Every finding on record at Crook County Medical Services District Long Term C

Based on staff schedule review, payroll based journal (PBJ) review, and staff interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days per week during 1 of 4 quarters reviewed (1st quarter of fiscal year 2025). The census was 27. The findings were: 1. Review of the PBJ Staffing Data Report for quarter 1 of fiscal year 2025 (October 1,2024 through December 31, 2025) showed there was no RN on duty for 8 consecutive hours for 2 days in November 2024, 11/9 and 11/23. Further review showed there was no RN on duty for 8 consecutive hours for 5 days in December 2024, 12/7, 12/14, 12/21, 12/22, and 12/29:2. Review of the staff schedule for November and December of 2024 confirmed there were no RNs on duty for 8 consecutive hours on 11/9, 11/23, 12/7, 12/14, 12/21, 12/22, and 12/29. 3. Interview with the DON on 8/14/25 at 10:46 AM confirmed the facility did not have RN coverage 7 days a week for at least 8 consecutive hours a day on the days identified.

Based on observation, resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure a safety assessment, including entrapment risk, of bedrails was completed for 1 of 5 sample residents (#21). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #21 had diagnoses which included cerebrovascular accident, and a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. Interview with the DON on 8/13/25 at 2:39 PM confirmed there should have been a safety assessment for the bedrails. The following concerns were identified: a. Observation on 8/11/25 at 4:42 PM showed resident #21 had bilateral bed canes built into the frame of his/her bed. b. Review of the resident's medical record showed no evidence a bedrail assessment, which included entrapment risks, had been completed. c. Interview with resident #21 on 8/13/25 at 3:15 PM revealed s/he used the bedrails for positioning. 2. Review of the policy Proper use of Bed Rails provided by the DON on 8/14/25 at 8:24 AM and last updated 4/29/25 showed .vi. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail .

Based on observations, staff interview, policy and procedure review, the facility failed to ensure infection prevention was maintained in 1 of 2 dining observations and 1 of 4 residents (#22) with urinary catheter observations. The findings were: Regarding urinary catheter drainage bags: 1. Observation on 8/13/25 at 2:15 PM showed LPN #1 and LPN #2 entered resident #22's room and the resident's catheter drainage bag was positioned on the floor at the foot of the bed, without a cover or other type of protection. Interview with LPN #2, at that time, revealed the facility expected the bag to not be on the floor and to be covered. 2. Interview with the IP on 8/14/25 at 9:32 AM revealed the expectation was for the urinary catheter drainage bag to be positioned below the bladder and covered. She confirmed the bag should not be placed on the floor, and there were basins provided to prevent placement of the bag on the floor. 3. Review of a education form Proper Catheter Care for CNAs hand delivered on 8/14/25 at 8:25 AM by the DON showed .General Guidelines .Ensure the drainage bag is securely attached to the bed frame or chair - never place it on the floor. We have fabric bags for this but can put plastic basins on floor if needed . Regarding hand hygiene in the dining room: 1.Observation on 8/11/25 beginning at 5:39 PM showed CNA #1 assisted residents to eat at the assisted dining table. The CNA provided a bite of food to resident #25 who was sitting on her right, and then she turned to the resident on her left, adjusted the footrests, placed the resident's feet on the footrests, repositioned the resident in the wheelchair, and then provided additional bites of food to resident #25 without performing hand hygiene. 2. Interview with the IP on 8/14/25 at 9:41 AM confirmed hand hygiene should be performed between tasks. 3. Review of policy titled Hand Hygiene and last revised 4/2022, showed .Hand hygiene continues to be the primary means of preventing the transmission of infection .

Based on staff interview and state agency incident database review, the facility failed to ensure investigations for abuse allegations were reported within 5 working days for 1 of 1 sample residents (#3). The findings were: 1. Review of the state survey agency incident database showed an allegation of staff to resident abuse was made by resident #3 to the facility charge nurse on 9/20/24. Further review showed the initial report was sent to the State Survey Agency on 9/23/24; however, there was no evidence the facility's investigative findings were reported as of 11/5/24. 2. Interview with the director of nursing on 11/5/24 at 5:17 PM confirmed the investigation had not been reported. Further interview revealed she did know she needed to report the investigation to the state survey agency.

Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 2 sample residents (#1 and #2) reviewed for allegations of abuse. The findings were: 1. Review of an incident report dated 7/30/24 showed resident #2 assaulted his/her roommate, resident #1, with the metal clip of a pair of suspenders. Further review showed the clip caused a 1centimeter (cm) laceration to resident #1's left cheek and the resident required treatment in the emergency room (ER). The following concerns were identified: a. Review of medical record dated 7/31/24 showed resident #1 was transferred to the ER and received treatment of the wound with steristrips. Bruising also developed at the site of the wound. b. Interview with CNA #6 on 9/4/24 at 5:30 PM confirmed CNA #6 had assisted resident #1 to the restroom and walked resident #1 into the bedroom when resident #2 ran across the room, jumped up and swung suspenders at resident #1, hitting resident #1 in the face. CNA #6 revealed resident #2 continued to swing at resident #1 and he had to hold resident #2 back to prevent further assault. c. Interview with RN #2 on 9/4/24 at 5:58 PM revealed CNA #6 had to keep resident #2 back from resident #1 after resident #2 hit resident #1 in the face with the buckle of his/her suspenders. RN #2 reported resident #1 was in shock after the incident and was sent to the ER for evaluation and treatment. 2. Interview with the resident representative for resident #1 on 9/4/24 at 1:41 PM revealed s/he questioned why staff had put a roommate in with resident #1 due to the resident's blindness, deafness and inability to communicate. The resident representative reported resident #1 never saw it coming. 3. Interview with the DON on 9/4/24 at 2:55 PM revealed she was working on a different system for reporting incidents and investigations which will include having a paper copy and witness statements. She revealed there is not a performance improvement plan (PIP) in place and staff have monitored resident #2 to figure out how to manage behaviors, though there is no documentation on that. 4. Review of the policy titled Abuse and Neglect - Clinical Protocol & Guidelines last reviewed 8/2016 showed .a. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to develop and implement interventions to address the residents' dementia care needs for 1 of 2 sample residents (#2) reviewed for dementia treatment and services. The findings were: 1. Review of the admission Minimun Data Set (MDS) dated [DATE] showed resident #2 had moderately impaired cognitive skills, inattention/disorganized thinking behavior present, inability to recall staff names/faces, inability to recall s/he lived in a nursing home, and a mood interview score of 21, indicating severe depression. The following concerns were identified: a. Review of progress note dated 7/23/24 showed resident #2 arrived in the facility and verbally expressed his/her displeasure at his/her arrival. Resident #2 was disheveled, ungroomed and wore unclean clothing. Resident #2's family stated it had been 2 weeks since they were able to get him/her to shower, and reported s/he was becoming more incontinent and refused to wear incontinence products. Resident #2 refused to eat meals and ate only ice cream bars and banana bread. b. Review of a progress note dated 7/24/24 showed resident #2 paced up and down the hall looking for his/her family, went in and out of rooms and needed redirecting and explanations repeated multiple times. c. Review of a progress note dated 7/25/24 showed resident #2 had his/her prescription of Seroquel increased on 7/24/24. S/he had been awake most of the night, and shown where his/her bathroom was multiple times. S/he had been in and out of other's rooms, was difficult to remove at times, and argued I'll go anywhere I damn well please and I don't care whose room it is. While in other resident's rooms s/he yelled and swore, and raised his/her fists multiple times when CNAs removed him/her from the rooms. d. Review of a progress note dated 7/25/24 showed resident #2 cursed the staff for 1.5 hours, accused staff of holding him/her hostage, followed the staff, and tried to open the doors, setting off alarms. S/he asked for water and then accused staff of doping it up. Staff offered food and tried to visit with the resident. e. Review of a progress note dated 7/30/24 showed Resident #2 assaulted his/her roommate with the metal clip of a pair of suspenders, and caused a 1 cm laceration to resident #2's left cheek. 2. Interview with the DON on 9/4/24 at 2:55 PM revealed staff have monitored resident #2 to figure out how to manage his/her behaviors, though there was no documentation on that. 3. Interview with the DON on 9/4/24 at 4:07 PM revealed there was no facility policy on behavior management or dementia care, and the DON planned to create these policies. 4. Interview with the DON on 9/5/24 at 9:54 AM revealed there had been no education given to staff on dementia care for the past two years. It had been planned for last month but was postponed due to area fires and the the bike rally. The DON revealed the training was rescheduled for the upcoming all-staff meeting.

50485 Based on observation, staff interview, review of the dishwasher and refrigerator/freezer temperature log sheets, manufacturer's instructions, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen. The census was 20. The findings were: 1. Observation on 5/6/24 at 2:39 PM showed the facility used a [NAME] chemical sanitizing dishwashing machine. The temperature of the water and the concentration of the chlorine sanitizer solution were to be monitored at breakfast, lunch and dinner. Review of the [NAME] dishwashing machine manufacturer's instructions showed the minimum temperature of the wash and rinse water was 120 degrees Fahrenheit (F), with a recommended temperature of 140 degrees F. The concentration of the chlorine sanitizer should be between 50 and 100 parts per million (ppm). The following concerns were identified: a. Review of the March 2024 dish machine log sheet showed the required concentration of the sanitizer and temperature of the wash and rinse water was not documented on the form 32 out of 93 opportunities. Review of the April 2024 dish machine log sheet showed the required concentration of the sanitizer and temperature of the wash and rinse water was not documented on the form 23 out of 90 opportunities. b. The dinner wash cycle, rinse cycle and sanitizer concentration were missing on 3/1, 3/3, 3/4, 3/5, 3/6, 3/8, 3/13, 3/15, 3/18, 3/21, 3/22, 3/25, 3/27, 3/31, 4/1, 4/2, 4/3, 4/6, 4/8, 4/9, 4/15, 4/16, 4/18, 4/19, 4/25, 4/29, and 4/30. c. The breakfast, lunch, and dinner wash cycle, rinse cycle and sanitizer concentration were missing on 3/2, 3/30, 4/7, and 4/13. d. The breakfast and lunch wash cycle, rinse cycle and sanitizer concentration were missing on 3/9, 3/10, and 3/23. e. The breakfast sanitizer concentration was missing on 3/16. f. The lunch and dinner wash cycle, rinse cycle and sanitizer concentration were missing on 3/16, 3/17, 3/24, and 4/21. g. The dinner sanitizer concentration was missing on 4/17. h. The lunch wash cycle, rinse cycle and sanitizer concentration was missing on 4/28. 2. Review of the March and April 2024 Walk-In Cooler Temperature Log showed the temperature was to be documented on both the morning and afternoon shifts. The expected ranges of the refrigerator were not posted on the log sheet. The following concerns were identified: a. The morning and afternoon shift temperatures were missing on 3/1, 3/2, 3/3, 3/4, 3/5, 3/30, and 3/31. b. The afternoon shift temperature was missing on 3/18, 4/15, 4/23, and 4/30. c. The morning shift temperatures were missing on 3/28, 3/29, 4/11, 4/14, 4/15, 4/16, 4/20, 4/21, 4/22, 4/24, and 4/26. d. On the afternoon shift of 4/7 the temperature was recorded as minus 10 degrees F. e. On the afternoon shift of 4/8 the temperature was recorded as minus 12 degrees F. f. On the afternoon shift of 4/9 the temperature was recorded as 0 degrees F. g. On the afternoon shift of 4/10 the temperature was recorded as minus 8 degrees F. 3. Review of the March and April 2024 Walk-in Freezer temperature log showed the temperature was to be documented on both the morning and afternoon shifts. The expected ranges of the freezer were not posted on the log sheet. The following concerns were identified: a. The morning and afternoon shift temperatures were missing on 3/1, 3/2, 3/3, 3/4, 3/5, 3/30, 3/31, 4/11, 4/14, 4/15, 4/16, 4/20, 4/21, 4/22, 4/24, and 4/26. b. The afternoon shift temperature was missing on 3/18, 4/12, 4/19, and 4/30. c. The morning shift temperatures were missing on 3/28, 3/29, 4/10, 4/11, 4/16, 4/17, 4/20, 4/22, and 4/26. 4. Review of the February 2024 and May 2024 Reach-In Cooler Temperature Log showed the temperature was to be documented on both the morning and afternoon shifts. The expected ranges of the refrigerator were not posted on the log sheet. The following concerns were identified: a. The morning and afternoon shift temperatures were missing on 2/1, 2/2, 2/3, and 2/4. b. The afternoon shift temperature was missing on 2/18. c. The morning shift temperatures were missing on 2/19, 2/28, and 2/29, 5/1, 5/2, 5/3, and 5/4. 5. Interview with the administrator on 5/9/24 at 9:09 AM confirmed the temperature log and dish machine sheets were incomplete. 6. Review of the undated Dishwasher Temperature policy provided by the administrator on 5/8/24 showed .2. The wash temperature of the spray dishwasher will be at 150 degrees or above. 3. The rinse temperature of the dishwasher will be at 160 or above. 4. The final rinse temperature will be at 180 degrees or above. 5. Temperatures below 180 degrees require corrective actions. 6. Water temperatures will be measured prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes and recorded on the Dishwasher Temperature Chart. 7. Review of the undated Monitoring of Cooler/Freezer Temperature policy provided by the administrator on 5/8/24 showed .1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. Temperatures will be checked and logged at least twice per day by designated personnel. Logs will be changed out and filed each month. 2. Thermometers shall be placed inside each cooler/freezer and calibrated at least once per week. Calibration between the inside thermometer and the outside gauge of the unit will be checked as well. 3. All refrigerated storage must be maintained at or below 41 degrees F, unless otherwise specified by law. 4. All frozen storage must be maintained at or -4 degrees F, unless otherwise specified by law. 5. If temperatures are above 41 degrees for coolers or 10 F for freezer, the supervisor will be notified immediately for corrective action. 8. According to the 2022 FDA Food Code 4-703.11 Hot Water and Chemical. Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization. When surface temperatures of utensils passing through warewashing machines using hot water for sanitizing do not reach the required 71oC (160oF), it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in SS 4-501.112 and 4-501.113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces.

Based on Payroll Base Journal (PBJ) review and staff interview, the facility failed to ensure direct care staffing information was submitted on schedule specified by CMS for 2 of 4 quarterly periods (1st quarter, 10/2023-12/2023, 3rd quarter, 4/2023-6/2023). The findings were: 1. Review of the [NAME] Payroll Base Journal showed the facility failed to submit data for quarter 1 (10/2023- 12/2023) and quarter 3 (4/2023-6/2023). 2. Interview with payroll management on 5/8/24 at 2:42 PM revealed the facility had missed the deadlines for submission of the data on both quarters. 3. Interview with the administrator on 5/9/24 at 10 AM confirmed the facility had missed the deadlines for submission to the PBJ on the 2 quarters.

Based on staff interview, medical record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS assessment information was an accurate reflection of resident status for 1 of 12 sample residents (#8) reviewed. The findings were: 1. Review of the 3/6/24 quarterly MDS assessment for resident #8 showed the resident was admitted to the facility on [DATE] and had a diagnosis of atrial fibrillation. Review of the November 2023, December 2023, January 2024, February 2024, and March 2024 medication administration records showed the resident was administered 5 milligrams of Eliquis (an anticoagulant) every 12 hours. The findings were: a. Review of the 12/6/23 and 3/6/24 quarterly MDS assessments showed the resident was not coded as receiving an anticoagulant during the 7-day look-back period. b. Interview with the ADON on 5/9/24 at 9:57 AM confirmed the MDS assessments had been coded incorrectly. 2. According to the MDS 3.0 RAI Manual version 1.18.11 page 483 N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised as needed to reflect the resident's current needs for 2 of 12 sample residents (#8, #9). The findings were: 1. Review of the 3/20/24 quarterly MDS assessment showed resident #9 was admitted on [DATE] with diagnoses which included a primary medical condition of moderate dementia without psychotic disturbance, heart failure, and depression. Review of an 3/19/24 Office Clinic Note Physician report showed the resident had been recently placed on comfort cares as his/her dementia seems to be progressing and [s/he] is no longer eating well and is losing weight. A discussion was had with the POA and a mutual decision was made to discontinue medications with the exception of liquid Tylenol. The following concerns were identified: a. Review of the care plan, last reviewed 3/20/24, failed to show revisions related to comfort care. b. Interview with the ADON on 5/9/24 at 9:54 AM confirmed the care plan had not been revised to reflect the resident's comfort care status. 2. Review of the 9/6/23 admission MDS assessment showed resident #8 was prescribed scheduled and as needed pain medication, and had mild pain almost constantly which did not interfere with sleep or activities. The following concerns were identified: a. Review of the 12/6/23 quarterly MDS assessment showed the resident had pain almost constantly at an intensity level of 10 out of 10 which affected both sleep and interfered with activities. b. Review of the 3/6/24 quarterly MDS assessment showed the resident had pain almost constantly at an intensity level of 10 out of 10 which frequently affected his/her sleep, interfered with therapy activities almost constantly, and occasionally interfered with day-to-day activities. c. Review of the resident's current physician orders showed the resident was prescribed acetaminophen 325 milligrams and tramadol (an opioid) 50 milligrams every 12 hours. d. Review of the resident's care plan, last reviewed 3/6/24, failed to show the care plan had been revised to include goals and interventions related to pain. e. Interview with the ADON on 5/9/24 at 9:50 AM confirmed the care plan should have been revised to include pain management.

Based on observation, staff interview, and professional standards review, the facility failed to ensure infection prevention techniques were followed during 1 of 1 wound care observation(#8). The findings were: 1. Observation of wound care for resident #8 on 5/8/24 at 11:27 AM showed RN #1 donned gloves, placed a barrier under the resident's legs, and set unopened supplies on the table. She removed an old dressing from the right leg. She cleaned the wound with gauze and wound cleaner. Doffing her gloves, she fanned the wound with a dressing packet. She performed hand hygiene, donned gloves and opened the packet and placed the calcium alginate. She then opened the abd pad packet and placed it over the calcium alginate and then opened the kerlix gauze packet and wrapped the right lower leg. The nurse then moved to the left lower leg, doffing, hand hygiene, donning gloves. She removed the old dressing, cleaned the wound with wound cleaner and gauze, and fanned the wound with an unopened dressing packet. She offed her gloves, performed hand hygiene, and donned new gloves. She then opened the calcium alginate packet and placed the dressing to the wound. She opened the abd pad packet and placed it over the calcium alginate, then opened the kerlix gauze package and wrapped the dressing around the lower leg. 2. Interview with RN #1 at the end of the dressing change revealed she was not wound care certified. She confirmed that was how she normally did the wound dressing change. She stated she fanned the wounds because the resident liked it. She confirmed that outer packets were dirty and were opened when she was in the clean process. 3. Interview with the ADON on 5/8/24 at 12:20 PM revealed it was the expectation for staff during wound care to keep clean procedures clean, change gloves between dirty and clean, and do not fan a wound. 4. Review of website https://www.ncbi.nlm.nih.gov/books/NBK593201/ on 5/17/24 showed . A break in the skin allows bacteria to enter and begin to multiply.Step 1. Gather supplies: 2. Perform safety steps: Perform hand hygiene, Check the room for transmission-based precautions, .Be organized and systematic . Perform hand hygiene immediately prior to arranging the supplies at the bedside. 6. Place a clean, dry, barrier on the bedside table. Create a sterile field if indicated by agency policy. 7. Pour sterile normal saline into opened sterile gauze packaging to moisten the gauze. Normal saline containers must be used for only one patient and must be dated and discarded within at least 24 hours of being opened. Commercial wound cleanser may also be used. 8. Expose the dressing. 9. Perform hand hygiene and apply nonsterile gloves. 10. Remove the outer dressing. 11. Remove the inner dressing. Use transfer forceps, if necessary, to avoid contaminating the wound bed. 12. Remove gloves, perform hand hygiene, and put on new gloves. Wrap the old inner dressing inside the glove as you remove it, if feasible, to prevent contaminating the environment. 13. Assess the wound. 14. Drape the patient with a water-resistant underpad, if indicated, to protect the patient's clothing and linen. 15. Apply gloves and other PPE as indicated. Goggles, face shield, and/or mask may be indicated. 16. Cleanse the wound based on agency policy, using moistened gauze, commercial cleanser, or sterile irrigant. When using moistened gauze, use one moistened 2 x 2 sterile gauze per stroke. Work in straight lines, moving away from the wound with each stroke. Strokes should move from a clean area to a dirty area and from top to bottom. Note: A suture line is considered the least contaminated area and should be cleansed first. 18. Remove gloves, perform hand hygiene, and apply new gloves. 19. Apply sterile dressing (4 x 4 sterile gauze), using nontouch technique so that the dressing touching the wound remains sterile. 20. Apply outer dressing if required. Secure the dressing with tape as needed. 21. Remove gloves and perform hand hygiene.

Based on daily staff posting review and staff interview, the facility failed to ensure the data requirements were included on the the daily staff postings. The findings were: The census was 20. 1. Review of 2 weeks look back of the daily staff postings showed the facility failed to include the facility's name. 2. Interview with the ADON on 5/8/24 at 11:37 AM revealed she was unaware the facility's name needed to on the daily staff postings, and confirmed the facility name was not on the daily staff postings.

Based on staff schedule review, payroll based journal report review, and staff interview, the facility failed to ensure the services of an RN were utilized for 8 consecutive hours per day, 7 days per week for 5 of 5 months (Oct. 2022, Nov. 2022, Dec. 2022, Jan. 2023, Feb. 2023) reviewed. The facility census was 23. The finding were: 1. Review of the payroll based journal report showed No RN Hours triggered (Four or More Days within the Quarter with no RN hours) or was not reported during quarter 2, 3, and 4 of 2022 and quarter 1 of 2023. 2. Review of the nursing schedule for October 2022 showed the facility failed to provide RN services for 8 consecutive hours on 4 of 31 days, on 10/5, 10/6, 10/8, and 10/9. 3. Review of the nursing schedule for November 2022 showed the facility failed to provide RN services for 8 consecutive hours on 5 out of 30 days, on 11/5, 11/6, 11/19, 11/20, and 11/26. 4. Review of the nursing schedule for December 2022 showed the facility failed to provide RN services for 8 consecutive hours on 5 out of 31 days, on 12/3, 12/4, 12/17, 12/18, and 12/24. 5. Review of the nursing schedule for January 2023 showed the facility failed to provide RN services for 8 consecutive hours on 5 out of 31 days, on 1/7,1/8, 1/21, 1/22, and 1/29. 6. Review of the nursing schedule for February 2023 showed the facility failed to provide RN services for 8 consecutive hours on 2 of 15 days, on 2/4 and 2/5. 7. Interview with ADON/Scheduler on 2/15/23 at 2:55 PM confirmed she failed to ensure an RN was scheduled to cover 8 consecutive hours per day, 7 days per week.

Based on staff interview, and review of compliance history information, the facility failed to develop and implement policies and procedures for how it will develop, monitor and evaluate performance indicators to prevent repeat deficiencies from previous surveys. The census was 23. The findings were: 1. Review of the [NAME] 3 report last updated on 2/8/23 showed F727 was previously cited on 3/2/22, F758 was previously cited on 3/2/22, and F880 was previously cited on 3/2/22 as well as in 2021 and 2018. 2. Interview with the ADON on 2/16/23 at 1:09 PM revealed the QAPI committee did not discuss the areas identified as repeat deficient practice during the QAPI meetings and the facility was not working on any performance improvement plans related to any of the areas identified as repeat deficient practice.

Based on observation, medical record review, staff interview, and review of policy and procedures, the facility failed to ensure assistive devices were functioning appropriately for 4 of 4 sample residents (#7, #15, #16, #17) reviewed for elopement. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 3 out of 15, which indicated sever cognitive impairment, and diagnoses which included non-Alzheimer's dementia. Further review showed a wander/elopement alarm was used daily. The following concerns were identified: a. Review of a progress note dated 9/7/22 and timed 3:34 PM showed the resident was pacing and looking for his/her car. The resident was mad for being dumped at the facility. Further review showed the resident exited the building 3 times and a wander-guard was placed. b. Observation on 2/13/23 at 3:35 PM showed resident #7 and resident #16 ambulating in the facility hallway. The residents attempted to go out the main doors; however, they attempted to push the door out and the hinges swung in. The residents turned and ambulated toward the desk and down the other hallway. Continued observation showed the residents entered several rooms looking for resident #7's cat. c. Review of the care plan last reviewed on 1/11/23 showed no evidence of a wander-guard placement or routine checks to ensure proper function. d. Review of the MAR/TAR for December 2022, January 2023, and February 2023 showed no evidence of wander-guard placement or routine checks to ensure proper function. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #16 had a BIMS score of 3 out of 15, which indicated sever cognitive impairment, and diagnoses which included Alzheimer's disease. Further review showed a wander/elopement alarm was used daily. The following concerns were identified: a. Review of a progress note for resident #16 dated 9/20/22 and timed 10:55 PM showed resident continued to pace and attempt to open the office doors from 1800-2100 [6 PM to 9 PM]. Asking why we are keeping [him/her] here and looking for [his/her] truck . b. Observation on 2/13/23 at 3:35 PM showed resident #7 and resident #16 ambulating in the facility hallway. The residents attempted to go out the main doors; however, they attempted to push the door out and the hinges swung in. The residents turned and ambulated toward the desk and down the other hallway. Continued observation showed the residents entered several rooms looking for resident #7's cat. c. Review of the care plan last reviewed on 1/18/23 showed no evidence of a wander-guard placement or routine checks to ensure proper function. d. Review of the MAR/TAR for December 2022, January 2023, and February 2023 showed no evidence of wander-guard placement or routine checks to ensure proper function. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #15 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia. Further review showed the resident's balance was not steady and s/he wore a wander-guard. The following concerns were identified: a. Review of the MAR/TAR for December 2022, January 2023, and February 2023 showed no evidence of wander-guard placement or routine checks to ensure proper function. 4. Review of the quarterly MDS assessment dated [DATE] showed resident #17 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease, anxiety disorder, sensorineural hearing loss, and macular degeneration. Further review showed the resident was independent and required set-up help only for bed mobility, transfers, walking in and out of the room, and locomotion on the unit, and a wander/elopement alarm was used daily. a. Observation on 2/14/23 at 9:43 AM showed resident #17 was wandering in the unit. b. Review of the care plan titled I am an elopement risk/wanderer AEB [as evidenced by] history of attempts to leave the facility unattended, impaired safety awareness, inability to redirect my behavior, poor safety awareness, resident wanders aimlessly, significantly intrudes on the privacy of others last reviewed on 1/18/23 showed the resident had a wander-guard on his/her ankle. There were no routine checks to ensure proper function. d. Review of the MAR/TAR for December 2022, January 2023, and February 2023 showed no evidence of wander-guard placement or routine checks to ensure proper function. 5. Interview with the MDS coordinator/IP on 2/16/23 at 11:08 AM confirmed the residents all had a wander-guard in use and the facility had previously placed wander-guard checks on the TAR to ensure the system was functioning correctly. Further interview confirmed the facility was unable to prevent residents from leaving the facility if the system was not functioning correctly. 6. Review of the policy titled Elopements and Wandering Residents Policy and Procedure last revised 8/2016 showed .6. Monitoring and Managing at Risk for Elopement or Unsafe Wandering .e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly . 37603

Based on observation, staff interview, and review of Centers for Disease Control (CDC) guidelines the facility failed to ensure infection control techniques were implemented to prevent spread of COVID-19 during 7 random observations. The census was 23. The findings were: 1. Observation of room [ROOM NUMBER] on 2/13/23 at 4:51 PM showed the room was on transmission-based precautions due to COVID-19 and the door was open. Further observation showed the room was located across from the main dining area and the door remained open until 5:30 PM, which included the time during the dinner meal. 2. Observation of room [ROOM NUMBER] on 2/13/23 at 5:08 PM showed the room was located across from the main dining area, was on transmission-based precautions due to COVID-19 and the door was left open. Observation on 2/14/23 at 8:15 AM showed the door was open. 3. Observation of room [ROOM NUMBER] on 2/15/23 at 4 PM showed the room was on transmission-based precautions and the door was open. 4. Interview with the MDS coordinator/IP on 2/16/23 at 12:47 PM revealed the facility expected isolation room doors to remain closed while on precautions for COVID-19. 5. Observation showed on 2/13/23 at 5:04 PM MA-C #1 donned PPE in the hall and entered room [ROOM NUMBER]. Upon exit, the MA-C doffed the PPE in the hall and discarded it in the trash between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 2/13/23 at 5:19 PM showed the MA-C exited room [ROOM NUMBER] and doffed the PPE in the hall and discarded it in the trash between room [ROOM NUMBER] and 203. 6. Observation on 2/14/23 at 9:17 AM showed CNA #1 donned PPE which included a gown, N95 mask, goggles, and gloves in the hall outside room [ROOM NUMBER] and entered room [ROOM NUMBER]. Upon exit, the CNA doffed the PPE while standing near the isolation cart outside room [ROOM NUMBER]. After removing her mask, the CNA removed the goggles and placed them on top of the isolation cart. The CNA performed hand hygiene, applied clean gloves, and wiped the goggles with a wipe obtained from the isolation cart. The CNA performed hand hygiene and donned PPE which included a gown, N95 mask, gloves, and the goggles she had just wiped, and entered room [ROOM NUMBER]. Upon exit, the CNA doffed the PPE while standing near the isolation cart outside room [ROOM NUMBER]. After removing her mask, the CNA removed the goggles and placed them on top of the isolation cart. The CNA performed hand hygiene, applied clean gloves, and wiped the goggles with a wipe obtained from the isolation cart. The CNA immediately placed the goggles in the top of the cart, donned a surgical mask, and left the area. No sanitation of the top of the isolation cart, where the goggles were placed, was performed and all PPE items were discarded in a trash between room [ROOM NUMBER] and 203. 7. Interview with CNA #1 on 2/14/23 at 9:28 AM revealed staff doff PPE outside the room; however, It probably should be done inside the room. 8. Interview with the MDS coordinator/IP on 2/16/23 at 12:47 PM revealed the rooms were crowded so staff doffed PPE outside the room. She revealed the contact time for the solution used to sanitize goggles was 1 minute and nothing contaminated should be placed on top of the isolation cart; however, if items were placed on top of the cart, staff were expected to sanitize the cart. Further interview revealed a staff member's mask should be replaced as soon as one was removed when donning or doffing PPE. 9. Review of https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html accessed on 2/24/23 showed .Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room . 10. Review of the https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html showed .Use personal protective equipment (PPE) appropriately, including gloves and gown.Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents or their representatives received written information about their right to formulate an advanced directive for 1 of 17 sample residents (#16). The findings were: 1. Review of the medical record for resident #16 showed an election for do not resuscitate dated 3/22/22. Further review showed no evidence the resident or representative was provided written information about the right to formulate an advanced directive. 2. Interview with the MDS coordinator/IP on 2/15/23 at 7:59 AM revealed the resident was originally admitted for a respite stay and a modified admission packet was used. When the resident's stay was changed to long term, the normal admission documents were not completed. Further interview confirmed the resident's representative completed an advanced directive; however, the written education related to the resident's rights was not provided. 3. Review of the policy titled Advance Directives last revised 4/2008 showed .1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives .

Based on medical record review, staff interview, review of the HLS incident database, and policy and procedure review, the facility failed to ensure allegations of abuse were reported for 1 of 4 sample residents (#5) reviewed for abuse. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and diagnoses which included weakness and age-related osteoporosis without current pathological fracture. Further review showed the resident required extensive physical assistance of 1 person for bed mobility, transfers, dressing, and toilet use. The following concerns were identified: a. Review of a progress note dated 9/14/22 and timed 10:37 PM showed the resident called out for help and staff found the resident on the floor in the chapel area. The resident was lying on his/her right side with resident #17 standing over him/her. The resident reported s/he asked resident #17 to move so resident #5 could see the TV and resident #17 flipped my wheelchair over and that's how I ended up here. The resident repeated the scenario to other staff members. 2. Interview with the MDS coordinator/IP on 2/16/23 at 8:56 AM revealed the incident on 9/14/22 was an incident the facility would normally investigate as a resident to resident altercation or abuse. 3. Interview with the MDS coordinator/IP on 2/16/23 at 10:49 AM revealed the facility did not have evidence the incident was investigated and reported as abuse and confirmed it should have been. 4. Review of the HLS incident database showed no evidence a resident to resident altercation or allegation of abuse which involved resident #5 and resident #17 was reported. 5. Review of the policy titled Abuse, Neglect and Exploitation last revised on 10/2022 showed .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: 1. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 2. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure allegations of abuse were investigated for 1 of 4 sample residents (#5) reviewed for abuse. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and diagnoses which included weakness and age-related osteoporosis without current pathological fracture. Further review showed the resident required extensive physical assistance of 1 person for bed mobility, transfers, dressing, and toilet use. The following concerns were identified: a. Review of a progress note dated 9/14/22 and timed 10:37 PM showed the resident called out for help and staff found the resident on the floor in the chapel area. The resident was lying on his/her right side with resident #17 standing over him/her. The resident reported s/he asked resident #17 to move so resident #5 could see the TV and resident #17 flipped my wheelchair over and that's how I ended up here. The resident repeated the scenario to other staff members. 2. Interview with the MDS coordinator/IP on 2/16/23 at 8:56 AM revealed the incident on 9/14/22 was an incident the facility would normally investigate as a resident to resident altercation or abuse. 3. Interview with the MDS coordinator/IP on 2/16/23 at 10:49 AM revealed the facility did not have evidence the incident was investigated and reported as abuse and confirmed it should have been. 4. Review of the policy titled Abuse, Neglect and Exploitation last revised on 10/2022 showed .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .

Based on medical record review and staff interview, the facility failed to ensure residents or residents' representatives received a written notice of transfer or discharge for 1 of 2 sample residents (#4) reviewed for hospitalization . The findings were: 1. Review of the resident progress notes showed resident #4 discharged from the facility on 2/9/23, with return anticipated. Further, the progress notes showed the resident returned to the facility on [DATE] with a diagnosis of pneumonia. Review of the medical record showed no evidence a written notice of transfer or discharge was provided to the resident, or resident's representative, at the time of transfer. 2. Interview with the MDS coordinator/IP on 2/16/23 at 11:01 AM revealed the facility did not think to provide a written transfer or discharge form since the hospital was right next to us, and the resident was acute.

Based on medical record review, staff, resident and resident representative interview, review of facility incident reports, and policy and procedure review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (#1) reviewed for resident-to-resident altercations. This failure resulted in harm to resident #1 who experienced verbal abuse a reasonable person would have found humiliating, intimidating, demeaning, and degrading. The findings were: 1. Review of the 5/18/22 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE], had a BIMS score of 10/15 (moderate cognitive impairment), and had diagnoses which included moderate intellectual disabilities, unspecified psychosis not due to a substance or known physiologic condition, depression, and post-traumatic stress disorder. Further review showed the resident independently used a wheelchair for locomotion, and did not exhibit any behaviors, wandering, or rejection of care. Review of the 5/17/22 quarterly MDS assessment showed resident #2 was admitted to the facility on [DATE], had a BIMS score of 9/15 (moderate cognitive impairment), and had diagnoses which included non-Alzheimer's dementia and delusional disorders. Further reviewed showed the resident independently used a wheelchair for locomotion, exhibited verbal behaviors directed toward others 1 to 3 days of the 7-day look-back period, and exhibited behaviors not directed toward others every day of the 7-day look-back period. The following concerns were identified: a. Review of resident #2's medical record from 2/23/22 to 8/24/22 showed the following nurse progress notes with the following concerns: i. Review of a 2/23/22 note showed several residents were watching a movie when resident #2 attempted to pull resident #4 away from resident #3. When resident #4 refused to move, resident #2 used a closed fist and hit him/her in the left arm and shouted you do not need to be breathing all over [him/her] with your diseases. ii. Review of a note dated 3/11/22 showed resident #2 called resident #1 a retard and a slut and said, [s/he] hasn't done anything with her life but color and that's a compliment. iii. Review of a 3/19/22 note showed resident #2 wheeled up behind resident #1 who was playing with a slot machine and said we have to bow down to the queen and other things that staff could not hear. iv. Review of a 3/28/22 note stated resident #2 was chasing resident #1 and yelled you are a disgrace and should be ashamed of yourself because you are so fat. v. Review of a 4/22/22 note showed resident #2 had stated the Dr. said I have dementia so my behaviors are excused. An additional note showed resident #2 told resident #1 to put your boobs away you are acting like a whore. vi. Review of a 6/18/22 note showed resident #2 was hitting resident #1 with a clothing protector. vii. Review of 6/19/22 note showed resident #2 kept going to the end of the hallway and looking into [resident #1's] room and mumbling intangibly, she then attempted to go into the front lobby looking for [resident #1] and became angry when redirected Further the note stated resident #2 verbally attacked resident #1 when s/he entered the dining room. viii. Review of a note dated 7/7/22 showed resident #2 was purposely going up to resident #1 and trying to irritate him/her. ix. Review of a note dated 8/22/22 showed resident #2 pushed resident #1's wheelchair into the wall near the coloring poster. When resident #2 was redirected s/he pointed at resident #1 and stated you fat asses are hippos like [s/he] is. b. Interview with CNA #1 on 8/25/22 at 10:23 AM stated resident #2 had developed an attachment to a resident of the opposite gender (resident #3) and followed him/her around the facility. c. Interview with CNA #2 on 8/25/22 at 10:54 AM revealed resident #2 had an obsession with resident #3 and would get jealous if resident #1 was near him/her. In addition, CNA #2 stated she thought resident #2 was with it cognitively and resident #1 was innocent in the altercations. d. Review of the Resident Incident Report forms received from the facility showed the only incident reported form documenting altercations between resident #1 and resident #2 was dated 6/18/22 and showed resident #2 was hitting another resident [resident #1] with clothing protector during exercise. e. Interview with resident #1 on 8/25/22 at 11:10 AM revealed s/he did not know what was going on except that resident #2 thought s/he was flirting with resident #3 and would glare and bump into him/her. The resident stated s/he sat where the staff placed him/her and would be taken back to his/her room if resident #2 became upset. In addition, the resident stated s/he liked the facility because of all the activities the facility had. f. Interview with resident representative #1 on 8/25/22 at 11:44 AM revealed resident #2 was mean to resident #1 and would kick, hit and was bossy. Further the resident's representative stated the facility was not doing anything to stop the behavior and had told her they just needed to work it out and you can always take [resident #1] out of the facility and put [him/her] someplace else. g. Interview with resident representative #2 on 8/25/22 at 11:48 AM revealed she had witnessed resident #2 kick, hit, call resident #1 a fat bitch, and told resident #1 which activities s/he could or could not do. The resident's representative stated she had also witnessed resident #2 ramming his/her wheelchair into the double doors to prevent resident #1 from leaving the facility. h. Telephone interview with resident representative #3 on 8/31/22 at 5:10 PM revealed she was concerned about resident #1's safety and well-being, as resident #1 had been targeted by resident #2 for almost a year. The representative felt like the situation was getting worse with nothing being done about it. In addition, she had witnessed resident #2 knock down a Christmas tree in resident #1's room, bar the double doors so s/he could not leave the facility, throw plastic [NAME], and push chairs into resident #1. The resident's representative stated resident #1 used to be more outgoing and now she felt the resident was more quiet and reserved. i. Interview with dietary aide #1 on 8/25/22 at 12:10 PM stated she had witnessed resident #2 get into resident #1's face, throw a slot machine at him/her, and purposely run into other residents. j. Interview with dietary aide #2 on 8/25/22 at 12:16 PM revealed she had witnessed resident #2 go into resident #1's room and take his/her possessions. In addition dietary aide #2 had witnessed resident #2 hit resident #1 with a plastic kids shovel, call him/her multiple rude names, stare him/her down, try to isolate resident #1 by placing his/her wheelchair in front of resident #1's room and also block the double doors, which led out of the facility, so resident #1 could not leave. k. Telephone interview with the social worker on 9/2/22 at 8:20 AM revealed resident #2 was very protective of resident #3 which caused obsessive behavior when resident #1 was near him/her. She stated resident #1 was the main focus of behaviors exhibited by resident #2, however other residents were also affected at times. The social worker stated all we can really do is supervise because of staffing and we talk to resident #2 when s/he was being inappropriate. 2. Interview with the DON on 8/25/22 at 1:02 PM revealed resident #2 had an obsession with resident #3, and was jealous and showed behaviors when other residents were near him/her. The DON stated she did not think resident #2 intentionally targeted resident #1, however his/her behaviors were more directed at resident #1 than any other resident and occurred approximately 2 times per week. The DON stated the aggressive behaviors were better during the day when there was more staff. Further, the DON stated this was no way to live or have to live and had approached resident #1's family about transferring resident #1 to a different facility. 3. Review of the policy and procedure titled Abuse and Neglect-Clinical Protocol & Guidelines last approved on 2/2022 showed .Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with the support of the providers, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations .4. The provider and staff will address causes of problematic resident behavior where possible, such as mania, psychosis, and medication side effects.

Based on observation, resident, staff, and resident representative interview, medical record review, and policy and procedure review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 3 sample residents (#1, #2, #3) involved in resident-to-resident altercations. This failure resulted in harm to resident #1, who was not protected from another resident whose actions a reasonable person would find demeaning and humiliating. The findings were: 1. Review of the 5/18/22 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE], had a BIMS score of 10/15 (moderate cognitive impairment), and had diagnoses which included moderate intellectual disabilities, unspecified psychosis not due to a substance or known physiologic condition, depression, and post-traumatic stress disorder. Further review showed the resident independently used a wheelchair for locomotion, and did not exhibit any behaviors, wandering, or rejection of care. The following concerns were identified: a. Interview with resident representative #1 on 8/25/22 at 11:44 AM revealed resident #2 was mean to the resident and would kick, hit and was bossy. b. Interview with resident representative #2 on 8/25/22 at 11:48 AM revealed she had witnessed resident #2 kick, hit, call the resident a fat bitch, and would tell the resident which activities s/he could or could not do. The resident's representative stated she had also witnessed resident #2 ramming his/her wheelchair into the double doors to prevent the resident from leaving the facility. c. Telephone interview with resident representative #3 on 8/31/22 at 5:10 PM revealed she had witnessed resident #2 knock down a Christmas tree in the resident's room, bar the double doors so the resident could not leave the facility, throw plastic [NAME], and push chairs into the resident. d. Interview with dietary aide #1 on 8/25/22 at 12:10 PM stated she had witnessed resident #2 get into the resident's face, throw a slot machine at the resident, and purposely run into other residents. e. Interview with dietary aide #2 on 8/25/22 at 12:16 PM revealed she had witnessed resident #2 go into the resident's room and take his/her possessions. In addition dietary aide #2 had witnessed resident #2 hit the resident with a plastic kids shovel, call the resident multiple rude names, stare the resident down, and try to isolate the resident by placing his/her wheelchair in front of the resident's room and also block the double doors leading out of the facility so the resident could not leave. f. Review of nurse progress notes for resident #2 from 2/23/22 to 8/24/22 showed multiple instances where resident #2 had shown verbal and physical aggression toward the resident. g. Review of the resident's care plan, last reviewed 6/7/22, showed no evidence a care plan had been developed to include interventions to protect the resident. 2. Review of the 5/17/22 quarterly MDS assessment showed resident #2 was admitted to the facility on [DATE], had a BIMS score of 9/15 (moderate cognitive impairment), and had diagnoses which included non-Alzheimer's dementia and delusional disorders. Further reviewed showed the resident independently used a wheelchair for locomotion, exhibited verbal behaviors directed toward others 1 to 3 days of the 7-day look-back period, and exhibited behaviors not directed toward others every day of the 7-day look-back period. The following concerns were identified: a. Interview with CNA #1 on 8/25/22 at 10:23 AM revealed the resident had some rough days, could be ornery and was attached to a resident of the opposite gender. The CNA stated when the resident was upset she would let the resident calm down and reapproach at another time. b. Interview with CNA #2 on 8/25/22 at 10:54 AM revealed the resident had an obsession with a resident of the opposite gender (resident #3) and would get jealous if resident #1 was near him/her. The CNA stated interventions included to keep resident #1 and resident #3 separated and to have the DON or the social worker speak with the resident when s/he was upset. c. Telephone interview with LPN #1 on 9/1/22 at 11:35 AM revealed interventions included 1-to-1 supervision and redirection. In addition LPN #1 stated when the resident's behaviors were escalating s/he could not be reasoned with. d. Review of the nurse progress notes from 2/23/22 through 8/24/22 showed multiple instances of verbal and physical aggression directed towards staff and residents; refusal of care; disruption of group activities; the use of intramuscular Ativan (antianxiety medication); adjustments in the resident's medication regimen; interference in the care of other residents; and entering other resident's rooms. In addition, the progress notes documented the obsession with resident #3 and noted on 3/21/22 the resident was rubbing and kissing on resident #3; 3/22/22 showed the residents were inappropriately touching each other; and on 3/28/22 showed the residents were kissing and fondling. e. Observation on 8/25/22 at 12:03 PM showed resident #3 was seated next to resident #2 for the noon meal. Resident #3 was patting and holding resident #2's hand and was touching his/her leg. f. Review of the resident's care plan, last reviewed 6/16/22 showed no evidence a resident assessment had been completed and care planning interventions developed to address the resident's distressed physical, sexual, and verbal behaviors. 3. Review of the 5/26/22 quarterly MDS assessment for resident #3 showed the resident was admitted to the facility on [DATE], had a BIMS score of 3/15 (severe cognitive impairment), and had diagnoses which included depression. Further review showed the resident independently used a wheelchair for locomotion, and did not exhibit any behaviors, wandering, or rejection of care. The following concerns were identified: a. Interview with CNA #2 on 8/25/22 at 10:54 AM revealed resident #2 had developed an obsession with the resident and for the majority of the time [resident #3] appeared to be okay with it, however she had witnessed the resident push resident #2 away. b. Telephone interview with resident representative #3 on 8/31/22 at 5:10 PM revealed she had witnessed the resident push resident #2 away and state you are not my wife. c. Review of nurse progress notes from 2/23/22 to 8/24/22 for resident #2 showed multiple notes related to resident #2's obsession with the resident. On 7/12/22 showed the resident attempted to move away from resident #2 and was yelling NO NO NO and on 7/25/22 resident #2 attempted to prevent the resident from participating in an activity and later attempted to enter the resident's room while care was being provided. In addition the residents had been observed rubbing and kissing, inappropriately touching, and kissing and fondling. d. Review of the resident's care plan, last reviewed 6/16/22, showed no evidence a resident assessment had been completed and care planning developed to address the resident's sexual contact with resident #2 or what interventions were in place to protect the resident. 4. Interview with the DON on 8/25/22 at 1:02 PM confirmed the care plans were incomplete. 5. Review of the policy titled Reviewing and Revising the Care Plan last approved 12/2018 showed .B. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. C. Procedure for reviewing and revising the care plan when a resident experiences a status change: 1. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. 2. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. 3. the team meeting discussion will be documented in the nursing progress notes. 4. The care plan will be updated with the new or modified interventions. 5. Staff involved in the care of the resident will report resident response to new or modified interventions. 6. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. 7. The MDS Coordinator or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. 8. The MDS Coordinator or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, review of policy and procedure, resident and staff interview, and review of professional standards, the facility failed to implement infection control practices to prevent the spread of infectious disease including COVID-19. Specifically, the facility failed to ensure source control through face coverings and social distancing, and failed to ensure effective hand hygiene. It was determined these failures placed the residents in immediate jeopardy. The census was 27. On 3/2/21 at 12:55 PM the administrator was informed of an immediate jeopardy situation in the area of infection control related to the lack of source control, and insufficient hand hygiene. The facility submitted an action plan which included the following immediate changes: 1. Effective immediately staff will put dirty water glasses directly into a bin on their cart instead of the railing. Staff will perform hand hygiene per policy. Dirty water glasses will be taken to kitchen immediately after task is finished. Dirty glasses will not be on the cart at the same time as any clean glasses. 2. Effective immediately the charge nurse on each shift will supervise water pass until it is determined that the above infection protocol is being routinely utilized and then randomly supervised to ensure continued compliance. 3. Effective immediately all staff will utilize facility surgical masks or N95 masks in accordance with CDC guidelines at the start of their shift and will change PPE as needed throughout the shift. 4. Effective immediately the screener will document that a new surgical mask or N95 mask was obtained for each employee presenting for their shift. 5. Effective immediately the staff will be educated on hand hygiene at the start of their next shift. 6. Effective immediately Management/IC will supervise meal times until it is determined that proper hand hygiene is being routinely utilized. After that time meal times will be randomly supervised to ensure continued compliance. 7. Effective immediately residents have been reeducated on the importance of wearing a mask and social distancing. DON/IC will review importance of masks and social distancing with residents or designated POA, if resident is not mentally competent to understand, and a signature will be obtained. They understand they have the right to refuse a mask, but staff will ask them to wear a mask when leaving their room. Residents will be educated that staff will be asking every time they leave their room. 8. Effective immediately 6 feet social distance will be maintained and masks will be encouraged. 9. Effective immediately during activities and dining 6 foot distance will be maintained in between residents. Roommates and spouses will be allowed to sit at the same table <6 feet apart. The action plan was accepted on 3/3/21 at 5:20 PM. Observation on 3/4/21 at 8:23 AM showed IP performing re-education to kitchen staff regarding hand hygiene. Observation during the lunch meal on 3/4/21 at 11:56 AM showed the staff were wearing surgical face masks and performing hand hygiene between handling the resident cups and assisting the residents. The residents were seated at the dining area tables, and were socially distanced. Further observation on 3/4/21 at 12:04 PM showed the meal being served to the residents and staff assisting the residents. Hand hygiene was observed after each resident. Staff were all wearing surgical face masks. Interview with the DON and IP on 3/4/21 at 12:20 PM revealed the facility was performing re-education to staff before the start of their shift. Documentation provided showed the specific education given to the staff, and the staff who had received the education. Review of IP audit at that time showed initial evaluations being performed, with no annotations of corrective actions needed to that point. The implementation of the action plan was verified and immediacy was removed on 3/4/21 at 1:05 PM, however, deficient practice remained at a scope and severity of F. The survey findings were: Review of CMS memo QSO-20-39-NH (updated 3/10/21) showed the core infection prevention principles for preventing the spread of COVID-19, which should be adhered to at all times, included the following: .Hand hygiene (use of alcohol-based hand rub is preferred) .Glove use is not a substitute for hand hygiene .Use enough alcohol-based hand sanitizer to cover all surfaces of your hands, keeping them wet for at least 20 seconds, rubbing them together until dry .Healthcare providers not performing hand hygiene 100% of the time at every opportunity for cleansing, they put themselves and their patients at risk for infections .Face covering or mask (covering mouth and nose) .Social distancing at least six feet between persons .Cleaning and disinfecting high-frequency touched surfaces in the facility often, and designated visitation areas after each visit .Appropriate staff use of Personal Protective Equipment (PPE) . Review of facility policy titled Standard Precautions - Overview and last reviewed January 2017 regarding standard precautions showed staff were to .Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply [the following] infection control practices during the delivery of health care . and to utilize hand hygiene when .Hands are visibly soiled, or after caring for a resident . Further review showed Gloves . are not a substitute for hand hygiene . and .Staff must perform hand hygiene even if gloves are utilized . Staff are expected to Remove gloves after contact with a patient, bodily fluid/excretions, and the surrounding environment (including medical devices) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. The following concerns were identified: Regarding source control: 1. Observation of the evening meal on 3/1/21 from 4:59 PM to 5:20 PM showed initially 18 residents were sitting at small square tables in the dining area, rising to 21 residents by the end of the observation. The residents were not wearing masks, and were not distanced at least 6 feet apart. Staff were not observed to encourage residents to wear masks or to socially distance. There were 7 total tables, of which 2 tables had 4 residents sitting side by side, 2 tables had 2 residents sitting beside each other, and 3 tables with 3 residents sitting by each other. In addition, two unidentified CNAs were observed wearing cloth face masks while passing trays and assisting residents with their food. 2. Observation on 3/02/21 at 9:24 AM showed an activity being conducted with a small group of 7 residents, all of whom were within arms length of each other. The residents were positioned in a circle and hitting a balloon back and forth. None of the residents were wearing masks. Staff were not observed to encourage the residents to wear masks or to socially distance. The activity was observed to be still ongoing at 9:35 AM. 3. Interview with the IPC/MDS coordinator on 03/01/21 at 2:47 PM revealed the facility had relaxed source control requirements for residents. She stated 20 residents had been vaccinated with the 2 doses, 3 residents refused the vaccination, and 2 more residents were scheduled for their vaccinations. Later interview at 3:01 PM confirmed facility residents were not wearing face masks, with the IPC stating, Some of the residents would not even wear the mask if offered. Some would blow up if asked to wear a mask. Our county positivity is zero. That is why they are not wearing face masks .We have relaxed the expectation on residents. 4. Review of CMS county positivity data for the week ending 3/2/21, found at COVID-19 Nursing Home Data - Test Positivity Rates | Data.CMS.gov, retrieved 3/12/21, showed Crook County administered fewer than 20 tests. However, positivity rates for 3 surrounding counties (Campbell County WY, Fall River County SD, and [NAME] County SD) ranged from 1.7% to 11.4%. Regarding hand hygiene: 5. Observation on 03/01/21 at 3:04 PM showed used water containers had been removed from resident rooms and placed on the handrails outside the rooms. CNA #3 was observed leaving room [ROOM NUMBER] wearing gloves. She did not remove her gloves or perform hand hygiene upon exit. She then grabbed the dirty water containers that were sitting on the handrail, and placed them onto the cart she was utilizing. This cart contained clean water containers that she was distributing, as well as the dirty water containers from the handrails. She then pushed the cart farther down the hall and entered room [ROOM NUMBER], all while wearing the same contaminated gloves, with no hand hygiene or glove exchange observed prior to entering the room. While wearing the same contaminated gloves, she then delivered clean water containers into the room, grabbing the dirty containers from the handrail upon exiting, and placing them onto the cart with the clean containers. No glove removal or hand hygiene was observed upon exit. She pushed the cart down the hall to room [ROOM NUMBER], delivered clean water containers, and collected the dirty containers from the rail upon exit, still wearing the same contaminated gloves. No glove exchange or hand hygiene observed upon entry or exiting of the room. Observations of entry and exit of rooms 207, 209, 210, 211, 212, 213, 214, 215, 216, and 217 showed the CNA continued to collect dirty water containers and distribute clean water containers wearing the same gloves for the duration of this entire task. No glove exchange or hand hygiene was observed upon entry or exit of the rooms, or after contamination of the gloves. 6. Observation on 03/01/21 at 3:25 PM showed RA-CNA #4 leaving room [ROOM NUMBER]. No hand hygiene was observed upon exit. She then returned to room [ROOM NUMBER] at 3:29 PM, with no hand hygiene prior to entry. She exited a few seconds later, did not perform hand hygiene, and then entered room [ROOM NUMBER] without performing hand hygiene. She was observed moving the resident's tray table, and assisting the resident with positioning in bed. Next, she exited the room, again with no hand hygiene observed. She went down the hall to the restorative therapy office, retrieved two small hand-held exercise balls, and then entered room [ROOM NUMBER]. No hand hygiene was observed upon entry. 7. Observation on 03/01/21 at 4:14 PM showed RA-CNA #4 entered room [ROOM NUMBER], with no hand hygiene observed before entry. She exited at 4:19 PM, and no hand hygiene was observed. She then went into the clean utility storage/bathing suite to retrieve clothing protectors used for meals, and began disbursing them to every place setting in the dining room. 8. Observation on 3/01/21 at 4:35 PM showed RA-CNA #4 walking with resident #22, who was utilizing a crutch, to the dining room. After the resident was seated, RA-CNA #4 took the crutch and leaned it against the wall. She then retrieved a coffee cup for the resident and a communal pitcher of coffee for the table. Two more residents joined the table and poured themselves coffee from the communal pitcher. No hand hygiene was observed after contact with the resident or his crutch before contacting items to be shared at the table. 9. Observation on 3/01/21 at 4:39 PM showed CNA #2 took the coffee cup of resident #125 from the table to a microwave inside the nurses station to warm up its contents. She then took the cup to the beverage counter to add sugar, and returned the cup to the resident. No hand hygiene was performed after delivery of the cup. She then assisted two other residents with the warming and adding of condiments to their coffees, using the same microwave and beverage counter. No hand hygiene was performed in between contacts. 10. Observation on 3/01/21 at 4:43 PM showed dietary aide #1 wearing gloves in the dining room. He touched the shoulder of resident #14 with gloved hands, and then went to the clean dietary cart to put trays together with supplies for each resident. No hand hygiene or glove exchange was performed after the contact. 11. Observation on 3/01/21 at 4:53 PM showed LPN #1 helped resident #14 set up his/her meal place setting, and assisted the resident with positioning in his/her chair. No hand hygiene was observed before or after contact with the resident. LPN #1 then left the dining room and went to the nurses station, where she made contact with the counter and computer inside the nurses station. 12. Observation on 3/01/21 at 4:56 PM showed CNA-MA #5 made contact with resident #3 through a hug, and with the resident's food and place setting, as well. She then left the dining room, opened the gate to the nurses station, touched the med cart and its contents, and began retrieving the next resident's medications. No hand hygiene was observed between contacts or tasks. 13. Observation on 3/01/21 at 5:17 PM showed dietary aide #1 wearing gloves, and making contact with resident #3 and his/her wheelchair. He then returned to the clean dietary cart, touching the cart and passing out desserts. No glove exchange or hand hygiene was observed after contact. Review of the Centers for Disease Control ' s Preparing for COVID-19 in Nursing Homes found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 3/17/21, showed core practices included .Implement Source Control Measures. HCP should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance . Review of the Centers for Disease Control ' s Hand Hygiene in Healthcare Settings found at https://www.cdc.gov/handhygiene/index.html, accessed 3/12/21, showed . Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer. Immediately before touching a patient. After touching a patient or the patient ' s immediate environment .Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient. Carefully remove gloves to prevent hand contamination.

Based on observation, medical record review, and staff interview the facility failed to ensure wounds were reported to the physician for 1 of 2 sample residents (#8) who had wounds. The findings were: Review of the medical record showed resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] revealed the resident had swelling in the right foot, however, there were no open areas. Review of nursing notes showed a note dated 5/28/14 that the nurse, "noticed resident had a large blood spot on (his/her) sock on the right foot...looked and pinky toe was bloody and looked like the toe nail was missing." There was no documentation the physician was notified. Subsequent review of the medical record showed no documentation of the right pinky toe until a nursing note dated 6/8/14 that the resident's small toe was black and there was an open area between the 4th and 5th toes.The nurse also noted his/her lower leg was very red and swollen. The physician was notified and gave verbal orders for the resident to be sent to the hospital where s/he was admitted for a [DIAGNOSES REDACTED]. Review of a physician's progress note dated 5/19/14 indicated the resident was supposed to follow-up with podiatry and the physician would continue podiatry involvement in the resident's care due to his/her ongoing foot infections. Review of the medical records showed no documentation the resident was referred to podiatry for follow-up until 7/31/14. According to an interview with the social worker on 8/28/14 at 7:40 PM the podiatry appointment scheduled for 7/31/14 was cancelled by the facility because the resident saw the orthopedic surgeon on 7/30/14, and a recommendation was made by the orthopedic surgeon to perform a partial amputation of the right foot. Observation of the wound on the resident's right foot on 8/27/14 at 8:45 AM revealed the resident had an extensive wound with two exit sites on the top and bottom of the right foot, the wound had a slight foul odor and yellowish/green drainage. The resident was alert and oriented and verified s/he was supposed to have part of the right foot removed after the cardiologist cleared him/her for surgery.

Based on medical record review and staff interview, the facility failed to ensure effective supervision and interventions to prevent falls for 1 of 5 sample residents (#20). As a result a serious avoidable injury was sustained by the resident. The findings were: Review of the 1/31/13 nursing notes showed resident #20 was admitted to the nursing facility that day at 9:35 AM. The note showed the resident was ambulatory, was weepy, and had memory loss and confusion. Interview with the DON on 2/20/13 at 4:55 PM revealed the resident's son, who was present at the admission, stated the resident had not slept "for days." Review of nursing notes from the previous facility, provided during the nursing home admission process, verified the resident had not been sleeping and was having considerable trouble with confusion. Review of the fall risk assessment dated [DATE] showed the resident was at high risk for falls due to intermittent confusion, having had a fall in the past 3 months, being ambulatory and incontinent, and taking anti-hypertensive and cathartic medications. The attending physician further addressed the resident's [DIAGNOSES REDACTED]. Review of the H&P showed the resident had Alzheimer's type dementia with "frequent anxious features" and an ongoing history of "tearfulness and weeping." In addition, the physician noted the resident had "significant insomnia difficulties...has remained ambulatory and tends to wander with increasingly frequent visits and intrusions into other resident's rooms. (S/he) requires continuous supervision for (his/her) safety and well being." The following concerns were identified: a. Review of the interim care plan dated 1/31/13 showed the resident was assessed as being at high risk for falls, and the resident walked independently. However, the only approach documented was for staff to monitor the resident's whereabouts. b. Review of the 2/1/13 8:30 PM nurse's note showed the resident had a witnessed fall while ambulating in the hallway holding a baby doll and blanket. The note showed the resident began to drop the doll and tripped over his/her own feet in an attempt to catch the doll. The resident was assisted by three staff to a wheelchair and then to bed. The note further showed the resident yelled out with pain upon weight bearing. c. Review of the 2/1/13 nurse's note timed at 9:30 PM showed the physician was at the bedside to assess the resident. There were no notes for the hour between the fall and the arrival of the physician to show what/if any fall prevention/interventions were in place during that time. The 2/1/13 9:30 PM nurse's note further showed physician orders [REDACTED]. The note also showed nursing applied a tab alarm (a device to alert staff a resident is getting up) on the resident while awaiting the transfer for x-rays. This same note documented that after the tab alarm was placed, staff left the room and at an unidentified time, the resident fell again while getting out of bed unassisted. d. Review of the 2/1/13 10 PM nurse's note showed the resident was taken for x-rays, found to have a right hip fracture, and was transferred to a larger hospital. e. Interview on 2/20/13 at 7:20 PM with the nurse (LPN #1) and CNAs #1 and #2, who were all three on duty during this incident, revealed they were not sure how much time had passed between the time that staff left the room and the second fall. However, they verified it happened "quickly" after staff left the room. The staff further revealed the tab alarm did not sound. At this time, LPN #1 and CNAs #1 and #2 verified the resident was not continuously supervised after the first fall when she was placed into bed awaiting the physician.