (patient) stated she had take (sic) 48 tablets of pseudoephedrine in the last 3 days and she wanted to to be sent out to the ER (emergency room ) for eval (evaluation) and tx (treatment). Pt C/O (complains of) of (sic) chest pain and unable to sleep for the past three days. pt show (sic) nurse 2 empty boxes of pseudoephedrine and 3 empty benadryl boxes. Pt does not recall how much pt has taken taken benadryl. (Name of Physician) notified. Order to sent (sic) out to ER for eval and tx. VS (Vital Signs): P (pulse) 107, 92% at 4L (liters) - (Oxygen saturation), BP (blood pressure) 171/84, R (respirations) 20, T (temperature) 98.4." B. "2/18/2013 19:22 (7:22 PM) Nursing Note Text: Addition note: Pt came to up to nursing station at 1840 (6:40 PM) stated she had taken medications she had brought (sic) from (Name of Grocery Store)." C. "2/18/2013 19:28 (7:28 PM) Nursing Note Text: Sent to (Name of local acute care hospital) on 2-18-19 at 1915 (7:15 PM) for eval and tx r/t (related to) pt stated pt OD (overdosed) on pseudoephedrine and benadryle (sic) per (Name of Physician)." D. "2/18/2013 23:23 (11:23 PM) Nursing Note Text: Pt return on 2-18-2013 at 2315 (11:15 PM) from the ER with a [DIAGNOSES REDACTED]. (Name of Physician) notified of pt return and ER finding. Will monitor." On 2/19/13 the Discharge Instructions from the local acute care hospital were reviewed. The Discharge Instructions revealed that resident 44 was discharged with the Discharge [DIAGNOSES REDACTED]." E. "2/19/2013 07:21 (7:21 AM) Social Services Note Text: ACMHC (Assistant Clinical Mental Health Counselor) talked with resident about incident reported for (sic) staff regarding taking medications she bought at the store. She stated she had a cold and wanted to breath (sic) again, so she went to the store and got some benadryl to help with her cold. She stated she has been taking it for the past two weeks, but noticed she started to shake and get the sweats and decided to tell the nurse. Discussed mental health, denies any hallucination or delusions, States she was feeling a little depressed because of her cold. She denies any suicidal thoughts or ideations at this time. She told ACMHC that she was very tired and has not been sleeping at night. Discussed communicating this to nursing management, res agreed. Also Discussed communicating when she is feeling depressed or frustrated and coming to talk to ACMHC- resident agreed. ACMHC communicated finding to DON (Director of Nursing) and administrator." (Note: The ACMHC documenting the Social Services entries in the progress notes was the facility's Resident Advocate (RA) ). F. "2/19/2013 09:18 (9:18 AM) Social Services Note Text: ACMHC- talked with resident about creating a care plan to check for outside medications on her person when she goes out in the community. Resident agreed. Educated resident about outside medications are not allowed in facility, res agreed." On 2/19/13 at 9:50 AM, Assistant Director of Nursing (ADON) 1 was interviewed. ADON 1 stated that all mental health patients should be supervised when leaving the building "LOA" (Leave of Absence). ADON 1 further stated that the facility was now going to assess resident 44's safety to be in the community. ADON 1 stated that the incident with resident 44 should not have occurred. On 2/19/13 at 10:00 AM, Registered Nurse (RN) 2 confirmed that resident 44 was alert and oriented. RN 2 stated that resident 44 had had no episodes of elopement and did not require increased supervision. RN 2 stated that resident 44 was able to sign herself out and was assessed to be safe in the community. RN 2 further stated that resident 44 did not typically leave the premises. RN 2 stated that resident 44 had had a psychotic break a couple of months ago and spent time at the hospital on the inpatient psychiatric unit. On 2/19/13, between 10:00 AM and 10:20 AM, resident 44 was observed to be outside of the facility's first floor rear exit, near the facility parking lot. This area was not secured. At the time of the observation, resident 44 was smoking. There were no staff or other residents with resident 44. At 10:20 AM, RN 2 accompanied a surveyor to meet with resident 44 to assess the resident's hands for cigarette burns. As the facility nurse returned inside the building, resident 44 remained outside, with no staff supervision. Prior to RN 2 locating resident 44 outside in the smoking area, no observations were made of RN 2 checking the LOA book to see if resident 44 had signed herself out of the building. It should be noted that the observation of resident 44 on 2/19/13 between 10:00 AM and 10:20 AM was the day after resident 44 had been sent to the hospital for an overdose of over - the - counter medications. On 2/19/13 at 10:10 AM the facility Administrator was interviewed. The Administrator stated that nursing staff did an assessment upon admission to evaluate safety in the community. The Administrator stated that the staff looked at information from the hospital and previous behaviors and involved Social Services in determining safety in the community alone. The Administrator stated that if the resident had mental health concerns then Social Services would have definitely been involved and an IDT (Interdisciplinary Team) meeting would have been held to determine safety alone in the community. On 2/19/13 at 12:30 PM, resident 44 was interviewed. Resident 44 stated that she (resident 44) had purchased the pills from (Name of Convenience Store/Pharmacy) around 3 weeks ago. Resident 44 stated that she kept taking the pills because "the more I took, the more I wanted." Resident 44 further stated that she had thoughts of suicide almost daily but was not thinking about suicide when she took the pills. Resident 44 stated that when she began to have the chest heaviness her first thought was, "Great, this is the end." Resident 44 stated, while crying, that the facility staff did not listen to her and no one talked with her. Resident 44 stated that the RA began talking to her today (2/19/13) and that was it. Resident 44 stated that she had not seen a mental health professional, only someone who "pops their head into my room and tells me my medications are fine." Resident 44 expressed that it would be helpful for her to discuss her thoughts of harming herself to a counselor. Review of the medical record revealed a PASRR letter of determination dated 1/12/13. It was documented in the letter that "the Nursing Facility reports that you were discharged from (Name of facility) on 11/16/12 for inpatient psychiatric treatment and then readmitted on [DATE] to (Name of facility). Recommendations for specialized services are available on the PASRR evaluation which may be obtained through the Nursing Facility." Additionally, a PASRR Level II Assessment completed on 4/14/10 indicated that resident 44 would benefit from mental health treatment due to [DIAGNOSES REDACTED]. According to the PASRR evaluation, resident 44's "previous admission to (Name of facility) in December 2009 followed hospitalization secondary to an accidental overdose of Lortab..." On 2/19/13 at 12:35 PM, the facility Resident Advocate (RA) was interviewed. The RA stated that PASRR had no current recommendations for resident 44. The RA stated that the facility should have been following the recommendations from the PASRR done in 2010. Review of Social Service Progress notes revealed that resident 44 was being followed by (Name of local Mental Health Agency) and that resident 44 had Schizophrenia, paranoid type, Substance abuse (Valium and Lortab abuse) and that resident 44 had a history of [REDACTED]. No documentation could be found to show that resident 44 was receiving Mental Health Services as recommended on the PASRR evaluation. Review of the medical record revealed a care plan dated 1/10/13 and updated 1/24/13 for "I have ineffective individual coping R/T (related to) hx (history) of hurting myself, cuttling (sic) myself, suicide attempts, suicidal comments, h/o (history of) suicidal ideations." The goal of the care plan was, "I will not harm myself, make any suicidal gestures, or comments Q (every) day TNR (Til next review). I will not verbalize intent to harm myself Q day TNR. I will participate in mental health visits as scheduled TNR." The interventions listed on the care plan to help resident 44 achieve the stated goals were: "To prevent harm to myself: Encourage me to be out of my room much of the day, Ensure I swallow my pills. Attempt to ID (identify) my emotional triggers, for self-harn (sic) and offer support. Eval (evaluate) effectiveness of my psych meds Q 90 days and prn (as needed). If I verbalize suicidal ideations without a plan monitor me Q 15 min (minutes) for the next 24 hours or untic (sic) danger passes and review this care plan with staff again. If I try to harm myself: Monitor me closely 1:1 (one on one) until I can be transferred to the ER (emergency room ) and Notify the SS (Social Services), MD (Medical Doctor), DON." An additional care plan in resident 44's medical record was for "I have times when I feel down or depressed." The goals of the care plan were, "I want to say something positive everyday, I don't want to feel hopeless, I don't want to be sad, and I don't want to hurt myself because I feel down." The interventions listed to help resident 44 achieve the goals were: "Offer me frequent visits with my friends, Invite me to activities you think I would enjoy, Listen to what I have to say and allow me to express my feelings, Refer me to my (Name of Mental Health Agency) mental health therapist as needed, and refer me for review by the psychotropic med (medication) committee to review anti-depressant therapy." Review of the "Comprehensive Resident Admission Assessment" dated 1/10/13 revealed that facility staff had assessed resident 44 as not desiring to self administer drugs, resident received psychotropic medications, was independently mobile, did wander, and was cognitively intact, but did not have competent decision making capabilities. Review of the facility's Elopement Risk Assessment for resident 44 revealed that the facility

Based on observation, interview, and record review it was determined, for 2 of 32 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a Hospice resident had an injury to her lower extremity in November of 2012. Facility staff did not obtain the ordered X-ray of the lower extremity until February of 2013. Additionally, the Hospice resident had been in chronic pain with little relief from the current pain medication regimen and neither facility staff or Hospice staff had re-evaluated the resident's pain or obtained orders for an increase in the pain medication. Another facility resident experienced a change in condition including: weakness, lethargy, and melena. Facility staff did not notify the physician of the change in condition or obtain an order to send the resident to the local emergency room for more than 24 hours after the resident began to experience the change in condition. When the resident was admitted to the local acute care hospital, she received two units of packed red blood cells. Resident identifiers: 54 and 77. Findings include: 1. Resident 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/12/13 at approximately 8:30 AM, resident 54 was observed lying in her bed. Resident 54 was observed to try and adjust her position in the bed by using her left arm to push up on the bed and sit up straighter in the bed. At 8:34 AM, resident 54 was observed to use the bed controls to lower the lumbar portion of the bed down to get comfortable. While lowering the bed a facility nurse was observed to enter resident 54's room and ask resident 54 if she needed "some pain medication." Resident 54 was observed to tell the facility nurse that she did need pain medication and that her pain level was an 8, on a scale of 1 to 10. On 2/12/13 immediately following the facility nurse's departure from the room to obtain the pain medication, resident 54 was interviewed. Resident 54 stated that around 4 months ago a facility Certified Nursing Assistant (CNA) was helping resident 54 transfer when resident 54 felt and heard a "loud pop" in her right knee. Resident 54 stated that the facility staff had not obtained an X-ray of her knee and that her knee had been hurting since the incident. Resident 54 further stated that the facility staff had never helped her with her knee. Resident 54 stated that the facility staff did not come back and ask about her pain level after the administration of pain medication. Resident 54 stated that the facility nurses would bring in the pain medication in the morning and then not come back to check on her. On 2/12/13 from 8:34 AM until 9:15 AM, resident 54 was observed to attempt to adjust her position in the bed multiple times in what appeared to be an attempt to get comfortable. At 9:15 AM, the facility nurse was observed to bring resident 54 pain medication. Resident 54 waited 41 minutes to receive the requested pain medication even though she had told the facility nurse her pain level was at an 8. After swallowing the pain medication, resident 54 was observed to tell the facility nurse that she did not want to eat any more of her breakfast due to her pain level. During the observation of resident 54 and the interview of resident 54, resident 54 was observed to cry multiple times. On 2/12/12 resident 54's medical record was reviewed. Review of the medical record revealed the following Nursing Note entries: A. "11/9/2012 18:40 (6:40 PM) Nursing Note Text: Pt (patient) is complaining of severe pain in RLE (Right Lower Extremity), especially during cares/repositioning. CNA informed that pt had been in the process of being transferred to bed on Thursday 11/8/12 when a loud pop was heard. Leg pain was reported the next day. Hospice notified and an xray ordered per hospice." B. "11/10/2012 06:44 (6:44 AM) Nursing Note Text: TO (Telephone order) per hospice: D/C (Discontinue) [MEDICATION NAME] 50 mg (milligrams) q (every) 4-6 hours PRN (as needed). Start [MEDICATION NAME] 100 mg po (by mouth) q 4-6 hours PRN. Dx (Diagnosis): pain." C. "11/29/2012 18:37 (6:37 PM) Nursing Note Text: New order for prn pain meds per Hospice: (1) D/C [MEDICATION NAME] 100mg. (2). Start [MEDICATION NAME]/[MEDICATION NAME] 5/325mg: 1 tab (tablet) po (by mouth) Q 4-6 hrs. prn pain. Dx: chronic back pain. [MEDICATION NAME] provided per Hospice." Review of the medical record revealed a "Pain Risk Assessment" completed by facility staff on 11/9/12 and 2/12/13. According to the facility's "Pain Risk Assessment" a score of 10 or higher represents a "High Risk" for pain. Resident 54 scored a 14 on 11/9/12 and a 12 on 2/12/13. Review of resident 54's medical record revealed a care plan, dated 4/14/12, for "At risk for pain related to Impaired mobility." The goals listed on the care plan were: "Resident expressive (sic) discomfort decreased or resolved within 1 hour of medication being administered, Resident will require fewer pain medications, Resident will state pain relief has improved by, Resident will report relief of pain every day." The interventions listed on the care plan to help resident 54 achieve the stated goals were: "Administer pain medications as ordered, Assess characteristics of pain: location, severity on a scale of 1-10, type, frequency, Discuss with physician that for maximum pain relief pain medications are best given around the clock, with prns for breakthrough pain, ... Notify physician of any changes in level or frequency of pain, any increase in use of prn pain medications, and any noted side effects of pain medications, Observe/report s/s (signs and symptoms) non verbal expression of pain such as clenched teeth, grimacing, grinding teeth, wrinkled forehead, guarding body part, biting lower lip, moaning, frowning, fearful facial expressions, bracing, rubbing, sighing, breathing heavily, fidgeting, increasing or recurring restlessness, groaning, etc., ... Reassess interventions with any changes in response to pain or pain medications and with every assessment." Additionally, resident 54 had a care plan for "Declining Health Status R/T (Related to) Terminal Prognosis On Hospice Program for Comfort Care-Family/resident fully understand the risks and benefits Anticipate further overall decline in physical and mental status, health/medical condition Potential for grief, withdrawal, depression, or anxiety" initiated on 8/13/12. The goal listed on the care plan was, "Resident will have needs met with care coordinates between hospice, facility staff, family and MD (Medical Doctor)." The interventions listed on the care plan to help resident 54 achieve the stated goal were: "..., Observe/report increase pain rate and re-eval (re-evaluate) of medication as needed thru (through) hospice, ..., Facility staff will co work (sic) and closely communicate w/ (with) hospice staff in order to provide comfort care for the resident, Observe/report change of condition, increasing pain, change in LOC (Level of Consciousness), skin alteration to hospice staff and MD promptly, Hospice on call services available 24 hours/day, 7 days a week, ..., and Nurse from hospice to visit routinely and provide care, ... ." On 2/12/13 the "Pain Monitoring Form", used by facility staff, from December 2012 through 2/19/13 was reviewed. Facility staff had been documenting that, on average, resident 54's pain was at a 7-10 prior to the administration of pain medication. Facility staff were documenting that, on average, an hour after the pain medication had been administered resident 54's pain remained at a 2-6. No documentation could be found to show facility staff or Hospice staff were evaluating the effectiveness of the pain medication resident 54 was receiving. No documentation could be found to show that facility staff notified Hospice or resident 54's physician regarding resident 54's continued level of pain after the administration of pain medication. No documentation could be found in the medical record to show that facility staff obtained the X-ray, ordered by hospice on 11/9/12. On 2/12/13 and 2/13/13 survey staff requested a copy of the X-ray results ordered by Hospice on 11/9/12. Facility staff were unable to locate the X-ray results. Review of the Nurses Notes on 2/14/13 revealed the following entry: A. "2/14/2013 07:31 Nursing Note Text: Late Entry: MD (Medical Doctor) notified of x-ray results. No fractures of (sic) dislocation noted. No new orders received. Will continue to monitor." It should be noted that facility staff did not obtain the ordered X-ray for resident 54 until after the results of the X-ray were requested by the State Survey agency. On 2/14/13, the facility Director of Nursing (DON) was interviewed. The DON stated that the facility did not obtain the X-ray, ordered by hospice on 11/9/12. The DON stated that she did not know that hospice had ordered an X-ray in November of 2012. The DON confirmed that the facility had not obtained the X-ray for resident 54 until 2/13/13. On 2/19/13, resident 54's physician orders [REDACTED]. No documentation could be found to show that facility staff had notified the Hospice agency or resident 54's physician regarding resident 54's pain medication regimen. On 2/20/13, the facility DON was interviewed regarding the notification of Hospice and resident 54's physician. The DON stated that she had not notified Hospice or the doctor as of yet but would be notifying them today (2/20/13). It should be noted that facility staff were made aware of the concern regarding resident 54's pain and the pain medication regimen on 2/12/13. As of 2/20/13, facility staff had yet to address the concern with Hospice or resident 54's physician. 2. Resident 77 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 77's medical record was reviewed on 2/14/13. A Minimum Data Set assessment dated [DATE] revealed resident 77 had a Brief Interview for Mental Status score of 13. Resident 77's nurses notes were reviewed and revealed the following: a. On 11/20/12 at 11:17 PM, "Change of Condition Note Note Text: Resident was last seen sitting on the toilet. When resident was checked on again she was found sitting on the floor in the bathroom. When the resident was asked why she was sitting on the floor she stated "Just because I wanted to sit down." When asked how she got on the floor she stated "I just sat down" The nurse and CNA (certified nurses assistant) helped her stand up and get back into bed. No appearant (sic) injuries noted and no pain reported from resident. When taking the resident back to bed resident stated "I needed to[***](sic) so I sat down on the floor to go" Residents vital signs are WNL (within normal limits). MD (Medical Doctor) and management notified. Will continue to monitor" b. On 11/21/12 at 5:16 PM, "STAT (immediately) CBC (complete blood count), CMP (Comprehensive Metabolic Panel) ordered on [DATE] d/t (due to) increased confusion". c. On 11/29/2012 at 10:23 AM, "CBC on 11/29/12 dx: (diagnosis) Low HCT (hematocrit)". d. On 12/1/12 at 9:14 PM, "While showering it was reported that resident was having a bowel movement and also passed what looked like a red, mucus blood clot. MD notifice (sic). Has a CBC ordered recently order (sic). Will continue to monitor". e. On 12/1/12 at 9:51 PM, "Alert charting: Resident continues with PO (oral) ABX (antibiotic) therapy. No S&S (signs and symptoms) of infection. No c/o (complaints of) dysuria. Resident was a bit comfused (sic) this NOC (evening). She was having a hard time making requests. Resident took a shower for 45 minutes. Will continue to monitor". f. On 12/2/12 at 10:06 AM, "Alert charting: Resident continues with PO ABX therapy for UTI (urinary tract infection). No S&S of infection noted during this shift. No c/o dysuria. pt (patient) was having hard time getting out of bed and going to the bathroom this morning. The nurse had to help there (sic) get out of bed this morning. Will continue to monitor". g. On 12/2/12 at 10:46 PM, "Alert charting: Resident continues with PO ABX therapy. No S&S of infection. No c/o dysuria. Will continue to monitor" h. On 12/2/12 at 10:52 PM, "Vital signs 1930 (7:30 PM) : BP (blood pressure) 87/48 P (pulse) 85 SAT (saturations) 90 Resp (respirations) 12 Temp (temperature) 94 Blood sugar 270 Vital signs 2100 (9:00 PM): BP (Blood Pressure) 101/43 P (Pulse) 79 SAT (Oxygen Saturation) 98 Resp (Respirations) 22 Temp (Temperature) 94.3 It was reported that resident has a very loose BM (bowel movement) that was dark, tar colored then a bit later had a formed BM that was also the dark, tar color. Resident has been in bed almost all day. She is (sic) wakes up easily but has a hard time putting sentences together. PEARRL (Pupils Equal, Round, Reactive to Light) and heart WNL. Residents breathing was slow then was a bit labored the (sic) went back to normal. Resident was cool to the touch and we put on some more blankets. Her skin tugor is slow. MD notified and ordered to send resident to (local hospital). Management and family notified. Resident left via (local transportation agency) at 2145 (9:45 PM)." i. On 12/2/12 at 11:03 PM, "Transfer to (local hospital) ER (emergency room ) per MD (medical doctor) order for unstable vital signs." (Note: Facility staff documented that resident 77 was experiencing a change in condition on 12/1/12. No documentation could be found to show that resident 77's physician was notified of the change in condition on 12/1/12. Additionally, resident 77 continued to have a change in condition with no documentation that resident 77's physician was notified until 12/2/12, more than 24 hours after resident 77 began to have the change in condition.) Resident 77's laboratory values were reviewed and revealed the following. (Note: The normal rage for Hgb is 12.4-17.4 gm/dL (grams per deciliter) and the normal range for a Hct is 38.7-52.5%.) a. On 10/23/12 Hgb was 9.4 which was low and Hct was 29.0 which was low. The form revealed resident 77's doctor was notified and no action was taken b. On 11/18/12 Hgb was 7.3 gm/dL which was low and Hct was 24.5% which was low. The form revealed a date of 12/4/12 and recheck CBC in 1 week. c. On 11/21/12 Hgb was 8.2 gm/dL which was low and HCT was 28% which was low. There was a signature on the form but no information or new orders. d. On 11/28/12 Hgb was 6.9 gm/dL which was critically low and Hct was 22.0% which was low. The form revealed a nurse spoke to provider on 11/29/12 at 8:10 AM. There was a note to recheck Monday 12/3. No additional information was provided in nurses notes or on the form. Resident 77's History and Physical from the local hospital dated 12/2/12 revealed, ". . .the patient has remained at her baseline health until approximately 1 to 2 weeks ago when she began to notice that she was having dark black stools. This would occur once to twice a day. She did not notice any bright red bleeding per rectum. She suffers from baseline fatigue and weakness.. . . Of note, the patient has suffered from GI (gastrointestinal) bleeds in the past, most likely related to a [DIAGNOSES REDACTED] ulcer that was noted by EGD ([MEDICAL CONDITION] [DIAGNOSES REDACTED] scope) in August of 2010. She has required [MEDICAL CONDITION] in the past. . ." The history and physical further revealed, "hemoglobin 7.0, hematocrit 23.2". The "assessment and plan" section revealed " . . . who presents with 1 or 2 weeks of melena concerning for an upper [MEDICAL CONDITION]. It seams more likely that this is an upper [MEDICAL CONDITION], the patient does have a history of [DIAGNOSES REDACTED] ulcers requiring [MEDICAL CONDITION] in the past. Furthermore, she has a hemoglobin of 7.0 with a baseline hemoglobin of approximately 10, historically. This bleed has been going on for sometime and it appears not to be advancing rapidly. . . The patient will be made n.p.o (no oral intake) and will be placed on continuous telemetry 2 units of packed red blood cells have already been requested and we will consider transfusion with these blood products pending repeat check of the patient's hemoglobin. . ." Resident 77's "Discharge Summary" from the local hospital dated 2/18/13 revealed, ". . .She (resident 77) received 2 units of cross matched blood here with improvement in her hematocrit and no acute ongoing blood loss [MEDICAL CONDITION] that was apparent . . ." On 2/14/13 at 1:20 PM, an interview was conducted with the facility DON. The DON stated she could not remember everything about resident 77. The DON stated resident 77 was discharged home, as far as she knew, from the hospital. The DON stated there was a delay in laboratory results and notification of the medical doctor. The DON stated the laboratory took the blood to another state and the results were not provided for 24 hours. The DON further stated the facility did a Quality Assurance meeting and found a new laboratory company, as well as, a new medical director.

Based on observation, interview and record review it was determined that the facility was not administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident with known self-injurous behavior and mental health [DIAGNOSES REDACTED]. The deficient practice identified was found to have occurred at an Immediate Jeopardy level. Resident identifier: 44. Findings include: 1. The facility administration failed to provide supervision to prevent accidents. This failure resulted in a finding of immediate jeopardy for one resident. Resident identifier: 44. (Cross refer to F323)

Based on observation, interview and record review it was determined that the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, a resident with known self-injurous behavior and mental health [DIAGNOSES REDACTED]. The deficient practice identified was found to have occurred at an Immediate Jeopardy level. Resident identifier: 44. Findings include: 1. The facility Quality Assurance (QA) committee failed to supervision to prevent accidents. This failure resulted in a finding of immediate jeopardy for one resident. Resident identifier: 44. (Cross refer to F323) .