Every finding on record at Devon Gables Rehabilitation Center

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that appropriate infection prevention and control practices were followed regarding catheter bag placement, dining services and meal tray delivery services for 5 residents (#9, #117, #110, #52 and #145) The deficient practice could result in the spread of infection.Findings include:-Regarding Resident #9Resident #9 was admitted on [DATE] with diagnosis including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, major depressive disorder-recurrent, other cerebrovascular disease, vascular dementia-unspecified severity without behavior disturbance, psychotic disturbance, mood disturbance, schizoaffective disorder-bipolar type, essential hypertension, other urogenital candidiasis, unspecified urinary incontinence, elevated white blood cell count-unspecified and atherosclerotic heart disease.A review of the care plan revealed that the resident may use a condom catheter as needed and that the noted interventions included to not allow the tubing or any part of the drainage system to touch the floor and to position the bag below the level of the bladder with a start date of August 6, 2024. The care plan further revealed that when a catheter is used to keep the catheter system closed as much as possible.A review of the quarterly MDS (minimum data set) dated June 2, 2026 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further revealed that the resident had upper extremity impairment, had an external catheter and was on a urinary toileting program.A review of the physician orders revealed an order dated January 29, 2026 noting that the condom catheter is to be changed twice weekly on shower days and may be changed as needed if rolled or leakage is seen.An observation was conducted on June 23, 2026 at 9:08 AM on the facility's central hallway. Resident #9 was observed to be maneuvering his wheelchair with his feet past the main entrance of the building toward the hall on the right where the social service office was located. It was further observed that the resident's catheter bag was dragging on the floor underneath the resident's wheelchair. An interview was conducted on June 23, 2023 at 9:12 AM with the Director of Nursing (DON/ Staff #122) who was observed in the same central hallway. When the DON was asked about the resident's catheter bag, she stated that she observed the catheter positioned under the resident's wheelchair to be touching the floor. She stated that the catheter bag should always have a privacy bag on it and should not be touching the floor. She stated that the risk to the resident could include infection.An interview was conducted on June 26, 2026 at 8:46 AM with certified nursing assistant (CNA/ staff #34). Staff #34 stated that a catheter site should always be kept clean and monitored for any site of infection. She stated that if she observed anything of concern regarding a resident's catheter she would notify the nurse right away. She further stated that the catheter bag should be lower than the bladder but should never touch the floor. Staff #34 stated that if she observed a resident in a wheelchair with a bag touching the floor, she would conduct hand hygiene and adjust the catheter bag and then let the nurse know. Stated that a catheter bag on the floor could facilitate the transfer of germs.An interview was conducted on June 26, 2026 at 8:50 AM with licensed practical nurse (LPN/ staff #189). Staff #189 stated that with catheter care it's important to make sure that the peri-area is fine, line is patent, catheter bag is placed below the bladder but never on the floor for infection control. Staff #189 further stated that this included both indwelling and condom catheters, as per her report, germs can travel quickly. The LPN stated that if she observed a bag touching the floor, even if it was a condom catheter, she would take the resident back to the room and request to have the catheter changed out. Staff #189 stated that if a catheter is touching the floor underneath a wheelchair the risk would be one of infection or that the catheter could be pulled out.-Regarding Meal ServiceResident #117 was admitted on [DATE], latest return date of January 10, 2026 with diagnosis including Huntington's disease, post-traumatic stress disorder, unspecified dementia, anxiety disorder, restless and agitation and fever-unspecified.A review of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 04, indicating severe cognitive impairmentAn observation was conducted on June 22, 2026 at 12:15 PM in the main dining room. Certified Nursing Assistant (CNA/ Staff #217) was observed retrieving a straw for a resident, removing the paper cover first from one end of the straw, then from the other end of the straw, touching the straw with bare hands and then placing then placing the straw into the red cup for resident for resident #117.An interview was conducted on June 22, 2026 at 12:23 PM the dietary aide, staff #24. Staff #24 stated that a drinking straw should never be touched with bare hands. He then stated that He knew exactly who was being referenced and indicated that it was staff #217. He stated that the risk could include transmitting germs to the resident.An interview was conducted on June 22, 2026 at 12:28 PM with staff #217. Staff #217 stated that she could not recall if she touched the straw or not, but stated that the top of the straw should not be touched with bare hands as it could transmit germs.-Regarding Meal Tray DeliveryResident #110 was admitted on [DATE], latest return July 22, 2024 with diagnosis including senile degeneration of the brain, unspecified systolic congestive heart failure, dementia, chronic bronchitis, herpes viral infection, chronic pulmonary embolism, chronic allergic conjunctivitis, hypertensive heart and chronic kidney disease with heart failure and trigeminal neuralgia.A review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated that the resident was cognitively intact.Resident #52 was admitted on [DATE], latest return on June 15, 2026 with diagnosis including unspecified fracture of the lower end of the right femur, periprosthetic fracture around internal prosthetic right knee joint, subsequent encounter with wound vac, displaced comminuted fracture of right patella, and vascular dementia.A review of the 5-day MDS dated [DATE] revealed no documented BIMS score.Resident #145 was admitted on [DATE] with diagnosis including spastic diplegic palsy, unspecified atrial fibrillation, diarrhea-unspecified, peripheral vascular disease and long-term use of anticoagulants.A review of the quarterly MDS dated [DATE] revealed a BIMS score of 15.An observation was conducted on June23, 2026 at 8:41 AM on the long-term care upper south hall. A total of 3 meal trays were observed on a 2-tiered push cart. Each meal tray had accompanying drinks none of which were covered. One of the top trays had what appeared to be chocolate milk, the other top tray had what appeared to be orange juice in a cup and coffee in a mug. The bottom tray had what appeared to be another glass of juice. The cart was position outside of resident #110's room and remained there for approximately 7 minutes before a CNA (staff #) was observed to deliver the tray with an uncovered cup to the room of resident #110. The cart was then pushed approximately 46 feet to the room of resident #145, with cups uncovered. A tray was delivered to resident #145 and the CNA then walked the remaining tray and uncovered cup approximately another 45 feet back to the room of resident #52.An interview was conducted on June 23, 2026 at 8:52 AM with CNA/ staff #401. Staff #401 stated that when delivering meal trays all drink cups should be covered. She further stated that the cups for residents #110, #52, and #145 had not been covered but should have been. She stated that she did not know how far she could transport an uncovered cup. Staff #401 stated that the risk could include contamination.An interview was conducted on June 24, 2026 at 9:54 AM with the infection preventionist (IP/ Staff #40) who stated that touching a straw with bare hands after the cover has been removed is an infection control issue and stated that it did not meet facility expectations. The IP stated that the risk to the resident would be exposure to bacteria. The IP further stated that the expectation for transporting cups is that they be covered. She stated that the risk is of particulate matter in the air, which is infection control.An interview was conducted on June 26, 2026 at 11:31 AM with the Director of Nursing (DON/ staff #230). The DON stated that regarding drinking straws, the expectation is that they are not handled with bare hands if uncovered. The DON further stated that drinking cups, should be covered when being transported. The DON stated that regarding catheters, that all catheters should be covered with a dignity bag and that the bag of an indwelling catheter should not be touching the floor, but stated that she was uncertain of a condom catheter and would defer back to her clinical team for that. She stated that the risks to the residents could include transmitting germs.A review of the policy titled Catheter Care, Urinary, revised October 2023 revealed no evidence of proper catheter bag placement.The policy titled Surveillance for Infections, revised May 2023 revealed that that the purpose of the policy is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions and to prevent future infections.A review of the facility policy titled ADL (activities of daily living) Support revised March 2024 revealed that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance for hygiene, mobility, elimination dining (meals and snacks) and communication.

Based on observation, staff and residents interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered and stored according to policy for one out of 34 sampled resident (#13). The universe was 171. The deficient practice could result in overdose, negative medication interactions and other residents having unrestricted access to medications.Findings include: Resident #13 was admitted on [DATE] and readmitted on [DATE] with diagnosis including degenerative disease of the nervous system, cellulitis of right lower limb, bacteremia, methicillin resistant staphylococcus aureus infection, dementia, anxiety, obstructive sleep apnea, thrombosis of unspecified deep veins of unspecified lower extremity, spinal stenosis-lumbar region, obesity-class 3, partial loss of teeth, indwelling urethral catheter, and other psychoactive substance dependence.A review of the care plan revealed that the resident was at risk for skin impairment due to incontinence of bowel and bladder and the use of clothing, briefs and delaying care with a start date of August 27, 2025. The care plan further revealed that the resident had chronic pain and was at risk for alteration in comfort that could limit participation in ADL's (activities of daily living), tasks, therapy, socialization, sleep patterns, appetite and contribute to behavioral symptoms with a noted start date of February 5, 2025.The annual MDS (minimum data set) dated June 2, 2026 revealed that the resident had BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The physician orders revealed that the resident had an order for Muscle Rub (methyl salicylate-menthol) OTC (over the counter) cream 15-10%, noting to apply a liberal amount topically every shift; however, there was no evidence of an order for self-administration of the muscle rub. The physician's orders further revealed an order for Hibacleanse to be applied to the legs with showers once a day on Wednesday and Saturday; however, there was no evidence of an order to self-administer the Hibacleanse. A review of the physician's orders also revealed an order for Miconazole Nitrate [OTC] powder 2%, noting to apply a moderate amount topically to the abdominal pannus (apron belly) and then to cover with Interdry (a special fabric designed to manage moisture, friction and odor); however, there was no evidence of an order for self-administration of the Miconazole Nitrate powder. Further, there was no order in the electronic health record for Halls Cough Drops.A further review of the electronic health record revealed no evidence of an assessment or care planning of self-administration of medications.An observation was conducted June 22, 2026 at 11:40 AM in the room of Resident #13. A 3 ounce Thera Antifungal Powder (containing Miconazole Nitrate) container was observed on the resident's night table along with Hibacleanse antiseptic skin cleanser and Muscle Rub. Further observation revealed a bag of cherry flavored Halls Cough Drops on the bedside table. All items were observed to be in plain site on top of the table and nightstand.An interview was conducted with resident #13 on June 22, 2026 at 11:42 AM. The resident stated that the Cough Drops on the bedside table were brought in by his brother 2 days ago, as he could not obtain them through the facility. The resident further stated that staff was aware of the cough drops, and other medications on the table and stand and that he did not consider these to be medications.An interview was conducted on June 22, 2026 at 11:55 AM with licensed practical nurse (LPN/ staff #201), who stated that a medication is anything ordered by a provider that could include tablets, liquids, oxygen, topicals and even OTC medications. The LPN further stated that cough drops are also consider to be medications, as well as antifungal powders, antiseptic cleansers and muscle rubs. The LPN further stated that these medications should not be at bedside. The LPN also stated that she checks for medications at bedside every time she enters a resident's room. She stated that she had not observed anything out of the ordinary in resident #13's room that she had just entered a few minutes ago to answer the call light. The LPN stated that in order for a resident to self-administer medication they would need an order from the provider, a documented observation that they were safe to self-administer and use the medication properly. The LPN further stated that each resident that has been approved to self-administer medication would have a lock box with a key. The LPN reviewed the orders for resident #13 and stated that there were no orders for medication self-administration. Staff #201 entered the resident's room and came out with 2 containers of the Hibacleanse, 3 muscle rubs, the Thera Antifungal Powder and the cough drops and stated that none of these should have been at bedside. She stated that the risk to the resident could include that the medications could be used improperly.An interview was conducted on June 23, 2026 at 2:37 PM with the Director of Nursing (DON/ staff #122). Staff #122 stated that a medication can be ordered or over the counter and can include topicals and cough drops. The DON stated that medications are to be kept in the treatment/ medication carts. The DON further stated that medications should not be at bedside and that a resident must be assessed, have an order in place and have the medications placed in a secured location, either a lock-box, locked drawer or in the treatment cart/ medication cart. The DON reviewed the electronic health record for resident #13 and stated that she did not see an order for medication self-administration or an assessment. She further stated that she did not think that there was anyone in the facility that was currently authorized to self-administer medications. The DON stated that the risk to the resident could include that they would not utilize the medication in accordance with the provider's orders or that other people could have access to them.A review of the facility policy titled Administering Medications and Treatments, revised October 2023, revealed that residents may self-administer their own medications/ treatments if the attending Physician, in conjunction with the interdisciplinary care planning team, has determined that they may do so safely.

Based on clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one three resident's (#20) to be free from abuse by another resident. The deficient practice had the potential to result in further abuse of residents.-Regarding Resident # 35:Resident #35 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including unspecified dementia, altered mental status, and brief psychotic disorder.A quarterly Minimum Data Set (MDS) assessment, dated February 11, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, no behaviors of wandering were exhibited during the assessment period.A psychosocial well-being care plan, initiated on November 18, 2025, revealed the following problem area: Adjustment to living in a secure environment related to dementia, memory impairment and history of attempts to elope and wandering. The goal was for the resident to show acceptance living in a secure unit environment as evidenced by social interactions with staff and peers with a target date of July 29, 2026. Interventions included to assess characteristics that may impede ability to interact with others, determine/support the resident's ability and desire to relate to others,A nursing progress note dated April 10, 2026 reported that another resident (#20) wandered into Resident #35's room. The note revealed that staff heard yelling from the room and removed Resident #20 from the room, and Resident #35 remarked of attempts of thievery to his personal belongings. The note revealed that Resident #35 was moved to another room to avoid future incidents.An Event Report dated April 10, 2026, revealed that the resident exhibited paranoid behavior, and had no injuries related to the incident.A care plan revealed a focus initiated on April 11, 2026, for cognitive impairment related to dementia with increased confusion, paranoia, and self-directed speech. Interventions included staff education on resident behaviors, reassurance and calm redirection during paranoia, maintaining clear boundaries with belongings, and Behavioral Health Team follow-up as needed.An interview was conducted with Resident #35 on May 19,2026 at 1:18 p.m., who stated that he recalled Resident #20 as a former roommate and confirmed they previously shared the same room. Resident #35 reported that he struck Resident #20 in self-defense after being hit multiple times on the right shoulder and right thigh, stating the incident occurred prior to a room change. He also reported that staff assessed his skin for bruising following the incident.-Regarding Resident #20:Resident #20 (alleged victim) was re-admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified psychosis, anxiety disorders, depression, other specified mental disorders due to known physiological condition, chronic obstructive pulmonary disease, and hypertension.Review of the clinical records between November 18, 2025 and April 10, 2026 revealed no evidence of wandering behaviors or resident altercations.A care plan, initiated April 2, 2026, revealed a focus addressing the risk for adverse consequences related to antimanic medication use for treatment of vascular dementia, with interventions including monitoring behavioral and mood symptoms for potential risk to self or others and implementing interventions as needed.A behavior monitoring progress note dated April 9, 2026 revealed that the resident exhibited intrusive behavior twice, was redirected and interventions of 1 to 1, reassurance and food/fluids were effective.A nursing progress note dated April 10, 2026 revealed that the resident had been using the restroom and exhibited disorientation and confusion which lead to the resident entering a shared room. The note relayed that during the disorientation the resident approached another resident and that yelling was heard coming from the resident's room. The note indicated that staff responded immediately and reoriented Resident #20 to his room. The note revealed that discoloration to the left outer eye, the left shin and right knee were noted with discoloration and abrasions. The note revealed that the resident denied pain or discomfort, and stated he felt safe, neuro checks and 1:1 staff were initiated.A skin assessment completed for Resident #20 on April 10, 2026, documented bruising and abrasions to the left outer eye, bilateral upper extremities, left shin, and right knee. An Event Report dated April 10, 2026, revealed that the resident exhibited wandering behavior, and obtained bruising to the left eye, left shin and right knee during the episode. The report relayed that the resident was redirected, moved to a quiet area with 1:1 staff.Review of the updated care plan after the incident revealed a focus initiated on April 10, 2026, addressing cognitive impairment related to dementia with wandering, impaired room recognition, misdirected toileting, and occasional resistance to care. The care plan indicated that due to disorientation, the resident was at times unable to identify his room and entered other residents' rooms or handled their belongings, placing him at risk for safety concerns. Interventions included close staff proximity, redirection, and providing a structured, secure environment to support safe wandering on the behavioral dementia unit.A 5-day investigation report and Incident report revealed that the incident was related to injury of unknown origin and was a significant event. The report revealed that staff entered Resident #35's room due to yelling from the room, and observed Resident #20 in Resident #35's room. The report included that a Licensed Practical Nurse (LPN) separated the residents and noted bruising to the left eye and left shin of Resident #20. The report relayed that Resident #20 stated that the other guy hit me, but I'm ok. The report indicated that the facility determined that Resident #35's action was not willful intent to cause injury, but instead was protecting his belongings. The report revealed that Resident #35 was acting as any reasonable person would if someone was breaking into their property. The report included a type written statement from Registered Nurse (RN, Staff #120), who relayed that on April 10, 2026, Resident #20 reported that Resident #35 hit him. The statement also included that Resident #35 reported that Resident #20 was trying to steal his stuff, and that Resident #20 was hitting him in the shoulders and knees. The RN reported that Resident #35 further stated that he hit Resident #20 because Resident #20 was trying to steal his stuff.A telephonic interview was conducted with Certified Nursing Assistant (CNA/Staff #200) on May 19, 2026 at 2:01 PM, who stated that she heard yelling from resident #35's room, and along with Licensed Practical Nurse (LPN/Staff #300) entered the room. The CNA further stated that she observed Resident #20 inside Resident #35's room attempting to open a cabinet. The CNA reported that staff observed bruising to Resident #20's left eye, right shin, and right knee, which was not present prior to the incident. The CNA also stated that Resident #35 stated Resident #20 hit him first and attempted to take his belongings. The CNA stated that unwanted physical contact such as hitting or slapping a resident would be considered abuse.An interview was conducted with Licensed Practical Nurse (LPN/Staff #100) on May 19, 2026 at 2:07 PM, who stated that she was not present during the incident but was informed that an altercation occurred between Residents #20 and #35. The LPN stated that Resident #35 was relocated to a different room following the incident. The LPN further stated that staff reported bruising on Resident #20's left eye that was not present prior to the incident and were unaware of any prior altercations between the residents.An interview was conducted with the Director of Nursing (DON, Staff #400) on May 19, 2026 at 2:29 PM, who stated that she was not present during the incident but was informed that staff heard yelling, entered the room, and separated the residents. The DON also stated that Resident #20 was noted to have discoloration to the left eye and abrasions to the shin and right knee, with no prior documentation of these injuries before the incident. The DON reported no known history of abuse or issues between Residents #20 and #35.An interview was conducted with an LPN (Staff #500) on May 19, 2026 at 3:10 PM, who reported hearing yelling, entering the room with a CNA (Staff #200), and that Resident #35 was observed standing beside Resident #20, who was seated. The LPN further stated that new bruising to Resident #20's left eye, right shin, and right knee were observed. The LPN stated that Resident #35 admitted to striking Resident #20, stating he acted in response to being hit first. The LPN also reported that skin checks were completed, noting no injuries to Resident #35, and that neuro checks were initiated for Resident #20. The LPN relayed that interventions included signage placement, relocation of Resident #35, and 1:1 supervision for Resident #20.A facility policy titled, Preventing, Reporting and Investigating Abuse/Neglect, defined abuse as any act resulting in physical harm, pain, or mental anguish, including verbal, sexual, physical, mental abuse, exploitation, misappropriation of resident property, involuntary seclusion, and abuse facilitated or enabled through technology. The policy further stated that residents have the right to be free from abuse and that all employees, consultants, physicians, family members, visitors, and others were responsible for promptly reporting suspected or confirmed abuse, including injuries of unknown origin, to facility management for prompt and thorough investigation.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure three residents (#22, #26 and #27) were not abused by other residents (#125, #50 and#145). The deficient practice could lead to physical and psychosocial harm of residents.-Regarding Resident #22 (alleged victim):Resident #22 was re-admitted to the facility September 20, 2023, with diagnoses that included dysphagia, catatonic schizophrenia, cerebral infarction, hyperlipidemia, vascular dementia with behavioral disturbance, schizoaffective disorder, major depressive disorder with severe psychotic symptoms, and restlessness and agitation. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.A care plan dated November 8, 2017, revealed Resident #22 has socially inappropriate / disruptive behavioral symptoms as evidenced by making verbal unwanted statements and reaching out and grabbing staff and objects while being transported.A progress note dated April 6, 2023, revealed Resident #22 was involved in a physical altercation with his roommate. The roommate struck Resident #22 in the back. No injuries were noted. Both parties were separated and residing in private rooms at this time.-Regarding Resident #125 (alleged perpetrator):Resident #125 was re-admitted to the facility January 25, 2022, with diagnoses that included bipolar disorder, hemiplegia and hemiparesis affecting right dominant side, dysphagia, aphasia, catatonic disorder, ataxia, and unspecified mood disorder. An annual MDS assessment dated [DATE], revealed Resident #125 had a BIMS score of 00, indicating severe cognitive impairment.A care plan dated April 6, 2023, revealed Resident #125 is a threat to others due to physically assaulted another resident over a disagreement about the room temperature.A progress note dated April 5, 2023, revealed the behavioral health team was notified of a resident to resident altercation and requested Resident #125 have review and follow up by the behavioral health team. The resident struck his roommate with a closed fist on his back three times. No injuries were noted and the parties were separated for safety. Resident #125 admits he hit roommate because he doesn't listen to me. Both residents stating they were arguing over the temperature of the room. The Director of Nursing (DON) and social services were notified.A progress note dated April 7, 2023, revealed a certified nursing assistant (CNA) reports a second staff member required due to physical attempts of Resident #125 to grab at a female's groin and chest areas. The resident was very difficult to redirect from physical advances towards CNAs.A Witness Statement Form dated April 5, 2023, by a Licensed Practical Nurse (LPN / Staff #83), revealed the nurse was called to the room by a CNA. Resident #22 wheeled himself out of the room reporting that his roommate, Resident #125, hit him in the back four times with a closed fist. Resident #125 admitted to hitting Resident #22 because he doesn't listen to me. Both residents reported the incident occurred because of the heater being turned off and on. Resident #22 was removed from the room and the DON, social services, and the administrator were notified.A facility Reportable Event Record / Report submitted to the State Agency on April 8, 2023, revealed that on April 5, 2023, at approximately 12:20 PM, Resident #22 notified the nursing staff that his roommate, Resident #125, had struck him in the back four times. Resident #22 stated they had been arguing about the temperature of the room when the incident occurred. The nursing staff immediately separated the residents and notified the DON, social worker, and the Administrator of the incident. The DON spoke with both residents following the event. Resident #22 stated his roommate had struck him with a closed fist to the right shoulder/upper back area. He denied any pain or discomfort to the area and was able to move his right arm without difficulty. This writer assessed the area and noted no bruising, swelling or redness. The DON spoke with Resident #125 after the incident and asked if he had struck his roommate and he replied yes, I did but could not recall why he had done so. Per nursing staff, Resident #125 had stated that he had struck him because he doesn't listen to me. An interview was conducted with a CNA (Staff #101) on June 25, 2025, at approximately 10:45 AM. Staff #101 stated that she had heard about an altercation between those two residents, but did not see anything. Staff #101 stated that Resident #125 was getting very aggressive, and that Resident #22 was very sweet, but he did have a temper if anyone got in his way or said anything, then he could get violent. Staff #101 stated that the facility did investigate that incident, and both of those residents could not be in the dining room at the same time. An interview was conducted with the Social Services Director (Staff #148) on June 25, 2025, at 11:12 AM. Staff #148 stated that she was familiar with Resident #22, and that she believed he hit others when he was at the facility. Staff #148 stated she used to help serve in the dining room, and that she believed Resident #22 did have some history of getting into physical altercations. Regarding the incident between Resident #22 and Resident #125, Staff #148 stated that she did not recall what exactly happened, but that staff did a room change and separated the two residents, and that there may have been an incident report completed on it.A telephonic interview was conducted on June 25, 2025, at 12:04 PM, with Social Services staff (Staff #42), who stated that she could not remember the details of the incident between Resident #22 and Resident #125, but that she remembered trying to talk to the residents after the incident. Staff #42 stated that she could not recall who did what to who, but that staff separated the residents, and staff were interviewed. An interview was conducted with an LPN and Nurse Supervisor (Staff #244) on June 25, 2025, at 12:20 PM. Staff #244 stated that physical abuse is any kind of unwanted physical contact, and that if it occurs, to immediately ensure resident safety, and then report the incident immediately to administration and to the State Agency. Staff #244 stated that the floor nurse would do a head to toe assessment of the residents to determine if there are any injuries, and then interview the parties involved. Staff #244 stated he was familiar with the altercation incident between Resident #22 and Resident #125. Staff #244 stated that Resident #22 was struck in the back by Resident #125. Staff #244 stated he did not have any reason to believe that Resident #22 was making up the allegation.An interview was conducted with the facility Administrator (Staff #176) on June 25, 2025, at 12:41 PM, who stated that abuse is the intentional infliction of harm, and an example of physical abuse would be intentionally punching someone in the face with intent to harm, or holding someone down and causing bruises. If an allegation of abuse is made, Staff #176 stated that she would expect staff to make sure residents are safe, and report the allegation immediately to the Director of Nursing (DON) and Administrator so that an investigation could be started. Staff #176 stated regarding the incident between Resident #22 and Resident #125, that on April 5, at 12:20 PM, Resident #22 notified staff that Resident #125 struck him in the back four times, and that nursing staff interviewed Resident #125 who stated that he did hit Resident #22 because he doesn't listen to me.An interview was conducted with the DON (Staff #28) on June 26, 2025, at 11:14 AM. Staff #28 stated if an allegation of abuse were to occur, then staff would ensure resident safety and assess the resident, and report the allegation within a 2-hour timeframe. Staff #28 stated that abuse is harm to a resident with intent, and that unwanted physical contact would constitute physical abuse. Regarding Resident #22 and Resident #125, Staff #28 stated she was not employed at the facility during that timeframe of the incident. Staff #28 reviewed the records, and stated that her understanding of the incident was that Resident #125 did say that he hit Resident #22, so in that respect, that would be considered abuse. Staff #28 stated it was dealt with immediately, and the residents were separated.-Regarding Resident #27 (alleged victim):Resident #27 was re-admitted to the facility on [DATE], with diagnoses that included unspecified dementia, unspecified convulsions, altered mental status, schizoaffective disorder, extrapyramidal and movement disorder, and hypertensive heart disease.An annual MDS assessment dated [DATE], revealed a BIMS assessment interview was not performed.A progress note dated July 13, 2023, revealed Resident #27 was involved in an altercation with a peer. He was stuck to the right side of his face approximately three times. Resident #27 sustained a 1.2 cm superficial abrasion to the right side of face. Routine medications were administered for discomfort. Staff will continue to monitor Resident #27 routinely. He has since voiced no pain to his face at this time. -Regarding Resident #145 (alleged perpetrator):Resident #145 was admitted to the facility on [DATE], with diagnoses that included traumatic subarachnoid hemorrhage, other fracture of unspecified thoracic vertebra, influenza, mild cognitive impairment, unspecified dementia, anxiety disorder, and chest pain.An annual MDS assessment dated [DATE], revealed the resident had a BIMS assessment score of 15, indicating intact cognition.A Behavior Monitoring note dated July 4, 2023, revealed Resident #145 making delusional statements as evidence by I should be leaving here soon, I'm just waiting on my drilling and oiling license.A Behavior Monitoring note dated July 12, 2023, revealed Resident #145 making delusional statements and visual hallucinations as evidenced by there goes that puppy running around again.A progress note dated July 13, 2023, revealed Resident #145 was sent to the hospital for evaluation and treatment due to behavioral outburst (physically aggressive) with obscenities at peer, attempts to get at the other patient, delusional thought processes, unrealistic expectations of peers, and voiced likelihood of continued behaviors.An additional progress note dated July 13, 2023, revealed Resident #145 was discharged to the hospital. He was involved in a resident to resident incident this morning. All appropriate personnel were notified.A facility Reportable Event Record / Report submitted to the State Agency on July 14, 2023, revealed that on July 13, 2023, at approximately 8:40 AM, in the dining room of the dementia unit, nursing staff observed Resident #145 stand from his chair, take three steps, and then started hitting Resident #27 in the face. Resident #145 was able to strike Resident #27 three times before staff were able to intervene. Two male staff immediately separated the residents and returned them to their rooms. This incident occurred with staff present in the dining room during breakfast. Staff state Resident #145 was not acting like himself that morning and was quieter than usual. Resident #145 stated They wouldn't let me out of this place. When asked why he had struck Resident #27 in the dining room, Resident #145 stated Got your attention, didn't it?, and when asked if Resident #27 had done or said something to provoke him, he stated Have you seen him? Have you smelled him? Do you know what he does? He's always making noises and acting like he's going to throw up. I'd had enough! Per interview with Resident #145, it appears he was annoyed by grunting sounds Resident #27 was making, and perceived favorable treatment of Resident #27, and Resident #145 stated he would do it again. Resident #27 was assessed for injuries, and a small superficial abrasion noted by the right ear / cheek area, and no swelling or bruising noted to his face.A telephonic interview was conducted with a CNA (Staff #46) on June 25, 2025, at 10:41 AM. Staff #46 stated that he witnessed the incident, and that Resident #27 was burping, and that Resident #145 became bothered by that and started cursing and punching Resident #27 in the face. Staff #46 stated that he believed Resident #27 sustained a bruise to his eye area and that Resident #27 stated that his eye did hurt. Staff #46 stated that the facility kept the residents separated after the incident.An interview was conducted with an LPN and Nurse Supervisor (Staff #244) on June 25, 2025, at 12:30 PM. Staff #244 stated that he remembered Resident #27 was making audible noises and Resident #145 backed up his wheelchair, stood up, took a few steps toward Resident #27, and began to strike him in the head or face. Staff #244 stated that he personally saw Resident #145 make the strikes, and that he was the nurse on duty at the time. He stated that after the incident, the residents were separated and assessed, and that Resident #27 sustained superficial abrasions to the right side of his face. Staff #244 stated that given the idea of what abuse is, that this incident would be considered an instance of abuse.An interview was conducted with the Administrator (Staff #176) on June 25, 2025, at 12:41 PM, who stated that regarding the incident between Resident #27 and Resident #145, that Resident #145 definitely hit Resident #27, and as soon as staff saw it, they intervened to help prevent further injuries. Staff #176 stated that it sounds like Resident #145 did this to get staff's attention. -Regarding Resident #26:Resident #26's record was admitted to the facility on [DATE] with diagnosis that included dementia with behavioral disturbances and repeated falls.The Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the assessment.A Nursing Progress Note dated July 9, 2023, revealed a resident to resident altercation between resident #26 and resident #50. It explains that resident #26 went into a room and got into bed. Resident #50 and another resident, were in this room eating lunch together. Resident #50 attempted to get resident #26 out of bed and out of the room, and began yelling at resident #26.Resident #50 then attempted to pull resident #26 out of the bed. Resident #50 told staff when they entered that there had been a schoffel and that he did not remember what he did to resident #26 however, he did remember putting his hands on him.Resident #26 was noted to have a lump to the left eye and it was red in the sclera. -Regarding Resident #50: Resident #50's record was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances, and repeated falls.The quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact.The care plan dated March 29, 2023, revealed the resident was to be assessed for behavioral symptoms that present a danger to the resident and/or others. An update to the care plan, dated May 11, 2023, revealed the resident was noted to be intrusive with peers. The short term goal noted stated Resident will not invade residents personal space, hand and feet will remain to self.A Nursing Progress Note dated July 9, 2023 revealed the same resident to resident altercation. However, it also states thatresident #26 stated he hit me in the eye. The staff escorted resident #50 to the hallway where he stated I don't know what happened and where my room is. Staff escorted resident #50 back to this room where facility implemented a 1:1 sitter for monitoring of aggressive behaviors.On July 9, 2023 a Facility Reported Incident was submitted to the State Agency (SA) regarding the resident to resident altercation between both residents #26 and #50. On July 12, 2023 the Facility Investigation was submitted. The report reveals that the incident was unwitnessed by staff. However, the only resident witness to the event has advanced dementia and was unable to recall any details of the event. The Director of Nursing (DON) interviewed resident #26 after the incident, and he stated that resident #50 did not have a closed fist but he was struck by the back of his hand and that it was an accident. The DON also spoke with resident #50 and he stated he did not really remember. He explained I was trying to get him out of the room. I didn't mean to hit him and if I hurt him I'm truly sorry.A Nursing Progress Note dated July 10, 2023 reveals that resident #50 was noted to have edema to his right hand. Resident's provider applied a brace to the hand. A follow up X-ray revealed that the resident had sustained a right fifth metacarpal neck acute fracture. Resident was ordered a splint.A Nursing Progress Note dated July 10, 2023 reveals that resident #26 was sent to the hospital and did receive an X-ray to his left eye. No fractures were present. However, resident #26 would need follow up care with the Ophthalmologist.An interview was conducted on June 26, 2025 at 1:16 PM with the Administrator, staff #176, and the DON, staff #28. Staff #176 states yes, it happened and as soon as we found placement for resident #50. He was discharged . Review of the facility policy titled Preventing, Reporting and Investigating Abuse, Revised July 2023, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. All reports shall be promptly and thoroughly investigated by facility management. The facility is committed to protecting our residents from abuse by anyone. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes the following types of abuse: verbal, sexual, physical, mental, exploitation, misappropriation of resident property, involuntary seclusion, and including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. Failure to ensure the resident's safety could lead to resident harm. Findings include: Resident #33 was admitted on [DATE] with diagnoses of dementia, Major Depressive Disorder, and macular degeneration. A hospital history and physical dated October 7, 2023 included that this resident has chronic dementia and was unable to recall events of what happened. An admission assessment dated [DATE] included that this resident was attentive, disoriented, memory impaired, and had disorganized thinking. A care plan dated October 18, 2023 included that this resident is oriented to self and that this resident had Cognitive loss/dementia or alteration in thought processes related to diagnosis of dementia with behavioral disturbance as evidenced by impaired decision making, short and/or long term memory loss, and/or neurological symptoms. A treatment consent dated October 19, 2023 included that this resident's consents were signed by her Power of Attorney (POA). A care conference review report dated October 29, 2023 included that BIMS, she repeats three words, does not know year, month or day of week and can remember one of three words after five minutes, for a score of 05. A progress note dated November 5, 2023 included that this resident was observed exiting front courtyard with elder male and that the writer offered assistance with a leave of absence or an Against Medical Advice (AMA) form, and that the male reports I already did. This progress note included that the writer went to obtain Charge Nurse on duty as well as an AMA form, and a Certified Nursing Assistant (CNA) stopped the male's vehicle, prior to leaving premises. This progress note also included that the alleged perpetrator then signed AMA form and stated we might come back. However, review of both the medical and healthcare POA forms did not list alleged perpetrator as an agent. A progress note dated November 5, 2023 included the On Call Supervisor, DON, & Administrator were notified upon discovering the MPOA's were not the person who took the resident out of the facility. This note included that the MPOA advised writer to call the alleged perpetrator on cell phone and tell him to return this resident or police will be called. This note included that the writer called this person's primary number and left voice mail with clear instructions and called 911 and gave a description of event and description of the resident and her clothes, and a description of the alleged perpetrator, what he was wearing and what he was driving. A progress note dated November 5, 2023 included that an Officer with Tucson Police Department called to verify the resident was at her previous residence, safe and sound. A progress note dated November 5, 2023 included that per the resident's POA, this resident was safe at neighbor's home having coffee awaiting the co-POA and that an order of protection was to be filed against the alleged perpetrator, as family did not anticipate him taking this resident out of the facility. A progress note dated November 6, 2023 included that a POA contacted the facility to provide update on this resident's current situation and said that the family is obtaining a restraining order against the alleged perpetrator and was requesting that the alleged perpetrator be taken off the face sheet in case he returns to ask where the resident was being discharged to. This note included that the staff removed the alleged perpetrator from the face sheet. An interview conducted on June 26, 2025 at 1 P.M. with a Certified Nursing Assistant (CNA/staff #87) who said that she would report a resident going AMA to the nurse, and that the nurse is in charge and will get someone, and will notify the administrator. This CNA said that a resident leaving AMA was a risk for safety and environment. An interview conducted on June 26, 2025 at 1: 13 P.M. with a Registered Nurse (RN/staff #161) who said that if a resident wants to leave against medical advice, it would depend on if the resident is oriented. This nurse said that she would call the family members, and see if they could prevent the resident from leaving. This nurse also said that she would see if she could find the reason the resident wants to leave and see if she could help, then if the resident still wanted to leave, she would call the provider, educate the patient, and if the resident was oriented then the resident would sign the AMA sheet and they leave. This nurse said that if the person was not oriented that they would not be going home. This nurse reviewed the clinical record and said that she would call the POA, let her know what the alleged perpetrator is doing, let the physician know, find out why she wants to leave, but yeah she's not going to be going with the alleged perpetrator. She said that I would tell him She will not be leaving with you because that person is not the POA. This nurse said that this resident should not have left the building. This nurse said that this nurse should have talked to the medical POA prior to that. An interview was conducted on June 26, 2025 at 1:55 PM with a Licensed Practical Nurse (LPN/staff #240) who said that she remembered this resident and that she remembered the incident where she left with the alleged perpetrator and said that it was her first day taking care of this resident. This nurse said that when she went to look at the face sheet she realized that this person was not the POA and that when she called the POA's, they said she was not supposed to leave with the alleged perpetrator. This nurse said that police were called and APS. This nurse said that she had only worked with her a few hours and that she thought the alleged perpetrator was her husband. This nurse said that the resident made her needs known and that she was not aware that the family was the POA until she checked the face sheet. This nurse said that she should not have let the resident leave with the alleged perpetrator. An interview was conducted on June 26, 2025 at 2:41 PM with the Director of Nursing (DON/staff #28) who said that her expectation for residents leaving AMA would be that the staff talk to the resident to see if there is a need that we can meet, then contact the physician, herself, Social Services and then have the resident sign the AMA form and do a note, and then line up transport and prescriptions. This DON said that we facilitate a safe discharge, and then report it to APS. This DON said that for residents who are not capable of making decisions: that her expectations would be for a POA to make the decision to take the resident and that the staff would call the authorities if the persons BIMS is too low. This DON said that a person who is not the POA should not remove a person with a low BIMS from the facility. This DON reviewed the medical record and said that no that's not our expectation that something like that should happened and that she did not think this resident could make the decisions. A policy titled Resident Rights revised October 2021 included that the resident and/or their representative has the right to be informed of, and planning and participate in, his or her treatment, including: a) The right to be fully informed in implementing care language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. b) The right to be informed, in advance, of changes to the plan of care. c) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. A policy titled Elopements included that if an employee observes a resident leaving the premises, he/she should attempt to prevent the departure in a courteous manner, and get help from other staff members in the immediate vicinity, if necessary.

Based on clinical record review, staff interviews and review of facility protocol and policies the facility failed to ensure one resident (#5) was free from accidents during a hoyer transfer. The deficient practice could lead to major injury. Findings include: Resident #5 was admitted originally on October 5, 2020 and readmitted on [DATE] with diagnosis that included epilepsy, transient cerebral ischemic attach, other mechanical complication of internal fixation device of right femur, bipolar disorder, acute respiratory failure, non-ST elevation myocardial infraction. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 02. indicating severe cognitive impairment. Further review of the MDS assessment revealed the resident was dependent and needed the assistance of 2 or more helpers to complete any activities dealing with transfers. A care plan created May 26, 2025 revealed an approach that the resident is a hoyer lift with 3 staff persons present due to his utilization of a geriatric chair. A facility investigation dated June 6, 2025 revealed that the hoyer sling had impaired integrity and deemed that the root cause of the sling breaking and causing the resident to fall and suffer a hip fracture. A progress note dated June 5, 2025 at 9:45 a.m. revealed that staff reported that the resident's hoyer sling tore during a transfer. The note further reveals that the resident slid out of the sling and onto the floor and was complaining of right hip pain. The note details that 911 was called and the fire department transferred the resident to the local emergency room. The note concludes that notifications were made to the provider, hospice, case manager and responsible party. An Interdisciplinary Team (IDT) note dated June 6, 2025 at 10:23 a.m. revealed that the resident suffered a fall and that the root cause analysis showed that the resident's hoyer sling broke during the transfer. The note states that staff will use a bariatric sling for all transfers upon the residents return from the hospital. A progress note dated June 10, 2025 at 18:05 p.m. revealed that the resident returned to the facility with a right intertrochanteric fracture of his right hip as a result of his fall. Review of the clinical record did not reveal any orders or assessments done in regards to the accident during the hoyer transfer. An interview was conducted with a Certified Nursing Assistant (CNA/staff #29) on June 10, 2025 at 8:38 a.m. The CNA stated that the facilities' process is to always have 2 CNAs during a hoyer transfer but there could be a resident that requires 3. Staff #29 stated that there are in-services yearly where staff will be guided into a room and shown again how to properly operate the other lift. The CNA stated that she is also taught how to check and see if there is anything wrong with the function of the machine. The CNA stated that the night shift staff are responsible for setting up a resident in a hoyer sling prior to transfers. However she stated that she is still able to place a resident in a hoyer sling as needed. Staff #29 stated that she had entered the residents room and the resident already had the hoyer sling under him so she was unsure of the status of the slings integrity. She stated that there were 3 CNAs in the room as it was protocol for Resident #5's transfers. The CNA further stated that the resident was transferred from his bed to his geri chair for breakfast with no issues. She followed up by saying when the staff went to transfer the resident from his geri chair back to bed was when the sling ripped and the resident fell. An interview was conducted with a CNA (staff #34) on June 10, 2025 at 8:56 a.m. The CNA stated that the facility's process regarding hoyer transfers is to ensure that the right size of sling is being used and making sure its integrity is intact. She further stated that during a 3-person hoyer transfer one CNA would guide the resident's feet, one would guide the resident's body and one would operate the hoyer machine. The CNA stated that the resident was being transferred via hoyer back to his bed from his geri chair, and that during the transfer when the resident was lifted, the sling snapped and he fell to the ground. An interview was conducted with a CNA (Staff #98) on June 10, 2025 at 9:06 a.m. The CNA stated that the facility's process is to place the hoyer sling under the resident to ensure that the highest part reaches the resident's shoulder height. The CNA stated next they ensure that the right anchor points are being used and attached to the hoyer machine. Staff #98 stated that if a resident is heavier, they will most likely be a 3-person assist with hoyer transfers. The CNA said that when the resident was being transferred back to bed via hoyer the sling ripped towards the bottom right where the fabric strap attaches. An interview was conducted with a CNA (Staff #48) on June 10, 2025at 10:13 a.m. who stated that the facility's process is to find out what kind of sling the resident needs regarding their height and weight. The CNA followed up stating that he will glance over to ensure the slings are intact with no tears or withering away at the corners or the back part of the sling. He stated that he will roll the resident to the side and place the sling at the residents shoulders and ensure it is laid out appropriately. Staff #48 then stated that he would roll the resident to the other side and lay out the sling and help the resident lay back flat and ensure they are appropriately seated in the sling. The CNA stated that when operating he would also listen for any audible concerns and if he notes any he would let a nurse know. The CNA stated he checks a hoyer sling's integrity by stretching it out to make sure it is not over used or withered, as well as pulling on each corner and anchor point to make sure that there are no weak points or visible signs of fraying. The CNA stated that he had some concerns regarding Resident #5's hoyer sling due to some noises that were made during a transfer the day prior, and some fraying that he spotted during that transfer as well. Staff #48 stated that he let a team lead know regarding his concerns. An interview was conducted with a Licensed Practical Nurse (LPN/staff #56) on June 10, 2025 at 10:40 a.m. The LPN stated he was caring for the resident during the time of his incident and responded when he heard the CNAs calling for help. Staff #56 stated that the CNAs are usually responsible for hoyer transfers but a nurse can step in and aid if it is needed. The LPN stated that if there is a concern with a hoyer sling's integrity he would dispose of it and get a new sling. The LPN stated that when checking a hoyer sling's integrity he is looking at the stitching to ensure it is intact and that there aren't any visible signs of fraying. Staff #56 stated that he was not in the resident's room at the time of the hoyer incident, but after he responded he assessed the resident who ended up transferring to the local emergency room via 911. An interview was conducted with the Director of Nursing (DON/Staff # 27) on June 10, 2025 at 10:51 a.m. The DON stated that her expectations regarding hoyer transfers would initially start by checking the integrity of the hoyer sling that is going to be used, as well as proper placement of the hoyer sling on the resident. The DON continued by stating that she expects staff to use proper safety and placement with the anchor point of the sling, and that the chair or surface they are transferring, is placed appropriately to avoid any unsafe situations. She concluded by stating that she expects staff to verbalize what is being done during the transfer to the resident. The DON stated that she expects staff to check the the hoyer sling thoroughly by checking the integrity of the cloth as well as the seamlines. The DON further stated that if there are any concerns regarding the sling integrity, or a sling looks too worn, then the faulty sling should be placed in a bag and given to the lead CNA to be replaced. The DON stated that Resident #5 was a 3-person assist hoyer transfer and that it was reported to her that the staff transferring the resident had no issues initially, and at the time of the second transfer back to the resident's bed the sling ripped. The DON stated that there was impaired integrity to Resident #5's hoyer sling and that it was brought to her attention during her investigation after two CNAs identified issues with the sling's integrity prior to the incident. Staff #27 stated that the sling should have been pulled out of service, and she deemed this to be an area of improvement. The DON stated that the risk of using a hoyer sling with impaired integrity could result in the sling breaking and causing harm to a resident. A follow-up interview was conducted with CNA (staff #34) on June 10, 2025 at 11:06 a.m. who stated that nothing was reported to her the day previously regarding the sling's integrity. The CNA confirmed that the anchor point (strap) was still attached to the machine and the sling ripped at the seam where the anchor point was attached. A facility policy dated 2001 and revised February of 2014, titled, Lifting Machine, Using a Portable, revealed that staff are to document per facility protocol to report other information in accordance with facility policy and professional standards of practice.

Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that three residents (#33, #24, #11) were not abused. This deficient practice could result in further incidents of abuse. Findings include: Regarding resident #33 and resident #24 A facility reported incident was made on May 14, 2024. This report included Staff responded to visitor calling for help, stating those two men are fighting. She states that she heard raised voices coming from the room across the hallway. She looked across the hallway and observed (residents #24 and #33) in the bathroom doorway and appeared to be fighting. A 5 day report dated May 17, 2024 included Per staff report (resident #24) had been having increased behavioral episodes the prior day and night. He was seen packing his belongings, pushing at doors and very difficult for the staff to re-direct. Per night staff he had slept very little the previous night. (resident #33 can be very territorial about his room and belongings. This document also included (resident #24 and (resident #33) have different rooms but share a bathroom between them; it is thought that (resident #33) left the bathroom through the door to (resident #24)'s room by mistake,which created the verbal altercation in the bathroom area. -Resident #24 was admitted on [DATE] with diagnoses of Alzheimer's disease, Mood disorder due to known physiological condition with depressive features and Vascular dementia A Quarterly Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired and that the resident was able to independently walk in the corridor and around the room. A care plan dated December 19, 2022 included Cognitive loss/dementia or alteration in thought processes related to diagnosis as evidenced by impaired decision making, short and/or long term memory loss, and neurological symptoms and included interventions to redirect resident when entering unsafe areas. -Resident #33 was admitted on [DATE] with diagnoses of Schizoaffective disorder, unspecified dementia with other behavioral disturbance, and mild intellectual disabilities. A care plan dated May 14, 2023 included this resident has physical behavioral symptoms toward another resident (e.g. hitting, pushing) with a long term goal that this resident will not harm others secondary to physically abusive behavior. A progress note dated May 14, 2023 included that resident #33 was in bed and a 2 nurse body check was completed. This note included a hematoma forming to the right wrist area 2cm discoloration, with approximated skin tear measuring 0.75 cm and that the resident reports falling. This note stated that it was unclear why resident #33 was in sitting position in rm 117 between conjoined restroom and peers brown recliner with bedside table between both residents. An interview was conducted on October 22, 2024 at 3:11 P.M. with a Certified Nursing Assistant (CNA/staff #87) who said that this is a secured behavioral unit and that they attempt to prevent incidents by giving residents attention, reminding them and making sure they have what they need. This CNA said that resident #24 had a lot of behaviors which included being very forgetful and that he gets aggressive. This CNA said that this resident wanders into people's rooms. An interview was conducted on October 25, 2024 at 1:52 P.M. with a CNA (staff #43) who said that she remembered that she was in the dining room and heard bang like a bedside table, and she ran to the first room, and resident #33 was with the bedside table on top of resident #24. She said that she did not think it was an altercation, she thinks that the resident went into the wrong room. An interview was conducted October 25, 2024 at 2:23 P.M. with a family member who said that her husband is in the room across the hall, and that she heard something so she stood up and looked over there. She said that she saw the resident who belonged in the room and a resident who did not. She said that she saw 1 of them striking the other. She said that she then called out for help, and when people started running she sat down. She said that she told facility staff what she saw, and that she heard the yelling, because she was seated beside her husband's bed. Regarding resident #24 and resident #11 A facility reported incident was made on June 11, 2023. This report included that on June 11, 2023 Staff observed (resident #24) stroking (resident #11)'s penis. (resident #11) was laying in (resident #24)'s bed. Both residents have advanced Dementia and reside on a locked Dementia unit at the facility. Staff immediately separated the Residents. Implemented 1:1 staffing and 15 minute checks -Resident #11 was admitted [DATE] with diagnoses of unspecified dementia, and altered mental status. A care plan dated June 11, 2023 included that this resident was showing disinhibited behaviors in public and towards others with interventions to re-direct resident to his room when displaying inappropriate behavior and staff to encourage and attempt 6foot rule between him and peers until evaluated and treated by psych. However, this resident had no prior care plan for public disinhibition or public masturbation. A progress note dated May 3, 2023 included that this resident is being monitored for public masturbation. Progress notes dated May 11, 2023 and June 9, 2023 included that this resident had an instance of public masturbation. A progress note dated June 11, 2023 included upon staff assisting another resident down hall way, staff reports that they observed (resident #11) laying in male peers' bed next to male peer and was observed to have pants pulled down and peer was stroking (resident #11) erected penis. Staff intervened and assisted peer away from (resident #11). (resident #11) pulled pants up over penis and was observed to stand up and adjust self. staff assisted (resident #11) out of peers room and directed him to his room. 1:1 provided to (resident #11) at this time . An interview was conducted on October 25, 2024 at 10:54 A.M. with a CNA (staff #104) who said that resident #24 had dementia and that he was sometimes aggressive but that he was always confused. He said that heard of the incident between residents #11 and #24 and that the residents were separated from then on. An interview was conducted on October 25, 2024 at 1:52 with a CNA (staff #43) who said that resident #24 had started masturbating in the dining room though he had not previously been directly sexual with staff or residents. She said that the staff were start starting rounds in which they would check on the residents and change briefs if needed. She said that she turned around because resident #24 had left after the meal and she saw resident #11 on edge of bed kind of laying back and that resident #24 was massaging his private and that she said oh, in shock, and that resident #11 pulled his pants on really quick. She said that another CNA was with her and that she went and got a nurse. She said she told them what she had seen and started 1 on 1 supervision with resident #11. She said that resident #24 is really confused and that resident #11 was on 1 on 1 supervision until he left. An interview was conducted on October 25, 2024 at 10:45 A.M. with a Licensed Practical Nurse (LPN/staff #65) who stated that she remembered hearing about it and that in this situation residents should be separated and the management notified. She said that these residents would not have been capable of consent. An interview conducted on October 25, 2024 at 2:39 P.M. with a LPN (staff #56) who said that the MDS coordinator does care planning, the floor nurses do not. She said that if the nurses feel that the care plan needs a change, they notify the MDS and that staff will make changes. This nurse said that she makes sure that her residents are capable of consent if there is a possibility of a sexual relationship. This nurse said that abuse includes mental, physical, verbal, involuntary seclusion as well as other types and that being yelled at is verbal abuse. She said that a lot of their residents have dementia so consent is always a concern. An interview conducted on October 25, 2024 at 3:38 P.M. with the Director of Nursing (DON/staff #58) said that resident #24 is not capable of consent. She said that he is on the dementia unit and that his wife is was power of attorney and made his decisions. She said that resident #11 was moved out because of his constant behaviors and also would not have been able to consent. This DON said that we need to be advocates and protectors of the vulnerable population. This DON said that the onset of public masturbation should have been updated in the care plan. Regarding the altercation between resident #24 and #33, the DON said that it does not meet her expectations that residents were yelling and punching at each other. An interview was conducted with the administrator (staff #95) on October 25, 2024 immediately following this interview included that being assessed for the ability to consent is not obtained prior to residents attempting personal contact, so that an assessment was not warranted prior to the act. This administrator said that these two residents did not have prior contact. However, as these residents were not assessed as able to make decisions regarding their daily lives, an assessment of consent should have been conducted for sexual interactions to be considered consensual. A policy titled Preventing, Reporting and Investigating Abuse revised July 2023 included our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This document included our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to other residents. A policy titled Care Plans, Comprehensive Person-Centered revised March, 2022 revealed that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on clinical record review, staff and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#24) is free from preventable falls. This deficient practice could result in increased morbidity and mortality. Findings include: Resident #24 was admitted on [DATE] with diagnoses of Alzheimer's disease, Mood disorder due to known physiological condition with depressive features and Vascular dementia A 5-day Minimum Data Set (MDS) dated [DATE] included that this resident was unable to answer questions for cognition and that the resident had a fall prior to entry. A care plan dated December 19, 2022 included this resident is at risk for falls related to diagnosis and history of falls. A progress note dated July 27, 2023 included Upon entering pts room he was noted laying on back in front of closet. pt stated I fell . Body check done, no new injuries. Denies hitting head, no red, raised or open areas.Neuro check done due to unwitness fall. Passive ROM to upper and lower extremitys. Pt s/sx pain dont touch that refering to left leg 2-person assist to bed. Gripper socks applied A care plan intervention dated July 27, 2023 was added of Give resident verbal reminders not to ambulate/transfer without assistance. However, this intervention was cancelled the same day and no new interventions were put into place. A progress note dated August 5, 2023 included Resident found on floor in dining room with head and shoulders resting on wall. Resident stated he was attempting to stand when lost balance. No new injury noted at this time. Assisted back into chair and educated of safety awareness and mechanical lift order, resident smiled. VSS, noreports of new pained areas, skin intact. Neuros initiated and continuing, New order for Xray of left hipto compare from previous fall per provider, order input in matric and rapid ray. Spoke to [NAME] from rapidray order placed STAT. A progress note dated August 5, 2023 included Xray of left hip results as follows: left superior and inferior pubic rami fracture results related to on call provider, new telephone order to send resident toTMC ER for evaluation via transport, if exceeding 3hr wait please call for emergent transport. MOD and wife . made aware. Denies pain when asked, smiles and attempts to stand up. 1:1 supervision placed for safety. Call placed to the transport company, result is wait time up to 3 hours. A care plan intervention dated August 8, 2023 was added of Floor mat at bedside and bed in knee bend height position for safe entry and exit However, this intervention was cancelled the same day and no new interventions were put into place. An interview was conducted on October 22, 2024 at 3:11 P.M. with a Certified Nursing Assistant (CNA/staff #87) who said that this is a secured behavioral unit and that this staff's goal was to make sure everyone had a good day and had no accidents. This staff said they attempt to prevent incidents by giving residents attention, reminding them and making sure they have what they need with pads beside beds and call lights within reach. This CNA said that resident #24 had a lot of behaviors which included being very forgetful and that he had a bad hip. This CNA said that this resident had a pad for beside his bed. An interview was conducted on October 23, 2024 at 3:10 P.M. with a Licenced Practical Nurse (LPN/staff #89) who said that when a resident falls, the staff report it to her and she does an assessment. She said that if the resident is safe to transfer to bed, they will do so and begin the neurological assessments. She said that they will review the care plan and then the Registered Nurse will update the care plan. This nurse said that resident #24 sundowns and wants to get up in the evenings. She said that the interventions to prevent falls were to position bed to lowest, place a fall mat, and that if the resident was restless we will do a one on one, or the CNA's will put him at the desk. An interview was conducted on October 25, 2024 at 3:38 P.M. with the Director of Nursing (DON/staff #58) who said falls should be care planned. She said that with resident #24, she would have to find out why they removed the interventions immediately and that for him they use a lot of diversional opportunities. She said that since the left superior and inferior pubic rami fracture that this resident was not as mobile anymore, and that now he requires the assistance of a hoyer for transfer as he is not able to move on his own at all. She said that if there is not an added intervention for each fall then it would not meet her expectation. She said that placing an intervention and cancelling it within a day does not meet the requirement. A policy titled Care Plans, Comprehensive Person-Centered revised March 2022 revealed that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, resident and staff interviews and review of policy, the facility failed to maintain a safe, comfortable homelike environment related to ambient temperatures. The facility census was 227. The deficient practice may result in uncomfortable ambient temperature levels. Findings include: During a survey of the facility conducted 07/11/23 through 07/14/23, temperature findings were identified in common areas to include the following: -On 07/11/23 at 09:43 AM the fire door outside of room [ROOM NUMBER] measured 83.5 degrees Fahrenheit (F). -On 07/12/23 at 09:55 AM the Saguaro Room curtain temperatures ranged from 82-83 degrees F. -On 07/12/23 at 09:56 AM the air conditioner units in the hall by room [ROOM NUMBER] measured 82 degrees F. An observation of room [ROOM NUMBER] was conducted on 07/13/23 at 11:05 AM. Two fans were observed to be running in the room. The temperature of the room ranged from 78-80 degrees F. The two residents of the room stated that they were comfortable at that time, but that in the afternoon it was hot. They stated they did not want to have to close the curtains. Both of the residents stated that they had told staff that the room gets too hot in the afternoon, but that the facility had not made an adjustment to the temperature. During an observation of room [ROOM NUMBER] conducted on 07/13/23 at 11:09 AM temperatures of the curtain windows ranged from 86.5-88 degrees F. The privacy curtain measured 83.0 degrees F, and a chair in the room was 85 degrees F. The resident in bed B stated that she was hot, that staff were aware of the room's temperatures and that they had place 4 fans in the room. An interview was conducted with the Maintenance Director (staff #178) on 07/13/23 at 11:15 AM. The temperatures of rooms #10, #11 and #23 were conducted within 2 degrees of each other. room [ROOM NUMBER] ambient temperature was measured at 82 degrees F. Staff #178 stated that he would put a portable air conditioning unit into the room. Staff #178 stated that the air vents in the facility were being cleaned out as of 07/12/23 and that zone valves were being checked for the Lodge North and Lodge East sections of the facility. An observation of room [ROOM NUMBER] was conducted on 07/13/23 at 2:03 PM included ambient temperatures ranging from 81-84 degrees F. The resident in bed A was noted to be wearing a hospital gown and not covered with a blanket or sheet. The resident stated that she was warm and that she had informed staff that the room was too hot, but that nothing gets done. Per observation, the thermostat in the room was set to low and the fan in the room was set to high. An interview was conducted with a Licensed Practical Nurse (LPN/staff #150) on 07/13/23 at 2:31 PM. She stated she felt the facility was too hot. She stated that this was not a new problem and that she was aware of other staff complaining that it was too hot in the facility. She stated that she did not feel that this temperature was similar to a homelike environment. On 07/13/23 at 2:36 PM an interview was conducted with LPN/staff #176. She stated that she had worked throughout the whole facility and that there was not a section of the facility that was not hot. Staff #176 stated that some staff will wear ice vests to cool off. Staff #176 stated that she felt the facility was too hot and that this was not a new problem. Further, she stated that residents complained that their rooms were too hot as well. She stated that fell ow staff members complained that it was too hot and that the facility had not implemented any interventions to resolve the issue. Staff #176 stated that this was not a temperature that she would keep in her home. An observation of a staff member was conducted on 07/13/23 at approximately 2:45 PM revealed one staff member with an ice vest. On 07/13/23 at 2:42 PM an interview was conducted with LPN/staff #179. She stated that she felt the facility was too hot and that this was not a new problem. She stated that the facility had become warmer over the last few days. Staff #179 stated that she was aware of residents complaining and that staff had complained as well. Staff #179 stated that when a resident complained about about the temperature, she notified social services and maintenance. An interview was conducted on 07/13/23 at 2:57 PM with the Administrator (staff #68). She stated that she did not feel the facility was too hot and that the current temperature was one that she would keep in her home. Staff #68 stated that if a resident did complain about it being too hot, she would address it and implement solutions which would include providing portable air-conditioning unit for the resident's room. Review of the Quality of Life - Homelike Environment policy, revised November 2019, included that facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable temperatures.

Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure that three residents (#88, #109, and #108) received ROM (Range of Motion) as ordered. The deficient practice could result in residents experiencing a decrease in ROM. Findings include: -Resident #88 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated February 1, 2022 revealed the resident had decreased functional mobility and strength. The 5-day Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 which indicated the resident had moderate impaired cognition. The assessment included the resident is totally dependent on the staff for activities of daily living. A review of the care plan last reviewed April 25, 2022 revealed the resident receives restorative nursing services to maintain/improve functional mobility. The goal was that the resident will maintain joint function. Intervention included AROM (Active Range of Motion) 3-5 times a week by restorative nursing, and monitoring and recording any increased stiffness in joints and reporting it to the resident's nurse. Review of facility documentation revealed that for April 2022 the resident received PROM two times the first week of April, one time the second week, and two times the third week. During the month of March 2022, the resident was out at the hospital for 6 days in the beginning of the month, then on week 3 the resident received 3 sessions, and week 4 the resident received two sessions. During an interview conducted with the resident on April 26, 2022 at 11:17 AM, the resident stated that he has been getting weaker and weaker and now they do not get him out of bed anymore. The resident further stated that he would like to work on getting some of his strength back so that he could get up more. The resident added that he used to have exercises in bed but has not lately received any exercises. During an interview conducted on April 29, 2022 at 8:19 AM with the Rehabilitation Director (staff #106), she stated that the resident is a Long-Term Care patient and is not currently scheduled for any Physical Therapy or Occupational Therapy. Staff #106 further stated that the resident is to receive restorative nursing assistance on the unit and that it is run by the nursing department. During an interview conducted on April 29, 2022 at 8:45 AM with a Certified Nursing Assistant (CNA/staff #165), she stated that she is also the Restorative Nursing Assistant (RNA) who is assigned to the unit. She added that the resident is to receive RNA services for PROM, three to five times a week. She further added that she documents the services on paper in a book at the nursing station and not in the electronic medical record. She stated that the amount of restorative nursing assistance provided depends on the unit staffing whether or not she is assigned to the RNA work. The CNA stated that due to the lack of staff, she is working less than 50% of her time and that she has only had 10 days in the last month to perform the restorative services. She added that if the resident refuses the service she reports it to the nurse. During an interview conducted on April 29, 2022 at 8:53 AM with a Licensed Practical Nurse (staff #138), she stated that if the resident refuses to get up, then she would note that in her progress notes. She added that the resident is not receiving physical therapy, only Restorative Nursing Assistance, and that the rest of the staff will encourage the resident to assist with turning in bed, and that the resident tends to not want to get up. She added that the resident has some behavior issues. She also added that the unit is short staffed about 30% of the time. During an interview conducted on April 29, 2022 at 8:47 AM with the Director of Nursing (DON/staff #188), she stated that the Restorative Nursing Assistance program is per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She added that the staff from the RNA program are often pulled to do weights or other Certified Nursing Assistant duties. She further stated that this has been a concern as the residents should be getting services as ordered and that they are starting to look at a process improvement project. -Resident #109 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed an order dated January 7, 2019 for restorative nursing (RNA) 3 to 5 times per week to prevent a decrease in range of motion. A care plan dated March 12, 2019 revealed that the resident is receiving restorative nursing services to maintain functional ability. The goal is that the resident will maintain joint function. Approaches including AROM (Active Range of Motion) to the lower extremity as tolerated 3- 5 times per week. Review of the care plan dated July 17, 2020 revealed the resident is at high risk for falls related to limited function. Approaches included implementing an exercise program that targeted strength, gait and balance. The significant change in status minimum data set (MDS) assessment dated [DATE] revealed a score of 15 on the brief interview for mental status (BIMS) indicating the resident was cognitively intact. The assessment also revealed the resident required extensive assistance for bed mobility, toilet use, personal hygiene, and dressing with one-person assistance, and was totally dependent for transfer with two+ persons. The MDS assessment further revealed the resident received AROM 5 times during the 7-day lookback period and that the training and skill practice was in bed mobility. Review of the restorative flowsheet from November 2021 through April 2022 revealed the resident was not seen consistently 3 to 5 times per week despite notes that the resident was cooperative. One resident refusal was documented on March 3, 2022 and some difficulty in resident abilities were also noted in March 2022. On April 29, 2022 at 7:43 AM, an interview with Restorative (staff #225) was conducted. She stated that resident #109 was not being seen as ordered because of staffing shortages with RNA staff. She said that CNAs were doing weights and other CNA duties and had little time for their RNA duties. She said that the facility is aware that there were not enough staff to see all the restorative residents. She stated that they are very short staffed and management is very aware. She stated that the documentation does not reflect why the residents were not being seen as ordered. She stated that this had been ongoing since COVID and has been a facility wide problem. She said that it was a concern to her that the residents were not seen as ordered as they may lose their abilities. -Resident #108 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated March 8, 2022 revealed the resident is at high risk for falls related to general weakness. The admission MDS assessment dated [DATE] revealed a score of 15 on the BIMS indicating that the resident was cognitively intact. The MDS assessment also revealed the resident needed limited assistance with bed mobility with two+ person assistance, toilet use and personal hygiene with one-person assistance; and extensive assistance to transfer with two+ person assistance. The assessment further revealed the resident did not receive RNA. Review of the clinical record revealed a physical therapy (PT) discharge summary dated March 31, 2022 that the restorative program (RNA) was established. The discharge was per physician/case manager recommendation. A review of the clinical record revealed a referral to restorative nursing dated April 6, 2022 from PT for 3 to 5 times per week to maintain mobility and range of motion. Review of the RNA flowsheet for April 2022 revealed the resident was seen by RNA 8 times from April 6 - 28, 2022. The first visit was April 14, 2022. The included notes did not reveal any refusals or any explanation as to the delay of onset of services. An interview with the director of PT (staff #106) was conducted on April 7, 2022 at 2:02 p.m. She stated that resident #108 was receiving PT and occupational therapy (OT), was discharged , and currently receives RNA with staff #16. Staff #106 stated that the resident was referred to RNA services after the discharge from PT on March 31, 2022. On April 28, 2022 at 8:46 AM, an interview was conducted with the RNA (staff #16). She stated that she receives a paper order referral from PT and she then follows up with the resident. She said the order for resident #108 was put in on April 6, 2022. She said the purpose of restorative therapy is to maintain the progress a resident made during PT and OT. She further stated that a resident can be on RNA for weeks or years. Staff #16 stated she tracks the progress of the resident and documents on a paper chart not in the electronic health record. Staff #16 stated that this resident was not seen until April 14, 2022 because the resident was assigned to her when she was out sick. She said no other RNA picked up the resident in her absence and she is not sure why the resident was not seen by someone else while she was sick. Staff #16 said that the resident has been seen about 3 times per week since then, but that the resident is the same as when the resident started, no improvement, no decline. An additional interview was conducted with staff #106 on April 28, 2022 at 9:01 AM. She stated that as the director of therapy, she writes the order for a resident to receive RNA services. She stated she puts a copy in the box for staff #225, who is the coordinator for the RNA program and handles all the RNA scheduling. An interview with the DON (staff #188) was conducted on April 28, 2022 at 10:44 AM. She stated that for the RNA program, therapy makes a referral and the provider writes an order which is put into the electronic health record. The DON stated the order specifies the frequency per week which is usually 3 to 5 times a week. She said that staff #225 is in charge of assigning an RNA to all residents that receive RNA services and that this process usually takes 1-3 days to get the resident on the RNA schedule. The DON said her expectation is that if an RNA is sick or on vacation, a different RNA should be assigned to work with the resident, as waiting more than 3 or 4 days does not meet her expectation. The DON stated if a resident has to wait more than 3 to 4 days, the resident could regress and lose the progress made with PT. On April 29, 2022 at 7:43 AM, an interview with Restorative (staff #225) was conducted. She stated that she was the RNA team leader and handled RNA scheduling. She stated that in addition to doing RNA assignments, she had additional duties as a CNA and is in charge of weights for the facility. She said that RNA duties were divided by unit and there are 2 full time and 2 part time RNA staff members. She said that if a staff member is out, one of the other RNAs will pick up and fill in. Staff #225 stated there is a retired staff member that used to work RNA and often steps in to help. Staff #225 stated that she reviews the resident documentation to ensure that the documentation is complete at the end of month. She said if there are any issues, such as a resident refusal, the RNA staff should inform the charge nurse and the information should be documented on the flowsheet. She stated that resident #108 was not seen from April 7-13, 2022 because the RNA assigned to the resident was not in the building and there was no staff to pick up the resident visits. An additional interview was conducted with the DON (staff #188) on April 29, 2022 at 8:47 AM. She stated that the RNA program is per order and if the staff are not able to see the residents as ordered they are expected to advise her of the problem. She stated that the staff from Restorative are pulled often to do weights or other CNA duties. The DON stated that this is a concern, as the residents should be receiving services as ordered. She said they are starting to look at process improvement in this area. Review of the facility's policy Restorative Nursing Carry Over Following Physical, Occupational and/or Speech Therapy (5/2010) revealed that, nursing picks up restorative services as directed by therapies to reduce the risk of functional decline in the resident. Restorative nursing is overseen by the Director of Nursing or designee and is to reinforce and extend progress made in therapy. The policy further revealed that the restorative aide will follow the treatment plan and frequency written in the order and will document resident treatments on the restorative flow sheet.

Based on observations, staff interviews, and review of the policy and procedures, the facility failed to ensure that medications were dated according to the standard of practice, and failed to ensure that expired medications were not available for administration. The deficient practice could result in expired medications being administered to residents. Findings include: -An observation was conducted on April 28, 2022 at 1:30 p.m. of the medication cart on hall 209-228, sub-acute unit. An insulin box with a pharmacy label [MEDICATION(S)] Insulin contained two opened vials of insulin inside. The first vial with a maroon top was labeled Insulin [MEDICATION(S)], and the second vial with a silver top was labeled insulin [MEDICATION(S)]. The insulin vials had no resident's name, or open dates. An interview was conducted on April 28, 2022 at 1:33 p.m. with an RN (Registered Nurse/staff #204). Staff #204 stated each insulin is usually in an individual box with the resident's name and opened date. Staff #204 looked at the insulin vials and stated the maroon top is insulin [MEDICATION(S)], and the silver top is insulin [MEDICATION(S)]. The RN stated it was not a normal procedure for a box to have two different insulin vials, and no resident's name. -An observation was conducted on April 28, 2022 at 1:49 p.m. of the South medication room and medication refrigerator. Inside the medication refrigerator was a bottle of [MEDICATION(S)] solution with an expiration date of April 11, 2022, and an opened vial of regular insulin without an open date. An immediate follow up interview was conducted with staff #204, who stated the vial of insulin was opened because the vial was no longer sealed. Staff #204 stated she did not know how long the insulin had been opened because it did not have an open date on it. Staff #204 stated the expiration date on the [MEDICATION(S)] solution was April 11, 2022 and that the medication has expired. An interview was conducted on April 28, 2022 at 2:31 p.m. with the Director of Nursing (DON/staff #188). Staff #188 stated opened insulin vials are good for 28 days and should be dated. The DON stated expired medications should be discarded promptly. A facility's policy, Storage of Medications, stated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy included drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. The policy also included that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, and all such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on clinical record review, staff interviews, policy review and the Form Instructions for the Facility Advanced Beneficiary Notice (SNFABN), the facility failed to provide evidence that the Skilled Nursing Advanced Beneficiary Notice (SNFABN) was issued to one (#108) of three sampled residents. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #108 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Record face sheet revealed the resident was their own responsible party. The admission Minimum Data Set assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident had intact cognition. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the last day of coverage was on March 31, 2022. The notice also revealed an SNFABN form was provided to the resident. However, no evidence was revealed in the medical record that the SNFABN form informing the resident of care Medicare may not pay beginning on April 1, 2022 was issued to the resident. Further review of the clinical record revealed the resident continued to reside in the facility. An interview was conducted on April 26, 2022 at 2:23 PM with the Director of Social Services (staff #154). She stated that she does not complete the ABN form. She also stated that it should be completed with the Notice of Medicare Non-Coverage (NOMNC). She stated that she had reviewed the medical record and there were no signed, written ABN forms in the medical record. An interview was conducted on April 26, 2022 at 02:25 with the Admissions Coordinator (staff #228). He stated that they do not complete the ABN forms. He reviewed the Admissions packet given to residents on admission, and stated that the ABN is not included in the admission packet. An interview was conducted on April 27, 2022 at 11:51 AM with the Administrator (staff #114), who stated that when the NOMNC is ready to be issued, social services discusses with the resident the last covered day and with that discussion they will cover discharge plans and covered benefits, private pay and Medicaid. The Administrator stated that at this time there is no form that the resident or family signs regarding education of Advanced Beneficiary Notice for resident #108. Review of the facility policy titled, Advance Beneficiary Notice of Non-Coverage (ABN) Policy, revealed that it is the policy to inform any Medicare beneficiary of the termination of their part A/Skilled stay via a NOMNC letter and follow up with notice of skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) verbally with the resident and or representative when the NOMNC is delivered. This information is documented in the progress notes in the electronic medical record. The admission packet includes information on private pay rates and social services discusses private pay rates at the time the NOMNC is issued and documents the information provided Review of the form instruction for the SNFABN revealed that Medicare requires skilled nursing facilities to issue the SNFABN to Medicare beneficiaries prior to providing care that Medicare usually covers but may not pay for when the care is not medically necessary. The SNFABN provides information to the beneficiary so that the resident can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility.

Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that one resident (#43) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The sample size was 3. The deficient practice could result in necessary specialized services not being provided for residents that need it. Findings include: Resident #43 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Level I PASRR (Preadmission Screening and Resident Review) signed November 28, 2020 revealed the resident was for convalescent care and required 30 days or less nursing facility services. The section for Identification of Potential Mental Illness did not have anything circled. However, once the resident's stay exceeded 30 days, review of the clinical record revealed no evidence the Level I PASRR was updated. Review of a physician order dated August 3, 2021 revealed for [MEDICATION(S)] (antipsychotic medication) 175 milligrams by mouth once a day for [CONDITION(S)] disorder, [CONDITION(S)] type. Review of the care plan dated September 6, 2021 revealed the resident used [CONDITION(S)] drugs and is at risk for adverse consequence related to receiving antipsychotic ([MEDICATION(S)]) medication for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches included assessing if the resident's behavioral symptoms present a danger to the resident and/or others, intervene as needed. A physician order dated January 24, 2022 included [MEDICATION(S)] 3 milligrams orally at bedtime for [CONDITION(S)], current episode hypomanic. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed no evidence a PASRR Level I was updated/completed and that the resident was referred for a Level II PASRR. During an interview conducted on April 28, 2022 at 12:53 PM with a Social Worker (staff #218), she stated that the resident was admitted with a PASRR which indicated that the resident did not have any mental illness, but listed dementia as one of the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She added after reviewing the resident's record, that the resident was receiving psychiatric services on an ongoing basis. Review of the facility policy, Pre-admission Screening and Resident Review (PASRR), revealed that the PASRR helps to ensure individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid certified nursing facility be evaluated for mental illness and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting; and 3) receive the services they need in those settings including specialized services. The policy stated that for individuals requiring admission to a nursing facility for convalescent period or respite care (not to exceed 30 consecutive days), do not require a PASRR Level II evaluation. If it is later determined that the admission will last longer than 30 consecutive days, a new PASRR Level 1 screening must be completed as soon as possible or within 40 calendar days of the admitted to the nursing facility. Additionally, it stated that a resident is to be referred for a PASRR if there has been a change in diagnosis/addition of a mental health diagnosis.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure that one resident (#71) received a Level I Pre-admission Screening and Resident Review (PASRR) after remaining in the facility for longer than the predetermined 30-day convalescent stay. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs. Findings include: Resident #71 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Level I PASRR screening document dated 07/30/21 revealed the physician had certified the resident required 30 days or less of convalescent care after receiving acute inpatient care from the hospital, and that the resident required nursing facility services for the same condition. The document indicated the resident did not have a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a History and Physical dated 08/02/21 revealed the history of the resident's present illness included [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] disorder. In addition, the documentation indicated that the resident had previously demonstrated agitation which had required restraints. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The associated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 08/09/21 at 1:36 p.m. included that the resident had been yelling out that shift, more than twice per hour, Help! Someone come help me! The note indicated that the resident displayed obvious signs and symptoms of distress when staff entered the room as evidenced by crying, removing oxygen, pacing in the wheelchair, and restlessness. The resident demanded that the nurse Hand me the tic tac toe off the wall so I can untangle all of this! Give me the cord of my phone so I can put it in the bottom of my dresser I need my bed done so I can start the finish! The note included that despite redirection and reassurance the resident remained in a delusional state, and was inconsolable with interventions. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The associated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Another Level I PASRR screening document dated 08/30/21 revealed that the physician had certified that resident required 30 days or less of convalescent care after receiving acute inpatient care from the hospital, and that the resident required nursing facility services for the same condition. The document indicated that the resident did not have a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Social Services note dated 09/21/21 revealed that on that date the resident was to be transferred onto the long-term care unit. The note included that the resident and a family member were notified with no objections, and that social services would follow for the adjustment process as needed. However, review of the clinical record did not indicate a Level I PASRR was completed/updated and/or that the resident had been referred to the state authority for Level II PASRR screening. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 6 on the Brief Interview for Mental Status, indicating severely impaired cognition. The assessment revealed the resident had no mood issues or behaviors, including hallucinations or delusions. The resident required 2-person extensive assistance for most activities of daily living, active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received antipsychotic and antidepressant medications for 7 out of 7 days in the look-back period, and according to the assessment, had not received psychological therapy. On 04/27/22 at 2:04 p.m., an interview was conducted with the Director of Social Services (staff #154). She stated that there were 3 social workers in the facility who divided the residents between them. She stated that her expectation was that residents who are admitted for a 30-day convalescent stay, but remain in the facility longer, would receive additional PASRR screening. She stated that she would consider [CONDITION(S)] disorder to be a serious mental illness. She stated that she thought the screening was probably overlooked. An interview was conducted on 04/29/22 at 9:42 a.m. with the Director of Nursing (DON/staff #188). She stated that social services are responsible for management and review of the PASRRs. She stated that if a resident was enrolled into long-term care, a new screening evaluation will be completed. She stated that the lack of further screening did not meet her expectations. The facility's policy titled Pre-Admission Screening and Resident Review (PASRR) included that PASRR screening is guided by federal regulations that require all individuals being considered for admission to a Medicare-certified nursing facility (NF) be screened prior to admission to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition. PASRR helps to ensure that individuals are not inappropriately placed in nursing homes for long-term care, that they are offered the most appropriate setting for their needs, and that they receive the services that they need in those settings including specialized services. For individuals requiring admission to a nursing facility for a convalescent period or respite care (not to exceed 30 consecutive days), they do not require a PASRR Level II Evaluation. If it is later determined that the admission will last longer than 30 consecutive days, a new PASRR Level I screening must be completed as soon as possible or within 40 calendar days of the admitted to the nursing facility.

Based on observation, staff interviews, and review of policy, the facility failed to ensure medications were not left in the room of one resident (#95). The deficient practice could negatively impact residents' care, and could result in residents not receiving medications as ordered by the physician. Findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a Self-Administration of Medication Observation dated completed on December 22, 2021. The document stated the resident did not want to self-administer medications and that it was not appropriate for the resident to self-administer any medications. Review of the annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 which indicated the resident had intact cognition. During an observation conducted on April 25, 2022 between 10:21 AM, a white paper medication cup was observed on resident #95's bedside table. The cup contained approximately 11 medications. The bedside table was across the room, out of reach of the resident who was lying in bed sleeping. Another observation was conducted on April 25, 2022 at 10:39 AM, in which the medication cup containing medications was still on the bedside table away from the resident. The resident was sleeping in the bed. At that time, a CNA (Certified Nursing Assistant) entered the room and then exited. During a resident interview and observation conducted on April 25, 2022 at 11:04 AM, the medication cup containing pills was still on the bedside table. The resident was lying in bed awake. The resident stated that the pills were left on the bedside table, because he went to sleep before they gave them to him. He also stated that the nurses leave the pills at his bedside a couple of times a week. The resident further stated that they trust him to take the medications because he knows they are important. He also stated that the morning medications had been left on his bedside table this morning. An observation was conducted on April 25, 2022 at 11:45 AM. The medication cup containing medications was still on the bedside table, away from the resident's reach. An interview was conducted on April 25, 2022 at 11:50 AM with a Licensed Practical Nurse (LPN/staff #231), who stated that when administering medications, she stays in the resident's room until the resident has taken all of the medications and that this is the facility's policy. The nurse then entered resident #95's room and observed the medication cup containing medications on the bedside table. She stated that she did pass medications this morning between 8:00 thorough 10:00 AM, and that these medications had been left on the bedside table, and had not been taken. She stated that this did not follow the facility policy and the risk is that the resident's roommate may have taken them, and that the resident is not receiving the medications he needs, or as ordered. An interview was conducted on April 27, 2022 at 8:51 AM with a Certified Nursing Assistant (CNA/staff #15), who stated that if a resident was assessed for self-administration of medications, it would be on the care plan, and that it would not be for prescription medications. An interview was conducted on April 27, 2022 at 9:04 AM with the Minimum Data Set (MDS) Director (staff #53), who stated that there should be a physician's order for a resident to self-administer medications, and it would be documented on the care plan. She further stated that medications should not be left at the bedside for residents to take later. An interview was conducted on April 27, 2022 at 11:07 AM with the Director of Nursing (DON/staff #188), who stated that the facility process for medication administration includes checking for the right drug, patient, time, and route, then the medication would be administered to the resident. She also stated the nurse should stay at the bedside while the patient is taking the medication. The DON stated that it is not following the facility process for the nurse to leave medications at the bedside. She reviewed the resident's medical record, and stated that there is not a care plan or order for self-administration of medication. She also stated the risk of leaving medication at the bedside unattended could result in a medication error, especially with psychiatric medications not taken on time, and risk that another resident could take them. She further stated that this does not meet the facility policy and she has already educated the nurse. Review of the facility policy titled, Medication Administration/Oral revealed only licensed nurses may administer medications. The policy also revealed to document administration of medications immediately, discard used containers, and move onto the next resident. Review of the facility policy titled, Self-Administration of Medications, revealed that all administration of medications will be under the supervision of a licensed nurse and documented by the licensed nurse. If a resident wishes to self-administer their medication, and the interdisciplinary care team decides the resident is capable, the medication will be given to the resident by a licensed nurse at the appropriate time and allow self-administration. The medication will be stored in the medication cart, not in the resident's room. If the medical provider orders that a medication(s) is to be kept at the bedside, the facility will supply a locked cabinet to be used to store the medications to prevent the medications from falling into the wrong hands.

Based on resident and staff interviews, clinical record review, and review of policy and procedure, the facility failed to provide one sampled resident (#335) the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in the resident's hygiene needs not being met. Findings include: Resident #335 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day admission Minimum Data Set assessment dated [DATE] included that the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The resident displayed no behaviors including rejection of care, and required extensive to total 1-2 person physical assistance for most activities of daily living (ADL). An ADL Functional/Rehabilitation Potential care plan dated 04/20/22 related to debility post infection and hospitalization had a goal for ADL needs to be met daily. Interventions included assisting the resident with bathing body parts that the resident could not do. On 04/25/22 at 11:10 a.m., an interview was conducted with resident #335 who stated since arriving at the facility, he had only received one shower. The resident also stated that staff have not offered him opportunities to shower and that he would like to have showers more often. An interview was conducted on 04/28/22 at 2:29 p.m. with the Director of Nursing (DON/staff #238). She stated that all of the shower documentation could be found in the Certified Nursing Assistants' (CNA) documentation in the clinical record. However, review of the CNA documentation revealed that the resident had received only one shower on 04/18/22. Review of the nursing progress notes did not include documentation which indicated that the resident had refused showers. On 04/28/22 at 2:32 p.m., an interview was conducted with a CNA (staff #33). She stated that when she gives a resident a shower she will document it in the CNA point of care notes in the resident's clinical record. She stated that residents receive 2 showers per week. She said that if residents refuse their shower, she will return later and ask again. She stated that if the resident continues to refuse she will tell the nurse. She stated that she will document the refusal in her point of care notes. The CNA stated that she remembered assisting the resident with at least one shower. The CNA pulled up the resident's shower documentation and indicated that she had documented the shower on 04/18/22. However, she reviewed the documentation and stated that the CNA record did not indicate that the resident had received additional showering/bathing opportunities. She stated that if the resident had refused, it would specifically state that in the record. Staff #33 then pulled up the refusal area in the documentation program and stated that if the resident had refused it would be included as such in the documentation. She stated that the code did not occur meant that the resident did not receive a shower. An interview was conducted on 04/29/22 at 7:45 a.m. with a Licensed Practical Nurse (LPN/staff #50). She stated that she speaks with the CNAs daily and asks them to notify her if a resident is refusing showers. She stated that she was not made aware that resident #335 had refused showers. The LPN stated that 3 attempts should be made to shower the resident, after which the nurse will document the refusal in the clinical record. The LPN stated that it would not meet her expectation for a resident not to receive 2 showers per week. On 04/29/22 at 9:49 a.m., an interview was conducted with the Director of Nursing (DON/staff #238). She stated that residents are offered 2 showers per week and that staff try to accommodate additional showers if requested. She stated that if the resident refuses, the CNAs are instructed to tell the nurse. The DON said that additional refusals would warrant a call to the provider and family. The DON stated that she thought that if a resident refused, it would be documented as did not occur in the resident's record. She stated that her expectation was for CNAs to offer showers to the residents 2 times each week and to accommodate their preferences accordingly. The facility's policy titled Bath/Shower included that the facility has a schedule for each unit to include bathing at least twice weekly.

Based on facility documentation, staff interviews, policy review, and the Centers for Disease Control (CDC), the facility failed to ensure the screening for COVID-19 was thorough for one staff (staff #6). The deficient practice could result in the spread of infection, including COVID-19 to residents and staff. Findings include: During the entrance conference conducted with the facility administrator (staff #28) and the Director of Nursing (DON/staff #56) on January 25, 2021 at 9:15 am, the administrator stated one staff member (staff #6) reported to the facility Infection Preventionist (IP/staff #32) on January 14, 2021 that she had been experiencing COVID-19 symptoms since January 7, 2021. The administrator stated the symptoms were not reported on the screening for COVID-19. The Start of Shift Employee Screening logs for the month of January 2021 revealed staff #6 was screened and that no COVID-19 symptoms were documented on January 1, 4, 5, 7, 8, 9, 10, 12, 13, and 14, 2021. The facility's employee routine testing records for the month of January 2021 revealed staff #6 was tested for COVID-19 using the facility's rapid [MEDICATION NAME] test on January 5, 8, 12, and 14, 2021, all with negative results. Review of the facility's line list tracking for COVID-19 revealed staff #6 received a COVID-19 polymerase chain reaction (PCR) test on January 14, 2021 and the positive result was reported on January 15, 2021. In the interview conducted with the administrator and the DON on January 25, 2021 at 9:15 a.m., the administrator stated that education was provided to staff regarding reporting symptoms and that a question was added to the screening for COVID-19. On January 25, 2021 at 2:40 pm, an attempt was made to interview staff #6 via phone, a voicemail was left. An interview was conducted with the IP (staff #32) via facetime on January 25, 2021 at 3:50 pm. Staff #32 stated staff #6 reported to her on January 14, 2021 that she had been experiencing fatigue and muscle aches since January 7, 2021 and had developed a cough on January 14, 2021. The IP stated that staff #6 said that she thought her symptoms were side effects from the COVID-19 vaccine she had received at the facility on January 5, 2021. Staff #32 stated staff #6 was tested at the facility at that time (January 14, 2021) using the facility's rapid [MEDICATION NAME] test and that the test was negative. The IP stated staff #6 was sent home and a sample was sent for PCR testing. The IP stated the PCR test result was positive for COVID-19. Review of the facility's document titled Education 1/20/2021 revealed to always report symptoms no matter if you think they are side effects from the vaccine etc. The facility's policy COVID-19 Clinical Protocol for Visitor and Employee Screening included that as part of routine practice, health care personnel (HCP) will be asked to regularly monitor themselves for fever, respiratory symptoms and COVID-19 like symptoms. It also included that HCP should be reminded to stay home when they are ill, and if HCP develop COVID-19 like symptoms while at work, they should immediately put on a facemask (if not already wearing), inform their supervisor, and leave the workplace. The policy was revised January 25, 2021, for screening to include questioning all HCP if they have symptoms related to COVID-19 vaccine. The CDC guidance Preparing for COVID-19 in Nursing Homes Updated Nov. 20, 2020 stated to screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Facilities should reinforce sick leave policies, and remind HCP not to report to work when ill. The CDC Post Vaccine Considerations for Healthcare Personnel updated December 13, 2020, revealed strategies are needed for healthcare facilities to appropriately evaluate and manage post-vaccination signs and symptoms among healthcare personnel (HCP). Systemic signs and symptoms, such as fever, fatigue, headache, chills, myalgia, and arthralgia, can occur following COVID-19 vaccination. Preliminary data from mRNA COVID-19 vaccine trials indicate that most systemic post-vaccination signs and symptoms are mild to moderate in severity, occur within the first three days of vaccination, resolve within 1-2 days of onset, and are more frequent and severe following the second dose and among younger persons compare to those who are older (>[AGE] years). Inform HCP about the potential for short-term systemic signs and symptoms post-vaccination. Develop a strategy to provide timely assessment of HCP with systemic signs and symptoms post-vaccination. Evaluate the HCP with signs and symptoms that may be from either the COVID-19 vaccination, [DIAGNOSES REDACTED]-CoV-2 infection, or another infection. Offer nonpunitive sick leave options (e.g., paid sick leave) for HCP with systemic signs and symptoms post-vaccination to remove barriers to reporting these symptoms.

Based on observations, staff interviews, review of the Center for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure infection control standards were followed. The deficient practice could result in the spread of infection, including COVID-19. Findings include: On May 27, 2020 at approximately 1:15 p.m. an observation of the Central Unit was conducted with the Director of Nursing (DON/staff #41). Staff #41 stated that the Central Unit was a secured dementia unit that housed both male and female residents. She stated there were currently 20 residents that resided there. Upon entry to the unit, a communal dining room was observed on the left side of the main hallway. 17 residents were observed in the dining room eating their meals. 13 of the residents were eating independently. Five square tables in the room were observed to accommodate 2 residents each. Three over-the-bed tables had one resident seated at each table. Two horseshoe shaped tables were observed along the left wall of the room. Each horseshoe shaped table accommodated two residents and a Certified Nursing Assistant (CNA). The CNA assisted both residents at their table with their meals. Each resident in the room was observed to be within one arm's length of one or more other residents. 6 feet social distancing was not observed. During the observation, one of the residents seated at the square table in the middle of the room was observed to reach across the table and take the other resident's roll off her plate and begin eating it. The DON quickly walked into the dining room and asked the resident for the roll. The resident gave the DON the roll. The DON requested another roll for the resident whose roll was taken. Directly behind each CNA seated at the horseshow shaped tables, a hand sanitizer dispenser was observed mounted on the wall. The CNAs were assisting the residents with eating and drinking. They alternated their assistance between each resident seated at their tables. However, neither of the CNAs was observed to utilize hand sanitizer between residents. An interview was conducted with the DON on May 27, 2020 at 1:25 p.m. She stated that the residents dine communally due to their risks for choking and aspiration and that some of the residents required cueing. On May 27, 2020 at 2:10 p.m., an interview was conducted with a member of the maintenance staff (staff #33) regarding the size of the tables in the dining room. Staff #33 measured the tables and stated that the two horseshoe tables measured 6 feet long by 4 feet wide, the five square tables measured 42 inches by 42 inches, and the over-the-bed tables measured 30 inches long by 15 inches wide. 6 feet is 72 inches. An interview was conducted on May 27, 2020 at 3:08 p.m. with a CNA (staff #64). She stated that it was facility policy to sanitize your hands between residents when assisting residents with their meals. She further stated that day; she had forgotten to sanitize her hands between residents. The facility's policy titled COVID-19 Resident Dining Protocol revised March 16, 2020 revealed a key reason for cancelling communal dining is linked to the concept of social distancing (e.g., limiting people being in close proximity to each other for periods of time; ideally people should keep about 6 feet apart). Social distancing is recommended by CMS for facilities regarding resident interactions. Communal dining is a common group activity that places residents in close proximity to each other. This can spread respiratory viruses. The policy included the facility will follow the CMS guidance with the following protocol: Implement social distancing in dining practices. Recommended approaches included: 1. Provide in-room meal service for those that are assessed to be capable of feeding themselves without supervision or assistance. 2. Identify high-risk choking residents and those at risk for aspiration who may cough, creating droplets. Meals for these residents should ideally be provided in their rooms; or the resident should remain at least 6 feet or more from others if in a common area for meals, and with as few other residents in the common areas as feasible during their mealtime . 3. If residents need to be brought to the common area for dining, do this in intervals to maintain social distancing . 4. Residents who need assistance with feeding should be spaced apart as much as possible, ideally 6 feet or more or no more than one person per table (assuming a standard 4 person table) . The policy also revealed staff member who are providing assistance for more than one resident simultaneously must perform hand hygiene with at least hand sanitizer each time when switching assistance between residents. The CDC guidance titled Preparing for COVID-19 in Nursing Homes stated that given the congregate nature and resident population served, nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. The guidance stated that implementation of social distancing measures should include aggressive social distancing measures (remaining at least 6 feet apart from others), and cancelling communal dining and group activities. The CDC guidelines titled Considerations for Memory Care Units in Long-term Care Facilities included limiting the number of residents or space residents at least 6 feet apart as much as feasible when in a common area. The CDC guidelines titled Hand Hygiene in Healthcare Settings stated multiple opportunities for hand hygiene may occur during a single care episode. The clinical indications for hand hygiene include immediately before touching a resident and after touching a resident or a resident's immediate environment.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#172) was free from abuse by another resident (#427). The deficient practice could result in the potential for further resident to resident abuse. Findings include: -Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan with a start date of 1/08/2019 revealed the resident had socially inappropriate and disruptive behaviors related to [MEDICAL CONDITION] and dementia which included wandering into peers' rooms and physical aggression. Interventions included assessing whether the resident's behaviors endangered himself or others and intervening as needed, every 15 minute checks when indicated, maintaining a calm environment and approaching to de-escalate or prevent a situation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive skills for daily decision making was moderately impaired. The assessment included the resident needed supervision for walking in the corridor and locomotion on the unit. Review of a nursing note dated 10/25/2019 revealed that at 6:20 AM resident #172 wandered into resident #427's room. Resident #427 became anxious, aggressive, and combative hitting resident #172 in the face with his foot. The residents were separated. Resident #172 continued to be mad stating he wants to kill him referring to resident #427. The note included the area to resident #172's right temple was cleaned and neuro checks were initiated. -Resident #427 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan with a start date of 6/3/2019 revealed the resident was a threat to himself and others related to wandering in other residents' rooms and outside without purpose, and refusing to take medications. The goal was that the resident would have minimal harm to self and others. Interventions included assessing whether the behavior endangered the resident or others and intervening if necessary, maintaining a calm environment, and when the resident begins to become socially inappropriate and/or disruptive, provide comfort measures for his basic needs. A quarterly MDS assessment dated [DATE] revealed the resident's cognitive skills for daily decision making was moderately impaired. The assessment included the resident could walk independently in the corridor and needed supervision for locomotion on the unit. A nursing note dated (MONTH) 25, 2019 at 7:30 AM revealed a certified nursing assistant (CNA/staff #252) responded to noise on the hall and that resident #427 was observed holding resident #172 by the shirt dangling him off the floor before he dropped him on the floor and started stomping on resident #172 with his foot. The CNA separated the residents. Resident #427 was very upset and kept repeating beat his ass. The note included one to one supervision was provided for resident #427. Review of the facility's investigation report dated 11/07/2019 revealed that on 10/25/2019 at approximately 6:20 AM a noise was heard in the hall. A CNA (staff #252) who was providing care to a resident went out into the hall and observed resident #172 on the floor in the doorway of resident #427's room with resident #427 over resident #172 holding resident #172 by the shirt. The CNA told resident #427 to let go of resident #172. Resident #427 let go of resident #172's shirt. Resident #427 then stepped over resident #172 striking him in the torso with his bare foot. Both residents were cursing and agitated at one another. The residents were separated and resident #427 was placed on 1:1 supervision. Resident #172 was observed to have a superficial abrasion on his cheek. No redness or bruising was noted on resident #172's torso. Resident #172 calmed down after a short period. Resident #427 continued to be agitated and focused on resident #172, stating that resident #172 had gone into his room. The report included resident #427 did not de-escalate from the incident and was ultimately sent to the hospital for evaluation of his agitation and behaviors at approximately 12:45 PM. An interview was conducted on 12/11/19 at 09:47 AM with the Director of Nursing (DON/staff #204). The DON stated that she was on duty when the incident happened. She stated the CNA (staff #252) did not see resident #172 being kicked in the face that the CNA only saw resident #172 being kicked in the torso. She stated that resident #172 was assessed to have no bruising, marks, or signs of pain to the chest but was observed to have a small scratch on his face that was assumed to have come from the altercation. The DON stated resident #172 was not observed hitting resident #427. The DON also stated that resident #427 was unable to calm down and was sent to the hospital. An interview was conducted on 12/11/19 at 3:17 PM with the CNA (staff #252) who witnessed the incident. Staff #252 stated that he heard resident #427 and resident #172 cursing and yelling. The CNA stated that he found resident #427 holding the shirt of resident #172 while resident #172 was on the ground, kicking resident #172 in the chest. He stated resident #427 stopped kicking resident #172 and continued to yell profanities at resident #172. Staff #252 stated the residents were separated and assessed for injury. Staff #252 also stated that resident #427 and resident #172 was placed on 1:1 supervision while the incident was being reported and investigated. During an interview conducted on 12/12/19 at 10:35 AM with the administrator (staff #85), the administrator stated that they are doing all they can to prevent incidents of abuse from occurring. Review of the facility's policy regarding preventing, reporting, and investigating abuse revised (MONTH) (YEAR), revealed their residents have the right to be free from abuse and that they are committed to protecting their residents from abuse by anyone including other residents. The policy also revealed abuse means the willful infliction of injury with resulting physical harm, pain or mental anguish. The policy included willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy also included instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

Based on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure the Office of the State Long-Term Ombudsman was sent a copy of the hospital transfer notice for two of four sampled residents (#185 and #229). The deficient practice could result in the ombudsman not being notified of transfers/discharges. Findings include: -Resident #185 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of a nursing note dated (MONTH) 9, 2019 at 12:14 a.m., revealed the resident was transferred to the hospital due to a change in condition. However, review of the clinical record revealed no evidence the Long-Term Care Ombudsman was sent a copy of the transfer/discharge notice. -Resident #229 was admitted to the facility on (MONTH) 13, 2019 with [DIAGNOSES REDACTED]. Review of the nursing discharge summary progress note dated (MONTH) 2, 2019 revealed the resident was sent to the hospital to be evaluated and treated for [REDACTED]. However, review of the clinical record revealed no evidence the Long-Term Care Ombudsman was sent a copy of the transfer notice. During an interview conducted with the social worker (staff #279) on (MONTH) 10, 2019 at 2:25 p.m., staff #279 stated that they did not notify the ombudsman when residents were discharged to the hospital. An interview was conducted with the administrator (staff #85) on (MONTH) 10, 2019 at 2:35 p.m. Staff #85 stated that they used to email the ombudsman when residents were discharged to the hospital and that she thought it was no longer a requirement to notify the ombudsman. Later at that day at 3:30 p.m., staff #85 stated that the ombudsman should have been notified when the residents were discharged to the hospital. Review of the facility's policy Transfer or Discharge Notice revised (MONTH) 2012 revealed the state long-term care ombudsman will be sent a copy of the transfer or discharge notice when an immediate transfer or discharge is required by the resident's urgent medical needs.

Based on clinical record review, staff interviews, facility documentation and policy and procedures, the facility failed ensure services provided met professional standards of quality, by failing to ensure that one resident (#370) received anticoagulant medication per the admission orders [REDACTED] Findings include: Resident #370 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. On the admission orders [REDACTED]. However, the recapitulation of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR for (MONTH) (YEAR) revealed documentation that a 24 hour chart check was completed for accuracy of daily new orders on 10/16/17, however, there was no documentation that the [MEDICATION NAME] and INR orders were identified as being missed from the recap and the MAR. Review of the Nurse Practitioner (NP) Initial Comprehensive Evaluation (H&P) dated 10/17/17, revealed the resident had HCVD (hypertensive cardiovascular disease) with [MEDICAL CONDITION]/CAD/AVR ([MEDICAL CONDITION]/[MEDICAL CONDITION]/aortic valve replacement). A baseline cardiovascular care plan dated 10/17/17 included under Cardio-output that the resident had a history of [REDACTED]. The section to include the potential for bleeding related to anticoagulants was not selected and there were no interventions related to the use of anticoagulants. An Interim Medication Regimen Review was conducted on 10/18/17, which included documentation that no medication related issues were found. An admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Additional physician and NP notes dated 10/25/17, 10/27/17, 10/31/17, 11/01/17 contained documentation that the resident had a history of [REDACTED]. of any anticoagulant therapy. Review of recap for 10/16/17 through 11/16/17 revealed no orders for [MEDICATION NAME] or INR lab tests, however the orders were signed by a staff member and a Registered Nurse (RN) who noted the orders on 10/17/17. The recap was also signed by the physician. A review of the MARs from 10/16/17 through 11/20/17 revealed the resident's chart was checked on the night shift every 24 hours for accuracy of daily new orders. A physician's orders [REDACTED]. An INR lab test was completed on 11/21/17 and the lab result was 1.2 which was a sub-therapeutic level. (Therapeutic INR levels for secondary prevention after a [MEDICAL CONDITION] infarction or for patients with high-risk mechanical prosthetic heart valves is 2.5 to 3.5. There was no clinical record documentation that the physician was notified of the sub-therapeutic INR result. A nurse progress note dated 11/22/17 revealed that around 7:30 p.m., the resident appeared to be confused. The resident's vital signs were stable, but her blood sugar was elevated at 447 and was administered insulin. The note also included that a family member requested the resident be sent to the hospital, so 911 was called and the resident was transported to the hospital at 9:00 p.m. Review of the emergency department physician note dated 11/22/17 revealed the resident presented with altered mental status. [DIAGNOSES REDACTED]. The resident was admitted to the Telemetry Unit in stable condition. A hospital physician's note dated 11/27/17 revealed the chief complaint of the patient was [MEDICAL CONDITION] with dysarthria (difficulty speaking). The History of Present Illness included, she has now suffered [MEDICAL CONDITION] being sub-therapeutic on her [MEDICATION NAME]. Review of the hospital course summary dated 11/29/17 revealed the resident was on chronic anticoagulation, due to mechanical aortic valve replacement. The resident presented to the emergency department due to progressive worsening of altered mental status, lethargy, and recent somnolence. In addition to confusion, the patient was having difficulty talking. The summary included the resident's INR level was 1.6, which is sub-therapeutic and given the patient's mechanical aortic valve, the resident should have a goal INR of 3. The documentation further included the patient was found, on repeat Computerized Tomography (CT) imaging to have an acute stroke, and this is thought to be embolic given her subacute therapeutic INR. Per neurology recommendations, we will continue [MEDICATION NAME] with up-titration still as to get her INR back in to range at a goal of 3.0. In an interview conducted on 10/31/18 at 1:48 p.m. with a Licensed Practical Nurse (LPN/staff #214), who stated that the medication orders are supplied by the hospital and signed by the hospital physician or NP. Staff #214 said that on admission, the orders are reviewed with the physician, usually by reading them over the phone, and then the orders are entered into the electronic chart. He stated that after the orders are entered, the order recap is printed, reviewed and signed by the physician at the facility. He said they also have a chart check process which is completed every 24 hours by the night nurse and includes a check of the new orders and verification that the order recap is correct. Staff #214 stated if there are medications that were on the hospital orders and not on the order recap, the nurse should look for a note as to why or call the physician. Staff #214 stated he would expect a resident with clinical indications for long term anticoagulants would continue on that medication while at the facility. He also stated that if the medications were missed when adding them to the electronic record, he would expect them to be caught during the chart check process. He said if a resident is on long term anticoagulants and they were suddenly stopped, it could result in coagulation of the blood leading to clots, [MEDICAL CONDITION] embolism, [MEDICAL CONDITION] and stroke. An interview was conducted on 11/01/18 at 9:15 a.m. with the Director of Nursing (DON/staff #241), who stated that the admitting department works on getting the resident information and orders from the hospital. The DON stated when she became aware of the missed [MEDICATION NAME] and labs for resident #370, she started a Performance Improvement Plan (PIP) for our Quality Assurance Process Improvement (QAPI) committee, which was designed to identify how this occurred and ensure there is a process in place so it does not happen again. The DON stated there was some confusion on the new admission orders [REDACTED]. The DON said that now staff make a note as to which order list was used for reconciliation and they continue to do random audits on orders and 100% audits on all admission charts. The DON stated all staff were re-educated on the process. She said in the case of resident #370, all of the hospital orders had [MEDICATION NAME] on them, and that it just got missed, and fell through all of their safety checks. She said the 24-hour chart checks missed it, the physician did a History and Physical the next day and missed it, and the pharmacy review did a review 2 days later and it was missed. The DON stated the Unit Manager brought it to her attention that the [MEDICATION NAME] was missed since admission and the physician was contacted and orders were obtained for the medication and lab tests on 11/20/18. The DON stated the INR was drawn on 11/21/17 and the result was 1.2, and the physician should have been notified, because it was at a sub-therapeutic level. The DON stated that as part of the PIP, a section was added to the MAR indicated [REDACTED]. An interview was conducted on 11/01/18 at 9:41 a.m. with the Administrator (staff #87), who stated the facility has initiated the following measures: -The nurse managers and weekend supervisors are completing chart audits and notify the Administrator if any discrepancies are identified -Staff education was initiated when this event was identified -Chart audits were completed on 100% of new admissions and randomly on other charts and no medication reconciliation issues were identified -Physicians are now asked to review the hospital orders for medications and the facility transcribed orders when they come in to see a new resident -The facility sends the hospital orders and the facility transcribed orders to the pharmacy for review -The pharmacy consultant reviews all medications errors and assists with identifying any process concerns and remedies -The medical director and the pharmacy consultant sign off on all medication errors. -The PIP was completed in (MONTH) (YEAR) and the issue was then turned to ongoing QAPI quality audits. Review of the facility PIP and ongoing QAPI documentation revealed the following: QAPI Action Plan was initiated on 11/28/17 with the root cause identified as multiple medication lists received from the hospital, causing confusion and changes to physician verified orders, which caused confusion with the chart checks. The tasks included education for licensed nurses on admission order transcription and 24-hour chart check process, updates to the admission audit process to ensure hospital orders and facility orders are reconciled and noted by the admission nurse, DON and Unit Managers will review all admission audits. All reports on activity for QAPI Action Plan will be reviewed every 2 weeks. The QAPI Action Plan also included the following: -Notes of ongoing review identified no new concerns on 12/15/17, 12/29/17, 1/11/18, 1/25/18, 2/8/18 and 2/22/18 -Action Plan did not note any concerns since staff education and the plan then transitioned to monthly updates at the QAPI Committee meeting -Staff education materials included 24-hour chart check steps and responsibilities, how to check orders for all admissions, and the procedure for admission order transcription and verification -Sign in sheets for 65 staff members between 11/28/17 and 1/9/18 -Admission audit sheets -Audits completed since beginning of PIP with no identified concerns Review of the facility's investigation and actions in response to the event included: -QAPI plan -Medication error report for the nurse that admitted resident #370 and reconciled the initial orders which were signed by the staff member, supervisor, DON, Medical Director, Administrator and Pharmacy Consultant. -Components of the clinical record that included the admission order sheet with handwritten notes, the transcribed orders appearing on the order recap, Interim Medication Regimen Review, H&P, and all documents from the QAPI plan -Chronological summary of events that included how the medication was missed at multiple check points during the first few days of admission to the facility, the description of events on the 11/20/17 when it was discovered that the medication was not administered, the events on 11/22/17 when the resident's condition changed and was transported to the hospital, and the resident's return to the facility following a stroke on 11/29/17. Review of the facility's policy titled, admission orders [REDACTED]. All admitting orders are to be reviewed by a licensed nurse. The nurse will document that the admission orders [REDACTED]. The nurse will then fax the admission orders [REDACTED] Review of the facility's policy titled, Anticoagulation - Clinical Protocol revealed that as part of the initial assessment, the physician will help identify individuals who are currently anticoagulated and assess for any signs or symptoms of adverse drug reactions and evidence of effects related to the sub-therapeutic or greater than therapeutic drug level. The policy included the nurse shall assess and document/report current drug and dosage of anticoagulation therapy, lab results and monitoring, active diagnoses, and other current medications. The physician will verify underlying causes of conditions requiring anticoagulation therapy and will prescribe the therapy in accordance with recognized guidelines and will order appropriate lab testing to monitor the therapy. The facility's policy titled, 24-Hour Chart Checks stated that the 24-hour chart checks will be completed by the night shift. The policy included that each chart is checked for new orders and if any error is noted it is reported to the unit manager and corrected immediately. If clarification of orders are needed, it must be followed-up promptly and reported. Staff will initial on the 24-hour chart check sheet located in the front of the physician's orders [REDACTED].

Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#370) was free from a significant medication error, by failing to administer an anticoaglulant medication per the admission orders [REDACTED] Findings include: Resident #370 was admitted from a hospital to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. On the admission orders [REDACTED]. However, the recapitulation of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR further showed that 24-hour chart checks were conducted daily, without recognition of the missed medication. As a result the resident did not receive the anticoagulant medication from the time of admission on 10/16/17 to the time of the discovered missed medication on 11/20/17 (for a total of 34 days). In addition, no INR lab tests were obtained. A physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed the resident was administered [MEDICATION NAME] on 11/20/17, 11/21/17 and 11/22/17. According to the INR lab test dated 11/21/17, the INR result was 1.2 (sub-therapeutic level). Further review of the clinical record revealed there was no documentation that the physician was notified of the sub-therapeutic level for the INR. A nurse progress note dated 11/22/17 revealed that around 7:30 p.m., the resident appeared to be confused. The note included the resident's vital signs were stable, but her blood sugar was elevated at 447 and was administered insulin. The note also included that a family member requested the resident be sent to the hospital, so 911 was called and the resident was transported to the hospital at 9:00 p.m. Review of the emergency department physician note dated 11/22/17 revealed the resident presented with altered mental status. [DIAGNOSES REDACTED]. The resident was admitted to the Telemetry Unit in stable condition. A hospital physician's note dated 11/27/17 revealed the chief complaint of the patient was [MEDICAL CONDITION] with dysarthria (difficulty speaking). The History of Present Illness included, she has now suffered [MEDICAL CONDITION] being sub-therapeutic on her [MEDICATION NAME]. Review of the hospital course summary dated 11/29/17 revealed the resident was on chronic anticoagulation, due to mechanical aortic valve replacement. The resident presented to the emergency department due to progressive worsening of altered mental status, lethargy, and recent somnolence. In addition to confusion, the patient was having difficulty talking. The summary included the resident's INR level was 1.6, which is sub-therapeutic and given the patient's mechanical aortic valve, the resident should have a goal INR of 3. The documentation further included the patient was found, on repeat Computerized Tomography (CT) imaging to have an acute stroke, and this is thought to be embolic given her subacute therapeutic INR. Per neurology recommendations, we will continue [MEDICATION NAME] with up-titration still as to get her INR back in to range at a goal of 3.0. An interview was conducted on 10/31/18 at 1:48 p.m., with a Licensed Practical Nurse (LPN/staff #214). Staff #214 stated that when a resident is admitted from the hospital, the hospital sends admissions orders, which are reviewed with the facility's physician, usually by reading them over the phone, and then entering them into the electronic chart. Staff #214 stated that after the orders are entered, the order recap is printed and the physician will review and sign the order recap. He stated that a chart check process is also completed every 24 hours by the night nurse which includes checking for new orders and verifying that the order recap is correct. Staff #214 stated that if there are medications that were on the hospital admission orders [REDACTED]. He stated that if the medications were missed when adding them to the electronic record, it should have been caught by the 24 hour chart check process. The LPN said that he would expect a resident on long term anticoagulants would continue on the medication while at the facility. He further stated that if a resident is on long term anticoagulants that were suddenly stopped it could result in coagulation of the blood leading to clots, [MEDICAL CONDITION] embolism, [MEDICAL CONDITION] and stroke. During an interview conducted on 11/01/18 at 9:15 a.m. with the Director of Nursing (DON/staff #241), the DON stated the admitting department obtains the resident information and orders from the hospital. She stated that when she became aware of the missed [MEDICATION NAME] and labs for resident #370, she started a Performance Improvement Plan (PIP) for their Quality Assurance Process Improvement (QAPI) committee. She said the PIP was designed to identify how this occurred and to ensure there is a process in place so that it does not happen again. The DON stated that in the case of resident #370, the hospital admission orders [REDACTED]. The DON stated that the 24-hour chart check missed it, the physician did a History and Physical the next day and missed it, and the pharmacy review conducted their review 2 days later and missed it. An interview was conducted on 11/01/18 at 9:41 a.m. with the Administrator (staff #87). The Administrator stated that the facility has initiated the following measures: -Chart audits were conducted on 100% of new admissions and randomly on other charts and any discrepancies are reported to the Administrator and none were identified -Staff education was initiated and completed -Physicians and the Pharmacy now review the hospital orders for medications and the facility orders when they come in to see a new resident -All facility physicians and NPs were alerted to what occurred and their role in reviewing new admission orders [REDACTED] -The medical director and the pharmacy consultant review and sign off on all medication errors. -The PIP was completed in (MONTH) (YEAR) and the issue was then turned to ongoing QAPI quality audits. Review of the facility's PIP and ongoing QAPI audits revealed the following: -QAPI Action Plan initiated on 11/28/17 with the root cause, tasks, and reporting process for findings -Notes of ongoing review identified no new concerns on 12/15/17, 12/29/17, 1/11/18, 1/25/18, 2/8/18, and 2/22/18 -Action Plan did not note any concerns since the staff education and the plan then transitioned to monthly updates at the QAPI Committee meeting -Staff education materials and education sign-in sheets -Admission audit sheet results Review of the facility's policy titled, admission orders [REDACTED]. All admitting orders are to be reviewed by a licensed nurse. The nurse will document that the admission orders [REDACTED]. The nurse will then fax the admission orders [REDACTED] Review of the facility's policy titled, Anticoagulation - Clinical Protocol revealed that as part of the initial assessment, the physician will help identify individuals who are currently anticoagulated and assess for any signs or symptoms of adverse drug reactions and evidence of effects related to the sub-therapeutic or greater than therapeutic drug level. The policy included the nurse shall assess and document/report current drug and dosage of anticoagulation therapy, lab results and monitoring, active diagnoses, and other current medications. The physician will verify underlying causes of conditions requiring anticoagulation therapy and will prescribe the therapy in accordance with recognized guidelines and will order appropriate lab testing to monitor the therapy. The facility's policy titled, 24-Hour Chart Checks stated that the 24-hour chart checks will be completed by the night shift. The policy included that each chart is checked for new orders and if any error is noted it is reported to the unit manager and corrected immediately. The policy included that if clarification of orders are needed, it must be followed-up promptly and reported. Staff will initial on the 24-hour chart check sheet located in the front of the physician's orders [REDACTED].

Based on clinical record review, staff and resident interviews, and hospital documentation, the facility failed to ensure the resident's environment remained free of accident hazards, by failing to ensure one resident (#168) was transferred safely using a hoyer lift. Findings include: Resident #168 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11, which indicated the resident had moderate cognitive impairment. Under functional status, the resident was assessed to be totally dependent with transfers and required the assistance of two persons. Review of a falls care plan revealed the resident was at risk for falls. The goal included that the resident will remain free from injury due to falls. An approach included for a two person transfer using the hoyer lift. A nursing note dated June 26, 2016 indicated a Licensed Practical Nurse (LPN/staff #96), heard a noise in the room of resident #168. Upon entering, the resident was on the floor and two CNAs (staff #18 and 181) were in the room. Staff #96 asked what happened and one of the CNAs stated something popped off. The LPN then observed that the top left top strap unhooked from the hoyer. The note further included that 911 was called, as the resident's head was bleeding. Another nursing note dated June 26, 2016 included that the resident returned to the facility and had 2-3 staples to the back of her head. Review of the facility's investigative report revealed the resident was alert and oriented times two, had expressive aphasia and right sided [DIAGNOSES REDACTED]. On June 26, 2016, the resident was being assisted out of bed by two staff members via hoyer transfer when it appears a strap slipped off a loop and she fell to her right side landing on her buttocks then falling back hitting her head. The resident sustained [REDACTED]. The report indicated two staples were placed to the laceration on the resident's head and the CT scan was negative for internal injuries. The resident returned to the facility the same day. The report further included that the hoyer lift and the sling straps were immediately checked for failure and no faulty equipment was found. The report also noted It appears that as the hoyer was lifted a strap slipped of (sic) the hook on the hoyer. In an interview conducted with resident #168 on July 27, 2016 at 11:40 a.m., the resident stated she was getting transferred from the bed to her wheelchair by two CNAs (Certified Nursing Assistant) using the hoyer lift. She stated she was being lifted up and the left upper sling strap slipped off and she fell . She further stated she hurt the left side of her body and cut her head and had to go to the hospital. An interview was conducted with CNA (staff #313) and CNA (staff #303) on July 27, 2016 at 11:50 a.m. The CNAs stated they always used two staff to transfer a resident when using the hoyer lift and that they had training on the use of the lift, as part of the initial and ongoing training at the facility. An interview was conducted with a LPN (staff #96) on July 27, 2016 at 3:05 p.m. Staff #96 stated that on June 26, 2016, she was passing medications when she heard a loud noise. She stated she ran in the room and there were two CNAs (staff #18 and #181). She said she asked what happened and CNA #181 said she was guiding the hoyer by the feed and heard a pop and the resident fell to the floor. She stated she looked at the straps of the sling and nothing was wrong with them. She said the resident's head was bleeding, so 911 was called. She stated that she didn't want to move the resident, because of how high she was when she fell . She stated the resident was approximately 4-5 feet off the floor when she fell . An interview was conducted with CNA (staff #18) on July 28, 2016 at 7:55 a.m. Staff #18 stated that staff #181 hooked up the top of the sling and she hooked up the bottom of the sling. Staff #18 stated her role during the transfer was to guide the resident. She stated staff #181 voiced that there was resistance when moving the hoyer and thought the hoyer might be caught on a cord from under the bed. She said at that moment the hook on the top right of the hoyer came undone and the resident fell to the floor. Staff #18 stated she looked at the equipment following the fall and there were no tears, rips, or defects on the sling. She also stated the resident was not moving or flailing during the transfer. In an interview conducted with CNA (staff #181) on July 28, 2016 at 8:00 a.m., staff #181 stated that staff #18 was the one who hooked up the upper sling loops and she hooked the lower sling loops, and that her role in the transfer was to raise the hoyer and guide the lift out from under the bed to position it for transfer to the wheelchair. She stated that staff #18 was to guide the resident, however, staff #18 left the head of the resident and went to move the wheelchair, so she was not near the resident's head to watch the sling loops, as she was supposed to do. She stated that is when the upper right loop slipped and the resident fell to the floor. Staff #181 stated she looked at the equipment and sling following the incident and there were no defects identified. She also stated the resident was not moving or flailing during the transfer. In an interview conducted with the Director of Nursing (DON/staff #276) on July 28, 2016 at 10:15 a.m., the DON stated that during the transfer a sling strap slipped off the hook on the hoyer lift. A policy regarding the use of hoyer lifts was requested, however, the facility did not have a policy related to the use of hoyer lifts.

Based on clinical record reviews, staff interviews, review of facility and hospital documentation, and review of facility policies and procedures, the facility failed to ensure safety measures were implemented for two residents (#36 and #440) who fell and sustained fractures. The sample size was five. Findings include: -Resident #440 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Fall Risk care plan updated on May 8, 2013, which identified the resident was at high risk for falls. An approach to prevent falls included "...bed in low position...alarm to bed ... " The CNA (Certified Nursing Assistant) Activities of Daily Living (ADL) cardex documented "Special Equipment: Low Bed..." A physician's progress note dated August 5, 2013, documented the resident was under hospice care and required maximum assistance with all care. According to a Condition Change Form dated September 12, 2013, the following was documented: "Resident observed sitting on floor next to bed on grey mat...Alarm not in place, bed in high position..." A physician's orders [REDACTED]. Review of the x-ray results dated September 12, 2013, revealed the resident had a fractured left hip. According to the facility's investigation, a CNA had provided care to the resident and left the room. The CNA did not lower the bed or apply the bed alarm and the resident fell out of bed. Review of a Notice of Counseling Action dated September 12, 2013, documented "...resident bed in high position. No bed alarm in place on patient which led to patient fall..." Another Notice of Counseling Action dated September 13, 2013, documented "CNA failed to lower bed after providing care or replace personal alarm for resident who is known fall risk. Bed reported at chest height. resident sustained [REDACTED]. Employee was terminated." An interview was conducted with the DON (Director of Nursing) on February 26, 2014. The DON stated that the CNA did not lower the resident's bed or put the alarm on, after providing care to the resident and the resident fell to the floor, sustaining a hip fracture. The DON stated that it specified on the resident's care plan that the resident was a fall risk and the bed should have been lowered and the alarm applied. The DON stated that the CNA did not follow the resident's care plan, which was documented on the cardex in the ADL book for CNA's. A facility policy regarding the Safety and Supervision of Residents documented "...Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The policy also included to ensure that interventions to reduce accident risks and hazards are implemented. A review of the facility's policy on Personal, Chair and Bed Alarms included, "Resident will be provided use of alarm system, personal, chair, or bed, in order to alert staff to unassisted ambulation." -Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a fall risk evaluation dated April 1, 2013, revealed the resident had fallen 1-2 times in the past three months and was at high risk for falls. Review of the resident's care plan revealed that the resident was at high risk for falls related to her high fall risk score and due to multiple falls. A care plan for ADLs identified that the resident required extensive assistance with transfers. The interventions included to use the pro-assist lift (PAL), as needed. According to a physical therapy evaluation dated April 2, 2013, the resident's status was discussed with the nurse and was able to do PAL transfers with the CNAs, without difficulty. The note documented to continue with the PAL transfers. The ADL information sheet also noted that the resident required PAL transfers for mobility and positioning. A quarterly Minimum Data Set (MDS) assessment dated [DATE], included the resident was assessed to require extensive assistance with transfers including from the bed, chair and wheelchair and required one person physical assistance. Review of the assistive devices care plan updated on June 3, 2013, documented that an occupational therapy evaluation had been completed and the resident was to be a PAL lift transfer by staff to bed, wheelchair, shower, and toileting. Review of the nurse's weekly resident skin check updated on June 6, 2013, revealed under the activity and mobility section, that the resident was checked as needing a PAL lift for transfers. Review of the nursing notes revealed that on June 11, 2013 at 4:00 p.m., the resident was being transferred from her bed to the wheelchair and the CNA lost her balance and they both fell . The resident was noted to have hit the right side of her head against the wall. She denied pain upon assessment. A fall tracking log dated June 11, 2013, noted that an environmental factor related to the fall was that the wheelchair was unlocked, when the resident fell . The resident was noted to have right hip pain and had hit her forehead. Review of the facility's investigation revealed that the CNA who was transferring the resident admitted that she was not using the PAL lift and was transferring the resident with no assistance, when they lost their balance and fell to the floor. In addition, the resident's wheelchair was not locked all the way during the transfer. According to the Final Licensed Nurses Progress Note and Discharge Summary dated June 11, 2013, the resident had gone out on leave (the same day as the fall) with her family, when she began to complain of pain from the fall and she was taken to the hospital and admitted . The facility's investigation also included a statement by a LPN who stated that it was her opinion that if the resident felt okay and had no pain, it would be alright for her to go on the outing. Review of the hospital records dated June 11, 2013, revealed the resident was admitted to the hospital. The records included the resident's right leg was shortened and internally rotated and she was in significant pain. The resident was diagnosed with [REDACTED]. The records noted that the resident had also sustained a small abrasion over her right elbow and had tenderness over the right eyebrow. The resident was discharged back to the facility on [DATE]. In an interview with the DON at 1:45 p.m. on February 25, 2014, she stated that the resident was care planned to use the PAL lift, but the CNA transferred the resident without the lift. She stated that the CNA should not have done this. She said that the PAL lift can be used by one person. In an interview at 2:30 p.m. on February 25, 2014, the resident stated that she remembered the fall and was being transferred from the wheelchair to the bed. She said the CNA did not use the lift and tried to move her by herself. She said they both fell and the CNA ended up being on top of her. She said there was a lot of pain from the fall. In an interview at 8:30 a.m. on February 26, 2014, a CNA stated that she will know if a resident needs a PAL lift by reviewing the ADL sheet or by reviewing the care plan. She said that if these documents say to use the PAL lift, she would not lift a resident unless she was using the lift. She said that as part of this process, she would lock the wheelchair wheels if the resident is being transferred out of the chair. Review of a facility policy and procedure for mechanical lifts revealed that lifts are used to move a resident by a mechanical means, to move and lift a resident safely, and to prevent injury to residents and staff during transfers. The policy noted that PAL lifts may be done with one nursing staff member.