Every finding on record at Draper Rehabilitation and Care Center

Based on interview and record review, the facility failed to ensure residents received a safe diet that met their special dietary needs for 1 out of 24 sampled residents. Specifically, Resident 1, who had a diet order for a minced and moist texture, was provided or obtained a muffin, which resulted in an airway obstruction. Resident identifier: 1Resident 1 was initially admitted to the facility on [DATE] with diagnoses including Parkinsonism, chronic obstructive pulmonary disease, dementia, acute kidney failure, and epilepsy. A review of Resident 1's medical record revealed a physician's order initiated on 11/18/2025 for a minced and moist diet.A review of a Nursing Note dated 7/20/2026 at 5:40 PM stated that nursing staff were called to the dining room and found Resident 1 cyanotic and unresponsive. Staff placed a call to 911, CPR was initiated, and paramedics arrived at the bedside.On 8/24/2026, the surveyor interviewed CNA 1. CNA 1 stated that a volunteer group had completed an activity in the dining room while residents prepared for dinner on 7/20/2026. CNA 1 stated that while passing out bibs to residents, CNA 1 observed Resident 1 leaning back in a chair with their head back, unresponsive, and gasping for air. CNA 1 looked into Resident 1's mouth, observed part of a muffin, removed the muffin, and alerted nursing staff for help. CNA 1 stated it was unknown how Resident 1 obtained the muffin.On 8/24/2026, the surveyor interviewed RN 1. RN 1 stated that CNA 1 reported a resident needed help. RN 1 responded first as the closest nurse and initiated vital signs in the dining room. RN 1 stated observing a muffin wrapper and pieces of a muffin on the table near Resident 1. RN 1 noted Resident 1's oxygen saturation was approximately 50%. Resident 1 was returned to their room for oxygen, 911 was called, and paramedics transported Resident 1 to the hospital.On 8/24/2026, the surveyor interviewed Admin 1. Admin 1 stated that an anonymous concern was reported to the facility's compliance officer that a resident received food outside of their diet order. Admin 1 stated that on 7/20/2026, a volunteer group was at the facility from 4:00 PM to 5:00 PM and handed out muffins. Admin 1 stated that the volunteer group and facility staff reported they did not give Resident 1 a muffin, and the facility was still investigating how Resident 1 obtained the muffin.On 8/24/2026, the surveyor interviewed two volunteer members. The volunteers stated they visit weekly and observed Resident 1 in the dining room around 5:00 PM on 7/20/2026. They stated they typically hand out snacks to residents who are able to eat, and were aware that Resident 1 required small pieces and supervision while eating. The volunteers stated they did not give Resident 1 any snacks on 7/20/2026 and left prior to the change of condition.On 8/24/2026, the surveyor interviewed Resident 24. Resident 24 stated being in the room when Resident 1 experienced a medical event. Resident 24 stated not seeing anyone give Resident 1 food or seeing Resident 1 eat, but recalled Resident 1 coughing a few times before staff rendered care.On 8/25/2026, the surveyor reviewed Resident 1's emergency department hospital records. An Emergency Department Note stated EMS initiated resuscitation after removing food obstructing the airway, suggesting an aspiration event as the precipitating cause. The note further documented that Resident 1 was found unresponsive and pulseless, requiring advanced cardiac life support interventions, airway management for food aspiration, CPR, defibrillation, and medication administration. Differential diagnoses included cardiac arrest secondary to a hypoxic event from aspiration.On 8/24/2026, the surveyor interviewed the Medical Director (MD). The MD stated that the emergency room reported food debris was removed from Resident 1 during intubation and that it was possible the cardiac event was caused by low oxygen from a food obstruction.

Based on interview and record review, the facility failed to ensure, for 2 of 7 sampled residents, that alleged violations involving residents were thoroughly investigated. Specifically, facility-reported incident investigations lacked complete information regarding interviews, protective measures, substantiated determinations, and systemic corrective actions. Resident Identifiers: 1 and 3. On 8/5/2026, the surveyor conducted a review of a facility reported incidents.The facility reported an incident involving Resident 1 on 7/7/2026. The facility failed to provide documentation of a 5 day follow-up investigation. The facility reported an incident involving Resident 1 on 7/1/2026. The facility's investigation stated, Follow up to [Resident 1]. He went to First Step to get his documents just like he said he was going to do when he signed himself out. He called us for a ride back, and we are enroute to get him. The police have also been notified. The investigation contained no further information.The facility reported an incident involving Resident 3 on 6/9/2026. The facility's investigation stated, Resident had fall 6/8/26 at 7am, rolled out of bed onto floor mat next to bed. After fall resident started to complain of pain in left hip. NP [name redacted] was notified and ordered XRAY. Nurse spoke with residents son [name redacted], he stated resident has had pain in that left hip for years and has refused any work up or intervention. Will only lay on right side due to pain in that hip. XRAY still ordered, results received evening 6/8/26 and showed acute left femurfracture. Resident sent to ER where he will receive surgery. Resident was quietly sleeping in bed before fall at 7am. The investigation contained no further information. On 8/5/2026, the surveyor conducted an interview with the interim administrator (IA), who stated that the previous administrator completed the final investigations.On 8/5/2026, the surveyor interviewed the acting Director of Nursing (DON), who stated the investigations were not thoroughly completed and acknowledged there was missing information. The acting DON stated that the investigations should include details about who was interviewed, what steps the facility took to protect the residents, if the allegation was substantiated or unsubstantiated, and, if applicable, information about new processes that need to be put in place.

Based on interview and record review, the facility did not provide care to prevent pressure ulcers. Specifically, for 1 out of 26 sampled residents, a resident developed a pressure ulcer from wearing an ankle foot orthosis (AFO) device. This resulted in a harm. Resident identifier: 7.Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential tremor, difficulty in walking, generalized muscle weakness, and unsteadiness on feet.On 11/17/25 at 10:23 AM, an interview and observation was conducted with resident 7. Resident 7 stated that she had a wound on her left heel that she had for a very long time. Resident 7 was sitting in her wheelchair with her left foot wrapped and in an off-loading boot. Resident 7's medical record was reviewed on 11/17/25 through 11/24/25.A review of resident 7's progress notes revealed the following:a. On 2/23/24 at 4:19 PM, an order note documented, REFER TO [name redacted] CLINIC TO REFIT/REPLACE AFO 2/28/24 @ [at] 11AM.b. On 1/7/25 at 3:11 PM, a nursing note documented, Noted swelling and indentation from brace. No open areas. Educated staff on removal while at rest and immediately at HS [bedtime] post transfer into bed. Reported to wound care team and to PT [physical therapy]. MD [medical doctor] aware.c. On 2/21/25 at 1:07 PM, a note documented, New R [right] buttock, sacral, and L [left] heel wounds.Tx [treatment] updated per [name redacted] NP [nurse practitioner]. Pt [patient] tol [tolerated] well. Pt to not wear AFO for now. Pt continues air mattress and pad for w/c [wheel chair]. Frequent repositioning. Pt started on liquacel, vitamin c, and multivitamin to promote wound healing. Family & provider aware of progress. WCTM [will continue to monitor].d. On 2/25/25 at 5:23 PM, a note documented, L HEEL BLISTER; PAINT SURE PREP THEN COVER WITH SILICON BORDERED FOAM QOD [every other day] AND PRN [as needed] every day shift every other day Start Date: 2/26/2025 clear fluid filled blister noted today that may have come from wearing AFO.e. On 3/7/25 at 4:33 PM, a note documented, Wound to L heel heel intact fluid filled blister continues, R buttock and sacral wound stage 2 continue. Pt tol tx well. Pt continues offloading boots and not to wear AFO for now.f. On 3/13/25 at 12:51 PM, a note documented, Seen by wound NP today. L heel blister is bigger with blood in it. Now a DTI [deep tissue injury] and NP assessed for any pressure causing the blister to get worst [sic]. Resident wears offloading boot all the time. Encouraged also to float with pillows. Consulted PT to make sure wheel chair is not causing pressure to heel. PT removed wheel chair foot strap to see if that makes a difference. Resident aware of TP [ treatment plan].g. On 4/18/25 at 1:19 PM, a note documented, Wound to L heel continues, 100% dry eschar with new blood blister to wound margin. NP aware. Pt tol tx well. Pt continues air mattress and offloading boots. Pt continues supplements to promote wound healing. Family & [and] provider aware of progress. WCTM.h. On 6/12/25 at 12:49 PM, a note documented, L heel wound 75% unstageable 25% dry eschar. Pt continues air mattress and roho cushion. Pt to not wear AFO for now. Pt continues multivitamin, vitamin c, and liquacel to promote wound healing. Diabetic mgmt [management] perprovider [sic] orders. Family & provider aware of progress. WCTM.i. On 11/6/25 at 12:59 PM, a note documented,Seen by wound NP today and she debrided the L heel wound. Resident tolerated well. Scant bleeding noted from the debridement. Updated treatment started. Resident was notified of the TP and she verbalized understanding.A review of resident 7's wound notes revealed:a. On 2/27/25, a wound progress note documented, .Left Heel is a Stage 2 Pressure Ulcer acquired on 2/27/25 and has received a status of Not Healed.b. On 3/31/25, a wound progress note documented, .Wound #1 Left Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 2/27/25 and has received a status of Not Healed.There is no change noted in the wound progression.c. On 7/24/25, a wound progress note documented, . Wound #1 Left Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 2/27/25 and has received a status of Not Healed.small open area noted approx [approximately] 5-6 o'clock with epithelialization noted to area.d. On 8/7/25, a wound progress note documented, . Patient given update on stability of wound # 1 with the eschar remaining stable. Will talk with therapy to ensure no pressure is being applied to that area with her therapy sessions.e. On 11/6/25, a wound progress note documented, . The wound is deteriorating.eschar is no longer stable.f. On 11/13/25, a wound progress note documented, . Wound #1 Left Heel is a Stage 3 Pressure Injury Pressure Ulcer acquired on 2/27/25 and has received a status of Not Healed.Adipose is exposed. There is a Moderate amount of sero-sanguineous drainage noted which has no odor.On 11/19/25 at 1:05 PM, an interview was conducted with the Wound Nurse. The Wound Nurse stated that resident 7's pressure ulcer had started as a blood blister and the facility tried to keep it from bursting, but it burst. The Wound Nurse stated that a Nurse Practitioner from an outside wound service came and rounded on the pressure ulcer weekly. The Wound Nurse stated that resident 7 got the pressure ulcer from wearing her AFO device. The Wound Nurse stated that the pressure ulcer was avoidable. On 11/19/25 at 1:33 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that she tried to round on every resident every two hours and would check for wet briefs. NA 1 stated that she would reposition residents only if they needed a brief change. On 11/19/25 at 1:35 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 7 could not move the left side of her body. CNA 1 stated that resident 7 frequently needed her feet and hips repositioned because she could not move them. CNA 1 stated that resident 7's feet would slip off the foot pedal of her wheelchair and would come out of her offloading boots often.On 11/20/25 at 8:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNAs were the nursing staff that repositioned residents and she expected them to reposition residents in a timely manner. The DON stated that therapy managed any braces that residents used and no order was placed in the resident's medical record. The DON stated that resident 7 had an AFO device and it caused a pressure ulcer. The DON stated that the therapy department was responsible for teaching staff about how to properly use an AFO device. The DON stated that AFO's can cause pressure and she hoped that they fit residents correctly. The DON stated that nursing staff should monitor the site because they put the device on and off resident 7. The DON stated that resident 7 had the AFO device placed in the morning and then it was removed at night before bed. On 11/20/25 at 8:23 AM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that AFO devices should only be worn during weight-bearing or transferring for joint stability. The DOR stated that an AFO device was hard plastic and could cause skin irritation and wounds. The DOR stated that resident 7 did not need to have the AFO device on while she was sitting in her wheelchair because her foot was in the correct position and the AFO was not needed. The DOR stated that an AFO device should only be worn for 4-6 hours if the resident was doing any weight bearing activities.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated food items stored in the refrigerator, dry storage, and freezer, a beardnet was not worn by a dietary aide; resident refrigerators' had undated and opened juice and food, and the sanitizer bucket was not testing at the required sanitation levels.Findings included:1. On 11/17/25 at 8:36 AM, an initial tour of the kitchen was conducted. The following observations were made:a. A box of fudgesicles was opened and undated in the freezer.b. Two Boston Cream pies were undated in the freezer.c. A container of sugar free lemonade was not labeled and undated in the refrigerator.d. A container of juice was not labeled and undated in the refrigerator.e. An opened and undated bag of hardboiled eggs was in the refrigerator.On 11/17/25 at 8:43 AM, during the initial tour of the kitchen, the Dietary Manager (DM) stated that the sanitizer bucket had been changed this morning at 7:00 AM. An observation was made of the DM testing the sanitizer bucket. The testing strip stayed orange which meant that no chemical was measured. The DM stated that he came in this morning and checked the sanitizer bucket logs and thought that it was done but it appeared that it had not been done.On 11/17/25 at 8:45 AM, the DM changed the sanitizer bucket solution and retested. The strip turned green and showed the level at 200 PPM (parts per million). The DM stated that 200 PPM was the correct level. 2. On 11/17/25 at 9:00 AM, an observation of the resident refrigerator was made. The following were observed:a. The resident fridge had an opened container of apple juice.b. The resident fridge had an opened container of prune juice with a date of 4/5 on the lid.c. The resident fridge had a container of macaroni and cheese and chicken nuggets with a date of 11/6/25.3. On 11/20/25 at 11:20 AM, a follow-up tour was conducted of the kitchen. The following was observed during the lunch tray line:a. The dietary aide was observed to have a beard and was not wearing a beard net.b. There was an opened bag of cabbage that was undated in the refrigerator.c. At 11:39 AM, the cook washed her hands and put gloves on. d. At 11:41 AM, the cook opened the oven while wearing the same gloves.e. At 11:42 AM, the cook touched the Brussels sprouts with the same gloved hands and then left the station to open a drawer and get another scoop. f. At 11:43 AM, the cook left her station with the same gloved hands and got a ladle. g. At 11:44 AM, the cook picked up a roll with gloved hands and touched Brussels sprouts with the same gloved hands.h. At 11:45 AM, the cook touched pasta on the plate with the same gloved hands, picked up a roll and placed it on a plate, and then left her station to get into the oven to get pot pies out to check the temperature. The pot pies were not at the correct temperature and the cook put them back into the oven while wearing the same gloves.On 11/20/25 at 11:33 AM, an interview was conducted with the DM. The DM stated that everything in the refrigerator, freezer, and dry storage should have a date of when it was received and when it was opened. The DM stated that the sanitizer bucket was changed every 2-3 hours and was changed before every meal service. The DM stated that he got rid of all the food and beverages that were undated after the initial walk through of the kitchen was done. On 11/20/25 at 12:50 PM, a follow-up interview was conducted with the DM. The DM stated that facial hair was a gray area and that the Dietary Aide should have a beard net on. The DM stated that his expectations of the kitchen staff were to change gloves when you change what you were doing or if you were dishing up food then gloves stay on unless they were ripped or dirty. The DM stated that if you leave your area and go to the oven then you need to change gloves. On 11/24/25 at 9:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that housekeeping cleaned out the resident refrigerator. The DON stated that resident food should be labeled and dated. The DON stated that food in the resident refrigerator was usually good for five days after it had been opened.

Based on interview and record review, the facility did not ensure that residents who use psychotropic drugs received a gradual dose reduction (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 4 out of 26 sampled residents, residents did not have an attempted GDR for psychotropic medications. Resident identifiers: 4, 9, 10, and 11.Findings included:1. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, cognitive communication deficit, dementia, generalized anxiety disorder, and mood disorder due to known physiological condition with depressive features. Resident 4's medical record was reviewed. A physician's order dated 1/12/23, documented to monitor hours of sleep every shift. According to the November 2025 Medication Administration Record (MAR) resident 4 slept an average of six hours during the night time hours. A physician's order dated 8/8/24, documented valproic acid capsule 125 milligrams (mg) two times (BID) a day for mood. A physician's order dated 8/9/24, documented mood stabilizer: monitor episodes every shift of behavior: angry outbursts. According to the November 2025 MAR there were no behaviors documented. A physician's order dated 8/20/24, documented temazepam capsule 7.5 mg at bedtime for insomnia. The Psychotropic Medication Review Form dated February 2025, documented GDR not indicated related to ongoing depressive and agitated behaviors. The form did not indicate which medications were not to have a GDR. Valproic acid documented zero angry outbursts. No documentation could be found stating a GDR of the valproic acid or temazepam had been attempted since 2024, or that a dose reduction was contraindicated. It should be noted the medical record did not reflect the date of a GDR attempt, the outcome of the dose reduction attempt, or a documented physician rationale for why GDR attempts were clinically contraindicated for each medication. On 11/24/25 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident 4 did not sleep and that was why they had not done a GDR. The DON stated the valproic acid did not have a GDR because resident 4 still had very aggressive behaviors. 2. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, schizophrenia, anxiety disorder, obsessive compulsive disorder, major depressive disorder, and cognitive communication deficit. Resident 11's medical record was reviewed. A physician's order dated 2/3/2020, documented number of hours slept. According to the November 2025 MAR resident 11 slept an average of seven hours during the night time hours. A physician's order dated 7/15/21, documented to monitor episodes of depression every shift as evidenced by negative statements about self/situation. According to the November 2025 MAR there were no behaviors documented. A physician's order dated 8/29/23, documented Lamictal tablet 25 mg. Give two tablets BID for major depressive disorder. A physician's order dated 9/18/23, documented mood stabilizer: monitor episodes every shift of behavior crying/tearfulness. According to the November 2025 MAR there were no behaviors documented. A physician's order dated 9/18/23, documented mood stabilizer: monitor episodes every shift of behavior: angry outbursts. According to the November 2025 MAR there were no behaviors documented. A physician's order dated 10/4/23, documented Cymbalta capsule delayed release 60 mg daily for major depressive disorder. A physician's order dated 7/26/24, documented trazodone tablet 50 mg at bedtime for insomnia. No documentation could be found stating a GDR of the Lamictal or Cymblata had been attempted since 2023, or that a dose reduction was contraindicated. In addition, no documentation could be found stating a GDR of the trazodone had been attempted since 2024, or that a dose reduction was contraindicated. It should be noted the medical record did not reflect the date of a GDR attempt, the outcome of the dose reduction attempt, or a documented physician rationale for why GDR attempts were clinically contraindicated for each medication. On 11/24/25 at 10:55 AM, an interview was conducted with the DON. The DON stated they had only increased resident 11's medications and just got the resident stable. The DON stated when resident 11 first arrived at the facility resident 11 would cry the entire time. The DON stated they tried reducing the Seroquel and the resident continued to have behaviors, so they added the Seroquel back. The DON stated there was a period where resident 11 was stable and doing really well and then resident 11 started the crying again. The DON stated they tried adding Depakote and that was too sedating so the Lamictal was added and resident 11 was stable on the Lamictal. The DON stated that resident 11's husband did not want the medications decreased without his permission. The DON stated there was more of a focus on the high risk medications and they forgot about the antidepressant. 3. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, anxiety disorder due to known physiological condition, major depressive disorder, cognitive communication deficit, and altered mental status. Resident 10's medical record was reviewed. A physician's order dated 11/30/23, documented monitor episodes every shift of depression as evidenced by crying and tearfulness. According to the November 2025 MAR there were no behaviors documented. A physician's order dated 11/30/23, documented monitor and document number of psychotic behavior every shift as evidenced by mood swings. According to the November 2025 MAR there were no behaviors documented. A physician's order dated 12/19/23, documented duloxetine capsule delayed release 30 mg. Give two capsules daily for depression. No documentation could be found stating a GDR of the duloxetine had been attempted since 2023, or that a dose reduction was contraindicated. It should be noted the medical record did not reflect the date of a GDR attempt, the outcome of the dose reduction attempt, or a documented physician rationale for why GDR attempts were clinically contraindicated for each medication. On 11/20/25 at 11:38 AM, an interview was conducted with the DON. The DON stated the psychotropic medication reviews were done on admission and quarterly. The DON stated that all residents were reviewed at the same time. The DON stated the pharmacist, DON, Assistant Director of Nursing, Minimum Date Set (MDS) Coordinator, social services, and the Medical Director attended those meetings. The DON stated they would review behavior tracking and anything that had been done on the floor. The DON stated that they would make medication changes as necessary and review for dose reductions. The DON stated the MDS coordinator would come to the meeting and care plan as they went. The DON stated they were doing other reductions with resident 10 and the team liked to only adjust one medication at a time. The DON stated that resident 10 had been more depressed lately because the granddaughter was going to take her home and then she could not. On 11/20/25 at 11:59 AM, an additional interview was conducted with the DON. The DON stated in April 2024 they were trying to decrease resident 10's Zyprexa because the duloxetine was increased. The DON stated they waited to make sure resident 10 was stable and in January 2025 the Ativan was decreased. The DON stated they waited again and in April 2025 they did not make changes because resident 10 had an infection. The DON stated in July 2025 the Zyprexa was decreased again and in August 2025 they wanted to make sure resident 10 was stable. The DON stated that resident 10 would be reviewed again this month. The DON stated they were trying to decrease the high risk medications first to be free from antipsychotics, benzodiazepines, and be stable. The DON stated that duloxetine was part of resident 10's chronic pain. 4. Resident 9 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Resident 9's medical record was reviewed from 11/18/25 through 11/24/25. A physician order dated 4/11/22, documented Ativan tablet 0.5 mg BID for anxiety. A review of resident 9's anxiety behavior monitoring revealed resident 9 had no complaints of anxiety or episodes of extreme restlessness during the months of September and November 2025. Resident 9 had eight days during the month of October 2025 where she exhibited symptoms of anxiety and extreme restlessness. Resident 9 complained of anxiety on two days in October 2025. A psychotropic medication review was conducted. a. On 8/20/24, Ativan 0.5 mg BID; diagnosis: anxiety; Increase/start date: 4/11/22; Target behavior #1: c/o [complaints of] anxiety- 0 episodes. The recommendation was to maintain the dose. b. On 11/19/24, Ativan 0.5 mg BID; diagnosis: anxiety; Increase/start date: 4/11/22; Target behavior #1: Anxiety-0 episodes. The recommendation was to maintain the dose. c. On 2/18/25, Ativan 0.5 mg BID; Increase/start date: 4/11/22; Target behavior #1: c/o anxiety-0 episodes; Target behavior #2: extreme restlessness-0 episodes. Recommended action was to review again in 90 days. d. On 5/20/25, Ativan 0.5 mg BID; diagnosis anxiety; Increase/start date: 4/11/22; Target behavior #1: c/o anxiety-0 episodes. The recommendation was to maintain the dose. No documentation could be found stating a GDR of the Ativan had been attempted since 2022, or that a dose reduction was contraindicated. On 11/24/25 at 12:32 PM, an interview was conducted with the DON who stated resident 9's Ativan had been decreased from four times a day to two times a day a few years ago, but no additional GDR had been attempted. The DON stated that she looked at the dates on the psychotropic meeting forms to determine if and when a dose reduction should be attempted. The DON stated they had reviewed resident 9's orders, psychotropic review meeting notes, and provider notes. The DON stated she was unable to find any documentation stating that there was a contraindication to a GDR of the Ativan. The DON stated that contraindication documentation was something that should be documented and she would discuss it with the team reviewing psychotropics at the next meeting.

Based on observation, interview, and record review, the facility did not ensure that the resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. Specifically, for 1 out of 26 sampled residents, a resident was observed lying flat during an enteral tube feed infusion. Resident identifier: 6.Findings included:Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, protein calorie malnutrition, profound intellectual disabilities, dysphagia, and gastrostomy status. On 11/17/25 at 10:31 AM, an observation was conducted of resident 6. Resident 6 was observed laying flat in bed with the tube feeding running and resident 6 had an occasional wet cough. The head of the bed was elevated but resident 6 was laying flat. On 11/17/25 at 10:33 AM, another surveyor verified that resident 6 was laying flat. A bag of Nutren 2.0 was infusing at a rate of 60 milliliters per hour (ml/hr). The water flush bag was infusing at a rate of 75 ml/hr.On 11/18/25 at 1:08 PM, an observation was conducted of resident 6. Resident 6 was observed to be positioned on his left side, laying flat in bed with the tube feeding running. Resident 6 had an occasional wet cough.On 11/19/25 at 1:19 PM, an observation was conducted of resident 6. Resident 6 was observed in bed laying flat with the tube feeding running.Resident 6's medical record was reviewed.A care plan Focus initiated on 12/13/22, documented [Resident name redacted] requires tube feeding r/t [related to] Dysphagia, Swallowing problem, Weight Loss, malnutrition, healing pressure ulcer. 2cal [calorie] tube feeding as ordered.The care plan interventions initiated on 12/13/22, included, but were not limited to, head of bed (HOB) elevated 45 degrees during and thirty minutes after tube feed and elevate HOB at least 30-45 degrees at all times during feeding.A physician's order dated 12/21/23, documented Enteral Feed Order every shift ELEVATE HOB AT LEAST 30 DEGREES DURING FEEDING AND ONE HOUR AFTER.A physician's order dated 9/23/25, documented Enteral Feed Order every shift 2CAL HN (high nitrogen) 60ml/hr with 75ml/hr free h20 [water] continuous.On 11/19/25 at 1:32 PM, an observation and interview was conducted with the Director of Nursing (DON). The DON stated that resident 6 was wiggly in bed. The DON stated that it looked like the staff tried to get resident 6 at 30 degrees. The DON stated that resident 6 would slide down in bed. The DON stated that resident 6 always had a wet cough because resident 6 was unable to swallow his secretions and resident 6 needed suctioning all the time. The DON stated that resident 6 had a peg tube. During the observation the DON adjusted resident 6's HOB. The DON stated that resident 6 was now at a 45 degree angle. The DON observed a pillow that had been placed under resident 6's left side. The DON stated that the pillow that was under resident 6's left side was propping resident 6's belly up so it was even with his chest. The DON stated that she was not aware that the pillows were causing resident 6 to be laying flat. The DON stated that resident 6 was on an air mattress with bolsters. On 11/19/25 at 2:09 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 6's mom was very particular with how resident 6 was positioned in bed and the pillows. LPN 2 stated that resident 6's mom was putting the pillows around resident 6 and not the staff. LPN 2 stated that she would speak with resident 6's mom about not placing the pillows under resident 6. LPN 2 stated that resident 6 moved around in the bed and the staff had to constantly reposition him. LPN 2 stated when resident 6 was awake the staff had to check on him almost every 15 minutes.

Based on observation and interview, it was determined, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed without eye protection when the county community transmission rate was high and staff were observed to not be wearing their surgical mask appropriately to prevent the spread of infection. Findings included: On 6/1/22 at 7:45 AM, the survey team entered the facility. Certified Nursing Assistant (CNA) 1 was observed without eye protection. CNA 1 assisted the survey team with the Coronavirus Disease 2019 (COVID-19) screening. On 6/1/22 at 8:00 AM, a Housekeeping staff member was observed without eye protection. On 6/1/22 at 9:06 AM, Registered Nurse (RN) 1 was observed wearing glasses without side shields or goggles. RN 1 asked this surveyor if I was wearing eye protection over my prescription glasses at my own discretion. On 6/1/22 at 12:17 PM, CNA 2 was observed in resident room [ROOM NUMBER] assisting the resident in bed A. CNA 2 was observed with their eye protection placed on top of their head. CNA 2's surgical mask was observed to be placed below the nose. On 6/1/22 at 12:17 PM, CNA 1 was observed exiting resident room [ROOM NUMBER]. CNA 1 was observed with their surgical mask placed below the chin. On 6/1/22 at 12:19 PM, CNA 4 was observed wearing glasses without side shields or goggles. On 6/1/22 at 12:35 PM, CNA 3 was observed walking through the 100 hallway with their eye protection placed on top of their head. On 6/1/22 at 12:38 PM, CNA 4 was observed wearing glasses without side shields or goggles. On 6/1/22 at 12:49 PM, RN 1 was observed wearing glasses without side shields or goggles. On 6/1/22 at 12:49 PM, a staff member was observed walking from the East end of the 100 hallway to the West end of the 100 hallway without a surgical mask or eye protection. The staff member used their key card to exit through the West door on the 100 hallway. On 6/1/22 at 10:51 AM, an interview was conducted with the Receptionist. The Receptionist stated the front door was always locked and she must unlock the door when a visitor arrived. The Receptionist stated she would ask the visitor who they were at the facility to visit, if they had been to the facility before, and if not, she would help the visitor go through the screening process. The Receptionist stated the screening program would beep if a visitor answered yes to any screening question or if they had an elevated temperature. The Receptionist stated the visitor could screen again if needed but if the visitor were having any signs or symptoms of illness, the visitor was not allowed to stay. The Receptionist stated there was someone at the front desk on the weekends who followed the same process. On 6/1/22 at 1:01 PM, an interview was conducted with CNA 3. CNA 3 stated that colored dots were placed around the facility, at every entrance, and where the staff clocked in for their shift. CNA 3 stated the colored dots would indicate what personal protective equipment (PPE) the staff were to wear while in the facility. CNA 3 stated the red dot indicated the staff were to wear a mask and eye protection. CNA 3 stated the orange dot indicated the staff were to wear a mask and eye protection. CNA 3 stated if the dot was yellow or green the staff should always wear a mask. [Note: The dot observed at the nurses station and near the CNA staffing board was red.] On 6/1/22 at 1:23 PM, and interview was conducted with CNA 5. CNA 5 stated when a new resident was admitted , they were put on isolation for 7 days. CNA 5 stated a sign was put on the door stating what PPE was required when entering the room. CNA 5 stated they were to wear full PPE. CNA 5 stated there were different signs for the different transmission-based precautions (TBP). CNA 5 stated he tried to memorize what PPE was required for each TBP. CNA 5 stated he knew what PPE was required in the facility because there were four colored circles by the time clock that were associated with the different levels of the county transmission rate. CNA 5 stated whatever color was on display determined what PPE should be worn in the facility. It was observed that red colored circles were placed throughout the facility that correlated with the current county transmission rate. On 6/1/22 at 2:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the current PPE required in the facility was a surgical mask and eye protection. The DON stated there were red dots throughout the facility that would indicate to the staff what the county transmission rate was and what PPE should be worn. The DON stated she updated the dots as she received updated information. The DON stated a red dot would indicate twice weekly COVID-19 testing, surgical mask, and eye protection. The DON stated she would track community transmission rates and county positivity rates to determine what PPE the staff should be wearing. The DON stated if the dot was green or yellow eye protection was not required. The DON stated if the dot was orange or red eye protective was required. The DON stated if staff were not vaccinated they were required to test twice weekly even if the positivity rate was low. The DON stated that the staff member that was observed walking through the 100 hallway was in the facility as a visitor. The DON stated that the staff member had an uncle who was a resident. The DON stated the staff member completed resident rounds once a week with an outside company. The DON stated that visitors would enter through the locked front door and were screened by the front desk staff member. The DON stated the front desk staff member would provide the visitor with a mask if they needed one. The DON stated that the front desk staff member was probably not at the front door and the staff member used her key card to obtain entry. The DON stated that staff were to enter at the employee entrance at the back of the facility. The DON stated that the physical therapy staff would enter through the front entrance, screen, and go to the therapy room. The DON stated the staff member was not working today, was considered a visitor, and knew to screen at the front entrance and get a mask. Review of the Centers for Disease Control and Prevention (CDC) guidance on 6/1/22, the Salt Lake County community transmission rate was High. https://covid.cdc.gov/covid-data-tracker/#county Review of the CDC guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Implement Universal Use of Personal Protective Equipment for HCP [Healthcare Personnel] that If [CONDITION(S)]-CoV-2 [Coronavirus Disease] infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The guidance was last updated on February 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Based on observation, interview and record review, it was determined that the facility did not store food in accordance with professional standards of food service safety. Specifically, food in the freezer, refrigerator and dry storage room was not labeled or dated, and food was open to air. Findings include: On 11/29/21 at 8:30 AM, an initial walk-through was completed in the facility kitchen. In the refrigerator a metal container was found that was not labeled or dated and had a light brown substance within it. The container was covered with plastic wrap. An interview was conducted with the morning cook (MC). The MC stated he was unsure if it was gravy or uncooked scrambled eggs. The MC took the container out of the refrigerator and asked a kitchen aide what the substance was. The kitchen aide stated it was gravy from a couple of days prior. The MC stated he would throw the substance away. On 11/30/21 at 1:50 PM, an interview was conducted with the facility Dietary Manager (DM). The DM stated all kitchen staff were responsible for putting food shipments away. The DM stated staff had been educated to put a received date on the food items before putting them away. The DM stated he was not aware of the process the previous dietary manager had been using for receiving food shipments and putting items in their designated locations. The DM stated the kitchen staff were not putting open dates or expiration dates on the food items. The DM stated most food came with an expiration date on it. The DM stated the Registered Dietitian (RD) had not performed any kitchen audits or staff education since he started at the facility 3 weeks ago. On 12/1/21 at 12:00 PM, a second walk-through of the kitchen was conducted. In the freezer, a box of cut Granny Smith apples was found to be open to air with ice crystals accumulated on them. A large item of meat was wrapped in plastic wrap with no label or date on it. Three bags of frozen vegetables were found not to be labeled or dated. In the dry storage room, a bulk box of pretzel sticks was found unsealed and open to air. In the refrigerator, a bulk plastic container of maraschino cherries was labeled with a received date of 2/23 and an open date of 3/10. The DM stated he would discard the cherries as there was not an expiration date on the item and no year indicated as to when they were opened.

Based on observation, interview, and record review it was determined the facility did not ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, for 1 out of 21 sampled residents, a resident was not provided assistance with showers. Resident identifier: 21. Findings included: Resident 21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/29/21 at 10:50 AM, an interview was conducted with resident 21. Resident 21 stated since October 4th he had only received two showers. Resident 21 stated he usually tried to shower himself prior to breaking his leg. Resident 21's medical record was reviewed on 11/30/21. An Admission Minimum Data Set assessment dated [DATE], documented that resident 21 required supervision and set up only for personal hygiene and physical help in part of bathing activity of one person physical assist. A review of the Shower Sheet / Skin Observation forms and Task ADL bathing the following entries were documented: a. On 10/6/21, received a shower. [Note: 1 shower was provided the week of 10/4/21.] b. On 10/13/21, received a shower. c. On 10/16/21, received a shower. d. On 10/21/21, received a shower. [Note: 1 shower was provided the week of 10/17/21.] e. On 10/26/21, received a shower. [Note: 1 shower was provided the week of 10/24/21.] f. On 11/6/21, refused shower. [Note: 1 shower was offered the week of 10/31/21.] g. On 11/10/21, received a shower. h. On 11/13/21, received a shower. i. On 11/20/21, received a bed bath. [Note: 1 shower was offered the week of 11/14/21.] j. On 11/27/21, received a shower. [Note: 1 shower was offered the week of 11/21/21.] On 11/30/21 at 11:04 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 21 was showered two times a week on Wednesday and Saturday in the evening. CNA 1 stated showers were documented on the shower sheets or the resident medical record. CNA 1 stated resident 21 was usually a set up only for showers and she would assist resident 21 with washing his back. CNA 1 stated if a resident were to refuse a shower she would document the refusal on a shower sheet. On 11/30/21 at 2:02 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 21 had never complained of missing showers but the shower sheets were not there. The DON stated they were in the process of providing an in-service for staff.

Based on interview and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that the residents were free from abuse, neglect, misappropriation of property and exploitation. Specifically, a Certified Nurse Assistant (CNA) exhibited sexually aggressive behavior by making inappropriate sexual comments and questions towards a resident. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21 the facility investigation documentation was reviewed. Review of the initial entity report to the state agency (SA) documented that the incident was reported to the facility staff by the resident on 8/5/21 at 8:45 AM. The report documented that the resident reported to CNA 1 that a Spanish speaking aide, whom the resident had never seen before, came into her room to take her vital signs. The aide told the resident that she was beautiful and asked how many children she had. The resident told the aide that she had 8 children. The report documented that the aide replied You must like to have sex if you had that many children. The report then documented that the aide asked the resident if she would like company because he knew someone that could have sex with her and could provide some companionship. The resident declined. The aide then asked the resident if she had ever performed oral sex. The resident reported that the aide never touched her but that she felt uncomfortable about the inappropriate comments. Resident 2 only speaks Spanish and waited until CNA 1 came into the facility to report the incident. The report documented that the staffing agency was notified of the aides conduct and the allegations and that the individual would not be allowed back inside the facility. Review of the staffing agency Invoice documented that the male agency CNA 2 worked 8 hours on 8/4/21. Review of resident 2's Quarterly Minimum Data Set (MDS) Assessment on 6/11/21 for the Brief Interview for Mental Status (BIMS) revealed that the resident scored an 8 out of 15. This would indicate moderate cognitive impairment. The resident was not able to report the correct day of the week (C0300C) nor recall the 3 words previously mentioned to her (C0400A, B, & C). The assessment documented No to the question was there any acute change in mental status from baseline (C1310A). The assessment documented that inattention was continuously present (C1310B), but that disorganized thinking and altered level of consciousness was not present (C1310C & D). The assessment documented under section E for behavior that the resident did not have hallucinations or delusions (E0100A & B). On 8/24/21 at approximately 9:15 AM an interview was conducted with the facility Administrator. The Administrator stated that the Licensed Clinical Social Worker (LCSW) handled the investigation and reporting. On 8/24/21 at 12:04 PM, an interview was conducted with the LCSW. The LCSW stated that she was filling in that week for the facility Social Service Worker (SSW) who was on vacation. The LCSW stated that on the morning of the incident the Staff Development Coordinator (SDC) reported that resident 2 had stated that CNA 2 had said some inappropriate comments. The SDC had determined that it was a Spanish speaking male agency CNA 2. The incident was reported to have occurred the night prior, and the resident did not know the exact time. The resident waited until a CNA that she knew came on shift to report the incident. The resident reported it CNA 1. The LCSW stated that she talked to CNA 1 and resident 2, and the story had remained the same without any inconsistencies. The LCSW stated that resident 2 reported that the agency CNA 2 had come into her room to take the her vital signs. CNA 2 had asked some normal questions at first and then asked some inappropriate questions. The LCSW stated that resident 2 reported that CNA 2 had told her she was beautiful. He asked if she had kids, and the resident replied she had 8. Resident 2 reported that CNA 2 said oh you must like to have sex a lot. The LCSW stated that the resident reported that she felt uncomfortable. The LCSW stated that CNA 2 then asked if she wanted companionship and she declined. The LCSW stated that the resident said he was asking if she was lonely. The LCSW stated that she could not tell if it was someone else or himself that he was offering companionship with. The LCSW stated that CNA 2 then asked the resident if she performed oral sex. At this point the resident ended the conversation. The LCSW stated that the resident did not say how she ended the conversation. The resident stated that the CNA left and she did not see him the remainder of the night. The LCSW stated that resident 2 stated that this interaction made her feel confused, and she felt it was inappropriate. The LCSW stated that resident 2 was worried that this would happen to someone that was not able to speak up. The LCSW stated that the resident felt uncomfortable, and worried that he might get upset after she reported this and come back to the facility. The LCSW stated that the SDC had already reached out to the agency, and informed them of the incident and that it would be investigated. The LCSW stated that she called the agency contact after she interviewed the resident. The LCSW stated that the agency contact person stated that she had called CNA 2, and he denied it. The agency contact person stated that they felt uncomfortable by the allegation, and they terminated CNA 2. The LCSW stated that she also reached out to the CNA registry and they referred her to Adult Protective Services (APS). The LCSW stated that the timing for notification to APS should be in the same timeframe for the SA, and that it was within a few hours of interviewing resident 2. The LCSW stated that all the dates and times were documented in the abuse report. The LCSW stated that as far as she knew APS called the resident a week later. The LCSW stated that resident 2's biggest concern was that CNA 2 would come back to the facility. The LCSW stated that she called the resident and family member to let them know that CNA 2 would not be allowed back inside the facility. The LCSW stated that she placed a copy of the CNA's driver's license at the front desk and notified staff to not to not allow this individual access inside the building. He is to not to be in the building for any reason. The LCSW stated that the family and resident were satisfied with that intervention. The LCSW stated that the resident reported that CNA 2 did not touch her or make gesture towards her. It was just comments. On 8/24/21 at 12:36 PM, an interview was conducted with the SSW. The SSW stated that she translated by telephone for APS last week on 8/16/21 for an interview with resident 2. The SSW stated that the APS investigator asked questions about what had happened and the resident answered consistently with what was in the report. The SSW stated that the resident said that CNA 2 told her she was pretty, asked how many children she had, said she must like to f***, and then said I bet you know how to do oral as well. The SSW stated that the resident replied no to the question about how to perform oral sex. The SSW stated that resident 2 reported that she felt embarrassed by the whole thing. The SSW stated that resident 2 was also worried if CNA 2 had a family, and did not want to get him into trouble. The SSW stated that the APS worker explained that it was wrong and important to know so it would not happen again to another person. The SSW stated that resident 2 said it made her feel better and trusted the staff at the facility. The SSW stated that resident 2 denied CNA 2 touching her. The SSW stated that resident 2 had no behaviors, hallucinations, but some mild confusion. The SSW stated that resident 2 always remembered her, and that her memory was really good. On 8/24/21 at 12:52 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 2 reported that CNA 2 told her she was very pretty. He then asked how many children had, did she perform oral sex, and that he had a friend that he thought she could date. CNA 1 stated that Licensed Practical Nurse (LPN) 1 was present when the resident was reporting the incident and she speaks Spanish also. CNA 1 stated that LPN 1 reported the incident to management and she spoke with the SDC when she came into the facility. CNA 1 stated that the resident was nervous that she reported it. CNA 1 stated that she reassured the resident and informed her that things like that should be reported and were serious. CNA 1 stated that the resident was afraid of the CNA 2 losing his job, and of him returning to the facility after she reported it. CNA 1 stated that resident 2 seemed rattled, nervous, and scared that he would come back to the facility. CNA 1 told the resident that he was not allowed back inside the facility. CNA 1 stated that CNA 2 made sexual comments towards the resident, but did not touch her. CNA 1 stated that CNA 2 was an agency employee and she had not seen him before. CNA 1 stated that this was the first time she had seen him in the building. CNA 1 stated that resident 2 did not have any behaviors and did not have hallucinations. CNA 1 stated that resident 2 had short term memory deficits, forgets where she placed things and had a short attention span. On 8/24/21 at 1:25 PM, an interview was conducted with the resident 2 with Spanish translation by the SSW. The resident stated that CNA 2 came in early in the morning to do the vital signs. Resident 2 stated she asked his name as she had not seen him before. Resident 2 stated that CNA 2 started saying things that he should not have said. Resident 2 stated that he started by saying how pretty she was. Resident 2 stated that she felt this was done to make her feel more comfortable or to give her confidence, but she was feeling embarrassed. Resident 2 stated that the CNA asked her if she f***ed around and did she know what oral was? Resident 2 stated that she told him I don't know anything, I don't know what you are talking about. Resident 2 stated she did not pay attention to him. Resident 2 stated he was not doing what he was supposed to do. The resident stated that CNA 2 did not touch her. Resident 2 stated that CNA 2 did not proposition her or ask her to do any of those things to him. No inappropriate gestures were made, just the words. Resident 2 stated that she felt disrespected and she did not want to talk to him. Resident 2 stated that she did not feel afraid, but was surprised at the words coming out of his mouth. Resident 2 stated that CNA 2 did not do her any harm. She was more embarrassed about it. Resident 2 stated that she never understood how someone in his position could say those things. Resident 2 stated that she felt like he was insinuating something. The resident stated that the good thing was that he did not try to do anything to her. Resident 2 stated that she was hoping that because people have talked to him about it he would not do this again. Resident 2 stated that she felt protected and safe at the facility because everyone was watching out for her. On 8/24/21 at 2:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that at the time of the incident she was on vacation and was not involved in the investigation, but was made aware of it. The DON stated that the resident did not have any behaviors, and no history of delusions or hallucinations. The DON stated that the resident did not have a history of making any allegations of abuse in the past. The DON stated that resident 2 had mild cognitive impairment but for the most part was alert and oriented times 3. The DON stated that the resident knows self, place, and situation. She knows the time of day but I don't know if she could tell you the exact date. The DON stated that resident 2 had a problem with memory and her last BIMS was an 8. The DON stated that the resident was unable to recall three objects on her assessment and the day of the week. The DON stated that resident 2 had occasional short term memory deficits. The DON stated that CNA 2 had never been to the facility before. The DON stated that they made a copy of the CNA's drivers license and posted at the front desk to ensure that he would not be allowed entrance into the building. The DON stated that he worked the graveyard shift on 8/4/21 to the morning of 8/5/21 from 10 PM to 6 AM. On 8/24/21 at 3:35 PM, an interview was conducted with the facility Administrator. The Administrator stated that he was newly hired on 8/1/21 and was out taking his licensing exam on the date the incident occurred. The Administrator stated that he had his phone turned off for this purpose and did not see the notification of the incident until he turned his phone back on at approximately 1:00 PM. The Administrator stated that resident 2 informed the CNA 1 at approximately 9:00 AM. The Administrator stated that the LCSW was in the building that week and the Assistant Director of Nursing (ADON) notified her of the incident. The Administrator stated that the ADON informed him of the incident, and he called her immediately when he turned his phone back on. The Administrator stated that he spoke to the LCSW and she said that she had already alerted the SA and APS, and the alleged perpetrator was removed from the building. The Administrator stated that the LCSW stated that she had interviewed the resident, the roommate, and residents in the area that had received care from CNA 2. The LCSW stated that she had interviewed other residents and none had reported any inappropriate interactions with that aide. The Administrator stated that resident 2's roommate reported that she had heard the resident and CNA 2 talking in Spanish but did not know what they were saying. The Administrator stated that the other residents were asked was there any abnormal behavior by this aide. The Administrator stated that he does not know who or how many other residents were interviewed. The Administrator stated that no other residents had any complaints with the aide. On 8/25/21 at 8:07 AM, a telephone interview was conducted with LPN 1. The LPN stated that resident 2 was scared, nervous, and uncomfortable because of the comments CNA 2 had made. LPN 1 stated that resident 2 had reported that she did not want to ring her call light for help so he would not come back into the room. LPN 1 stated that resident 2 reported that CNA 2 asked how many kids she had, stated that she must have liked sex, must have liked oral sex, and then told her she was beautiful. The resident stated that the CNA did not touch her, but made her feel really uncomfortable with the comments. LPN 1 stated that resident 2 was worried for days that CNA 2 was going to come back into the building. LPN 1 stated that CNA 2 told the resident that he could help her if she was in need of a sexual encounter. LPN 1 stated that once the incident happened she reported it to the DON and ADON by telephone. LPN 1 stated that after it was reported she did not mention it again to the resident because she did not want her to be concerned about it. LPN 1 stated that it was reported to the LCSW and she came in early in the morning. LPN 1 stated that the facility SSW was on vacation and she did not recognize this LCSW. LPN 1 stated that CNA 2 was not allowed back into the building and his picture was posted at the front door. The LPN stated that she asked if she needed to document anything and the ADON told her that the LCSW would take care of it. LPN 1 stated that resident 2 was alert and oriented times 4. LPN 1 stated that resident 2 knows where she was at, who she was, and can communicate well. LPN 1 stated that the resident did not have a history of making accusations like this in the past. LPN 1 stated that resident 2 did not have any behaviors and was compliant with care. LPN 1 stated that the resident did not have a history of hallucinations or delusions. The resident's roommate at the time of the incident, stated that she was not able to sleep because the resident was speaking in Spanish to the CNA. On 8/25/21 at 11:40 AM, a telephone interview was conducted with the SDC. The SDC stated she was informed of the incident by CNA 1 and LPN 1. The SDC stated that they had already reported the incident to the ADON. The SDC stated that she called the staffing agency and reported the incident. The contact person stated they would immediately start an investigation. The SDC stated that the incident that was reported to her by CNA 1 and LPN 1 was that resident 2 was uncomfortable talking to CNA 2 because he made comments about how beautiful she was, how many children she had, and she must like having sex. The SDC stated she did not speak to the resident herself as she does not speak Spanish and did not want to complicate the matter. The staff had reported that the resident had not been touched by CNA 2. The SDC stated that she was not made aware of any comments about oral sex and a person available to provide companionship to the resident. The SDC stated that resident 2 was alert and oriented time 3 to person, place, and situation. The SDC stated that in the past resident 2 had some confusion about time, but was very sick at the time. The SDC stated that resident 2 often tries to teach her Spanish. The SDC stated that resident 2 had no history of making allegations of abuse, and no behaviors. The SDC stated that when resident 2 first arrived at the facility she had some confusion and was very sick at the time with a urinary tract infection and COVID. The SDC stated that this confusion had since cleared now that the resident had recovered from her infections.

Based on interview and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation was made to the facility administrator or other officials, State Survey Agency, and Adult Protective Services (APS). Specifically, an allegation of sexual abuse was not reported to APS within 2 hours of the facility being made aware of the incident, Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21 the facility investigation documentation was reviewed. Review of the initial entity report to the state agency (SA) documented that the incident was reported to the facility staff by the resident on 8/5/21 at 8:45 AM. The report documented that the resident reported to CNA 1 that a Spanish speaking aide, whom the resident had never seen before, came into her room to take her vital signs. The aide told the resident that she was beautiful and asked how many children she had. The resident told the aide that she had 8 children. The report documented that the aide replied You must like to have sex if you had that many children. The report then documented that the aide asked the resident if she would like company because he knew someone that could have sex with her and could provide some companionship. The resident declined. The aide then asked the resident if she had ever performed oral sex. The resident reported that the aide never touched her but that she felt uncomfortable about the inappropriate comments. Review of the Report of Suspected Dependent Adult/Elder Abuse made to APS documented the date and time of notification as 8/5/21 at 2:54 PM. It should be noted that this notification was made six hours after the facility was informed of the allegation of sexual abuse. On 8/24/21 at approximately 9:15 AM an interview was conducted with the facility Administrator. The Administrator stated that the Licensed Clinical Social Worker (LCSW) handled the investigation and reporting. On 8/24/21 at 12:04 PM, an interview was conducted with the LCSW. The LCSW stated that she was filling in that week for the facility Social Service Worker (SSW) who was on vacation. The LCSW stated that on the morning of the incident the Staff Development Coordinator (SDC) reported that resident 2 had stated that a male CNA 2 who spoke Spanish and worked last evening had said some inappropriate comments. The SDC had determined that it was a Spanish speaking male agency CNA 2. The incident was reported to have occurred the night prior, and the resident did not know the exact time. The resident waited until a CNA that she knew came on shift to report the incident to. The resident reported it CNA 1. The LCSW stated that she talked to CNA 1 and resident 2, and the story had remained the same without any inconsistencies. The LCSW stated that resident 2 reported that the agency CNA 2 had come into her room to take the her vital signs. CNA 2 had asked some normal questions at first and then asked some inappropriate questions. The LCSW stated that resident 2 reported that CNA 2 had told her she was beautiful. He asked if she had kids, and the resident replied she had 8. Resident 2 reported that CNA 2 said oh you must like to have sex a lot. The LCSW stated that the resident reported that she felt uncomfortable. The LCSW stated that CNA 2 then asked if she wanted companionship and she declined. The LCSW stated that the resident said he was asking if she was lonely. The LCSW stated that she could not tell if it was someone else or himself that he was offering companionship with. The LCSW stated that CNA 2 then asked the resident if she performed oral sex. At this point the resident ended the conversation. The LCSW stated that she reached out to the CNA registry and they referred her to Adult Protective Services (APS). The LCSW stated that the timing for notification to APS should be in the same timeframe for the SA, and that it was within a few hours of interviewing resident 2. The LCSW stated that all the dates and times were documented in the abuse report. On 8/24/21 at 3:35 PM, an interview was conducted with the facility Administrator. The Administrator stated that he was newly hired on 8/1/21 and was out taking his licensing exam on the date the incident occurred. The Administrator stated that he had his phone turned off for this purpose and did not see the notification of the incident until he turned his phone back on at approximately 1:00 PM. The Administrator stated that resident 2 informed CNA 1 of the incident at approximately 9:00 AM. The Administrator stated that the LCSW was in the building that week and the Assistant Director of Nursing (ADON) notified him of the incident. The Administrator stated that he spoke to the LCSW and she said that she had already alerted the SA and APS, and the alleged perpetrator was removed from the building.

Based on observation and interview it was determined for 1 of 20 sampled residents that the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections. Specifically, licensed nursing staff did not sanitize a pair of scissors prior to use during a dressing change. Resident identifier 37. Findings include: Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/9/19 at 9:43 AM, an interview was conducted with resident 37. Resident 37 stated that she had a PU on her right buttocks. A wound vac dressing was observed on resident 37's right gluteus. Resident 37 stated that the wound vac dressing was placed last Wednesday, and the PU was also debrided last week. Resident 37 stated that the wound was healing slowly. On 9/9/19 at 10:31 AM, an observation was made of resident 37's PU dressing change by the wound nurse. Certified Nurse Assistant (CNA) 1 was observed assisting the wound nurse during the dressing change. The wound nurse was observed to gather the supplies necessary for the dressing change from a supply cart. Among the supplies was a pair of scissors. No observation was made of the wound nurse sanitizing the scissors. The wound nurse was observed to sanitize hands and apply new gloves. The wound nurse was observed to remove the wound VAC dressing drape from the sterile package. The wound nurse utilized the scissors to cut a hole in the center of the drape the size of the wound opening. The wound nurse then applied skin prep to the outer edges of the wound circumference, and the drape was applied. The wound nurse then cut a second piece of clear drape dressing and applied to the skin tracking away from the wound towards the right hip. The wound nurse discarded gloves, sanitized hands and reapplied new gloves. The wound nurse then removed the foam dressing from the sterile package and cut it with the scissors to the size of the wound bed. The foam dressing was then observed to be placed inside the wound bed. The wound nurse then applied another clear drape dressing over the foam dressing to secure in place. The wound nurse then cut the distal end of the foam dressing near the right hip and the vacuum suction tubing was applied. The vacuum suction was turned on and the negative pressure was set at 125 mm (millimeters)/hg (mercury). An immediate interview was conducted with the wound nurse. The wound nurse stated that she obtained the scissors from the wound cart and that she sterilized the scissors after each use with a micro-kill bleach wipe. The wound nurse stated that the floor nurse also had access to the dressing supply storage cart. The wound nurse stated that the other facility nurses could utilize the scissors in the cart. The wound nurse then stated that she also sterilized the scissors before use, but that she had forgotten this time. On 9/11/19 at 12:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for cleaning the scissors was to sanitize after each use. The DON stated that the wound nurse only cleaned the scissors after each use and not prior to use.

Based on observation, interview, and record review, the facility did not ensure that pain management was provided for 1 of 20 sampled residents. Specifically, a resident experiencing pain during wound care did not receive ordered pain medication. Resident identifier: 10. Findings include: Resident 10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/9/19, resident 10's medical record was reviewed and contained the following notes: a. On 8/22/19, Order summary: R Buttock. Dakins (wound cleanser) moist to wet, pack lightly then cover with absorbent dressing QD (daily) and prn (as needed). b. On 8/29/19, Order summary: [MEDICATION NAME] 5 mg (milligrams) to wound prior to wound care PRN. c. On 9/6/19 at 10:28 AM, physician progress notes [REDACTED]. On 9/10/19 at 9:30 AM, the wound nurse was observed performing a dressing change to the pressure ulcer on resident 10's right buttock. As the wound nurse scrubbed the wound with a Dakins soaked 4 x 4 gauze dressing and a large cotton swab, the resident made a fist and clenched the bed sheet in her right hand, grimaced, clenched her jaw, and shut her eyes tightly. She made slight whimpering noises and jerked her buttocks away from the nurse. When asked by this surveyor if she was in pain the resident stated, It hurts but I'm okay. (Note: The wound nurse did not use the ordered [MEDICATION NAME].) After the wound nurse left the room an immediate interview was conducted with resident 10. When asked if the wound cleaning had hurt she stated yes. When asked to rate her pain on a 1 to 10 scale with 1 being no pain and 10 being unbearable pain, she rated it at a 5/10. Resident 10 stated she had never been offered pain medication prior to wound care. At 11:51 AM, the wound nurse was interviewed. When asked if resident 10 has any medication to help with possible pain during wound care, she stated, No. She hasn't requested any either. I kind of like it when the patient reacts to a little bit of pain because that way I can tell the new tissue is growing. The wound nurse came returned a few minutes later and stated, It looks like she has an order for [REDACTED].>On 9/11/19 at 2:39 PM, the Director of Nursing (DON) was interviewed regarding resident 10's wound care. The DON stated, (resident 10) has [MEDICATION NAME]. I'd have to ask (wound nurse) when she uses it. Staff has told me that (resident 10) has said it's uncomfortable. When asked her expectation for using the ordered [MEDICATION NAME] for pain relief, the DON stated, If (resident 10) says, Ow, (wound nurse) would stop and get the [MEDICATION NAME] I would assume.

Based on observation, interview, and record review, the facility did not provide the appropriate treatment and services to prevent possible complications of enteral feeding for 1 of 20 sample residents. Specifically, one resident did not receive periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders: Resident identifier: 10. Findings include: Resident 10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/9/19 at 7:18 AM, resident 10 was observed in her room, lying in bed with a feeding tube attached and running. The bag of formula was not labeled with the type of formula, the time it was last filled, or the amount it was last filled with. On 9/9/19 at 12:21 PM, resident 10 was observed in her room, lying in bed with a feeding tube attached and running. The bag of formula was not labeled with the type of formula, the time it was last filled, or the amount it was last filled with. On 9/10/19 at 7:57 AM, resident 10 was observed in her room, lying in bed with a feeding tube attached. The bag of formula was labeled as follows: 0100 (1:00 AM) 9/10/19 2 cans 0100 2 cans 0600 (6:00 AM) (Note: Two cans of formula would be enough to run for approximatley 6 hours.) On 9/11/19 at 7:57 AM, resident 10 was observed in her room, lying in bed with a feeding tube attached. The bag of formula had the same label as it did on 9/11/19. The feeding pump was turned off and the formula bag was empty. At 9:04 AM, resident 10 was observed in her room, lying in bed with a feeding tube attached. The pump was still turned off and the formula bag was still empty. At 9:52 AM, the formula bag was observed with the following label: 9/11/19 09 [MEDICATION NAME] 1.2 80 ml/hr (milliliters per hour) H2O (hour) flush 25 ml/hr Resident 10's medical record revealed the following order: every (sic) shift continuous tube feeding: [MEDICATION NAME] 1.2 80ML/HR with H2O 25ML/HR. Resident 10's Medication Administration Record [REDACTED]. The record did not show documentation of the total feed resident 10 received, when formula was added to the tube feed bags, or when the pump was turned off and on. Resident 10's current care plan revealed the following: Registered Dietician (RD) to evaluate quarterly and PRN (as needed). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. On 9/11/19 at 3:22 PM, Licensed Practical Nurse (LPN) 1 was interviewed. When asked how staff tracks the volume of formula resident 10 is receiving each day, LPN 1 stated, It should say in the order, but it's a continuous feed. On 9/11/19 at 3:25 PM, the Director of Nursing (DON) was interviewed. When asked how the facility ensured resident 10 received the ordered fluid volume, the DON stated, We don't record it. We don't record how much she gets. When asked how resident 10's caloric needs are met if the facility was unsure of how many calories the resident received, the DON stated, We track weights and labs to make sure her caloric needs are being met.

Based on observation, interview, and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, packages of ready to eat luncheon meat were stored open to air and there was significant dust and debris in the food preparation area. Findings include: On 9/9/19 at 7:29 AM, the following observations were made in the kitchen. a. In the walk-in refrigerator, three packages of ready to eat luncheon meat in zip-top bags were open to air. b. There was significant dust on a window sill. The window was open. The window faced the oven and food preparation area. c. There was significant dust on a wall mounted water flirtation system in the kitchen. d. There was dirt and debris under the storage racks in the kitchen. On 9/11/19 at 9:15 AM, the dust on the window and filtration system remained. The Dietary Manager (DM) was interviewed. The DM stated that they tried to regularly clean the window sill. The DM stated that they recently cleaned the top of the oven and that the window sill should have been cleaned at that time as well, but had not.

Based on interview and medical record review it was determined, for 3 of 37 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as is possible. Specifically, one resident sustained [REDACTED]. area. Resident identifiers: 24, 44 and 148. Findings include: 1. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18, resident 24's medical record was reviewed. A nursing progress note dated 8/17/18 at 15:27 (3:27 PM), revealed Pt (patient) signed out LOA (leave of absence) to have smoke break, fell outside on break, skin tear to right arm, bleeding, cleansed with wound cleanser, applied steri-strips, vital signs, post fall checks initiated. No fall assessment could be located in the medical record to show whether or not resident 24 was safe to sign herself out LOA, ambulate away from the facility and to ambulate in the gravel to have a smoke break. On 8/28/18 at 10:50 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that she had resident 24's lighter and cigarettes in the medication cart and that whenever resident 24 wanted to go for a smoke break, she would send an aide with her because she was a fall risk. RN 5 stated that she did not know what other nursing staff would do with resident 24. 2. Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/27/18 at 1:43 PM, an interview was conducted with resident 44. Resident 44 stated that a facility nurse snipped him with scissors when changing the dressing over his pressure ulcer approximately 2 weeks ago. Resident 44's medical record was reviewed on 8/29/18. On 8/20/18 at 10:45 AM, the Director of Nursing (DON) documented in a progress note, Resident stated today that wound nurse cut him with her wound scissors when changing her (sic) dressings. Wound nurse and aide present when his dressing was changed on Saturday. Wound nurse did not use any scissors near residents skin, only used scissors at bedside table to cut dressings. On 8/29/18 at 11:07 AM, an observation was made of Registered Nurse (RN) 1 while changing resident 44's dressings to his pressure ulcer. RN 1 was observed to place a drape. RN 1 cut the drape using a pair of sharp pointed scissors to trim the drape around resident 44's pressure ulcer twice and then used the sharp pointed scissors to trim a thick black foam dressing around resident 44's pressure ulcer which placed resident 44 at risk for injury. On 8/29/18 at 12:06 PM, an interview was conducted with RN 1. RN 1 stated that it was easier to cut the drape and the black foam dressing using the sharp pointed scissors. 3. Resident 148 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/27/18 at 2:04 PM, an observation was made of resident 148 while laying in bed. Resident 148 was observed to have two 1/2 side rails on both sides of the bed. There was a gap, approximately 3 1/2 inches, between the mattress and the side rail on the left side of resident 148's bed. Resident 148's medical record was reviewed on 8/28/18. On 8/17/18, a progress note documented, Resident assessed by therapy and consent signed by patient for 1/4 side rails. Side rail does not restrict purposeful movement and is not being used as a restraint. Resident is aware of possible negative outcomes and would still like side rails. Bed and side rails are appropriate for residents height and weight. On 8/17/18, resident 148's care plan for ADL (Activities of Daily Living) Self Care Performance was updated to include the intervention of, SIDE RAILS: 1/4 side rails up as per Dr.s (doctors) order for safety during care provision, to assist with bed mobility. On 8/20/18 at 10:27 AM, the Assistant Director of Nursing (ADON) documented in a progress note, 1/4 SIDE RAILS FOR BED MOBILITY AND POSITIONING-NON RESTRAINT. clarification resident assessed by therapy and new order received. There was no additional information available for review to indicate resident 148's mattress and side rail were assessed for proper sizing of the mattress to decreased resident 148's risk of entrapment. On 8/28/18 at 1:55 PM, an interview was conducted with RN 2. RN 2 stated that the nursing staff watches for entrapment risk. RN 2 was not aware of the 3 1/2 inch gap between the mattress and the side rail. On 8/28/18 at 2:00 PM, an interview was conducted with the DON. The DON stated that the Maintenance Director was suppose to evaluate and check resident 148's bed and mattress for entrapment risks. The DON stated that the nursing department and staff conducted ongoing assessments for entrapment risks. The DON was not aware of the 3 1/2 inch gap between resident 148's mattress and side rails. On 8/28/18 at 2:04 PM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that he applied the 1/2 side rails to resident 148's bed. The Maintenance Director stated that he did not identify and did not measure the gaps between the mattress and the side rail.

Based on observation, interview and record review it was determined the facility did not ensure that the resident could exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility for 6 of 37 sample residents. Specifically, two alert and oriented residents were not allowed to smoke on or off facility property, three residents did not have privacy bags covering their down drains and two residents were pulled backwards in a shower chair with the buttocks exposed. Resident identifiers: 8, 27, 39, 44, 46 and 151. Findings include: 1. Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/29/18 at approximately 1:50 PM, and interview was conducted with resident 44 related to the facility smoking policy. Resident 44 stated that he was told that he needed to quit smoking or go to another place. Resident 44 stated that he was told to turn in his cigarettes and lighter and that he had not been allowed to smoke since his cigarettes had been confiscated and he could not afford to buy more. Resident 44's medical record was reviewed on 8/29/18. Review of the electronic progress notes revealed the following entries related to smoking: a. 7/27/18 at 9:34 AM: Social Worker informed by staff that resident was seen out in the community and was purchasing cigarettes. Social Worker spoke with resident about making sure and signing himself out and also that building is a non smoking building. Social worker informed that there are facilities that allow smoking if he wants social worker to assist with transferring. Resident stated he wanted to stay would be alright with complying with request. b. 8/3/18 at 6:28 AM: pt found outside smoking on (Name of facility redacted). pt was educated that this (Name of facility redacted) is a non smoking facility. Pt became verbally aggressive with nurse. WCTM (Will Continue To Monitor). c. 8/3/18 at 4:30 PM: .Reeducated on (Name of facility redacted) being a non-smoking facility and must check self out if he chooses to go off grounds to smoke. 2. Resident 151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/27/18 at 1:29 PM, resident 151 was interviewed. Resident 151 stated that he wanted to go outside and was told that he was not allowed to go outside. Resident 151 that he wanted to go outside to smoke and that he was treated like a common criminal. Resident 151's medical record was reviewed on 8/29/18. Review of the electronic progress notes revealed the following entries related to smoking: a. 8/20/18 at 12:25 PM: Social Worker spoke with resident today to see if he wanted to transfer to smoking facility. Resident has been signing himself out and smoking. Resident stated he wants to stay at this facility and gave social worker cigarettes and lighter. b. 8/27/18 at 2:19 PM: Stated that he wanted to go outside and was told that he was not able to go outside. On 8/28/18 at 10:10 AM, an interview was conducted with the facility Social Worker (SW). The SW stated that the facility was a nonsmoking building and that the facility tries to admit non-smoking residents. The SW stated that if a resident wanted to smoke, the family would be encouraged to come to the facility and take the resident out, off facility property, to smoke. The SW stated that she assisted resident's with transfers to a smoking facility if the resident's chose to smoke. On 8/28/18 at 10:20 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that potential resident's were to be notified that the facility was a non-smoking facility by the admissions coordinator prior to admission to the facility. The DON stated that if a resident chose to smoke, the resident would have to sign themselves out as a LOA (Leave of absence) and would have to leave the premises to smoke. Review of the facility Smoking Policy and Procedure, updated on 8/28/18, documented the following: POLICY: RESIDENTS & GUESTS: It is the policy of this facility that (Name of facility redacted) does not permit residents or guests to smoke in the facility, nor outside on Draper Rehab grounds. It is also our policy that residents who choose to reside at this facility agree not to smoke when residing at the facility. Residents are not permitted to retain any smoking material in their rooms or in their possession under any circumstance, for safety reasons. STAFF: Staff members are permitted to smoke only in the designated staff smoking area in the back corner parking lot. PR[NAME]EDURES: Smoking material in the resident's possession on admission will be placed in the Social Worker's office or at the nurses' station(s). Smoking material purchased by or for the resident will be turned over to the Social Worker or the charge nurse on duty. Smoking material found in the resident's room will be removed and placed with the Social Worker or at the Nurses' station(s), where family is able to pick up. Smoking materials will be returned to the residents upon discharge from the facility. MD (Medical Doctor) will be notified and smokers will be given options per MD orders (e.g., patch, gum, etc.). Smoking policies will be reviewed with employees, residents and guests as appropriate. All residents unable to comply with this policy will be assisted in finding appropriate placement, should they be unable or unwilling to quit. 3. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/27/18 at 7:08 AM, an observation was made of resident 27 being wheeled backwards down the hallway in a shower chair to the shower room. Additionally, resident 27's buttocks was observed to be exposed as well as her underwear top. Resident 27 was observed to be taken to the shower room by the facility Hospitality Aide (HA). 4. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/27/18 at 10:25 AM, an observation was made of resident 39 being wheeled backwards back to her room after having a shower. Additionally, resident 39's buttocks were observed to be exposed. Resident 39 was observed to be taken back to her room by the facility HA. On 8/29/18 at 7:20 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that residents should always be fully covered with nothing exposed. CNA 3 stated that it was never ok to push residents backwards in their chairs. CNA 3 stated that residents should always be able to see where they are going. On 8/29/18 at 7:25 AM, an interview was conducted with CNA 4. CNA 4 stated that residents should be fully covered when taken to the shower room and taken back to their rooms. CNA 4 stated that residents should be able to see where they were going, rather than being taken backwards to and from the shower room. On 8/29/18 at 7:43 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the CNAs should always make sure residents were covered completely. The facility DON stated that residents should always be able to see where they were going. The facility DON stated that residents should never be wheeled backwards, unless a resident prefers to be transported that way. 5. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/30/18 at 12:54 PM, an observation was made of resident 8's down drain bag. The down drain bag was observed to not be covered by a dignity bag. 6. Resident 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/30/18 at 12:56 PM, an observation was made of resident 46's down drain bag. The down drain bag was observed to not be covered by a dignity bag. On 8/30/18 at 9:51 AM, an interview was conducted with the facility DON. The facility DON stated that the catheter down drains were to be covered by a privacy bag.

Based on interview and record review, it was determined for 1 of 5 sample Nursing Assistants (NA), the facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless that individual was competent to provide nursing and nursing related services and has completed a training and competency evaluation program. Specifically, the facility Hospitality Aide (HA) was observed to provide direct cares to residents without completing and passing a training and competency evaluation program. Findings include: On 3/14/18, Hospitality Aide (HA) was employed at the facility as a Nurses Aide (NA). On 8/27/18 at 7:08 AM, an observation was made of resident 27 being wheeled backwards down the hallway in a shower chair to the shower room. Additionally, resident 27's buttocks was observed to be exposed as well as her underwear top. Resident 27 was observed to be taken to the shower room by the facility HA for her shower. On 8/27/18 at 10:25 AM, an observation was made of resident 39 being wheeled backwards back to her room after having a shower. Additionally, resident 39's buttocks were observed to be exposed. Resident 39 was observed to be taken back to her room by the facility HA from the shower room after her shower. On 8/29/18 at 8:23 AM, an observation was made of resident 15 as she received her breakfast meal. The facility Hospitality Aide (HA) was observed to attempt to reposition resident 15 from her left side. 8/30/18 at 7:50 AM, interview with Certified Nursing Assistant (CNA) 3. CNA 3 stated that the HA was providing direct cares to the residents of the hall. CNA 3 stated that she was repositioning, feeding and showering residents and that she was doing this because they have had about 3 people quit in the last 3 weeks or so and 2 terminated. CNA 3 stated that he did not know if the HA was using the hoyer lift. CNA 3 further stated that the HA she should not be providing those cares. On 8/30/18 at 8:05 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they were using the NA as a HA because she had taken the certification test 3 times and had not passed the skills portion of the test. The facility DON stated that she was not providing direct care to residents, that they used her to pass fresh water, fluff pillows etc. The facility DON was asked for a job description for the HA, and stated that she did not have one. The facility DON stated that it was ok for the HA to shower residents as long as she had an NA following her and training her. (NOTE: No observation was made of anyone following the HA into the shower room to shower both residents. No observation was made of anyone assisting the HA to reposition the resident.) On 8/29/18 at 8:42 AM, an interview was conducted with the facility HA. The facility HA stated that she was not directly caring for residents on the floor, that she was there to pass water and to fluff pillows. On 8/30/18 at 3:25 PM, an interview was conducted with the CNA Supervisor. The CNA Supervisor stated that the HA was not allowed to have hands on and one on one care with residents and was not being utilized as a CNA on the floor. No documentation could be located in the HA's employee file that she had completed a training and competency evaluation program.

Based on interview and record review, it was determined, for 7 of 39 sample residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not hold hypertensive medications when blood pressure measurements were outside of physician ordered parameters for a resident. Additionally, the facility did not administer hypertensive medications when blood pressure measurements were within physician ordered parameters for the same resident. Resident identifiers: 10, 21, 24, 27, 28, 39 and 203. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18 resident 10's medical record was reviewed. physician's orders [REDACTED]. Hold for SBP (systolic blood pressure) < (less than) 110. physician's orders [REDACTED]. Hold for SBP < 90. The Medication Administration Record [REDACTED] a. 7/4/18 - No SBP recorded b. 7/6/18 - SBP - 108 c. 7/23/18 - SBP - 98 d. 8/18/18 - SBP - 93 2. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18 resident 39's medical record was reviewed. physician's orders [REDACTED]. Hold for SBP < 110. physician's orders [REDACTED]. Hold for SBP < 110 or Pulse (P) < 60. The MAR for resident 39 for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that resident 39's [MEDICATION NAME] 5 mg and [MEDICATION NAME] ER 25 mg, had been administered or held without a SBP or P or with a SBP or P outside of the parameters set by the physician or that resident 10's SBP had not been monitored to know if the medications should be administered or held on the following dates: a. 7/8/18 - SBP - 95 in the evening b. 7/11/18 - No SBP recorded, No P recorded in the morning c. 7/18/18 - No SBP recorded, No P recorded in the evening d. 7/23/18 - No SBP recorded, No P recorded in the evening e. 7/26/18 - No SBP recorded, No P recorded in the evening f. 7/27/18 - SBP - 102 in the morning g. 7/31/18 - SBP - 100 in the evening h. 8/4/18 - SBP - 108 in the morning i. 8/13/18 - No SBP recorded, No P recorded in the morning j. 8/21/18 - SBP 96 in the evening k. 8/25/18 - No SBP recorded, No P recorded in the evening 3. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18 resident 21's medical record was reviewed. Resident 21's physician's orders [REDACTED]. Hold for SBP < 110 or P < 60. The MAR for resident 21 for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that resident 21's [MEDICATION NAME] ER 150 mg, had been administered or held without a SBP or P or with a SBP or P outside of the parameters set by the physician or that resident 10's SBP had not been monitored to know if the medications should be administered or held on the following dates: a. 7/6/18 - SBP - 102 b. 7/7/18 - P - 52 c. 8/4/18 - SBP - 109 d. 8/18/18 - SBP - 108 4. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18 resident 27's medical record was reviewed. physician's orders [REDACTED]. Hold for SBP < 110 and Carvedilol 12.5 mg twice daily. Hold for SBP < 110 or P < 60. The Medication Administration Record [REDACTED] a. 7/1/18 - [MEDICATION NAME] held, SBP and P within parameters b. 7/15/18 - [MEDICATION NAME] held, SBP and P within parameters c. 7/23/18 - P - 58 d. 7/29/18 - [MEDICATION NAME] held, SBP and P within parameters e. 8/19/18 - [MEDICATION NAME] held, SBP and P within parameters 5. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18 resident 24's medical record was reviewed. physician's orders [REDACTED]. Hold for SBP < 110. physician's orders [REDACTED]. Hold for SBP < 110 or P < 60. The Medication Administration Record [REDACTED] a. 7/4/18 - No P recorded b. 7/11/18 - No P recorded c. 8/10/18 - SBP - 143 d. 8/17/18 - SBP - 100 in the morning e. 8/17/18 - No SBP recorded in the evening f. 8/18/18 - SBP - 107 in the morning g. 8/19/18 - SBP - 107 in the evening The facility Pharmacy reviews for (MONTH) (YEAR) and (MONTH) (YEAR) indicated that there was a problem with the hypertensive medications being given or held outside of the parameters set by the physician. The facility Pharmacy review for (MONTH) (YEAR) revealed that the facility pharmacist recommended monitoring of hypertensive medications. The facility pharmacist stated, Let's keep an eye on VS parameters for blood pressure medications. A couple of nurses appear to be giving medication outside prescribed parameters a few times each month. It may be due to pulling 'last recorded' vitals. On 8/28/18 at 2:23 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that if he did not have a set of vital signs (VS) including a SBP and P, he would obtain a set of VS so that he would know if blood pressure medications should be administered or not. RN 2 stated that if he had a resident with a consistently low SBP, he would notify the resident's physician. On 8/28/18 at 2:55 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the nurses should always monitor the SBP and P to know whether or not to administer hypertensive medications. The facility DON stated that she had been aware of the lack of monitoring or that medications had been given outside of the parameters set by the physician and had inserviced the facility nursing staff regarding the correct administration of the medications. The facility DON stated that obviously it didn't work. 6. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28's medical record was reviewed on 8/30/18. On 6/13/18 a physician's orders [REDACTED]. The Losartan was to be held if the sbp was less than 110 millimeters of mercury (mmHg). The June, (MONTH) and (MONTH) (YEAR) MARs were reviewed. The licensed nursing staff documented that the Losartan was administered daily. The licensed nursing staff did not document what resident 28's blood pressure was on the MAR's. Review of the Weights and Vitals Summary report revealed the following systolic blood pressures that were lower than 110 mmHg: a. 6/14/18: 106 b. 6/26/18: 107 c. 6/29/18: 98 d. 7/1/18: 101 e. 7/2/18: 103 f. 7/8/18: 104 g. 7/13/18: 104 h. 7/27/18: 101 i. 7/29/18: 104 j. 8/2/18: 104 k. 8/22/18: 109 l. 8/24/18: 101 It should be noted that the Losartan Potassium 50 mg was administered on the above days despite the systolic blood pressures that were lower than 110 mmHg. On 8/30/18 at 8:26 AM, an interview was conducted with RN 3. RN 3 stated that blood pressures were to be obtained daily prior to the administration of the Losartan Potassium 50 mg. RN 3 stated that the Losartan Potassium was to be held when the systolic blood pressure was less than 110 mmHg. 7. Resident 203 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/18, resident 203's medical record was reviewed. Resident 203's physician orders [REDACTED]. a. [MEDICATION NAME] HCl ([MEDICATION NAME]) tablet .Give 7.5 mg (milligrams) by mouth three times a day for [MEDICAL CONDITION] .hold for sbp (systolic blood pressure) (greater than) 100 .Order date 8/21/18 . Resident 203's Medication Administration Record [REDACTED]. The occurrences are detailed below: (Note: resident 203's [MEDICATION NAME] was ordered for three times a day. There was a morning dose, an afternoon dose and a nighttime dose. The exact times of the administration was unknown. The dose times shall be differentiated as morning, afternoon and nighttime.) a. On 8/21/18 at nighttime, sbp was 102 b. 8/22/18 in the morning sbp was 137 c. 8/22/18 in the afternoon sbp was 137 d. 8/22/17 at nighttime 1 sbp was 137 e. 8/23/18 in the morning sbp was 137 f. 8/23/18 at afternoon sbp was 137 g. 8/23/18 at nighttime sbp was 137 h. 8/26/18 at afternoon sbp was 103 i. 8/26/18 at nighttime sbp was 112 On 8/30/18 at 8:05 AM an interview was conducted with the DON. The DON was informed of the medication administration occurrences. No further information was provided.

Based on observation and interview it was determined, for 4 of 37 sample residents, that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there was an accumulation of dirt and debris on the floor next to the clean linen cabinet, there was two tables with food and/or dried liquid spills, there was sheetrock damage in a resident room, there were dead bugs and mosquitoes on a window sill, there was toenail clippings and debris underneath a bureau, and soiled linen had not been replaced after a resident had been discharged from the facility. Resident identifiers: 38, 151, 152 and 199. Findings include: 1. An initial tour of the facility was conducted on 8/27/18 at 7:00 AM. The following was identified: a. There was an accumulation of dirt and debris on the floor in front of the clean linen storage area across from the north nurses station. b. Two tables in the north dining room had food debris and dried liquid spills. Two residents were seated at the tables. 2. On 8/27/18 at 9:33 AM, resident 38's room was observed to have sheetrock damage underneath the window. Resident 38 stated that he caused the damage when he was parking his electric wheelchair. There was sheetrock debris on the floor directly below window. Resident 38 stated that housekeeping had already cleaned his room, but did not clean up the sheetrock debris. 3. On 8/27/18 at 10:48 AM, resident 152 was interviewed related to the cleanliness of his room. Resident 152 stated that his roommate was discharge the previous Friday and that his roommate's bed had not been made. There was an unmade bed with used sheets observed on the unoccupied side of resident 152's room. 4. On 8/27/18 at 2:21 PM, resident 151 was interviewed related to the cleanliness of his room. Resident 151 stated that there was a dead bugs and mosquito's on the window sill. Dead flying insects were observed on the window sill in resident 151's room. On 8/30/18 at 11:33 AM, and interview was conducted with the Maintenance Director (MD). The MD stated that dining room tables were to be cleaned after each meal or before resident's were seated at the tables. The MD stated that resident rooms were to be cleaned daily including the floors and window sills. The MD stated that he was not aware of the sheetrock damage in resident 38's room.

Based on observation, interview, and record review it was determined for 1 of 28 sample residents that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident waited approximately an hour for requested pain medication. Resident identifier: 70. Findings include: Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/29/15 at 11:00 AM, Registered Nurse (RN) 1 and a surveyor entered resident 70's room to observe the resident. Resident 70 was observed to be rocking back and forth in her wheel chair. Resident 70 stated to RN 1, kiss me, kiss me, please kiss me. Resident 70 then stated, Help me, Help me, Please Help me! Resident 70 was observed to be grimacing and began repeating over and over again, Help me, Help me, Please Help me! RN 1 was observed to ask resident 70 if she was in pain. Resident 70 was observed to state that, Yes she was in pain. RN 1 was observed to ask resident 70 if she wanted something for pain. Resident 70 was observed to say, Yes!. RN 1 was observed to tell resident 70 that he would go and get her some pain medication. On 2/29/16 at 11:30 AM, the surveyor approached resident 70. Resident 70 was observed to be grimacing and rocking back and forth in her wheel chair. Resident 70 stated, Help me, Help me, Please Help me! Resident 70 appeared to be anxious and in distress while speaking with the surveyor. The surveyor asked resident 70 if she had received pain medication. Resident 70 responded with, NO! Resident 70 then proceeded to chant, Help me, Help me, Please Help me. The surveyor then asked resident 70 if she was in pain. Resident 70 responded with Yes, I am in pain! Please Help me! On 2/29/16 a continuous observation was made of resident 70's room from 11:30 AM until 11:55 AM. The following observations were made: A) At 11:32 AM, the facility Marketer was observed to enter resident 70's room. At 11:35 AM, the facility Marketer was observed to leave resident 70's room and proceed down the hall. No observations were made of the facility Marketer approaching staff regarding her interaction with resident 70. B) At 11:46 AM, an unidentified visitor was observed to enter resident 70's room. The visitor was observed to leave resident 70's room at 11:55 AM. No observations were made of the visitor approaching staff to discuss her interaction with resident 70. At 11:55 AM, the surveyor entered resident 70's room. Resident 70 was observed to be rocking back and forth in her wheel chair, moaning, and had facial grimacing. Resident 70 stated, Please Help me, Please Help me! The surveyor asked resident 70 if she was in pain. Resident 70 stated, I have a headache everywhere! while pointing to her pelvic region. At 11:56 AM, RN 1 was interviewed. RN 1 stated that he had not administered pain medication to resident 70 when she requested the pain medication at 11:00 AM. When asked why he had not administered the pain medication, RN 1 stated, Because I didn't think she needed it! RN 1 then stated, Do you think she needs something now? RN 1 and the surveyor proceeded to resident 70's room. When the surveyor and RN 1 entered resident 70's room, the facility Assistant Director of Nursing (ADON) was inside assisting resident 70 with toileting. RN 1 asked resident 70 if she was in pain. Resident 70 stated, Yes, I am hurting! RN 1 stated he would go and get her some pain medication right away. On 2/29/16, resident 70's medical record was reviewed. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On 2/29/16 at 12:17 PM, resident 70 was interviewed. Resident 70 stated that she had been given the pain medication. When asked if resident 70 was still in pain, resident 70 stated that she felt better. On 2/29/16 at 12:30 PM, the facility Marketing Director (MD) was interviewed. The MD stated that her interaction with resident 70 consisted of resident 70 repeatedly saying, Help me, Help me. When asked how the MD could determine if resident 70 was in pain, the MD did not have a response. The MD stated, She is always the same, She only ever says, Help me, Help me! On 2/29/16, during the continuous observation of resident 70's room, the facility Director of Nursing (DON) was interviewed. The DON stated that resident 70 had behaviors that consisted of continually repeating phrases such as, Kiss me, Kiss me, or Help me, Help me! When asked if resident 70 could tell staff if she was in pain, the DON stated that resident 70 was able to tell staff that she was in pain. Additionally, the DON stated that when resident 70 was in pain, she would have facial grimacing and her behavior of repeating Help me, Help me! would become more frantic and that resident 70 would say the phrase louder and louder. On 2/29/16 at 12:35 PM, RN 1 was interviewed. RN 1 stated that he had administered the pain medication to resident 70 and that she was a Completely different person now. RN 1 stated that resident 70 was calm and not complaining of pain anymore. On 2/29/16 at 2:30 PM, RN 1 was re-interviewed. RN 1 stated that he did not remember asking resident 70 at 11:00 AM if she was in pain. When asked if he told resident 70 that he would get her some pain medication at 11:00 AM to placate resident 70, RN 1 stated that he did not remember telling resident 70 that he would bring her pain medication. RN 1 further stated that if a resident was in pain and receiving scheduled pain medication that if the scheduled pain medication was not managing the resident's pain, he would call the physician to let the physician know about the pain. RN 1 further stated that resident 70 would always say she was in pain and that if the surveyor was to ask resident 70 right now, resident 70 would state that she was in pain. On 2/29/16 at 2:40 PM, resident 70 was interviewed in the presence of two surveyors. When asked how she was doing, resident 70 stated, I'm much better! Resident 70 was observed to be smiling and interacting with a facility Physical Therapist. Review of resident 70's care plan revealed the following care plan: Has acute / chronic pain r/t (related to) right hip ORIF (open reduction internal fixation), generalized. The goals listed on the care plan were, Will voice level of comfort through the review date and Will not have discomfort related to side effects of [MEDICATION NAME] through the review date. Facility staff listed the following interventions to help resident 70 achieve the stated goals: Administer [MEDICATION NAME] medication as per orders, Give 1/2 hour before treatments or care, Anticipate need for pain relief and respond immediately to any complaint of pain, Assess for facial grimacing, also able to express pain states 'I'm in pain', Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact of cognition, Follow pain scale to medicate as ordered, Monitor / document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to physician., Monitor / record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g. continuous, intermittent); Aggravating factors; Relieving factors., Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain., Pain assessment every shift., and Therapy evaluation and treatment per physician orders. On 3/1/16 at approximately 10:30 AM, the facility Administrator was interviewed. The Administrator stated that he had visited resident 70 the night before (2/29/16) and that when he asked resident 70 specific questions, resident 70 was able to answer the questions appropriately. The Administrator further stated that just because resident 70 had behaviors of stating, Help me, Help me! that was no reason for facility staff to ignore her request for pain medication.

Based on interview and medical record review it was determined for one sampled resident that the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. Specifically, facility staff and the Medical Director were aware, based on laboratory values, that a resident was dehydrated six days before the resident was admitted to the hospital. Resident Identifier: 42. Findings included: On 2/23/11 resident 42's closed medical record was reviewed. Review of resident 42's medical record revealed that resident 42 was admitted to the facility with an order to receive tube feedings to meet his nutritional needs. Review of resident 42's medical record revealed an admission MDS (Minimum Data Set) assessment dated [DATE]. Facility staff assessed resident 42 as being alert and oriented, having no behaviors, no signs of [MEDICAL CONDITION], and no acute mental status change. Review of the Dehydration Risk Assessment completed by facility staff on 1/11/11 revealed that resident 42 received a score of 20 indicating that resident 42 was a low risk of developing dehydration. On 2/23/11, the laboratory values ordered by the physician on 1/20/11 and 1/23/11 were provided to the state survey team by the Director of Nursing. (It should be noted that the lab values were not available in resident 42's closed medical record). Review of the Basic Metabolic Panel ordered on [DATE] and reported to facility staff on 1/21/11 revealed resident 42 had an increased sodium of 148 (normal range is 135-145), and increased CO2 (Carbon [MEDICATION NAME]) of 33 (normal range is 22-30), and an increased BUN (Blood Urea Nitrogen) of 50 (normal range is 7-25). On 2/22/11 at 1:40 PM, the facility Medical Director was interviewed regarding lab values. When asked what an increased or normal sodium, increased CO2 and increased BUN indicated the Medical Director stated that those lab values indicated that the person was dehydrated and the Medical Director would treat the person with Intravenous (IV) fluids or encourage the resident to drink more fluids depending on the severity of the dehydration. On 2/23/11 the admission History and Physical from the Hospital where resident 42 was admitted was obtained and reviewed. Review of the Hospital Admission History and Physical dated 1/27/11 showed that when resident 42 was admitted to the hospital his Sodium was 162 (normal range 135-145). It was documented on the Hospital Admission History and Physical that resident 42 had: "1. Mental Status changes. Multiple etilogies include new pneumonia, acute [MEDICAL CONDITION] and azotemia, urinary tract infection, [MEDICAL CONDITION], and [MEDICAL CONDITION]." 2. ... 3. ... 4. "Acute [MEDICAL CONDITION], presumably pre renal in etiology. Check urinalysis. Administer IV fluids. ..." 5. ... 6. "[MEDICAL CONDITION], probably from inadequate free water. We will administer free water and correct this very slowly. We will administer some through his tube feeds and additionally by IV. According to his rehab records, he was supposed to get 200 ml (milliliters) of free water every 6 hours, and 30 ml flushes with medications. If he actually received this, he would need additional free water which we are giving through the IV." No care plan for dehydration could be found in resident 42's closed medical record. No documentation could be found in resident 42's medical record to indicate that the Registered Dietitian (RD) was notified of resident 42's lab values. On 2/23/11 at 1:50 PM, the facility RD was interviewed regarding resident 42. The RD stated that she was not aware that when resident 42 was admitted to the hospital that he had not been receiving adequate amounts of free water. (It should be noted that free water is water that is not included in the tube feeding formula but is water given through the feeding tube in addition to the tube feeding formula). On 2/24/11 at 9:30 AM, the facility Medical Director was interviewed regarding notification of lab values, specifically resident 42's increased sodium, CO2 and BUN. The facility Medical Director stated that she was notified of the lab values. The facility Medical Director verified that resident 42 was acutely ill which caused his lab values to be not within normal values. The Medical Director stated that she knew about the lab values but was continuing to monitor resident 42. The Medical Director further stated that even though resident 42's sodium and BUN were increased she was going to monitor resident 42 and re-check resident 42's laboratory values in one week. No entries could be found in resident 42's closed medical record to indicate that facility staff had initiated arrangements for follow-up labs to be done in one week after the Medical Director was notified of the above mentioned laboratory values and had ordered for labs to be repeated in one week for resident 42.

Based on interview and a closed medical record review, it was determined for two sampled residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a facility nurse helped to initiate Hospice Services with no physician orders. In addition, another resident was found to receive no assessment of dehydration status for six days before being admitted to the hospital with [REDACTED]. Resident Identifiers 42 and 58. Findings included: 1. Resident 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/17/11 resident 58's closed medical record was reviewed. Review of resident 58's medical record revealed a Physician order for [REDACTED]. The Power of Attorney (POA) indicated on the POLST that facility staff could administer antibiotics and administer a defined trial period of intravenous (IV) fluids. Review of resident 58's medical record revealed a nursing note entry dated 12/4/10 at 3:00 AM. It was documented in the nurse's notes by a facility nurse that, "CNA (Certified Nursing Assistant) reported that res (resident) was unresponsive and diaphoretic of shock. Assess res (resident) and VS (Vital Signs) take (sic), increased HR (heart rate), increased Respiratory rate, increased blood pressure. Notified MD (Medical Doctor) and family, MD order STAT (immediately) BMP (Basic Metabolic Panel). Family will come and see res." On 12/4/10 at 4:00 AM, it was documented by a facility nurse, "Social Worker from (name of Hospice Company) was here visiting another resident and I had her talk to the family. family (sic) will have hospice RN (Registered Nurse) eval (evaluate)." (It should be noted that a Hospice RN did evaluate resident 58 for Hospice Services on 12/4/10 but did not document the time of the evaluation on her admission paperwork.) On 12/4/10 at 5:00 AM, it was documented by a facility nurse, "family decided to put res on hospice." On 12/4/10 at 10:45 AM, it was documented by a facility nurse, "all oral meds discontinued. new orders obtained from hospice and noted." ON 12/4/10 at 11:00 AM, it was documented by a facility nurse, "reported BMP results to facility Medical Director. no new orders." Review of resident 58's medical record revealed no physician orders to evaluate for or admit resident 58 to hospice. No information could be found to show resident 58's family was given a choice regarding hospice companies. No information could be found to show that resident 58 was evaluated by a physician prior to resident 58 being placed on hospice. No physician orders could be found to show that all of resident 58's medications be discontinued. No information could be found in resident 58's medical record to show that family members of resident 58 were educated regarding resident 58's laboratory values or whether family wanted to give resident 58 a defined trial period of IV fluids, which was indicated on resident 58's POLST form. On 2/22/11 at 1:40 PM, the MD was given resident 58's lab values. The MD reported that the lab values indicated the person was dehydrated and she would treat them with IV fluids if listed on the POLST or have staff encourage the resident to drink more fluids depending on how bad the dehydration was. The MD further stated that hospice could not do an evaluation of a patient unless it is ordered by a physician. The Medical Director stated that in order for hospice to evaluate a patient for hospice services the physician must write a physician's order. On 2/23/11 at 7:30 AM, the DON was interviewed regarding his process for hospice evaluation and how residents were placed on hospice. The DON stated that if the facility staff or IDT (Interdisciplinary Team) team felt like a resident met criteria for hospice, the facility would talk with the physician and get an order from the physician to evaluate and treat the resident. The order would then allow hospice to come in and evaluate the resident for appropriateness of hospice and admit the resident if needed. He further stated that Social Services would usually speak with the family about hospice options in order to provide choices of hospice companies to families. The DON stated that the order given by the physician for Hospice to evaluate and treat is also the order to admit the resident onto Hospice Services. On 2/22/10 at 4:30 PM, the DON for the Hospice company used by resident 58's family was interviewed. The DON stated that when a resident is in a facility the Social Worker of the facility will usually call and make the referral for the hospice to come and evaluate the resident. She further stated that the hospice staff did not look through the resident medical record to determine if a physician's order had been written for the hospice to evaluate the resident. The DON stated that the only thing medicare requires is for the hospice company to obtain a physician certification which certifies that the resident only has 6 months or less to live. The DON stated that she could not find any physician orders in the chart of resident 58 at the hospice agency for hospice to evaluate resident 58 or admit resident 58 onto hospice services. On 2/22/11 at 3:50 PM, the Licensed Practical Nurse (LPN 2) who was delivering care to resident 58 on 12/4/10 was interviewed. LPN 2 stated that if a resident was found unresponsive, diaphoretic,in shock with an increased heart rate, blood pressure, and respiratory rate he would grab the crash cart and the chart. LPN 2 stated that he would then look at the POLST form to determine the code status. LPN 2 stated that if the resident was DNR but also had additional options listed such as antibiotics and IV fluids he would activate EMS and begin to perform life saving interventions if needed. He further stated that if the POLST form indicated that the resident was DNR with comfort measures only he would keep the resident comfortable and notify the family. LPN 2 further stated that alot of times when you call family to notify them of a change in condition they will still request that the resident be sent to the hospital even though the POLST indicated that the resident was comfort care only. When asked about referrals for Hospice services, LPN 2 stated that he would refer the hospice evaluation to Social Services because families need to have a choice regarding hospice services and companies. LPN 2 stated that Social Services would make the referral for hospice services because they understood the insurance issues and he did not. LPN 2 stated that he did not know the process of whether the facility needed a physician's order for the hospice evaluation to occur. When asked specifically why he did not activate EMS for resident 58, LPN 2 stated that he could not remember if he had activated EMS or not. LPN 2 further stated that when the family showed up at the facility they had asked LPN 2 how he thought resident 58 was doing and LPN 2 told the family that, "It didn't look good". LPN 2 further stated that the Social Worker from the Hospice company overheard LPN 2's conversation with resident 58's family and when LPN 2 left to go get resident 58's family a beverage the Social Worker from the Hospice company approached the family by herself and spoke with them regarding hospice. LPN 2 further stated that he did not know if the family had a choice regarding hospice companies. On 2/23/11 the DON stated that LPN 2 had reported to the DON that LPN 2 could not remember whether or not he had activated EMS and then cancelled EMS. The DON verified that the documentation regarding the activiation of EMS was not in the medical record. The DON stated that the family had not defined the trial period of IV fluids and that was why the facility had not administered the IV fluids. The DON further stated that he did not know if the family and facility Medical Director had been given all the information regarding resident 58's lab values and the options for treatment before resident 58 was admitted on to Hospice Services. On 2/23/11 the DON provided the survey team with a faxed copy of the Physician Certification from that the Hospice company had on file for resident 58. When the DON was asked where the physician's orders were to evaluate and admit resident 58 onto Hospice Services, the DON stated, "That is all I have." On 3/2/11, the DON provided a letter from resident 58's family. The family of resident 58 inidcated in their letter that when the facility nurse notified them on 12/4/10 at 3:00 AM, the facility nurse had told the family that resident 58 had stopped eating. 2. Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/23/11 resident 42's closed medical record was reviewed. Review of resident 42's medical record revealed that resident 42 was admitted to the facility with an order to receive tube feedings to meet his nutritional needs. Review of resident 42's medical record revealed an admission MDS (Minimum Data Set) assessment dated [DATE]. Facility staff assessed resident 42 as being alert and oriented, having no behaviors, no signs of [MEDICAL CONDITION], and no acute mental status change. Review of resident 42's care plan revealed a care plan for "Actual/Risk for Infection". Facility staff documented on the care plan that resident 42 was admitted with an actual infection [MEDICAL CONDITION] pneumonia. The goals listed in the care plan were for resident 42 to have no untreated s/s (signs or symptoms) of infection and the infection would resolve without complication by next review. The interventions listed on the care plan were for facility staff to give medications as ordered, complete vital signs every shift until infection had resolved, report signs and symptoms of infection to the Medical Doctor and family, perform labs and x-rays as ordered, follow universal precautions, perform treatments as ordered, notify the Medical Doctor if resident 42 experienced a lack of response to treatment, encourage increased fluid intake if not contraindicated, isolation precautions if required, and give [MEDICATION NAME] (an antibiotic) 600mg (milligrams) intravenously every 12 hours from 1/11/11 through 1/16/11. Review of nurse's notes revealed an entry dated 1/20/11 indicating that a Basic Metabolic Panel laboratory test was to be drawn on 1/20/11 at night. On 1/22/11 at 10:15 PM, it was documented in the nurse's notes that resident 42 had been, "found on floor. No injury noted. Res. (resident) denies pain. Assisted back to bed. Res. unable to relate details of fall. Neuro checks initiated WNL (within normal limits). ROM (range of motion) WNL for res. Notified MD and family. No new orders. Bed in lowest postion. Call light within reach. Will continue to monitor." On 1/22/11 at 11:30 PM, it was documented in the nurse's notes, "Notified MD (Medical Doctor) of T (temperature) 102.2. CBC (complete blood count) and UA (urinalysis) in AM." On 1/23/11 at 6:00 PM, it was documented in the nurse's notes, "Attempted to obtain a clean catch UA (urinalysis). res. had not urinated all day. treatment nurse straight cathed res obtained 1200 cc (cubic centimeters) with foul odor and bloody sediment. per MD orders left foley D.D. (down drain) in patent and draining (sic). Will f/u (follow up) with making res an appt to see Urologist." No documentation could be found in resident 42's medical record to indicate that facility staff had made resident 42 an appointment to see a Urologist. On 1/23/11 it was documented in the nurse's notes that the UA had been sent. On 1/24/11 it was documented in the nures's notes [MEDICATION NAME] be started that evening. No documentation could be found in the nurse's notes to indicate why resident 42 was being started on [MEDICATION NAME] for how long he would be receiving the Cipro. On 1/25/11 at 7:40 PM, it was documented in the nurse's notes, "Res found on blue mat on floor. Complete head to toe. No noted apparent injuries. No c/o (complaints of) pain. (Name of Medical Director) notified. Res. daughter (name) notified. Neuro checks initiated. Will cont (continue) to assess." On 1/26/11 at 10:30 AM, it was documented in the nurse's notes, "Increased temp this AM of 100.2, Tyl (Tylenol) admin (administered) secondary. temp re check at this time temp now 98.6. F/C (foley catheter) patent, draining cloudy urine with sediment. foul odor noted. Will report to MD and set up UA with C&S (culture and sensitivity) if indic (indicated). awaiting return call from (name of Medical Doctor)." On 1/26/11 at 11:40 AM, it was documented in the nurse's notes, "(Name of Medical Doctor) present new order obtained and noted. Send UA with C&S if indic." On 1/26/11 at 4:30 PM, it was documented in the nurse's notes, "Res found on floor on blue mat. ...." On 1/26/11 at 5:10 PM, it was documented in the nurse's notes, "New order obtained to send UA with C&S if indic. (Name of Medical Doctor) made aware of UA (+) awaiting C&S. Also labs ordered. ..." On 1/26/11 at 10:15 PM, it was documented in the nurse's notes, "Res keeps removing nasal canula and has decreased O2 (oxygen) sats (saturation), decreased LOC (level of consciousness) and increased temp. Crackles present in lungs bilaterally, Notified MD. MD wants res sent to ER (emergency room ). ... transport to hospital." On 2/23/11, the laboratory values ordered by the physician on 1/20/11 and 1/23/11 were provided to the state survey team by the Director of Nursing. (It should be noted that the lab values ordered by the physician could not be located in resident 42's closed medical record). Review of the Basic Metabolic Panel ordered on [DATE] and reported to staff on 1/21/11 revealed resident 42 had an increased sodium of 148 (normal range is 135-145), and increased CO2 (Carbon [MEDICATION NAME]) of 33 (normal range is 22-30), and an in increased BUN (Blood Urea Nitrogen) of 50 (normal range is 7-25). On 2/22/11 at 1:40 PM, the facility Medical Director was interviewed regarding lab values. When asked what an increased or normal sodium, increased CO2 and increased BUN indicated the Medical Director stated that those lab values indicated that the person was dehydrated and she would treat the person with Intravenous (IV) fluids or encourage the resident to drink more fluids depending on the severity of the dehydration. Review of the Complete Blood Count (CBC) ordered on [DATE] and results reported on 1/24/11 showed that resident 42 had an increased white blood cell (WBC) count of 14.8 (normal range is 4-11.5), a decreased red blood cell (RBC) count of 3.34 (normal range is 3.9-5.5), a decreased hemoglobin (HGB) of 10.8 (normal range is 11.5 - 16.5), a decreased hematocrit (HCT) of 33.4 (normal range is 35 - 49), and an increase in [DIAGNOSES REDACTED]s of 94.2 (normal range is 40 - 75). No documentation could be located in the medical record to indicate that the facility Medical Director was notified of the lab values. On 2/23/11 the DON was interviewed regarding physician notification of the lab values for resident 42. The DON stated that the nurse's just sign the bottom of the lab report and that indicated the lab values were reported to the physician. The DON further stated that the physician was made aware of the lab values by facility staff. When asked why the physician had not treated resident 42 after receiving notification of the lab values, the DON stated that he does not question the physician and he does not know why the physician did not treat resident 42. On 2/23/11 the admission History and Physical from the Hospital admission for resident 42 was obtained and reviewed. Review of the Hospital Admission History and Physical dated 1/27/11 revealed that when resident 42 was admitted to the hospital his Sodium was 162 (normal range 135-145). It was documented on the Hospital Admission History and Physical that resident 42 had: "1. Mental Status changes. Multiple etilogies include new pneumonia, acute [MEDICAL CONDITION] and azotemia, urinary tract infection, [MEDICAL CONDITION], and [MEDICAL CONDITION]. ..." On 2/24/11 at 9:30 AM, the facility Medical Director was interviewed regarding notification of lab values, specifically resident 42's increased sodium, increased WBC, decreased HCT and HGB and increased CO2 and BUN. The facility Medical Director stated that she was notified of the lab values. The facility Medical Director verified that resident 42 was acutely ill which caused his lab values to be not within normal values. The Medical Director stated that she knew about the lab values but was continuing to monitor the patient. The Medical Director further stated that even though resident 42's sodium and BUN were increased she was going to monitor resident 42 and re-check resident 42's laboratory values in one week. No orders could be found in resident 42's closed medical record to indicate that facility staff had ordered follow-up labs to be done in one week after the Medical Director was notified of the above mentioned laboratory values.