Every finding on record at Englewood Post Acute and Rehabilitation

Based on observations and interviews, the facility failed to 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 on two of four hallways. Specifically, the facility failed to: -Ensure appropriate infection control practices were followed during wound care; and, -Ensure housekeeping staff followed appropriate hand hygiene practices and disinfectant dwell times when cleaning residents' rooms. Findings include: I. Failure to ensure housekeeping staff followed appropriate hand hygiene practices and disinfectant dwell times when cleaning residents' rooms A. Facility policy and procedure The Infection Control Housekeeping policy, dated April 2024, was provided by the director of nursing (DON) on 11/7/24 at 5:45 p.m. It read in pertinent part, It is the policy of this facility to provide effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites (objects likely to carry infection). Frequent cleaning of the facility's interior will aid in physically removing some of the micro-organisms which might cause these hazards. Personnel working in resident areas will follow strict hand washing procedures. B. Manufacturer's recommendations The manufacturer's recommendations for Comet Professional Multi-Purpose Disinfecting Cleaner with Bleach was provided by the housekeeping supervisor (HSKS) on 11/7/24. The recommendations indicated the product should be left on surfaces for one minute in order to properly disinfect the surface. The manufacturer's recommendations for Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant were provided by the HSKS on 11/7/24. The recommendations indicated the product should be left on surfaces for 30 seconds to properly disinfect the surface. C. Observations During a continuous observation on 11/6/24, beginning at 9:38 a.m. and ending at 10:00 a.m., the following was observed: Housekeeper (HSKP) #1 was cleaning room [ROOM NUMBER], a double occupancy room with only one resident residing on side one of the room. HSKP #1 sprayed the toilet and sink with Comet Professional Multi-Purpose Disinfecting Cleaner with Bleach and said she would let that sit while she cleaned other parts of the room. HSKP #1 sprayed the over bed table and nightstand with Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant and immediately wiped both surfaces with her rag. -HSKP #1 did not allow the Clorox disinfectant to sit for at least 30 seconds, which was the manufacturer's required dwell time for disinfecting surfaces (see manufacturer's recommendations above). HSKP #1 sprayed the trash can with the Clorox disinfectant and immediately wiped it down, inside and outside. HSKP #1 got a clean rag from her cart and cleaned the call light, the cord and the television, spraying each item with the Clorox disinfect and wiping them off immediately. -HSKP #1 did not remove her soiled gloves, perform hand hygiene and put on clean gloves when changing rags and moving from the trash can to high touch surfaces. -HSKP #1 did not allow the Clorox disinfectant to sit for at least 30 seconds on the trash can, the call light, the cord or the television. HSKP #1 changed her gloves and began cleaning the bathroom. She sprayed and cleaned the mirror with a glass cleaner. She sprayed the grab bars and chrome on the back of the toilet with the Clorox disinfectant and immediately wiped them off. HSKP #1 opened a package of toilet paper and put it in the dispenser with the same gloves she was cleaning with. -HSKP #1 did not change her gloves and perform hand hygiene before opening the toilet paper and putting it in the dispenser and she did not follow the Clorox disinfectant dwell times. HSKP #1 wiped the top and bottom of the toilet, squirted a toilet bowl cleaner in the toilet and scrubbed it with the toilet brush. -HSKP #1 proceeded to wipe out the sink using the same rag and wearing the same gloves she used to clean the toilet. After cleaning the toilet and wiping the sink, HSKP #1 disposed of her soiled gloves and put on new gloves. -HSKP #1 did not perform hand hygiene before putting on the new gloves. During a continuous observation on 11/06/24, beginning at 10:10 a.m. and ending at 10:22 a.m., the following was observed: HSKP #2 was cleaning room [ROOM NUMBER], a single occupancy room. HSKP #2 sprayed the door handles, light switches, the sink and toilet with Comet Professional Multi-Purpose Disinfecting Cleaner with Bleach. After two minutes, HSKP #2 wiped down the door handles and light switches. She sprayed her rag with the same disinfectant and wiped the night stand, the over bed table, the call light, the bed control and the remote control for the television. -HSKP #1 did not allow the disinfectant to remain on the surface of the items for the manufacturer recommended dwell time (see manufacturer's recommendations above). HSKP #1 took a different rag and cleaned the bathroom and toilet. HSKP #2 got the mop and mopped the bathroom, changed mop heads and mopped the bedroom. -HSKP #2 did not change her gloves or perform hand hygiene after cleaning the bathroom and toilet. D. Staff interviews HSKP #1 was interviewed on 11/6/24 at 10:00 a.m. HSKP #1 said she did not know she should perform hand hygiene when changing gloves. She said she only performed hand hygiene when she completed cleaning a room. HSKP #2 was interviewed on 11/6/24 at 10:22 a.m. HSKP #2 said the Comet disinfectant did not need to sit on surfaces for any certain amount of time and she could wipe it off right away. The HSKS was interviewed on 11/6/24 at 3:00 p.m. The HSKS said housekeepers should change their gloves between surfaces when cleaning a room, usually three to four times per resident room. The HSKS said staff should perform hand hygiene when changing gloves. The HSKS said the dwell time for the Clorox disinfectant was 30 seconds to one minute. She said staff should leave the disinfectant on high touch surfaces for 30 seconds to one minute before wiping it off. The HSKS said the Comet disinfecting cleaner dwell time was three minutes and staff should leave it on surfaces for three minutes before wiping it off. -However, according to the manufacturer's recommendations for dwell times (see above), the Clorox disinfectant had a dwell time of 30 seconds and the Comet disinfecting cleaner had a dwell time of one minute. The DON was interviewed on 11/7/24 at 11:32 a.m. The DON said housekeeping staff should change gloves between surfaces, such as after cleaning the toilet. The DON said staff should perform hand hygiene when changing gloves. II. Failure to follow appropriate infection control practices during wound care A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Clinical Safety: Clean Hands for Healthcare Workers (2/27/24), retrieved on 11/12/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety,: If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves. B. Facility policy and procedure The Hand Washing and Hand Hygiene policy, dated October 2024, was provided by the DON on 11/7/24 at 5:45 p.m. It read in pertinent part, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on acceptable standards. Use alcohol based hand rub containing at least 62% (percent) alcohol, or alternatively soap and water, for the following situations: Before and after coming on duty, before and after direct contact with residents, before and after handling medication, before performing any non-surgical invasive procedure, before and after handling an invasive device, before donning (putting on) sterile gloves, before handling a clean or soiled dressing or gauze pads, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or body fluids, after handling used dressings or contaminated equipment, after contact with objects in the immediate vicinity of the resident, after removing gloves, before and after entering isolation precaution settings and after removing or disposing of personal protective equipment (PPE). The Clean Dressing Change policy, dated October 2024, was provided by the DON on 11/7/24 at 5:45 p.m. It read in pertinent part, It is the policy of this facility to provide wound care in a manner to decrease potential for infections and/or cross-contamination. Set up a clean field on the over bed table with needed supplies for wound cleansing and dressing application. Wash hands and put on gloves, loosen tape and remove the existing dressing, remove gloves pulling inside out over the dressing and discard. Wash hands and put on clean gloves, clean the wound as ordered, wash hands and put on clean gloves, apply topical ointments and clean dressing, mark dressing with initials and date. Discard gloves and disposable items in the trash receptacle and wash hands. C. Observations On 11/6/24 at 8:11 a.m. the minimum data set coordinator (MDSC) was providing wound care to Resident #30. The MDSC brought the wound care supplies into the resident's room and laid the supplies directly on the resident's mattress. -The MDSC did not set up a clean field to put the wound care supplies on. The MDSC took the clean gauze and saline and cleansed the wound. She opened the package of collagen dressing, cut a piece and applied it to the clean wound. -The MDSC did not remove her soiled gloves, perform hand hygiene and put on clean gloves after cleansing the wound and before applying the dressing to the wound. The MDSC completed the application of wound dressings, disposed of the soiled gloves and supplies and performed hand hygiene. D. Staff interviews The MDSC was interviewed on 11/6/24 at 8:15 a.m. The MDSC said she forgot to prepare a clean field for her wound supplies and should not have set them on the resident's mattress. The MDSC said she should have removed her gloves and performed hand hygiene before putting on clean gloves after cleansing the wound and before opening and applying the dressings to the wound. The DON was interviewed on 11/7/24 at 11:32 a.m. The DON said clean supplies for wound care should be placed on a clean area near the resident. The DON said staff should change gloves and perform hand hygiene after cleaning a wound and before applying the dressings.

Based on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for three (#15, #36 and #63) residents out of 40 sample residents. Specifically, the facility failed to: -Ensure the MDS assessments for Resident #15 and Resident #36 accurately documented that the residents had a preadmission assessment screening and resident review (PASRR) Level II qualifying diagnosis; -Ensure the MDS assessment for Resident #15 accurately documented the resident was receiving hospice services; and, -Ensure the MDS assessment for Resident #63 accurately documented the resident was receiving dialysis. Findings include: I. Professional reference According to the American Association of Post-Acute Care Nursing (AAPACN) The Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Process (October 2023), retrieved on 11/12/24 from https://www.aapacn.org/resources/rai-manual/, The RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. The MDS assessment is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which formed the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. II. Resident #15 A. Resident status Resident #15, age 72, was admitted on [DATE]. According to the November 2024 computerized physician's orders (CPO), diagnoses included bipolar disorder, manic severe with psychotic features, major depressive disorder and anxiety. The 8/22/24 MDS assessment documented that the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Additionally, there was no MDS assessment that accurately documented that the resident was receiving hospice service while a patient of the facility. B. Record review The comprehensive care plan, initiated 8/30/2020 and revised 5/16/23, documented a care focus for psychosocial conditions, as well as mood and behavior. The care plan revealed that the resident had a PASRR Level II diagnosis of major depression and an extensive history of psychiatric treatment. -However, the MDS assessment failed to document the resident's PASRR Level II diagnosis. A review of the resident's electronic medical record (EMR) revealed that the resident was admitted to hospice services on 8/24/24. -However, the MDS assessment was not updated to reflect hospice services were being provided for the resident. III. Resident #36 A. Resident status Resident #36, age 82, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included bipolar disorder, manic severe with psychotic features, moderate depression and anxiety. The 9/25/24 MDS assessment documented that the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. B. Record review The PASRR Level II assessment, dated 1/26/2020, revealed that Resident #36 was diagnosed with bipolar disorder before 2018. The assessment review documented in pertinent part, Based on the Level II evaluation, the state mental health authority has determined that the individual meets the criteria for a PASRR mental illness. The comprehensive care plan, initiated 10/11/18 and revised 1/20/24, documented a care focus for mood and behavior. The care plan revealed that the resident was reassessed for a PASRR Level II and the resident had a qualifying diagnosis for PASRR Level II. -However, the MDS assessment failed to document the resident's PASRR Level II diagnosis. IV. Resident #63 A. Resident status Resident #63, under the age of 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included dependence on renal dialysis, and chronic kidney disease stage 5. -However, the 9/25/24 MDS assessment failed to accurately document that the resident was receiving dialysis while a patient of the facility. V. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed together on 11/6/24 at 2:14 p.m. The SSD said she completed the MDS sections on hearing, speech and vision, cognition, mood, behavior, participation in assessments, state-specific and care area summary and the minimum data set coordinator (MDSC) or nursing staff completed the rest of the MDS assessment. The SSD said when a resident entered with a PASRR Level II diagnosis, she would notify the MDSC who completed the relevant section and the MDSC was responsible for accurately documenting the resident's PASRR level status. The SSD said the nursing staff and the MDSC were responsible for assessing the resident for medical diagnoses and services and making sure the MDS assessment was accurately documented for medical concerns and services. The MDSC was interviewed on 11/8/24 at 2:18 p.m. The MDSC said when completing the initial, quarterly, and significant change MDS assessments, she started by reviewing the resident's EMR to make sure entries to the MDS assessment were accurate. The MDSC said she reviewed the entire MDS assessment for accuracy and a registered nurse signed off on her work. The MDSC said she got resident PASRR information from the SSD, along with other updates and changes in resident care, in the morning meeting with the leadership team and then would update the MDS assessments as required. The MDSC said she had been on an extended leave so she was not sure why Resident #15, Resident #36 and Resident #63's MDS assessments were not accurate. The MDSC said she would work with the corporate MDS consultant to get the MDS assessments corrected with accurate information.

Based on observation and interviews, the facility failed to ensure that services provided met professional standards of quality for one (#21) of one resident out of 40 sample residents. Specifically, the facility failed to: -Ensure medications were not left unattended on top of the medication cart; and, -Ensure medications were not left unattended in Resident #21's room. Findings include: I. Professional reference According to the National Library of Medicine Nursing Pharmacology (Internet). 2nd Edition, Chapter 2: Legal/Ethical, retrieved on 11/13/24 from https://www.ncbi.nlm.nih.gov/books/NBK597872/, Use medicines safely: do not leave medications unattended. II. Facility policy and procedure The Medication Access and Storage policy, dated August 2024, was provided by the director of nursing (DON) on 11/7/24 at 5:45 p.m. It read in pertinent part, It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature control. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members legally authorized to administer medication. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medication are allowed access to medications. The medication rooms, carts and supplies are locked or attended by persons with authorized access. III. Resident status Resident #21, age greater than 65, was admitted to the facility on [DATE]. According to the computerized physician orders (CPO), diagnoses included renal (kidney) failure, dementia, anxiety and depression. The 8/20/24 minimum data set (MDS) assessment revealed Resident #21 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. IV. Observations On 11/5/24 at 4:24 p.m. registered nurse (RN) #1 was administering medication to residents on the second floor south hall. RN #1 prepared four pills (famotidine, gabapentin, magnesium oxide and propranolol) in a medication cup for Resident #21 and removed a bottle of eye drops and a tube of Aspercreme from the medication cart. She moved the cup of pills and the eye drops to the back of the cart behind her computer screen and left the Aspercreme on the front of the cart. All of the medications were on top of the medication cart, unsecured. -RN #1 left the medication cart and went to retrieve applesauce from the dining room. The cart was out of her sight during this time and the medications remained on top of the cart, unsecured. After approximately one minute, RN #1 returned to the medication cart and took the pills, eye drops and applesauce to Resident #21's room at the end of the south hall. -RN #1 left the Aspercreme medication behind, on top of the medication cart unattended. A cognitively impaired resident was observed wheeling his wheelchair near the unattended medication cart and another resident walked by the unattended medication cart on his way to the dining room. RN #1 took Resident #21's pulse with the pulse oximeter (a small device that measures oxygen saturation in the blood and pulse) and obtained a reading of 59 beats per minute (bpm), below the parameter to give the resident's propranolol (blood pressure medication). RN #1 said she needed to get her stethoscope to recheck the pulse and left the resident's room. -RN #1 left the medication cup of pills and eye drops unattended in the room with Resident #21 and her roommate. RN #1 walked back down the hall to the nurse's station and returned with a stethoscope, after approximately two minutes. She rechecked the resident's pulse manually, obtained a count of 61 bpm and proceeded to administer Resident #21's medications and eye drops. V. Staff interviews RN #1 was interviewed on 11/5/24 at 4:35 p.m. RN #1 said she forgot the Aspercreme medication was on top of the cart and she should not have left it unsecured and unattended. RN #1 said she should not have left the prepared medications unattended on the medication cart when she went to get the applesauce from the dining room. RN #1 said she moved the cup of medications out of sight, behind her computer, but she should have taken them with her when she left the cart unattended. RN #1 said she should also not have left the medications unattended in Resident #21's room. RN #1 said she should have taken the medications with her when she went to get her stethoscope. The DON was interviewed on 11/7/24 at 12:03 p.m. The DON said medications should not be left unattended on the medication cart or in a resident's room.

Based on record review and interviews, the facility failed to refer one (#20) of one resident reviewed out of 40 sample residents to the appropriate state-designated authority for Level II preadmission screening and resident review (PASRR) evaluation and determination for services. Specifically, the facility failed to: -Ensure Resident #20 was properly assessed on the PASRR Level I screen to gain and maintain their highest practicable medical, emotional and psychosocial well-being; and, -Submit a new PASRR Level I on three separate occasions when Resident #20 received qualifying mental illness diagnoses. Findings include: I. Professional reference According to John Hopkins Institute, Mood Disorders Overview, (reviewed 2024), retrieved on 11/19/24 from https://www.hopkinsmedicine.org/health/conditions-and-diseases/mood-disorders#:~:text=A%20mood%20disorder%20is%20a%20class%20of%20serious%20mental%20illnesses,can%20all%20have%20mood%20disorders, Mood disorders are serious illnesses. They are likely caused by an imbalance of brain chemicals. A mood disorder can negatively affect your ability to function normally. It can have serious consequences in all aspects of life, from personal to professional. The F39 diagnosis code represents an unspecified mood (affective) disorder. This is a broad category for mood disorders that do not meet the full criteria for a more specific mood disorder, like major depressive disorder or bipolar disorder. It can vary in severity and may or may not involve psychotic features. II. Facility policy and procedure The facility's PASRR policy was requested on 11/7/24. The director of nursing (DON) said the facility did not have a related policy and followed the regulation guidance for PASRR submissions. III. Resident #20 A. Resident status Resident #20, age 74, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included anxiety disorder, depression and mood affective disorder. The 4/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated the resident did not have a serious mental illness diagnosis and did not meet the criteria for a Level II PASRR. The assessment indicated the resident had active diagnoses of anxiety disorder, depression and unspecified affective mood disorder. B. Record review The Initial Admission Record assessment dated [DATE] documented the resident was receiving psychotropic medication. Resident #20's pre-admission PASRR Level I screening questionnaire, undated, documented the resident had no known or suspected diagnosis of a major mental illness and no signs or symptoms of a major mental illness. -However, the resident was admitted with diagnoses of anxiety disorder, depression and unspecified affective mood disorder (see resident status above). The PASRR Level I notice of determination (NOD), dated 4/4/24, documented the following in pertinent part, Determination: approved. Determination Reason: no Level II required The review of the submitted PASRR Level I Screen resulted in a finding of no known or suspected mental illness, or intellectual/developmental disability, or related condition. If the member's status changes or new information is acquired that provides evidence of a known or suspected PASRR condition as noted above, the facility should resubmit a new PASRR Level I. -However, the facility failed to include Resident #20's diagnoses of anxiety disorder, depression and unspecified affective mood disorder as potential qualifying mental illness diagnoses when the initial PASRR Level I was submitted. The Psychotherapeutic Medication Review Committee note dated 7/9/24 documented the resident received a new prescription for Abilify (an antipsychotic medication) for major depressive disorder. -However, the facility failed to submit a new Level I PASRR when the resident was diagnosed with major depressive disorder on 7/9/24. A social services assessment dated [DATE] documented Resident #20 had a history of anxiety disorder and depression. The resident scored a 15 out of 27 on her last Patient Health Questionnaire-9 (PHQ-9) assessment (a screening tool that helps diagnose and monitor depression) which indicated the resident had moderately severe depression. A medical note dated 9/26/24 revealed the resident had a history of psychiatric conditions including depression, anxiety and post-traumatic stress disorder (PTSD) and had past psychiatric hospital admissions. The resident was diagnosed with recurrent major depressive disorder with psychotic features. -However, the facility failed to submit a new Level I PASRR when the resident was diagnosed with recurrent major depressive disorder with psychotic features on 9/26/24. The Interdisciplinary Team (IDT) Care Plan Review document dated 10/30/24 documented that the resident was assessed to have a moderately severe mood disorder and was being followed by behavioral health for a psychiatric condition. -However, the facility failed to submit a new Level I PASRR when the resident was diagnosed with moderately severe mood disorder on 10/30/24. IV. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed together on 11/6/24 at 2:14 p.m. The SSD said PASRR assessments were completed upon admission and with a change of condition in mental health. She said the need for a PASRR Level II assessment was triggered if the resident had a diagnosed major mental illness. The SSD said the PASRR Level II assessment would review the resident's mental health history and current condition and provide the facility with treatment recommendations to ensure the resident's mental health condition was properly treated. The SSD said, upon a resident's admission, she would review the resident's admission intake information and complete a PASRR Level I questionnaire for submission to the state mental health authority. The SSC said she was not sure if Resident #20's diagnosis of unspecified mood adjustment mood disorder would be considered a major mental illness but the PASRR oversight agency should have been notified of the diagnosis for their consideration and possible care and treatment recommendations. The SSD said she would resubmit a new PASRR Level I assessment to the state mental health authority for Resident #20.

Based on interviews and record review, the facility failed to thoroughly investigate resident-to-resident allegations of physical abuse and staff-to-resident allegations of neglect of care to prevent further instances of abuse and residents from feeling neglected for two (#60 and #18) of four residents out of 40 sample residents. Specifically, the facility failed to: -Develop a care plan focus for Resident #18, who had a known history of aggressive behaviors towards others and a history of discharge from other facilities due to aggressive behavior; -Gather all pertinent unbiased observations to identify pertinent facts of the events that occurred before, during and immediately following the incident to determine necessary interventions to prevent further abuse. This could include but not limited to observations of the assailant's behavior; words; gestures; facial expression; demeanor; tone and volume of voice; proximity and assailant and victim during the incident; and other applicable details and responses of each resident; -Investigate the extent and medical implications of the assailant's alleged hallucinations to determine if they could occur in other settings including common areas of the facility if the resident fell asleep or experienced similar conditions that occurred during this reported incident on 9/24/24; and, -Complete thorough investigations of the alleged violation of resident-to-resident physical abuse between Resident #18 towards Resident #60 that included sufficient evidence to allow the nursing home administrator (NHA) to determine what actions were necessary to protect the victim, Resident #60, and others residents in the facility from potential abuse by Resident #18 when in common areas of the facility. Findings include: I. Facility policy and procedure The Abuse Prevention of and Prohibition Against Policy, revised October 2024, was provided by the NHA on 11/04/24 at 9:00 a.m. It read in pertinent part, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. All identified events are reported to the administrator immediately. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the administrator or his/her designee; An interview will be conducted with staff members (on all shifts) who may have information regarding the alleged incident. Interviews will be conducted with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident. The investigation will include the following: -An interview with the person(s) reporting the incident; -An interview with the resident(s); -Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; and, -A review of the resident's medical record, including a review of all circumstances surrounding the incident. At the conclusion of the investigation, the facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred. The investigation, and the results of the investigation, will be documented. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the facility will continue to assess, monitor and intervene as necessary to maximize resident health and safety. At the conclusion of the investigation, the facility will take action, as necessary, in light of the information gathered, which may include but is not limited to: -If the allegation is substantiated, analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred, and determining what changes are needed to prevent further occurrences; and, -Defining how care provision will be changed and/or improved to protect residents receiving services, if appropriate II. Resident to resident allegation of physical abuse towards Resident #60 by Resident #18 on 9/24/24 A. Facility investigation 1. Description of the incident The facility investigation, dated 9/25/24, revealed that nursing staff found Resident #18 standing over Resident #60 who was in bed. Resident #60 was holding on to Resident #18. The nurse separated the two residents. The responding nurse was not sure of what had occurred at the time of the intervention. A nursing note, in Resident #18's electronic medical record (EMR), dated 9/24/24 at 10:30 p.m. and written by the responding nurse, revealed that the nurse went to Resident #60 and Resident #18's room to answer the call light. Upon entering the room, the nurse observed Resident #60 sitting on the side of his bed holding on to the wrist of Resident #18. The nurse separated the two residents and took Resident #18 to the bathroom. -The nursing note failed to provide an assessment of Resident #18's cognitive status or assess his state of mind other than he was calm and cooperative as he was separated from Resident #60. There was no indication if the resident was assessed for consciousness or other altered state of mind as he was observed standing over Resident #60. 2. Witness statements Resident #60 was interviewed by staff just after the incident. Resident #60 said he woke up to find Resident #18 standing over him punching him in the left cheek with a closed fist. Resident #60 said he pushed Resident #18 off of him and held him by the wrist until the nurse was able to remove him. Resident #18 was interviewed by staff just after the incident. Resident #18 said he did not know what was going on and he did not have a problem with his roommate so he must have been hallucinating. A nursing note, dated 9/24/24 at 10:30 p.m., documented that Resident #18 was unable to tell the responding nurse what had occurred and that he did not know why he did that or what he did. Resident #18 said he did not mean it and apologized to Resident #60 several times then said I must have been hallucinating. The residents were moved to separate rooms pending an investigation. -There was no documentation in the investigative report indicating that the investigator asked the responding nurse for detailed information on the exact words of the residents involved or if she had any indication that Resident #18 might have been in an altered state or appeared to have been hallucinating at the time of discovery. There was no indication of which resident turned on the call light or why the call light was turned on in the first place. B. Resident #60 (victim) 1. Resident status Resident #60, age 68, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included cognitive communication deficit, generalized muscle weakness and acute respiratory disease. The 10/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident did not display aggressive behaviors. The resident had a full range of motion (ROM) in the upper extremities (arms) and limited ROM in the lower extremities (legs). He used a manual wheelchair to get around the facility but was able to stand and transfer himself. 2. Resident interview Resident #60 was interviewed on 10/7/24 at 10:30 a.m. Resident #60 said his old roommate punched him and he was glad he had a new roommate. 3. Record review A progress note dated 9/25/24, documented that the interdisciplinary team (IDT) reviewed the resident-to-resident physical altercation that occurred on 9/24/24 and all details in the investigative report (see above). The IDT determined the room move to separate the living situation of the two residents was sufficient to prevent further incidents for Resident #60. -The progress note had no determination of the root cause of the incident and no recommendations for preventing future incidents. -There was no additional information in the resident's EMR from what was in the facility investigation (see above). C. Resident #18 (assailant) 1. Resident status Resident #18, age 67, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included anxiety, depression and cerebral infarction (stroke caused by brain tissue death). The 8/1/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. Resident #18 required partial to moderate assistance from staff for bathing, dressing, transfers and bed mobility. He used a wheelchair for mobility. The MDS assessment did not indicate Resident #18 had hallucinations, delusions or aggressive behavior. 2. Resident interview Resident #18 was interviewed on 11/5/24 at 3:00 p.m. Resident #18 said he did have an altercation with another resident a long time ago. Resident #18 said he hit the other guy, who was his roommate at the time of the altercation. Resident #18 said he was hallucinating at the time. He said he got along with everyone now and he had his own room. 3. Record review -The comprehensive care plan, initiated 4/9/24, did not have a care focus to address Resident #18's history of aggressive behavior prior to the resident-to-resident alteration on 9/24/24. Following the resident to the resident altercation, Resident #18 was prescribed risperidone (an antipsychotic medication) on 9/25/24 for the diagnosis of aggression. A care plan was initiated for the antipsychotic medication and the incident (resident-to-resident altercation) on 9/26/24. -However, the care plan interventions for resident-to-resident altercations only provided interventions for the 72-hours post-incident and did not provide staff with interventions for the possibility of future resident-to-resident altercations. -There was no intervention for staff to monitor the resident for hallucinations as a precursor to aggressive acts towards their residents. The 9/10/24 psychiatric nurse practitioner follow-up note revealed Resident #18 had not been experiencing hallucinations but had a history of aggression and had been asked to leave previous long-term care facilities for his behavior. -However, there was no evidence in the resident's record that the facility addressed this assessment or that they care-planned the resident's history of aggression. According to the 9/24/24 nursing progress note, nursing staff found Resident #18 standing over the bed of Resident #60. The other resident said Resident #18 hit him on the left side of the face with a closed fist. Resident #18 was unable to tell staff what happened or why he would have hit the other resident. Resident #18 said he may have been hallucinating. The 9/26/24 physician's progress note documented Resident #18 had been hallucinating often, was combative with staff and was likely experiencing terminal agitation due to end-stage liver disease. -However, the nursing progress notes for September 2024 did not include any documentation about Resident #18 being combative with staff or hallucinating. D. Staff interviews The director of nursing (DON), the social services director (SSD), the social services consultant (SSC) and the NHA were interviewed together on 11/7/24 at 2:30 p.m. The NHA, the SSC and the DON said that they did not substantiate the allegation of abuse for the resident-to-resident altercation between Resident #18 and Resident #60 because neither of the residents were injured and neither were fearful. The DON said the IDT reviewed the incident and since Resident #18 said he was hallucinating, the IDT determined Resident #18's actions were not intentional. The DON said she had the staff assist Resident #18 to move to a different room on the second floor while Resident #60 stayed in his room and no longer had a roommate. She said both residents were happy with their new living arrangements. The NHA and the DON said they did not think of considering Resident 18's hallucination as a potential trigger for committing aggressive acts towards other residents whom he might encounter in the common areas of the facility. The DON said Resident #18's physician examined him after the incident and determined aggression had occurred. The DON said the physician ordered risperidone, to help him control his aggressive behaviors. The SSD said following the allegation/incident of physical abuse, the IDT implemented interventions for increased monitoring of Resident #18 that included daily visits from social services to assess the resident for risk of aggression and 15-minute checks by nursing staff to ensure he remained calm. She said these interventions remained in place for 72 hours after the incident occurred. She said, in that time, facility staff did not see any evidence of repeated aggression, so the monitoring interventions were considered completed. 50853

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to ensure: -Resident room [ROOM NUMBER], #204, #206, #209, and #212 were in good repair; and, -Baseboards in the common areas on the second floor unit were clean. Findings include: I. Facility policy and procedure The Safe Homelike Environment policy, revised October 2024, was provided by the nursing home administrator (NHA) on 11/8/24 at 10:12 a.m. It revealed in pertinent part, The facility provides a safe, clean, comfortable and homelike environment and allows the resident to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. II. Ensure resident rooms were in good repair A. Observations On 11/4/24 at 2:52 p.m. room [ROOM NUMBER] was observed to have multiple paint chips averaging six to twelve inches on the wall alongside the resident's bed. During a tour of the north 200 hallway on 11/5/24, from 4:05 p.m to 4:25 p.m., room [ROOM NUMBER], #204, #209,and #212 were observed to have multiple paint chips averaging six to twelve inches on the wall between the bathroom and closet. B. Resident interviews Resident #24 was interviewed on 11/5/24 at 2:19 p.m. Resident #24 said the resident rooms needed to be painted. She said she preferred her home to be in good repair. III. Ensure common areas were clean A. Observations During a tour of the second floor of the facility on 11/5/24, from 4:05 p.m. to 4:25 p.m., the baseboards were dirty. The baseboards had several black skid marks. IV. Staff interviews The maintenance director (MTD) was interviewed on 11/5/24 at 4:25 p.m. The MTD said he was responsible for the building's maintenance. He said he did not have additional staff to support the work orders for the building. The MTD said he knew the walls in room [ROOM NUMBER], #204, #206, #209 and #212 needed to be sanded and painted. He said he prioritized repairs that needed to be completed in the empty rooms after the residents were discharged . He said he did not know when the rooms with residents who lived at the facility long-term would be completed. The MTD said knew the baseboards needed to be cleaned. The MTD said he was in a backlog of maintenance tickets. The NHA was interviewed on 11/6/24 at 3:31 p.m. The said the facility started a repaint project about a month ago. He said he knew the walls in the resident rooms needed to be sanded and painted. He said he knew the baseboards in the hallway needed to be cleaned. He said the maintenance department prioritized the empty rooms after the residents were discharged . The NHA said he did not have a plan on how maintenance could paint the rooms with residents who lived at the facility long-term. The NHA said he realized his current paint project failed to include how to paint all of the resident's rooms including the rooms that were occupied.

Based on observations, record review and interviews, the facility failed to provide needed care of services, resulting in an actual decline in physical, mental and psychosocial well-being for one (#275) out of four residents reviewed out of 33 sample residents. Resident #275, who had a severe cognitive impairment, was admitted to the facility 1/26/23. The resident did not have a medical decision maker, so the facility proceeded to implement a medical health proxy on 3/5/23. The facility failed to notify and coordinate with the health care proxy regarding the resident's care, the contact documented with the health care proxy was 5/20/23. Resident #275 had lost weight since her admission to the facility on [DATE], 21.6% in total in four months, which was considered severe. Her admission weight was 108.4 lbs. (pounds) on 2/5/23 and on 6/1/23 she weighed 85 lbs. The registered dietitian (RD) implemented measures with the resident's weight loss; however, those interventions were ineffective due to the resident having ongoing swallowing problems and nausea/vomiting. Speech therapy worked with the resident due to her swallowing difficulties; however, the interventions were ineffective due to her medical condition. Resident #275 had an esophagram (a series of x-rays of the esophagus) on 3/3/23, however she did not see the gastroenterology outpatient provider until 5/5/23, which was over two months later. During this time, she lost an additional 4.6 lbs. Resident #275 went to a gastroenterology outpatient provider on 5/5/23 where they indicated she had narrowing of the esophagus. Resident #275 required a follow up diagnostic procedure, an esophagogastroduodenoscopy (EGD), to further examine her esophagus. Due to the facility's failures, including not coordinating with the health care proxy in a timely manner, Resident #275 continued to sustain significant weight loss as a result of impaired nutrition related to the narrowing of her esophagus. Resident #275 sustained an additional 10.4 lbs weight loss (10.7%) that occurred after the procedure was recommended on 5/5/23. Per the physician assistant at the outpatient clinic (see interview), the resident sustained the additional 10 lb weight loss as a result of her not getting the recommended procedure from the 5/5/23 appointment. Findings include: I. Resident status A. Resident #275 Resident #275, age 79, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia, subarachnoid hemorrhage (bleeding in brain), dysphagia (difficulty swallowing), fractured femur (broken leg), diabetes and muscle wasting. The 2/2/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident required two person physical assistance for transfer and toileting and one person assist for bed mobility, locomotion on the unit, dressing, hygiene and eating. Weight loss was not coded on the assessment. Difficulty with swallowing was coded on the assessment. The medical record showed the resident had a proxy decision maker by Statute dated 3/5/23. The proxy provided the authority to consent to medical procedures for Resident #275. II. Resident representative (health care proxy) and outpatient provider The healthcare proxy of Resident #275 was interviewed on 6/6/23 at 3:46 p.m. She said she had not been contacted by the facility to sign a consent form for the esophageal dilation until that week (the week of 6/6/23, which was over a month later). She said if she had been contacted on 5/5/23, she would have happily signed and showed up in person if that was needed. The gastroenterology physician assistant (GPA) was interviewed on 6/9/23 at 9:30 a.m. The GPA said she had seen the resident on 5/5/23 and it had been determined the resident required an esophageal dilation. She said the facility staff did not inform her or her office that the resident had a medical proxy in place since March 2023. She said the procedure could have been completed much sooner if the facility had communicated that to her. She said when she saw the resident, she was 95 pounds, and had lost approximately 10 lbs. of weight that was not needed because the facility failed to communicate timely. The GPA said the office tried to reach out to the facility previous to 6/1/23 to coordinate the follow up. III. Failure to ensure required medical procedure was scheduled Progress note dated 5/5/23 from the GPA showed the resident was seen for difficulty swallowing and nausea/vomiting. The GPA referred to an x-ray esophagram, which was done on 3/3/23. The esophagram indicated there was a narrowing of the esophagus, which prevented the passage of a tablet. The GPA indicated that the resident needed an EGD procedure (a diagnostic procedure that examines the esophagus) and the nursing facility had been contacted to determine the next steps to obtain consent for the EGD. IV. Observations On 5/31/23 at 1:40 p.m. the resident in her room provided eating assistance with her meal. She was coughing after eating bites of food. On 6/6/23 at 12:20 p.m. the resident was in the dining room and was assisted by certified nurse aide (CNA) #1. Resident #275 was periodically coughing after eating bites of food. She was observed to consume approximately 75% of her meal. V. Weight loss documentation The resident's weights were as follow: 2/5/23: 108.4 lbs. (10 days after her admission) 2/6/23: 107.6 lbs. 3/1/23: 100.8 lbs. 3/13/23: 100.2 lbs. 4/13/23: 95.0 lbs. 4/19/23: 96.2 lbs. 4/25/23: 96.4 lbs. 5/10/23: 95.2 lbs. 5/15/23: 91.6 lbs. 5/24/23: 86.0 lbs. 6/1/23: 85.0 lbs. The resident had lost 21.6% in total body weight since admission 1/26/23. Resident #275 weighed 95.2 lbs on 5/10/23 (five days after her GI consultation appointment). By 6/1/23, her weight was 85 lbs, which was 10.2 lbs. (10.7%) weight loss in 22 days, which was considered severe weight loss. The 6/1/23 RD progress note documented the reason for the weight loss was due to frequent vomiting after consuming food or liquid which was related to narrowing esophagus. The resident had a weight loss of 10.7% in the previous two weeks, 15.2% over 2.5 months and 21.6% weight loss over four months. VI. Medical proxy documentation The 5/4/23 social services director (SSD) progress note documented the resident did not have a representative in place for decision making. The 5/12/23, 5/18/23 and 5/24/23 SSD notes documented she requested assistance with getting the resident a representative for decision making. -However, the health care proxy was initiated on 3/5/23 (see above) to make medical decision for Resident #275. The 5/20/23 case manager (CM) progress note indicated the medical orders for scope treatment (MOST) form was signed and sent back to the facility by the proxy. VII. Staff interviews CNA #1 was interviewed on 6/6/23 at 1:30 p.m. CNA #1 said she was familiar with Resident #275. She said Resident #275 did well today, however, that resident struggled with swallowing during meals. The RD was interviewed on 6/6/23 at 2:00 p.m. The RD stated Resident #275 had weight loss for several months. The RD stated over the past three weeks she had significant weight loss. She stated an esophageal dilation procedure was needed for the resident to improve and the CM was working on this. The RD stated dilating the esophagus would allow the food to flow into her stomach. The RD stated Resident #275 had previously had an appointment with a gastroenterologist and the facility was waiting on a proxy placement for the resident to have the procedure that would help her. The SSD and CM were interviewed on 6/6/23 at approximately 2:30 p.m. The CM said Resident #275 did not have next of kin or friends, so the facility used a resource from a list. The healthcare proxy was completed when the resident went to long term care around 2/16/23. -However, the health proxy was not initiated until 3/5/23 (see above). The SSD stated she had been looking for permanent guardianship/conservatorship for the resident since she was not sure if the healthcare proxy could be used for medical care decisions. The SSD said she then found out that the proxy would have to be there in person. -However, the SSD made no attempts to coordinate with the health care proxy who was willing to go to the appointments (see interview above). The director of nursing, (DON) was interviewed on 6/6/23 at 3:15 p.m. The DON said the resident had a healthcare proxy in place. She said the signed consent was sent to the clinic on 6/1/23. The DON stated the gastroenterology office would not accept a proxy and education was needed on the clinic side. She said she was told the proxy had to show up in person. -However, there was no documentation of what the gastroenterology office had indicated to the DON. In addition, the GPA indicated the clinic had not been informed of medical proxy and it did not interfere with the resident being seen more timely by the office. She stated she left a message for the proxy today to see if she could be there in person. The DON said the consent could have been faxed to the clinic over a month ago. VIII. Facility follow-up The 6/1/23 CM progress note (during the survey) indicated she left a message for the GI (gastroenterology) clinic to request consent forms for treatment which would be sent to Proxy for signature, then resident can be scheduled for treatment for esophageal narrowing.

Based upon observation, interviews and record review, the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty received the appropriate treatment and services to correct the assessed problem or to attain the highest practicable physical, mental and psychosocial well-being for one resident (#65) reviewed for a mental disorder out of 33 sample residents. Specifically, the facility failed to ensure interventions were in place to address Resident #65's verbally aggressive behavior. Findings include: I. Resident status Resident #65, age 65, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included substance abuse and paranoid schizophrenia. The 4/24/23 minimum data set (MDS) assessment was documented with a brief interview for mental status (BIMS) score of eight out of 15, indicating moderate cognitive impairment. The MDS did not identify or code any behavioral symptoms. The MDS coded functional status of two persons assist for transfer, toileting and dressing and one person assist for locomotion, hygiene and eating. The MDS assessment documented Resident #65 participated in his activity preference assessment and revealed he listened to music that he liked, doing his favorite activities and going outside to get fresh air when the weather was good were very important to him. II. Record review Progress notes were reviewed related to the resident's behavior: 5/16/23 at 4:39 p.m., the nurse documented the resident was not cooperative with care, refused to be changed and cursed at staff. 5/17/23 at 5:57 a.m., the nurse documented the resident removed his brief and urinated on the floor. The resident was yelling and cursing at a certified nurse aide (CNA). Educated the resident about using respectful language. Two staff were placed for care and requested the social services director (SSD) be notified. 5/20/23 at 4:18 p.m., the nurse documented the resident was increasing with verbal sexually inappropriate behavior toward female staff and was verbally aggressive with most staff during the past week. Case manager was notified and was to pass on to the SSD. The resident was constantly yelling out and the roommate and his wife were very offended by his language. Resident #65 continued to urinate on the floor. 5/22/23 at 4:18 a.m., the nurse documented the resident was verbally aggressive with the nursing staff and redirection was attempted with little success. The resident threw soiled incontinence briefs on the floor and at staff. 5/29/23 at 11:40 a.m., the nurse documented the housekeeper reported Resident #65 called her into the room. The resident removed his brief and demanded she touch and reposition him. Staff were encouraged to care for the resident with two people. 5/31/23 at 6:57 p.m., the nurse documented she was notified of Resident #65 being accused of making threatening statements toward his roommate. The resident was placed on 15 minute checks and roommates were separated until his roommate was moved to another room. The physician was notified. The director of nursing (DON) was involved and the police department was notified. 5/31/23 at 7:49 p.m., the nurse documented the resident was verbally aggressive and combative during transfers and the resident cursed at the nurse. 6/1/23 at 4:34 p.m. (during the survey), the SSD noted that the resident was offered psych support and declined at that time. -There was no other documentation by the SSD addressing the resident's increasing behaviors. -The interdisciplinary team (IDT) did not develop and implement individualized care approaches to the resident's behaviors, addressing his diagnosis of paranoid schizophrenia and substance abuse. -The IDT did not monitor and provide ongoing assessment of what care approaches were effective with the resident's behaviors and identify the root cause of the resident's behaviors. The care plan, last revised 5/10/23, indicated the resident was at risk for impaired cognitive function/dementia and interventions included the following: Administer medications as ordered; Communicate with family/caregivers regarding residents capabilities and needs; Communication: Identify yourself at each interaction. Face resident when speaking and make eye contact. Reduce any distractions, including turning off television, radio and close door. Use simple direct sentences. Provide necessary cues. Stop and return if agitated; Give step by step instructions one at a time as needed to support cognitive function; Keep routine consistent and try to provide consistent care givers as much as possible to decrease confusion; and, Monitor/document/report to physician any changes in cognitive function. -The care plan had not been updated since reports of resident's behaviors in the nursing progress notes. -The nursing staff implemented two persons to provide care to the resident due to his behaviors. The intervention was not consistently implemented or incorporated into the resident's care plan. -The resident had known aggression with his roommate with no interventions implemented for his behaviors to protect other residents. III. Staff interviews CNA #2 was interviewed on 5/31/23 at 5:35 p.m. Resident #65 cursed a lot at other residents due to being impatient. The CNA stated she did not know the resident well and did not know what approaches were utilized for Resident #65's behavior. Registered nurse (RN) #1 was interviewed on 5/31/23 at 5:55 p.m. The RN said she was an agency RN and she was taking care of Resident #65 and his roommate today. The RN stated the roommate was upset at Resident #65, but Resident #65 did not seem upset. The RN stated the roommate told her Resident #65 was rude, bossy and demanding. The roommate told her to transfer him out of the room due to Resident #65 threatening him. The RN stated she planned to talk with the SSD to follow up. The RN did not know what strategies the facility implemented for Resident #65's aggressive behavior. The social services director (SSD) was interviewed on 6/6/23 at 4:41 p.m. The SSD stated staff expressed Resident #65's behaviors as being sexually inappropriate including complaints from staff about when the resident was showering. He was verbally aggressive toward staff. The SSD stated Resident #65 was pleasant when she interacted with him. The SSD stated on 5/31/23 was the first time she had heard of verbal aggression and threats toward his roommate. -However, the resident was aggressive previous to 5/31/23, when the case manager was notified to let the SSD know as early as 5/20/23 (see above). The SSD said Resident #65 denied yelling at his roommate and denied being aggressive toward anyone. The SSD stated she had checked on him every day since and he had been in a stable mood with no aggressive behaviors. She has since educated staff about triggers for Resident #65. The SSD stated the plan was to not have a roommate with this resident. -The SSD provided staff education on the resident's behaviors during the survey, however it was after the resident had been having increasing behaviors and she had been notified by the nursing staff about his behaviors. There were no individualized care approaches addressing his aggressive behaviors indicated on his care plan. The director of nursing (DON) was interviewed on 6/6/23 at 5:46 p.m. The DON stated that Resident #65's behaviors fluctuated from day to day and he could be stable one day, then not on the next. He could be verbally aggressive. The physician had thoroughly reviewed his medications. The care team has questioned whether his behavior worsened at night due to sundowning. The DON stated the previous roommate was not happy with the resident due to his urinating on the floor and his vulgarity. The DON stated the facility goal was to keep him in a private room since the report of the verbal abuse toward his roommate. -However, there was no documentation of the IDT addressing his aggressive behaviors toward staff and his roommate.

Based on observation, record review and interviews, the facility failed to ensure the residents personal privacy for one (#10) out of four residents reviewed for dignity out of 33 sample residents. Specifically, the facility failed to ensure a resident's personal privacy by offering a leg bag for the urinary catheter for Resident #10. Findings include: I. Resident status Resident #10, age 82, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), the diagnoses included neuromuscular dysfunction of the bladder (lack or bladder control). The 4/18/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required limited assistance of one staff member with transfers, dressing, toilet use and personal hygiene. The resident had an indwelling catheter. II. Observation and interview On 5/31/23 at 10:30 a.m. Resident #10 had catheter tubing (a tube inserted into the bladder, allowing urine to drain freely) coming out top of pants attached to a catheter bag (drainage bag that collects urine) hanging from the walker. Resident #10 said, upon admission, the facility had used a small bag attached to her leg, under her clothing, to collect urine but staff did not offer this option. Resident #10 said she preferred to use the smaller leg bag during the day. III. Record review Review of the June 2023 CPO revealed the resident had an order to change catheter bag as needed. -The order did not indicate an option was available for the type of catheter bag. -Review of Resident #10's progress notes with a date range of 4/11/23 to 6/6/23 did not reveal options that had been discussed regarding the type of catheter bag. Review of Resident #10's care plan, with a revision date of 5/3/23, revealed a catheter care plan. -The interventions did not include providing the resident with a choice for a type of catheter bag. -The certified nurse aides (CNA) tasks reviewed on 6/6/23 at 10:00 a.m., with a 30 day lookback time frame, did not reveal instructions to offer Resident #31 a different type of catheter bag. IV. Staff interviews Restorative Nurse Assistant (RNA) #1 was interviewed on 6/6/23 at 11:00 a.m. She said she was not aware of Resident #10 having a preference to use a leg bag. She said she thought Resident #10 preferred to have the catheter tube come out top of her pants and catheter bag attached to the walker. CNA #1 was interviewed on 6/6/23 at 11:10 a.m. She said Resident #10 refused to use a catheter leg bag because it filled with urine too quickly. She said staff encouraged Resident #10 to use a catheter leg bag but the resident declined. She did not know where to find information regarding catheter bag preference for Resident #10. She said staff had not charted if Resident #10 declined or accepted leg bag because they just knew to provide the option everyday. The minimum data set coordinator (MDSC) was interviewed on 6/6/23 at 11:49 a.m. She was unable to find information regarding preference of catheter bag being offered to Resident #10. She asked Resident #10 about catheter bag preference. She said Resident #10 accepted an offer to use a catheter leg bag. She said the care plan would be updated. The director of nursing (DON) was interviewed on 6/6/23 at 5:50 p.m. She said it was important to have proper positioning of catheter tubing and bag for comfort, flow and skin integrity. She said it was important to conceal tubing if possible to promote dignity. She said residents should have a preference regarding the type of catheter bag used. She said information on preferences should be available to facility staff in resident's care plans and communicated as a CNA task.

Based on observations, record review and interviews, the facility failed to ensure that self-administration of medications were stored and clinically appropriate for two (#31 and #38) of two residents reviewed for self-administration out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #31 stored medication she was assessed to self administer and the medications she was able to self-administered were stored appropriately; and, -Ensure Resident #38 was assessed for the appropriateness and safety for self-administration of medications. Findings include: I. Resident #31 A. Resident status Resident #31, age 76, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), the diagnoses included dystrophic nails (change in color, texture, growth of nails) and gastroesophageal reflux disease (GERD, stomach acid that can irritate the throat). The 4/28/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required limited assistance of one staff member with transfers, toilet use and personal hygiene. B. Observation On 5/31/23 at 11:04 a.m. and 6/1/23 at 1:00 p.m. a bottle with liquid was on the bedside table belonging to Resident #31. The label on the bottle read 6.6 milliliter (ml) Ciclopirox (antifungal medication), topical solution 8%. Three containers with a label reading Tums (antacid) were on the bedside table belonging to Resident #31. The medications were not secured. Resident #31 identified the bottle of liquid as antifungal medication she applied on her toes to remedy itching and she took Tums for heartburn. C. Record review The 9/7/22 self administration of medication evaluation for Ciclopirox medication revealed Resident #31 was fully capable of stating name medication, what the medication was for, when the medication should be taken and how much, how the medication should be applied, side effects of medication and was able to demonstrate secure storage of medication kept in room. The June 2023 CPO revealed Resident #31 was able to self administer Ciclopirox (antifungal medication) to toenails per orders. The order was to apply to toe nails topically at bedtime for dystrophic nails (change in color, texture, growth of nails). The June 2023 CPO revealed Resident #31 had an order for calcium carbonate oral tablet chewable (antacid) to be taken as needed for stomach acid. -It did not indicate Resident #31 could self administer the antacid medication. The 5/17/23 care plan revealed Resident #31 had a rash on toes related to diagnosis of dystrophic nail (change in color, texture, growth of nails). Intervention included medication be given as ordered, and side effects were to be monitored and documented for effectiveness. A focus on gastroesophageal reflux disease was indicated in the care plan. Interventions included the resident be given medications as ordered, and effectiveness be monitored and documented. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 6/1/23 at 11:04 a.m. She was unaware of the assessment process to determine residents ability to self administer. She said medications for residents who can self administer could be stored in the resident room or stored on a nursing medication cart. She said not all medications stored in a resident room have to be locked in drawers or cabinets. She said it depends who the resident was and what the care plan documented. Certified nurse aide with medication authority #1 was interviewed on 6/1/23 at 11:10 a.m. She said residents should be assessed prior to approval to self administer. She said medication should be stored on a nursing medication cart and provided upon resident request. She said medications stored in a resident room should be locked in a drawer or cabinet. The director of nursing (DON) was interviewed on 6/1/23 at 4:01 p.m. She said residents need to be assessed for ability to self administer medication if they wish to do so. She said after an assessment was completed a doctor's order needed to be in place. She said once it had been determined a resident was safe to self administer medication, the medication should be stored in a locked cabinet, drawer or box in the resident room. She said there needs to be two keys, one for the resident and one for nursing staff. She said another option was to store the medication on a nursing cart and provide upon resident request. II. Resident #38 A. Resident status Resident #38, age 68, was admitted on [DATE]. According to the June 2023 computerized CPO, the diagnoses included unspecified pain, polyp of colon (small clump of cells forming on lining of colon) and malaise (general discomfort). The 4/29/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. He required supervision and set up only with bed mobility, transfers, eating and toilet use. B. Observation and interview On 5/31/23 at 12:40 p.m. the bedside table of Resident #38 had saline nasal spray, fluticasone-propionate-nasal-spray, good sense nasal spray, topical skin cream-triamcinolone acetonide cream 0.1% (topical cream used to treat various skin conditions causing discomfort) and hemorrhoidal cream (ease discomfort of swollen veins of lower rectum). Resident #38 said he preferred to keep medication at his bedside. Resident #38 said he used nasal spray daily, hemorrhoidal cream and the topical treatment when needed for skin discomfort. C. Record review -Review of the June 2023 CPO revealed Resident #38 did not have a physician's order to self administer medication. -Review of Resident #38's assessment history revealed the resident had not had a self-administration of medications assessment conducted. -Review of Resident #38's comprehensive care plan, updated 3/28/23, revealed the resident did not have a care plan focus for the self-administration of medications. D. Staff interview and observation The minimum data set coordinator (MDSC) was interviewed on 6/1/23 at 2:38 p.m. She said a resident would need an assessment for ability to self administer medication. She said if a resident could self administer a medication, the medication would need to be in a lock box or stored in a nursing medication cart. She said all resident rooms have nightstands with a locking drawer or the facility could provide a lock box if needed. The MDSC entered room of Resident #38 and observed saline nasal spray, fluticasone-propionate-nasal-spray, good sense nasal spray, topical skin cream-triamcinolone acetonide cream 0.1% and hemorrhoidal cream. The MDSC informed Resident #38 an assessment for self administration would be completed and medications would need to be kept in a locked drawer of his choosing. The resident nodded his head and verbalized agreement.

Based on record review and interviews, the facility failed to provide one (#1) of three residents, out of five sample residents, adequate supervision and an environment as free from accident hazards as possible, contributing to an accident involving harm. On 6/8/21 at approximately at 12:45 p.m., nursing staff were alerted that Resident #2 had a fall in the facility transport van during his return from his appointment. The facility failed to ensure Resident #2 was securely fastened in his wheelchair during transport to and from his appointment. Upon return from his appointment the van driver (VD) #1 swerved to avoid hitting another vehicle and Resident #2 fell forward, out of his wheelchair, and sustained multiple fractures to his lower extremities. The facility's failure to ensure staff were educated properly on how to securely fasten residents while in their wheelchairs during transportation resulted in Resident #2's sustaining multiple fractures to his bilateral lower extremities. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/21/21-6/22/21, resulting in the deficiency being cited as past noncompliance with a correction date of 6/8/21. I. Immediate Jeopardy for serious harm A. Situation of Immediate Jeopardy On 6/8/21 at approximately at 12:45 p.m., nursing staff were alerted that Resident #2 had a fall in the facility transport van during his return from his appointment. Resident #2 was not securely fastened in his wheelchair during transport to and from his appointment. Upon return from his appointment the VD #1 swerved to avoid hitting another vehicle and Resident #2 fell forward out of his wheelchair and sustained fractures to lower extremities. The facility's failure to ensure the resident's environment remained free from accident hazards which caused harm. Upon interview with staff it was determined that VD #1 was not properly educated in his new role on how to securely fasten residents while in their wheelchairs during transportation, this resulted in Resident #2 falling out of his wheelchair during transport and ultimately sustaining multiple fractures to his bilateral lower extremities. The nursing home administrator (NHA) was notified of the immediate jeopardy on 6/21/21 at 4:30 p.m. that record review and interviews during the complaint investigation confirmed the deficient practice which had been corrected and the facility was in substantial compliance with F689 at the time of survey. B. Facility plan to remove the Immediate Jeopardy situation The facility developed the following immediate plan: The NHA provided the facility's plan of correction (POC) binder on 6/21/21 at 1:40 p.m. The binder included the following: -Immediate return demonstration and education provided to VD #1 completed on 6/8/21; -Safe Client Transport completed on 6/14/21 and 6/17/21 by VD #1; -Wheelchair safety and securement tips completed on 6/17/21 by VD #1; -The Art of comforting our patients completed 6/18/21 by VD #1; -Basics of defense driving completed on 6/18/21 by VD #1; -Driving in Bad Weather completed on 6/18/21 by VD #1; and -Wheelchair safety and securement tips completed on 6/18/21 by VD #2. Additionally the binder included weekly audits of residents being properly secured in the facility van. Reviewed audits for Resident #1, Resident #4 and Resident #5. Investigative Action: the facility initiated an immediate investigation which included staff interviews, a review of medical records and an IDT (interdisciplinary team) analysis of the situation. -Resident #2 was interviewed regarding the incident. -Van driver was interviewed regarding the incident. Upon return to the facility after the incident Resident #2 was assessed by nursing staff for injuries. -Other residents were interviewed who were recently transported in the facility van, none expressed any concerns. -The facility van was inspected. -The resident was transferred to the hospital for increased pain. Interventions to prevent recurrence: -Van driver was educated on how to secure a person in the van. -Weekly audits would be performed for three (3) months to ensure that residents are properly secured (Three audits were reviewed during survey 6/21/21-6/22/21). -Seatbelts for wheelchairs will be ordered prior to using the wheelchair area of the van. C. Removal of Immediate Jeopardy The immediate jeopardy situation was removed prior to the onsite investigation on 6/21/21-6/22/21. Interview and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained correction. Therefore, the deficient practice was corrected prior to the onsite investigation and represented past noncompliance at G level, actual harm that is isolated. II. Failure to ensure VD #1 was educated/trained to properly secure residents in their wheelchair for transport A.Resident #2 status Resident #2, age less than 60, was admitted on [DATE] and readmitted [DATE]. According to the June 2021 computerized physician orders (CPO), diagnoses included [CONDITION(S)], heart failure, acute respiratory failure and tibia/fibula fractures. The 6/4/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. He did not exhibit behavioral symptoms. He required extensive two-person assistance with, transfers and walking in room and in corridor did not occur. B. Resident interview Resident #2 was interviewed on 6/21/21 at 11:43 a.m. He was lying in bed, he had bilateral splints to both lower extremities. He said he was admitted from the hospital in January 2021. He said he had [CONDITION(S)] and did not walk and needed assistance to get in his wheelchair and to bed. He said the day of the incident (when he suffered multiple fractures) he was going to a neurology appointment. He said there was no seat belt for a wheelchair passenger in the Dodge caravan he was being transported in. He said VD #1 did not offer to secure him to the wheelchair because there is no strap to fasten during his transportation to and from his appointment. He said the facility was negligent in not obtaining seatbelt straps for the van. He said after the incident he arrived to the facility and staff assessed him and then sent him to the hospital. C. Record review The facility investigation was provided by the nursing home administrator (NHA) on 6/21/21 at 12:25 p.m. It revealed the following: -Resident #2 came back from an appointment in the (Name of facility) and rehab van with a staff member. During the drive back, another car pulled out in front of the (Name of facility) van driver. The staff member slammed on the brakes to avoid hitting the car. Resident #2 fell forward out of his wheelchair. The resident expressed pain to the staff member and requested the van be pulled over and he be moved. The staff member pulled over and unhooked the wheelchair so he could move the resident. The resident was laid on his back. After this, the staff member drove the van back to the facility to get assistance in getting the resident back in the wheelchair. Resident was then taken to (Name of the hospital) hospital due to the resident expressing pain. Resident #2 returned to the facility at approximately 7:30 p.m. on 6/8/2021. Resident #2's x-ray results indicated fractures in both left and right legs. The incident was reported to the State Agency. -Resident #2 was assessed on 6/8/21 before sending him to the hospital. The resident and driver were interviewed. Staff who assisted the resident back in the wheelchair were interviewed. The facility van was inspected. Residents who had recently been transported in the van were interviewed. -Resident #2 was taken to the (Name of hospital) hospital upon arrival to (Name of facility). Education was provided to staff members immediately after knowledge of the incident regarding how to properly secure a resident in the van. Staff member was also suspended pending the conclusion of the investigation. The provider was notified of the incident. The police department was notified of the incident. The family was notified of the incident. The ombudsman was notified of the incident. -Upon return to the facility compression stockings and knee immobilizers were provided to the resident and oxycodone was prescribed as needed for pain. The emergency department note dated 6/8/21 at 1:02 p.m. revealed the resident arrived with bilateral leg injuries and x-rays revealed bilateral proximal tibia/fibula fractures. The care plan, initiated 6/9/21 documented Resident #2 was being monitored for complications related to fractures. Interventions included as follows: -Follow weight bearing restrictions; -Monitor limbs for swelling, take pedal pulses; -Monitor/document pain on a scale of zero to 10 before and after implementing measures to reduce pain; -Monitor, document and report to the physician as needed signs and symptoms (s/s) of [CONDITION(S)] complications; -Monitor for contracture formations; -Monitor for embolism; and -Monitor for s/s of cyanosis, pain, petechiae, increased heart rate, [CONDITION(S)], tachypnea, difficulty breathing (dyspnea), infection at surgical site, impaired mobility, unrelieved pain, pneumonia, poor air exchange and incontinence. III. Observation of facility van On 6/21/21 at 2:15 p.m. the facility transport van was observed with the NHA and VD #1. No residents were scheduled for transport at this time. The white Dodge caravan transport vehicle had a small ramp to the back of the van which staff could get residents in and out of. The van driver demonstrated how he would buckle a resident in and secure the resident in their wheelchair, at this time the shoulder strap belt for wheelchair passengers was observed and functioning. IV. Staff interviews Van Driver #1 was interviewed on 6/21/21 at 2:03 p.m. He said he worked at the facility as a certified nurse aide (CNA) for six months and recently started working as the van driver in June 2021. He said he had worked as a concierge prior to taking the van driving position and had basic transportation knowledge, so what he did to prepare himself to become the van driver was watch a tutorial online (name of social media channel), which gave him instructions on how to place and secure residents on the van. He said NHA gave him an overview about driving prior to him accepting the position, the facility obtained copies of his driver's license and he completed all the necessary paperwork. -However, he did not receive any formal training by the facility staff such as return demonstration of how to safely secure a resident in the facility van or complete the facility's online training of how to safely secure a resident for transport. He said the day of the incident, he placed Resident #2 in the van, locked his chair, and placed the floor locks to his wheelchair; however failed to place a seat belt/shoulder belt (which hung from the side of the van) to secure the resident in his wheelchair. He said he had not used that particular strap/belt prior to transporting residents and it did not occur to him to use those straps/belt (shoulder strap) because he thought the resident was just like a passenger in a bus which did not have seatbelts. He said he had since been educated. The NHA and director of nursing (DON) were interviewed on 6/21/21 at 3:10 p.m. They said VD #1 should have completed his training on how to secure residents before transporting residents. The NHA said he was the one responsible to ensure the VD #1 was trained. They acknowledged no one in the facility had followed up to ensure VD #1 had been educated on how to transport residents safely to their appointments prior to him accepting the position. They said moving forward the facility would ensure that staff were trained to complete assigned tasks/duties. V. Facility correction Interview and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained correction. See above the facility plan to remove immediate jeopardy. Corrective actions identified in the plan to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained correction were reviewed during the complaint investigation. Interviews with the NHA and DON confirmed the corrective actions and therefore the facility's substantial compliance with F689 at the time of the survey. The NHA, DON and clinical resource nurse were interviewed on 6/21/21 at 4:30 p.m., at that time they were made aware of the immediate jeopardy in F689 past non-compliance for 6/8/21 due to their ongoing plan of correction that they put into place.They acknowledged the reasoning for the immediacy as the VD #1 had not received any training by the facility on how to secure residents for safe transportation prior to accepting the position.

Based on record review and interviews the facility failed to ensure personnel provided basic life support, including cardiopulmonary resuscitation (CPR), prior to the arrival of emergency medical personnel according to the advance directive for one resident (#1) out of three residents reviewed for CPR out of six total sample residents. Specifically, the facility failed to: -Follow the advance directive on the resident's medical orders for scope of treatment (MOST) form; and, -Ensure the resident's advance directive on the MOST form matched the orders in the electronic medical record, so care wishes were consistent and followed by staff. I. Facility policy and procedure The Advance Directives policy, revised ,d+[DATE], was provided by the director of nursing (DON) on [DATE] at 1:00 p.m. It read, in pertinent part: It is the policy of this facility that a resident's choice about advance directives will be respected. Prior to, or upon admission, the care plan team will ask resident, and/or their family members, about the existence of any advance directives. The facility has defined advance directives as preferences regarding treatment options. If advance directive documents were developed in another state, the facility will obtain a MOST form from Colorado. The facility will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care. The Emergency Procedures policy, revised ,d+[DATE], was provided by the DON on [DATE] at 10:00 a.m. It read, in pertinent part: It is the policy of this facility when an emergency situation occurs, the person finding the situation should implement emergency procedures. The purpose is to provide immediate medical care to a resident whose condition indicates a need. The Cardiopulmonary Resuscitation (CPR) policy, revised ,d+[DATE], was provided by the DON on [DATE] at 11:00 a.m. It read, in pertinent part: It is the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advance directives or a Do Not Resuscitate (DNR) order. Only staff members with current CPR certification for Healthcare Providers should perform the procedure. Procedures -Check for responsiveness, quality of breathing and pulse simultaneously. -If unresponsive, not breathing (occasional gasps are not breathing) and no pulse, activate EMS system: Call 911. -Position the resident face up, on a firm flat surface, supporting the head, neck and back in a straight line. -Start chest compressions: Perform 30 chest compressions at a rate at least ,d+[DATE] per minute. Compression depth of at least two inches for an average adult. -Open airway (tilt the head back and lift the chin up) give two rescue breaths. May use a bag valve or Ambu bag to give rescue breaths. Blow for about one second to make the chest clearly rise. -Continue cycles of CPR, 30 chest compressions to two rescue breaths. II. Resident #1 A. Resident status Resident #1, age 70, was admitted on [DATE], readmitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for mental status score of 12 out of 15 and exhibited rejection of care. He required extensive assistance of two staff members with bed mobility and transfers and extensive assistance of one staff member with his activities of daily living (ADLs). B. Record review Review of the resident's record revealed a MOST form dated [DATE] upon a readmission to the facility, which indicated Resident #1 did not want CPR if he had no pulse or respirations, but wanted full treatment if he did have a pulse and/or respirations. The resident signed the MOST form on [DATE] and the nurse practitioner (NP) signed the form on [DATE]. The readmission note from [DATE] read the resident was a full code. -This statement was not consistent with the resident's wishes on the MOST form. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -This order was not consistent with the resident's wishes on the MOST form and no new orders were added to reflect his wishes after the NP signed the MOST form on [DATE]. A progress note written by licensed practical nurse (LPN) #3 dated [DATE] at 5:01 a.m. read the nurse went into the resident's room to check his blood sugar and found him lying in bed with pulse and respirations ceased. The nurse called the RN who came to the resident's room and CPR was started with no success. The emergency medical system, 911, was called and EMTs attempted CPR with no success. The resident was pronounced dead. The EMS report dated [DATE] was obtained electronically on [DATE] at 2:00 p.m. It read, the call from the facility was received at 4:20 a.m. and EMTs arrived to the resident at 4:30 a.m. Upon arrival, the EMTs found the resident in bed pulseless and apneic (not breathing) with cool extremities, no rigor (stiffening of the joints after death) present, and with pupils fixed and dilated. The RN onsite reported CPR was started and chest compressions and ventilations continued for approximately 15 minutes. The patient was placed on a cardiac monitor and was found to be in asystole. The EMT physician was contacted for a field pronouncement with time of death being 4:40 a.m. III. Interviews LPN #3 was interviewed on [DATE] at 5:50 p.m. She stated she had been into Resident #1's room at 2:15 a.m. to give him snacks. She stated the resident was stating he did not want to go to [CONDITION(S)]. She stated he was alert and oriented and exhibiting his normal behaviors. She stated she started her routine blood glucose checks sometime between 4:00 and 4:15 a.m., but she was not positive about the time. She stated when she entered his room, he was cold, had no pulse, was not breathing, and was lifeless. She stated she immediately called for a certified nurse aide (CNA) and went to get the registered nurse (RN) in the building on the first floor as she was working on the second floor. She stated the RN came up and went to the resident's room. She stated she checked the resident's code status in the computer system and it said CPR. She stated she did not start CPR, but the RN did. She stated she called 911 when the RN was doing CPR. She stated the note she wrote about the incident was not very descriptive. RN #2 was interviewed on [DATE] at 6:18 p.m. He stated the LPN called him up at 4 something but he did not remember the exact time. He stated he knew there was an emergency and was not paying attention to the clock. He stated he checked the resident and there were no vitals, no pulse and no breathing and the resident was cold. He stated he brought the crash cart and the vitals machine with him and he started CPR on the resident because he was familiar with the resident and LPN #3 told him the resident was a full code. He stated he did at least five cycles of CPR and checked the resident's vitals again and there was no sign the CPR was working. He stated he checked all of the pulse points. He stated the LPN called 911. He stated he stopped CPR because it was not working. He stated paramedics and police arrived at the facility a couple minutes after he stopped CPR. He stated he did not write a progress note about the incident and he could not give a reason why. The DON was interviewed on [DATE] at 3:00 p.m. and 6:30 p.m. She stated the nurses should look in the resident's medical chart and/or at the MOST form to find the resident's code status. She stated the MOST form and the order in the electronic record should be the same. She stated the nurse who admits the resident discusses the MOST form with the resident or the resident representative upon admission, should have the resident or the representative sign the form, then the physician or licensed provider should sign the form acknowledging the wishes and enter an order into the electronic health record. She stated CPR should be started by the licensed nurse immediately and they should call for help from other staff to alert more people, call 911 and the physician. She stated once CPR is started, they should not stop until emergency personnel arrive or the physician tells them to. She stated the nurses should have verified his wishes by looking at the MOST form. She stated the facility would begin education to all staff immediately regarding advance directives, code status, documentation, and CPR. The medical doctor (MD) was interviewed on [DATE] at 10:28 a.m. He stated the nurse who found the resident should have started CPR until the code status was verified from the MOST form. He stated the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he was very familiar with Resident #1 and the resident changed or modified his code status each time he returned from the hospital. He stated the resident's medical condition was very complex and his prognosis was poor. He stated the resident often refused [CONDITION(S)] and had suffered cardiac arrests in the past which he no longer wanted aggressive treatment for. He stated he did not know that the resident had signed a do not resuscitate order when he returned to the facility on [DATE] and he was not the provider who signed the MOST form. The nurse practitioner (NP) was interviewed on [DATE] at 1:55 p.m. She stated she signed the resident's MOST form when she came to the facility for a readmission visit on [DATE]. She stated she remembered signing it and remembered that it was a change from his previous wishes. She stated she did not discuss the change with the resident because his prognosis was poor and they had had many palliative care conversations with the resident in the past. She stated she must have forgotten to change the order in the electronic record and did not change the code status on her note either. She stated the facility staff should always follow what is on the MOST form as it has the resident's signature and it is a legal document. She stated the nurse who found him should have started CPR until the code status was verified from the MOST form. IV. Facility actions On [DATE] the facility began providing education to all staff related to MOST forms to include discussing the MOST form with residents and/or responsible party, calling the provider to inform them of the resident's wishes so an accurate order can be written, the nurse completing the form filling out the back portion as a witness, placing the form in the MOST form book kept at the nurses station, and social services to be responsible for ensuring the MOST form is complete and the order in the record matches the signed MOST form. This education was completed with all staff by [DATE]. On [DATE] the facility began providing education to all staff related to advanced directives and what to do if a resident codes. This education was on the facility policies for CPR, emergency procedures, and advanced directives. This education was provided to all staff and was completed by [DATE]. On [DATE] the DON provided a schedule for practical CPR classes to begin on [DATE] for all staff to become CPR certified. -No additional information was provided by the facility after exiting the survey.

Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as coronavirus (COVID-19) in two of three units. Specifically, the facility failed to correctly use personal protective equipment (PPE) on non COVID-19 units. Findings include: I. Professional reference The Centers for Disease Control and Prevention (2020) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, retrieved from:https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed on 10/27/2020. It read in pertinent part, Health care professionals who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Put on an N95 respirator (or equivalent or higher-level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use strategies to optimize PPE supply. Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. II. Observations and interviews on the first floor unit (non COVID-19 unit) On 11/12/2020 at 5:05 a.m., registered nurse (RN) #1 was observed next to the medication cart, she was wearing goggles, and N95 mask with both strings hanging below the level of ears. -At 5:10 a.m., certified nurse aide (CNA) #3 was observed walking down the hallway, she was wearing a N95 mask and no eye protection. CNA #3 was interviewed on 11/12/2020 at 5:10 a.m. She said she did have a face shield, but she left it in her car when she stepped out for the break. She said wearing N95 and a face shield was a facility requirement. RN #1 was interviewed on 11/12/2020 at 5:45 a.m. She said the strings on her N95 mask slid down and she did not notice that. She said she was educated on proper wear of the mask and everyone was educated to check for the proper seal of N95 after donning. She said every medication cart had a supply of N95 masks that nurses were supposed to give to CNAs at the beginning of the shift if they do not have one. III. Observations and interviews on the second floor unit On 11/12/2020, the following observations and interviews were made on the second floor unit, where one resident with COVID-19 resided. -At 5:15 a.m., licensed practical nurse (LPN) #1 was observed sitting at the nurses station and documenting on the computer. Her N95 mask was sitting on the table next to the keyboard and goggles. -At 5:20 a.m., CNA #4 was observed leaving the resident's room. She was wearing goggles, and a KN95 mask with a surgical mask underneath. CNA #4 was interviewed on 11/12/2020 at 5:25 a.m. She said she was aware that the facility required everyone to wear a N95 mask and eye protection. She said when she came to her shift and asked LPN #1 for N95 mask, the LPN #1 gave her a KN95 mask and said she could wear a surgical mask underneath. LPN #1 was interviewed on 11/12/2020 at 5:30 a.m. She said she was charting on the computer and took her N95 off because it was hard to breath in it. She said she would put it back on when she went into a patient's room. She said she did not recall having a fit test for the mask and did not know what kind of test it was. IV. Administrative interview The director of nursing (DON) was interviewed on 11/12/2020 in the afternoon. She said the facility requirement was for every staff member to wear a N95 and eye protection in the building. She said all nurses and CNAs were educated regarding proper PPE on all units and were supposed to wear N95 and eye protection. All staff were trained to do seal check for N95 masks after donning. Medical carts had an additional supply of N95 masks that were available for staff who needed them. She said she will re-educate all staff members on proper PPE donning and conduct random audits to make sure night shift staff adhere to proper PPE use. V. Facility COVID-19 status The director of nurses (DON) was interviewed on 10/15/2020 at 2:15 p.m. She said they had 14 COVID-19 positive residents and seven COVID-19 positive staff. Facility was conducting COVID-19 tests for residents and staff members twice a week on Thursdays and Mondays.

Based on observations, record review, and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, needs for one (#28) of three residents reviewed for quality of care out of 33 sample residents. The facilities failure to provide Resident #28 with a wheelchair of the appropriate size to accommodate his weight and to provide a pressure relieving cushion that was the correct size for the wheelchair seat, contributed to the development of multiple stage 2 pressure ulcers on the resident's posterior thighs, causing undue discomfort. Cross-reference F686-failure to prevent the development of pressure ulcers. Findings include: I. Resident status Resident #28, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The 12/26/19 minimum data set (MDS) assessment revealed he was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. There were no documented skin issues but he received applications of ointments/medications other than to his feet. He required extensive assistance of one staff member with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was at risk for pressure ulcers and no skin issues were documented. He was not steady during transitions, had no impairment of upper or lower extremities, and used a walker and wheelchair for mobility. II. Observations On 3/4/2020 at 10:21 a.m. Resident #28 was seated in his wheelchair in his room. The wheelchair appeared too small for the resident's size. His lower body from his waist, at arm rest height, through his hips and thighs, to where his knees bend at the edge of the seat, was touching the wheelchair surfaces of the side panels, armrests, back of the wheelchair, and the seat. He said he would like a bigger wheelchair because his hips and legs touch both sides and they become sore, especially on the right leg. He was seen rubbing his right outer thigh. On 3/5/2020 at 4:00 p.m. the resident had returned from being out of the facility for the day. He was seated in his wheelchair in his room. When an unknown certified nurse aide (CNA) and registered nurse (RN) #4 assisted him to the restroom, it was noted his pants (jeans) and the pad on top of the cushion underneath him in the wheelchair were saturated with urine. He said he would sit in his wheelchair for three to four hours at a time without being assisted to stand. When his pants were lowered and his posterior thighs were exposed it was noted that both thighs were discolored, reddened, and purple in color. The skin appeared hardened and macerated (skin coming in contact with moisture for too long), with open creased areas on the outer right thigh and scaly areas on the left thigh. RN #4 said his posterior thighs had been that way for months. The director of nursing (DON) was present at this time and used a flashlight to visualize the open areas, but had no comment. While he was seated in the restroom, observation of the wheelchair revealed the cushion under the pad he had been sitting on, was circular in shape and did not fit the wheelchair seat. There were several inches of gap on each side between the cushion and the edges of the seat. After RN #4 applied barrier cream to both thighs and his lower legs, he was assisted with a clean brief and jeans and was assisted back into his wheelchair. Resident #28 said he had outgrown that wheelchair and needed a new one. The DON was asked to look at the resident's wheelchair. She said the cushion in the seat did not fit the wheelchair and the resident needed a different type of cushion. III. Record review Review of the care plan initiated 6/10/19 and revised 3/5/2020 revealed Resident #28 had potential/actual impairment to skin integrity related to decreased mobility, weakness, and Diabetes Mellitus. Interventions included to identify/document potential causative factors and eliminate/resolve where possible, follow facility protocols for treatment of [REDACTED]. After the resident's admission on 6/10/19, physical therapy (PT) did not evaluate him until 7/16/19 when the order was entered. He was referred by nursing to skilled PT due to increasing assistance needed for transfers. He had impaired strength of both lower extremities. There was no documentation of what type of wheelchair or cushion was provided to him. He was discharged from PT on 8/27/19 with instructions for the restorative nursing program (RNP). He was not evaluated by occupational therapy (OT) after admission. He had no further therapy evaluations after his discharge from PT on 8/27/19 until the concern for his wheelchair size, cushion size, and the skin issues mentioned above were brought to the attention of the DON on 3/5/2020. Review of the March 2020 CPO revealed an order entered on 3/7/2020 for PT to evaluate wheelchair positioning. an order for [REDACTED]. The 3/7/2020 PT evaluation indicated he was referred by nursing for wheelchair seating system assessment as he makes daily trips out of the facility from 9:00 a.m. to 4:00 p.m. He had impaired strength of both lower extremities with [MEDICAL CONDITION] (swelling), impaired gross motor coordination, and sensory processing. Recommendations included a standard wheelchair 20 inches wide in order to continue to be able to self propel. Skilled PT was indicated related to a decline in functional mobility and posture in current seating system due to fluctuations in weight. Patient with bilateral lower extremities pressed firmly against sides of chair and complained of discomfort in current seating system. The 3/7/2020 PT treatment encounter note read: Wheelchair management training in new standard chair in order to accommodate patient hip width and improve comfort/posture and ease of mobility. Improvement noted in functional posture with newly issued wheelchair. The 3/10/2020 PT treatment encounter note read: Patient states difficulty with propelling chair and presents with mild forward thrust. Provided patient with anti-thrust cushion that has increase in thickness in order to improve patient alignment in chair and accommodate patient height as unable to raise chair further from wheels. Patient requires 2 inch thick cushion 20 inches wide by 16 deep. Will plan to evaluate 20 inch wide versus 22 inch wide wheelchair to improve patient alignment in wheelchair, however, 22 inch wide wheelchair may pose difficulty for patient in mobility and toilet transfers. IV. Interviews Resident #28 was interviewed on 3/4/2020 at 10:21 a.m. He said he would like a bigger wheelchair because his hips and legs touch both sides of the wheelchair and become sore. He said he had outgrown his current chair because he had gained weight. He said he had not had any therapy for quite some time and had never received a different wheelchair, just the one I have now. The DON was interviewed on 3/5/2020 at 4:51 p.m. She said she had been working at the facility for about a month and a half and was the facility's wound care nurse. She said when she started, Resident #28 was not on the wound round list for her to look at. She said she was unaware of the condition of the resident's posterior thighs. She was unaware of the open areas on the resident's posterior thighs. She acknowledged the wheelchair the resident currently had was too small for him and the cushion in the seat of the wheelchair was not the correct size or shape and the resident's outer posterior thighs likely rested on the edges of the cushion as the cushion did not extend to cover the entire wheelchair seat. She said he needed a different cushion and wheelchair and she would have PT and OT evaluate him for a new wheelchair and pressure relieving cushion. The therapy manager (TM) was interviewed on 3/9/2020 at 8:25 a.m. She said Resident #28 had not been evaluated or screened for therapy, a new wheelchair, or cushion since admission. She said residents were not screened or treated unless nursing entered an order to do so. She said they received an order on 3/7/2020 to evaluate Resident #28 for wheelchair positioning and she provided a copy of the PT evaluation/screening done on that day that resulted in the resident receiving a different wheelchair and cushion. V.Follow up-cushion still not fitting appropriately Resident #28 was interviewed again on 3/9/2020 at 9:00 a.m. He said as far as he knew he did not have the areas on the back of his thighs when he was admitted to the facility. He felt the wheelchair and the cushion were part of the problem. He said the cushion did not fit the wheelchair and the chair was too small for him. He said the areas hurt and they had not put any cream on them since last week. He was seated in a different wheelchair this morning and he said they put a different cushion in it, but felt it was still not right.(see interview with DON below) The DON was again interviewed on 3/9/2020 at 10:46 a.m She said therapy provided a different wheelchair and cushion for Resident #28 on 3/7/2020. Upon observation of the new cushion with the DON revealed it still did not cover the entire surface of the wheelchair seat, with a gap on each side of approximately an inch. The DON acknowledged the cushion should cover the entire surface of the wheelchair seat to provide maximum protection.

Based on observations, record review, and interviews, the facility failed to ensure one (#28) of five residents reviewed for pressure ulcers out of 33 sample residents, received the care and services necessary to prevent pressure injuries and to promote healing. The facility failed to complete routine skin evaluations, evaluate his wheelchair for size and positioning, and failed to evaluate the size and effectiveness of the pressure relieving cushion in the wheelchair, contributing to the development of stage 2 pressure ulcers to Resident #28's thighs. The facility also knew Resident #28, who presented with multiple risk factors for skin breakdown due to co-morbidities and his dependence on one staff member for mobility, was at risk. Futhermore, the resident was observed with open areas to his right posterior thigh which were undocumented. Cross-reference F684-quality of care pertaining to appropriate positioning/mobility Findings include I. Professional references A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/2018) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014: Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor. C. According to the National Pressure Ulcer Advisory Panel, Pressure Injury Prevention Points, April 2016, http://www.npuap.org/wp-content/uploads/2016/04/Pressure-Injury-Prevention-Points-2016.pdf (December 2017), the following recommendations were identified: -Cleanse the skin promptly after episodes of incontinence. -Reposition weak or immobile individuals in chairs hourly. II. Facility policy The Pressure Ulcer Skin Monitoring and Management policy and procedure, dated 11/2019, provided by the director of nursing (DON) on 3/9/2020 at 3:45 p.m., read in pertinent part: It is the policy of this facility that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new avoidable sores from developing. -Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure ulcers which include; Impaired/decreased mobility and decreased functional mobility Co-morbid conditions such as Diabetes Mellitus Resident's refusal of some aspects of care and treatment Exposure of skin to urinary and fecal incontinence History of healed pressure ulcer and its stage if known -Assessment of wounds on admission, readmission, weekly, and discharge -Use preventative measures as appropriate such as pressure reduction, continence care, and mobility. III. Resident status Resident #28, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The 12/26/19 minimum data set (MDS) assessment revealed he was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. There were no documented skin issues but he received applications of ointments/medications other than to his feet. He required extensive assistance of one staff member with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was always incontinent of urine and was frequently incontinent of bowel. He was at risk for pressure ulcers and no skin issues were documented. He was not steady during transitions, had no impairment of upper or lower extremities, and used a walker and wheelchair for mobility. IV. Observations On 3/4/2020 at 10:21 a.m., Resident #28 was seen seated in his wheelchair in his room. The wheelchair was too small for the resident's size. His lower body from his waist, at arm rest height, through his hips and thighs to where his knees bent at the edge of the seat, was touching the wheelchair surfaces of the side panels, armrests, back of the wheelchair, and the seat. He said he would like a bigger wheelchair because his hips and legs touched both sides (width) and they became sore, especially on the right leg as he rubbed his right outer thigh. On 3/5/2020 at 4:00 p.m. the resident had returned from being out of the facility for the day. He was seated in his wheelchair in his room. When the unknown certified nurse aide (CNA) and registered nurse (RN) #4 assisted him to the restroom, it was noted his pants (jeans), brief, and the pad on top of the cushion underneath him in the wheelchair were saturated with urine. He said he would sit in his wheelchair for three to four hours at a time without being assisted to stand. When his pants were lowered and his posterior thighs were exposed both thighs were discolored, reddened and purple in color, and macerated (skin coming in contact with moisture for too long). The skin was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), with open creased areas on the outer right thigh and scaly areas on the left thigh. RN #4 said his posterior thighs had been that way for months. The director of nursing (DON) was present at this time and used a flashlight to visualize the open areas, but had no comment. While he was seated in the restroom, observation of the wheelchair revealed the cushion under the pad he had been sitting on, was circular in shape and did not fit the wheelchair seat. There were several inches of gap on each side between the cushion and the edges of the seat. After RN #4 applied barrier cream to both thighs and his lower legs, he was assisted with a clean brief and jeans and was assisted back into his wheelchair. Resident #28 said he had outgrown that wheelchair and needed a new one. The DON acknowledged at this time the cushion in the seat did not fit the wheelchair and the resident needed a different type of cushion. The DON was interviewed on 3/5/2020 at 4:51 p.m. She said she had been working at the facility for about a month and a half and was the facility's wound care nurse. She said when she started, Resident #28 was not on the wound round list for her to look at. She said she was unaware of the condition of the resident's posterior thighs. She said, Barrier cream would be appropriate for moisture associated skin damage (MASD) since the resident would sit in urine alot. She was unaware of the open areas on the resident's posterior thighs. She acknowledged the wheelchair the resident currently had was too small for him and the cushion in the seat of the wheelchair was not the correct size or shape, and the resident's outer posterior thighs likely rested on the edges of the cushion, as the cushion did not extend to cover the entire wheelchair seat. She said he needed a different cushion and wheelchair and she would have physical therapy (PT) and occupational therapy (OT) evaluate him for a new wheelchair and pressure relieving cushion. V. Record review The care plan initiated 6/10/19 and revised 3/5/2020 revealed Resident #28 had potential/actual impairment to skin integrity related to bowel/bladder incontinence, decreased mobility, weakness, and Diabetes Mellitus. Interventions included to follow facility protocol for treatment of [REDACTED]. Keep skin clean and dry. Monitor/document location, size, and treatment of [REDACTED]. Needs a pressure relieving/reducing chair to protect the skin while up in the chair. Resident #28 had potential for pressure ulcer development related to immobility with interventions that included: Administer treatments as ordered and monitor for effectiveness. Notify the nurse immediately of any new areas of skin breakdown noted during bath or daily care. Requires pressure relieving/reducing device on bed/chair. Weekly head to toe skin at risk assessment. Reposition for comfort as needed/tolerated. The 6/10/19 physician admission history and physical (H&P) documented Resident #28s skin as warm, dry, no rash. Review of the 6/15/19 initial licensed nurse skin evaluation, documented by RN #3, completed five days after admission, revealed five noted pressure areas: -Right thigh (rear)-Length (L) 2.8 centimeters (cm) x Width (W) 3.0 cm x Depth (D) .5 cm Stage II -Right thigh (rear)-L 2 cm x 1.0 cm x .5 cm Stage II -Right thigh (rear)-L 3.2 cm x 1.7 cm x .5 cm Stage II -Right thigh (rear)-L 3.0 cm x 2 cm x .5 cm Stage II -Sacrum L 1.5 cm x 1.5 cm x .02 cm Stage I Documentation read: Skin assessment reveals, posterior thigh pressure breakdown, shallow, open areas x 4. Red center, granular edges. Dried flaky skin surrounding. No drainage, blanchable and warm. Application of skin prep and barrier cream with peri care. teaching frequent weight shifts and encouraged him not to wear jeans as the thickness of the jeans may be the cause. sacral stage 1, blanchable, no heat, no odor, afebrile. oral mucosa pink moist, all other surface skin areas cdi (clean, dry, intact). The 6/10/19 admission Braden Scale for Predicting Pressure Sore Risk assessment was scored 18 indicating low risk, even though his skin assessment documented five pressure areas. The 6/17/19 MDS assessment documented Resident #28 was at risk for pressure ulcers but was negative for any unhealed pressure ulcers. He was not on a turning/repositioning program and did not receive pressure ulcer care. The 7/26/19 physician progress notes [REDACTED]. He was wheelchair bound. The July 2019 weekly skin evaluations documented by licensed practical nurse (LPN) #4 and RN #5 read: Skin clean, warm and intact. No skin concerns noted or reported. One skin evaluation was missing. The 8/14/2019 9:36 p.m. nursing note documented by an unknown nurse read: Found discoloration and maceration to posterior right thigh when resident assisted to bed. No open area noted. Resident with episodes of leaving facility in the morning and coming back at dinner. Also has episodes of refusing care when offered by staff. The August 2019 weekly skin evaluations documented by RN #5 and LPN #4 read: Resident skin remains clean, warm and intact.No skin concerns noted or reported. One skin evaluation was missing. The 9/10/19 Braden Scale score was 16 indicating low risk The 9/17/19 MDS assessment documented the resident was at risk for pressure ulcers and negative for unhealed pressure ulcers but was positive for MASD. He was not on a turning/repositioning program and did not receive pressure ulcer/injury care. The 9/25/19 and 12/26/19 MDS assessments revealed the resident was at risk for pressure ulcers, negative for any unhealed pressure ulcers, he was not on a turning/repositioning program and did not receive pressure ulcer care. The 10/9/2019 4:27 p.m. nursing note read: Resident's guardian asked nurse to do skin assessment in front of her. Patient was taken to his room. He stood up while holding onto the front wheeled walker and shirt and pants removed. Patient's buttocks cleansed (had small BM), brief changed and groin area examined. No redness noted. However, there was old scratch marks, and peeled off dry skin noted to posterior right thigh. When examined, there was a metal bottom to the corner of wheelchair right corner. Pt stated he sometimes sits on the bottom. Barrier cream was applied to the area, guardian stated she would go to the gym to talk to therapists to see if they could cover the metal bottom. The 12/10/19 Braden Scale score was 20 indicating low risk The 12/26/19 MDS revealed Resident #28s weight was 254 pounds. The 1/3/2020 weekly skin evaluation documented by LPN #2 read: Skin warm, dry and intact. Slight redness noted to buttocks and peri area, barrier cream applied as needed and with incontinence cares. No other redness or open areas noted. Review of the skin observation sheets for January and February 2020, completed by the CNAs on resident shower days, revealed no documented skin issues with multiple refusals by the resident. Review of the January 2020 treatment administration record (TAR) revealed Resident #28 was to have weekly skin evaluations completed on Mondays at 7:00 a.m. One evaluation out of four was documented as completed. The February 2020 TAR revealed two skin evaluations out of four were completed. 28 days had passed between the last evaluation in January to the first evaluation in February. The March 2020 TAR revealed no skin evaluation had been completed until 3/5/2020 after the facility was made aware of the posterior thigh skin issue noted above. It had been 17 days since the last skin evaluation was completed in February until the one was completed in March. The 3/5/2020 weekly skin evaluation-skin assessment completed by RN #1 read: Resident noted with MASD to left and right gluteal area, and resident noted with + 2 [MEDICAL CONDITION] to BLE. Resident also noted with patches of skin that are rough to BLE that causes him to itch, notified physician of findings, new order to continue to apply barrier cream to buttock and right and left gluteal area. Physician will assess on tomorrow. The 3/6/2020 physician progress notes [REDACTED]. Has MASD to buttocks. He primarily sits in wheelchair for most of the day. Will have in-house wound team follow as indicated. Monitor wounds for any signs of new skin disruption. The 3/9/2020 Braden Scale score was 14 indicating moderate risk The 3/9/2020 physician progress notes [REDACTED]. Primarily sitting in wheelchair most of the day. MASD to buttocks, small shallow open wound on buttock, being addressed by wound team and wound rounds. He is on wound rounds this week. On 3/9/2020 at 10:46 a.m. observation of the resident's posterior thighs with the DON revealed some of the areas on the right thigh have thin coverings of tan/reddish material over the open areas that were recognized on 3/5/2020 but one area remains open. The DON used a flashlight to visualize the area and acknowledged the one area was open, she did not measure the area or place any new treatment orders in the resident's chart. The 3/9/2020 wound/skin evaluation documented by the DON at 10:58 a.m. read: Open area to right thigh (rear) noted to be open. Wound bed noted to be pink. No drainage noted. No odor noted. Peri wound noted to be clean, dry and intact. No maceration noted. No complaints of pain or discomfort voiced. The 3/9/2020 5:25 p.m. nursing note documented by the DON read: Skin impairment noted to right upper thigh (rear) measuring approximately 1.5 x 0.3 x 0.1. Wound bed noted to be pink. Edges noted to be slightly macerated. Periwound noted to be clean, dry and intact without redness. No drainage noted. No odor noted. Continue to apply barrier cream to area. Education provided to resident regarding the needs and benefits of allowing staff to change brief frequently. The 3/9/2020 skin committee interdisciplinary team (IDT) note documented by the DON at 5:34 p.m. read: Skin impairment noted to right upper thigh (rear) measuring approximately 1.5 x 0.3 x 0.1. Wound bed noted to be pink. Edges noted to be slightly macerated. periwound noted to be clean, dry and intact without redness. No drainage noted. No odor noted. Continue to apply barrier cream to area. Resident is diabetic. Resident has history of pressure ulcers, decreased mobility, non-compliance with cares at times. Education provided to resident regarding the needs and benefits of allowing staff to change brief frequently. Resident continues to use cushion to wheelchair. Resident frequently goes out of facility for extended periods during the day. Resident is frequently observed to have wet pants upon return to facility. Resident evaluated by PT 3/7/2020 and OT 3/9/2020. VI. Interviews The DON was interviewed on 3/10/2020 at 9:27 a.m. She said she realized there was an issue with monitoring of the resident's skin and the weekly skin evaluations were not being done consistently and if they had been completed as required, the areas on his posterior thighs would have been recognized and addressed. She said the resident was on her radar now and on the routine wound rounds list to be seen by the wound doctor and she was going to ask him what product would be best to use for this resident because he was normally out of the facility for so long each day and sat in urine in his wheelchair all the time when he is away. LPN #3 was interviewed on 3/10/2020 at 9:51 a.m. He said residents' weekly skin evaluations were a head to toe assessment and were done routinely every week on a scheduled day and shift. He said they were to be done as scheduled and signed off as being completed by the LPN or RN. If a new skin issue was identified, a skin integrity form was to be filled out in the computer and an order for [REDACTED]. CNA #1was interviewed on 03/10/2020 at 10:26 a.m. She said when showers were given the CNAs were to look at all areas of the resident's skin and if any new areas were noted they fill out a shower sheet to document and describe the area. She said they were to report to the nurse as well if they identified a new area whether it was during a shower or during any cares. She said some of the nurses would come in during a shower to complete the resident's skin check but not all did that.

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically the facility failed to: -Properly clean and store blood glucose meters used for multiple residents requiring blood glucose monitoring; and, -Implement and maintain a water management program to test for legionella in their water systems. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (6/2019): The CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_ on 6/20/19, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. II. Facility policies The Infection Prevention Control Program policy, dated 8/29/16 and revised 9/2017, provided by the director of nursing (DON) on 3/9/2020 at 9:29 a.m. read in pertinent part: It is the policy of this facility to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreak. The Glucometer Disinfection policy, undated, was provided by the DON on 3/9/2020 at 9:29 a.m., read in pertinent part: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices (glucose meters) to prevent transmission of blood borne diseases to residents and employees. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. -Glucometers should be cleaned and disinfected before and after each use and according to manufacturer's instructions, regardless of whether they are intended for single resident or multiple resident use. -Glucometers should be disinfected with a wipe pre-saturated with an environmental protection agency (EPA) registered healthcare disinfectant that is effective against human immunodeficiency virus ,[MEDICAL CONDITION]., [MEDICAL CONDITION], and [MEDICAL CONDITION] virus. The facility currently uses Medline Micro-Kill Bleach Wipes, which have been validated by the glucometer manufacturer. -Because of the inadvertent contamination, the used glucometer should not be placed directly on a surface, for example (e.g. medication cart) until cleaned and disinfected. -Clean and disinfect the glucometer thoroughly with the disinfecting wipe following manufacturer's instructions: cleanse the glucometer with the disinfectant wipe; three minute contact time is required. Reapply wipe as necessary to ensure the surface remains wet for the entire contact time. Allow glucometer surface to air dry. III. Manufacturer's instructions A. Evencare G2 blood glucose monitoring system The cleaning and disinfecting guidelines for the glucometer read in pertinent part: -Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The following product is validated for disinfecting the meter and lancing device; Medline Micro-Kill Bleach Germicidal Bleach Wipes. -To disinfect your meter, clean the meter with one of the validated disinfecting wipes. -Wipe all external areas of the meter or lancing device including both front and back surfaces. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipes directions for use; allow to air dry. -If the meter or lancing device is being operated by a second person who is providing testing assistance to the user, the meter or lancing device should be disinfected prior to use by the second person. B. Micro-Kill Bleach Germicidal Bleach Wipe The healthcare facility disinfection directions for use read in pertinent part: -Apply pre-moistened towelette and wipe desired surface to be disinfected. A three minute contact time is required for efficacy. Reapply as many additional towelettes as necessary to ensure that the surface remains wet for the entire contact time. Allow surface to air dry. IV. Observations On 3/4/2020 at 8:51 a.m. observations of the medication carts (med carts) on the first and second floors revealed blood glucose meters lying on top of plastic boxes (similar to kids pencil boxes) or lying on top of the medication carts. There was no barrier between the devices and the surface they were on. At 9:40 a.m. the blood glucose meters were again lying on top of the medication carts or on top of the plastic boxes without barriers underneath. On 3/5/2020 at 9:00 a.m. the plastic boxes were seen on top of the medication carts on the first and second floors. Glucometers were seen on top of the boxes and lying on the medication cart without a barrier underneath. At 11:10 a.m. the certified medication aide (CMA), on the 1 South hall, was observed during a resident's blood glucose check. The equipment-lancets, alcohol prep pads, individual disinfecting wipes, and the glucometer, were contained in a plastic box with a snap lid. She removed the glucometer from the box, and used a disinfecting wipe to swipe the front and back of the device. She then placed it on a tissue on top of the med cart. She did not leave the device wet for the required three minute dwell time as recommended by the wipe manufacturer. She placed the machine back in the box on top of lancets, alcohol prep pads, and packaged disinfecting wipes. She closed the lid of the box and entered the resident's room. She placed the box on the resident's over bed table, without a clean barrier underneath. She removed the blood glucose meter from the box and obtained the blood glucose reading. She then removed an alcohol prep pad from the box and swiped the front and back of the machine and placed it back in the box. She returned to the medication cart, placed the box on top, removed the single disinfecting wipe and cleaned the outside of the plastic box and placed it back on top of the med cart. The glucometer remained in the box and was not cleaned with a disinfecting wipe as required by the manufacturer of the device. At 3:50 p.m. registered nurse (RN) #4 was observed during a resident's blood glucose check on the 2 North hall. The glucometer was lying on top of a plastic box on the med cart with no barrier underneath the device. The box contained lancets, alcohol prep pads and separately packaged, single use, disinfecting wipes. RN #4 opened a disinfecting wipe and cleaned the glucometer, she did not allow it to remain wet for the recommended three minute dwell time per manufacturer's instructions. She then placed it on top of the med cart without a barrier underneath. She opened the box, cleaned the inside of the lid of the box with the same wipe she used to clean the glucometer, closed the lid then wiped the entire outside of the box with the same wipe and placed the box on the medication cart and the glucometer on top of the box with no barrier underneath. She entered the resident's room and placed the box on the resident's bedside table without a clean barrier underneath. She obtained the blood glucose reading and placed the glucometer and the used lancet on top of the box. She exited the room, returned to the medication cart and repeated the same cleaning process (noted above) as she had done prior to obtaining the reading and placed the glucometer on top of the box with no barrier underneath. At 4:24 p.m. licensed practical nurse (LPN) #1 was observed obtaining a resident's blood glucose reading on the 1st floor North hall. A plastic box was lying on top of the med cart. The glucometer was inside the box on top of lancets, alcohol prep pads, loose 4 inch x 4 inch gauze pads, and single use packages of disinfecting wipes. LPN #1 cleaned the device with the disinfecting wipe and placed it on the med cart with no clean barrier underneath. She did not allow it to remain wet for the required three minute dwell time per manufacturer's instructions. She then picked it up and dried it with a gauze pad and placed it back on the med cart with no barrier underneath. She carried the box and the glucometer in her bare hands to the resident's room. She placed the box on the resident's over-bed table and obtained the blood glucose reading. She exited the room and returned to the medication cart. She used the disinfecting wipe to clean the machine, held it in her gloved hand for a few seconds and placed it back in the box on top of the med cart. She did not allow the device to remain wet for the required three minute dwell time. V. Interviews RN #4 was interviewed on 3/5/2020 at 11:30 a.m. She said each medication cart had one glucometer to be used for blood glucose monitoring for the residents on each hall. She said the 2 North hall had seven residents that required blood glucose monitoring and the 2 South hall had two residents with ordered blood glucose checks. At 5:12 p.m. RN #4 was again interviewed. She said she was told to never put the glucometer inside the box with the lancets, that they were never to touch. She said the procedure for cleaning the glucometer was to use the disinfecting wipe provided in the box, clean the entire glucometer and place it on top of the box until it was used the next time. She was unaware of how long the glucometer needed to remain wet or the dwell time recommended by the manufacturer of the disinfecting wipe. She said, A couple minutes?, um 2 minutes?, yeah 2 minutes. The DON was interviewed on 3/5/2020 at 5:30 p.m. She said the proper procedure for cleaning the glucometer machines was to use an approved disinfecting wipe. She was unsure of the dwell time recommended by the manufacturer of the wipe. She said the nurses were to clean all surfaces of the glucometer and it was to remain wet, or wrapped in the wipe, for the recommended time per the manufacturer and left to air dry. It was to be stored in the plastic box on the medication carts and not on top of the medication cart without a clean surface underneath it. She said it was to be cleaned after each use but did not have to be cleaned before use. The clinical resource RN #1 was interviewed on 3/5/2020 at 5:40 p.m. She said the facility had 23 diabetic residents that had physician ordered blood glucose monitoring with five of those residents having once monthly blood sugar checks. She said none of the diabetic residents had any blood borne pathogen diagnosis. VI. Facility follow-up After the facility was made aware, on 3/5/2020, of the above mentioned breaks in infection control, an observation on 3/9/2020 at 7:55 a.m. of all four medication carts in the facility revealed the plastic boxes that had been on top of the carts and contained blood glucose meters, alcohol prep pads, lancets, and disinfecting wipes, were removed from the carts. The DON said over the weekend, blood glucose meters had been purchased for each diabetic resident that required blood glucose monitoring and the devices were no longer shared. She said she had videos and in-service training in place that was required for all nurses that perform blood glucose testing. On 3/9/2020 at 8:43 a.m. the facility pharmacist was seen on the second floor dating the test strip containers, in each blood glucose meter case, with the open date. She said each diabetic resident that required blood glucose monitoring now had their own devices.

Based on observations, interviews, and record review, the facility failed to honor resident choices for three out of 25 resident ' s reviewed for self-determination. Specifically, the facility failed to ensure Residents #11, #42, and #43 received showers according to their choice of frequency. Findings include: I. Facility policy and procedure The Bath and Shower policy, revised November 2019, was provided by the director of nursing (DON) on 3/9/2020. It read, in pertinent part, When residents admit please review the preference sheet with the resident. Residents may choose the days of the week they choose to bathe or shower. Residents may change their preferences at any time during the stay. Facility is transitioned to electronic for bathing documentation through point of care. Facility is also completing shower sheets upon completion of showers by the aides. II. Resident #11 A. Resident status Resident #11, age above 70, was admitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The 12/14/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. She required one person supervision and set up help with activities of daily living (ADL). She used a wheelchair for mobility. The resident did not reject any cares during the assessment. B. Resident interview The resident was interviewed on 3/5/2020 at 2:00 p.m. She said she frequently missed showers and went a week without a shower multiple times. She said she has had to clean herself up in her sink because there was nobody available to give her a shower. She said she would like showers more than two times per week but she did not know she had the option for more frequent showers. C. Record review Documented preferences were requested for this resident, none given before exit. The shower schedule revealed Resident #11 was scheduled to receive showers every Tuesday and Friday. The shower records revealed the resident missed the following showers: -Six out of nine opportunities for a shower in December 2019; -Five out of nine opportunities for a shower in January 2020; and, -Five out of eight opportunities for a shower in February 2020. III. Resident #42 A. Resident status Resident #42 age, above 70, was admitted on [DATE]. According to the March 2020 CPO [DIAGNOSES REDACTED]. The 1/28/2020 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive one person assistance with ADLs. The resident did not reject any cares during the assessment. B. Resident interview Resident #42 was interviewed on 3/4/2020 at 9:35 a.m. She said she asked to shower daily because that ' s what she did at home but she was told by facility staff that she could not shower more than twice per week because they did not have enough staff to help her daily. She said one week she never got a shower. C. Record review The comprehensive care plan, revised 2/13/2020, revealed the resident ' s preference was to shower daily. The shower records revealed the resident received six showers since she was admitted to the facility on [DATE]. She missed 58 shower opportunities based on her preference to shower daily. IV. Resident #43 Resident #43 age, above 70, was admitted on [DATE]. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 1/29/2020 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required one person assistance with ADLs and she used a wheelchair for mobility. Rejection of cares occurred four to six times but less than daily. B. Resident interview Resident #43 was interviewed on 3/5/2020 at 2:00 p.m. She said she frequently missed showers and had gone weeks without getting a shower. She said she didn ' t know her shower schedule and was not asked her shower preference. She said she would accept two showers per week. C. Record review Documented preferences were requested for this resident, none given before exit. The shower schedule for Resident #43 revealed the resident was on the schedule to receive a shower on Wednesday only. The shower records revealed the resident received two showers in February and one in March. -There was no additional documentation for her showers. V. Staff interviews CNA #2 was interviewed on 3/10/2020 at 10:35 a.m. She said she followed the schedule posted in the shower book for daily showers. She said if a resident refuses a shower it should be documented on the shower sheet and the nurse should sign the shower sheet. She said a resident should be offered a shower three times before officially documenting as refused. She said residents get showers twice per week and if they want additional showers they can get one any time. CNA #3 was interviewed on 3/10/2020 at 11:46 a.m. She said she followed the schedule posted in the shower book for daily showers. She said the shower sheet should be completed and signed off by a nurse when showers were given and when the resident refused them. She said there was usually enough staff to give showers and residents could have additional showers if they wanted them more than twice per week. The DON was interviewed on 3/10/2020 at 1:03 p.m. She said the residents receive showers based on their preference sheet that was filled out upon admission. She said the facility offered two showers per week minimum, unless a resident requested more frequent showers. She said CNAs should complete shower sheets when they complete a shower and when the resident refuses. She said the CNAs should also document showers in the electronic medical records. She said she was unsure how often residents were asked on their preferences after admission to the facility. She said she was unaware Resident #43 was only on the schedule to receive a shower one time per week and she should have been offered a shower at least twice per week.

Based on record review and interviews, the facility failed to resolve grievances in a timely manner, including taking immediate action to prevent further violations of any resident right for eight (#13, #58, #56, #43, #26, #27, #61 and #28) out of 33 sample residents. Specifically, the facility failed to resolve grievances in a timely manner related to call light response for Residents #13, #58, #56, #43, #26, #27 and #28 and missing personal items for Resident #27. I. Facility policy and procedure Review of the Grievances policy, provided by registered nurse (RN) #2 on 3/9/2020 at 4:10 p.m. revealed in part, The facility ' s grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading to necessary investigations by the facility .general concerns may be voiced at resident and /or family council meetings .the grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations . II. Resident #13 and Resident #58 status Resident #13, age 81, was admitted on [DATE] with readmission 7/13/2017. According to the March 2020 computerized physician orders [REDACTED]. The 12/18/2019 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was an extensive assistant for transfers, dressing and personal hygiene. Resident #58, age 91, was admitted on [DATE] with readmission 6/15/2017. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 2/6/2020 MDS assessment revealed the resident had moderately impaired cognition with a BIMS score of 12 out of 15. The resident was an extensive assistance for transfers, dressing toilet use and personal hygiene. A. Record review and interviews Review of the grievance/feedback form, dated 1/3/2020, revealed: -Name of resident: Resident #13 and Resident #58 -Summary of concern: Call light taking too long to be answered, every shift is the worst, -Immediate action taken: concern form, validated. -Resolution: Residents educated, see care plan. -Grievance resolved: Yes. Resident #13 was interviewed on 3/4/2020 at 10:04 a.m. He said they got a bad certified nurse aide (CNA) every once in a while and at one point he had been left in his chair for over 12 hours. He said they asked nicely, but the staff would shoot out the door. Resident #58 said the CNA on 3/3/2020 had went off and left him. Review of the call analysis response time log (2/9/2020 through 3/9/2020) for Resident #13 and Resident #58 revealed call light time response was over 30 minutes for 74 out of 371 calls and over an hour for 24 out of 371 calls. The average response time was: 18.2 minutes. III. Resident #56 status Resident #56, age 74, was admitted on [DATE]. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 2/4/2020 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. The resident was an extensive assistance for bed mobility, dressing, toilet use and personal hygiene. A. Record review and interviews Resident #56 was interviewed on 3/4/2020 at 9:02 a.m. She said she had been waiting for over an hour a couple of days ago. She said the CNAs would come in to turn the light out and then never come back. She said she had complained about this to someone but could not remember who it was. Review of the call analysis response time log (2/9/2020 through 3/5/2020) for Resident #56 revealed call light time responses were over 30 minutes for 12 out of 208 calls and over an hour for three out of 208 calls. The average response time was: 9.3 minutes. IV. Resident #43 status Resident #43, age 77, was admitted on [DATE] with readmission 1/24/2018. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 1/29/2020 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. The resident was limited assistance for transfers, dressing and personal hygiene. A. Record review and interviews Resident #43 was interviewed on 3/4/2020 at 9:37 a.m. She said there was not enough staff on the day shift. She said she has had to wait up to an hour for a response. She said she would get tired of waiting and would go find someone to help her. Review of the call analysis response time log (2/9/2020 through 3/9/2020) for Resident #43 revealed call ight time response was over 30 minutes for 12 out of 71 calls and over an hour for seven out of 71 calls. The average response time was: 19.8 minutes. V. Resident #26 and Resident #27 status Resident #26, age 85, was admitted on [DATE] with readmission 2/18/2020. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 12/26/2019 MDS assessment revealed the resident had intact cognition with a BIMS score of 14 out of 15. The resident was an extensive assistance for transfers, dressing, toilet use and personal hygiene. Resident #27, age 63, was admitted on [DATE] with readmission 7/16/2019. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 12/26/2019 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. The resident was an extensive assistance for transfers, dressing, toilet use and personal hygiene. A. Record review and interviews Resident #26 was interviewed on 3/4/2020 at 9:11 a.m. He said he has had to wait up to three hours at bedtime. He said it took a long time for staff to answer his call light. He said the longest call light had been up to an hour, recently. Resident #27 was interviewed on 3/4/2020 at 9:33 a.m. He said he had to wait up to two hours the week before to remove feces from his brief. He said it burned his skin. He said he filed a grievance. He said he should not have to wait to get off the toilet. Review of the call analysis response time log (2/9/2020 through 3/9/2020) for Resident #26 and Resident #27 revealed call light time response was over 30 minutes for 54 out of 336 calls and over an hour for 15 out of 336 calls. The average response time was: 16.3 minutes. VI. Resident #61 status Resident #61, age 86, was admitted on [DATE]. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 2/7/2020 MDS assessment revealed the resident had intact cognition with a BIMS score of 13 out of 15. The resident was an extensive assistance for personal hygiene. A. Record review and interviews Resident #61 was interviewed on 3/4/2020 at 11:09 a.m. She said the staff did not always answer the call light. She said it took an hour or so. She said that had been going on for a long time. She said she thought she had filled out a grievance, but was not sure. Review of the call analysis response time log (2/9/2020 through 3/9/2020) for Resident #61 revealed call ight time response was over 30 minutes for 15 out of 69 calls and over an hour for three out of 69 calls. The average response time was 15.4 minutes VII. Resident #28 status Resident #28, age 68, was admitted on [DATE]. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The 12/26/2019 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. The resident was an extensive assistance for transfers, dressing, toilet use and personal hygiene. A. Record review and interviews Resident #28 was interviewed on 3/4/2020 at 10:12 a.m. He said he had to wait up to an hour for his call light to be answered. Review of the call analysis response time log (2/11/2020 through 3/9/2020) for Resident #26 revealed call ight time response was over 30 minutes for six out of 16 calls and over an hour for two out of 16 calls. The average response time was: 23.9 minutes. VIII. Interviews A group interview was completed on 3/5/2020 at 2:00 p.m. with five residents the facility deemed interviewable. Two residents said call light times were the longest around meal times and bedtime. Makes the residents feel like the staff doesn ' t care. The director of nurses (DON) was interviewed on 3/10/2020 at 9:13 a.m. She said the nursing home administrator (NHA) was in charge of grievances. She said nobody monitored the electronic call light responses regularly. She said she had noticed some staff going into a residents room and forgot to turn the light off. She said she would prefer a different call light system in which the light would be displayed above the door. She said they had call light screens on the halls and at the nursing station. The NHA was interviewed on 3/10/2020 at 12:07 p.m. She said she was responsible for the grievances along with social services. She said social services had been out sick. She said they tried to resolve grievances within three days, depending on the situation. She said Resident #58 and Resident #13 had called the facility instead of using their call lights, so education was completed with the residents. She said they would complete a call light audit as an intervention. She said they would pull the call light and see how long it took for staff to respond. She said the electronic call light system was only monitored when there was a concern. She said when the grievance said it was validate, that meant the electronic call light records matched what the resident said. She acknowledged the call light response times were long. IX. The undated facility Admission Agreement, provided by the NHA on 3/3/2020 at 9:00 a.m., read in pertinent part: A. Section XV (15) Personal and Other Property: -If damage or loss to resident's property, the facility will investigate each incident of loss or damage to determine liability and assess responsibility depending on the facts and circumstances of each incident. The facility shall be responsible for only such losses or damages as are attributed by the facility to be the negligence or fault of the facility. -If resident's personal property remains unclaimed for thirty days after permanent transfer or discharge, the facility may dispose of resident's property. B. Resident interview Resident #27 was interviewed on 3/4/2020 at 9:31 a.m. He said about eight months ago items went missing that included a coat, jacket, sneakers, shoes, shirts, and pants. He said he notified administration about it but they did not do anything. C. Record review Review of Resident #27s admission inventory sheet revealed two items, a pair of glasses and a cell phone. No clothing items were listed. Review of the social service notes from 7/16/19 through 10/25/19 revealed no mention of a grievance filed for Resident #27 for missing personal items. Review of grievances filed by Resident #27 revealed on 10/21/19 he reported the above mentioned missing items. CNA #4 assisted him with completing the grievance form. He said things had been missing since June 2019 when he was on the first floor. CNA #4 reported the missing items to the social worker and searched laundry but did not locate them. The grievance was marked as resolved on 10/25/19. The social worker documented, Explained to resident that items unclaimed after a month are donated. D. Staff interview The NHA was interviewed on 3/10/2020 at 12:20 p.m. She said, she and the social worker handle the grievances and they try to have them resolved in three days depending on the situation. If something needs to be ordered it may take longer to resolve. She said the social worker that handled this particular grievance was no longer employed at the facility. She said the resolution to this grievance was not acceptable. She said the resident's inventory sheet should be filled out completely upon admission and updated when new items were brought in. She acknowledged that was an issue the facility needed to work on. She said at this point she would re-approach the resident to find out what was still missing. She said if the resident purchased new items to replace those lost, and provided receipts, the facility would reimburse him for those items.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for three of three kitchens. Specifically, the facility failed to ensure: -Thermometers were cleaned properly; and, -Dietary supplements were disposed of upon expiration. I. Facility policy and procedure Review of the Checking Food Temperatures policy, revised ,[DATE], provided by the dietary director (DD) on [DATE] at 1:44 p.m. revealed in part, Thermometers should be clean and sanitized before and after use using an alcohol probe wipe or through a 3-step clean/rinse/sanitize process Review of the Food Storage policy, revised ,[DATE], provided by the DD on [DATE] at 8:49 a.m. revealed in part, Dietary staff should frequently monitor food storage areas so that foods may be used within the appropriate time frame or discarded if past the use-by-date or quality has diminished. II. Thermometer use The first floor dining room kitchen was observed on [DATE] at 12:06 p.m. Diet aide (DA) #3 was observed taking temperatures of the food on the steam table. She cleaned the thermometer with a towel and wiped her fingers on the same towel. No sanitizer was used. She took the thermometer out of a food item and cleaned the thermometer with a towel. She proceeded to place the thermometer into other food items without sanitizing. The second floor dining room kitchen was observed on [DATE] at 12:06 p.m. DA #2 was taking temperatures on the steam table. He took the thermometer out of the ground ham and wiped the thermometer with a towel. He placed the thermometer into the mashed potatoes without sanitizing. The first floor dining room kitchen was observed on [DATE] at 12:12 p.m. DA #1 was taking temperatures of the food items on the steam table. She placed her entire bare left hand on the thermometer stem and placed the stem into the pureed cornbread without sanitizing. III. Expired supplements The main kitchen was observed on [DATE] at 9:01 a.m. There were over 15 (8-ounce) containers of very high calorie supplement with a use-by-date of [DATE]. The DD said they usually used the other supplement. He said that he and the registered dietitian (RD) were responsible for ensuring expired foods were disposed of. IV. Interviews The DD was interviewed on [DATE] at 1:00 p.m. He said the staff needed to use alcohol pads when taking temperatures in between food items. He said he had just heard of staff using a towel to wipe the thermometers and he was trying to educate staff on the proper practice. He said he may have to educate staff every week. The RD was interviewed on [DATE] at 1:15 p.m. She said they did not usually use the very high calorie supplement. She said she did not know how that expired item got missed. She acknowledged the staff needed to be educated on proper infection control practices.

Based on record review and interviews; the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility for one (#3) of one out of nine sample residents. Specifically, the facility failed to ensure Resident #3 was safely discharged to a new environment with required community resources to meet his needs. Cross reference to F623 Notice Requirements of Transfer/Discharge because the facility failed to provide notice of the appropriate reason, to Resident #3, of the facility-initiated discharge; and notify Resident #3 of his right to appeal the facility-initiated discharge. Findings include: I. Facility policy and procedure The Discharge Against Medical Advice (AMA) policy and procedure, revised 5/18 was provided by the nursing home administrator (NHA) on 7/25/19 at 12:30 p.m. It read in pertinent part, Ensure the safest possible departure from the health facility when it is without medical approval. Procedures: Notify the physician, Notify the Executive Director, Director of Nursing Services, and Resident's family or responsible party. Give any appropriate instructions to Resident and instruct to contact physician immediately. Document instructions given on record. Complete unauthorized discharge form. If resident declines to sign AMA form, have two representatives witness acknowledgements of form. Document in nursing notes all occurrences and steps throughout the situation. II. Facility failure to give Resident #3 appropriate discharge notice and discharge him to a safe environment with community resources to meet his needs. Record review Review of Resident #3's medical record revealed he had an extensive list of comorbidities and required extensive assistance with activities of daily living (ADLs) and wound care treatments. During his stay progress notes revealed Resident #3 would often leave the facility for extended periods of time, (it was documented Resident #3 left the facility seven times from 4/28/19 through 7/23/19) and often would not sign himself out. Several notes revealed he missed medications and wound treatments and/or refused wound treatments, and at times was non-compliant with care. Resident #3 was provided verbal education multiple times regarding his non-compliance with facility expectations of being available for medications, treatments and not using illicit drugs while taking opioids, indicating the facilities knowledge of long history of behaviors and non-compliance; yet he was not provided appropriate notice of discharge, right to discharge to a safe environment with community resources and his right to appeal the facility-initiated discharge. Although Resident #3 was provided education surrounding non-compliance with wound care, and his risky behaviors. Record review revealed the facility did not provide Resident #3 with education and teaching of self care (including care of his [MEDICAL CONDITION], emptying of his suprabubic catheter, safe transfers, insulin injections and medication management); provided assistance with obtaining his identification, social security card or birth certificate, (all the necessary documents needed to obtain an apartment in the community), notification or contact with Resident #3's brother to see if he planned to help with care, or documentation of substance abuse programs offered or refused by the resident during his stay. Resident #3 did not experience a change in condition, he had been exhibiting risky, non-compliant behaviors since his admission. The facility had opportunities to set up and ensure safe discharge as well as document unwillingness to receive treatment, training, seek housing, and obtain personal identification prior to requiring Resident #3 to leave the facility AMA discharge. A. Resident #3's status Resident #3, age less than 50, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/13/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with brief interview for mental status (BIMS) score of 15 out of 15. He did not exhibit behaviors or reject care. He required extensive two-person assistance with mobility and transfers, and required extensive one-person assistance with toileting and hygiene. He had impairment to both lower extremities. He had an indwelling catheter and ostomy. He had two stage 4 pressure ulcers. He received insulin injections five days out of seven, and he received an anticoagulant six days out of seven. He had occasional moderate pain and was taking pain medication routinely and as needed. -It was documented there was no active discharge plan in place and blank under the resident's expectation to remain in the facility, discharge to the community, or discharge to another facility. B. Record review 1. Discharge a. Care plan The discharge care plan, initiated on 6/25/19 and revised on 7/1/19 revealed Resident #3 desired to discharge to the community by (MONTH) 2019. Interventions included to prepare and the resident contact numbers for all community referrals and to make arrangements with required community resources to support independence post-discharge (Specify: home health, physical therapy, occupational therapy, physician, and wound nurse). The care plan did not include interventions that would document the care and services needed to assist the resident in reaching the goal for discharge to community by (MONTH) 2019. b. Progress notes The social services summary dated 3/11/19 at 12:16 p.m. revealed Resident #3 was readmitted from the hospital to the facility for long-term care. He was treated for [REDACTED]. Resident #3 planned to find an apartment and discharge to the community with durable medical equipment (DME). Resident #3 planned to have his brother move in with him to help him with care. Resident #3's tribal case manager was contacted to access resources available to him at discharge. It was documented Resident #3 had a history of [REDACTED]. The nurses note dated 4/27/19 at 5:03 p.m. revealed Resident #3 had not returned from his pass and wound care could not be performed. The nurses note dated 4/28/19 at 9:33 p.m. revealed Resident #3 returned to the facility. Resident #3 requested to be sent to the hospital because he had been drinking. He refused all of his routine medications. The physician gave an order to transport Resident #3 to the hospital. The nurses note dated 5/2/19 at 3:37 p.m. revealed Resident #3 returned to the facility and the discharge goal remained the same. The nurses note dated 5/13/19 at 3:35 p.m. revealed Resident #3 refused afternoon and evening medications, treatments, and blood sugar monitoring. Resident #3 had been out all day the previous day drinking and said he was exhausted. The nurses note dated 5/15/19 at 6:08 a.m. revealed Resident #3 had been out the previous night and had missed all his bedtime medication and he returned to the facility at 3:00 a.m. The nurses note dated 5/23/19 at 2:02 a.m. revealed Resident #3 was out of the building and missed his bedtime medications and wound care. The physician was notified. The nurses note dated 6/3/19 at 9:10 p.m. revealed Resident #3 was out on pass. The nurses note dated 6/5/19 at 1:41 a.m. revealed Resident #3 returned to the facility at midnight, two days after he was out on pass. The nurses note dated 6/6/19 at 5:00 a.m. revealed Resident #3 returned to the facility after being out since 5:30 p.m. on 6/5/19. The discharge planning note dated 6/6/19 at 12:43 p.m. revealed the resident planned to discharge to an apartment in the community. He needed to obtain identification from the department of motor vehicle (DMV), birth certificate, and social security card. Family to visit and assist with looking for apartments. The nurses note dated 6/16/19 at 12:14 a.m. revealed Resident #3 left the facility at 3:45 p.m. and had not returned. The nurses note dated 6/20/19 at 1:10 a.m. revealed Resident #3 had not returned from his pass. The nurses note dated 6/24/19 at 7:29 p.m. revealed Resident #3 returned from the hospital with a [DIAGNOSES REDACTED]. The physician assistant progress note dated 6/27/19 revealed Resident #3 said when he left the facility he was with people using illicit drugs, but denied using them himself. The physician assistant made Resident #3 aware a toxicology screen would be ordered and if illicit drugs were found he would no longer prescribe opioids to the resident. The resident voiced understanding and agreed to weaning off of opioids. The nurses note dated 7/1/19 at 8:41 a.m. revealed Resident #3's toxicology screen was positive for ETOH (ethyl alcohol), cannabis, and [MEDICATION NAME]. Resident #3 was given verbal and written education regarding his risks of using narcotics with high risk drugs. The social services department would provide education on drugs and ETOH counseling; however, there was no documentation of the counseling being set up or refused by the resident. The social services summary dated 7/1/19 at 12:00 p.m. revealed Resident #3's discharge plan was to discharge to an apartment in the community with DME and his brother was supposed to help him with care. The nurses note dated 7/16/19 at 9:06 p.m. revealed Resident #3 returned to the facility after being out on pass for two days. The physician assistant progress note dated 7/18/19 revealed she did not believe Resident #3 would be safe leaving the facility unsupervised due to ETOH abuse and positive toxicology screen. The nurses note dated 7/18/19 at 10:23 a.m. revealed Resident #3 was made aware that his pass privileges were revoked by the physician who felt the resident was not safe due to his high risk behaviors; with positive drug use and non-compliance. He was made aware if he left the facility while his pass privileges were suspended it was considered against medical advice (AMA) and he would be discharged AMA. The nurses note dated 7/24/19 at 5:47 a.m. revealed Resident #3 told staff he was going outside to smoke at 11:00 p.m. the previous night 7/23/19. He had two visitors with him and apparently left the facility because no one had seen him. It was not documented the resident was given the AMA form to sign acknowledgement of AMA discharge at the time he left the faciity on [DATE] at 11:00 p.m.; however, the facility provided the AMA form during interview (see below). The nurses note dated 7/24/19 at 6:53 a.m. revealed Resident #3 had left the faciity on [DATE] and he was reminded he would be discharged AMA if he left the facility contrary to the 7/24/19 nursing note at 5:47 a.m. which indicated he had two visitors with him, went out to smoke, and apparently left the facility because no one had seen him. The nurses note dated 7/24/19 at 7:38 a.m. revealed Resident #3 returned to the facility and the staff informed him he was discharged AMA, he was given his medication list, reminded of an upcoming appointment and encouraged to check into the hospital. Resident #3 stated he would go to a friend's house and he was instructed to contact the facility when he arrived so the facility could set up home health services. Resident #3 left with his belongings. The social services note dated 7/24/19 at 9:28 a.m. revealed Resident #3 was given a list for housing, home health, substance abuse centers/programs, senior blue book, and resource guide. c. Education provided to Resident #3 On 7/25/19 at 11:15 a.m. the SSD provided documentation of facility education that was reviewed with Resident #3. On 6/25/19 the facility encouraged Resident #3 to be compliant with care and recommendations for proper wound healing. On 7/2/19 Resident #3 was provided education of his risky behavior compromising his health which could lead to a negative outcome. On 7/9/19 the facility had looked and offered additional placement. On 7/11/19 the SSD gave Resident #3 resources on housing. 2. Medical needs The physician progress notes [REDACTED]. The resident was tapered off his narcotics due to having empty liquor bottles in his possession, there were concerns of possible ETOH abuse. The plan was behavioral health to continue to treat the resident's possible addiction and [MEDICAL CONDITION]. 3. Resident #3's wound documentation The skin committee interdisciplinary (IDT) note dated 7/2/19 at 4:39 p.m. revealed: -The stage 4 pressure ulcer to the mid scrotum measured 5.5 cm (centimeters) x (by) 2.0 cm x 0.2 cm it had 100% (percent) granular tissue and was stable. -The left ischium surgical wound measured 2.5 cm x 2.4 cm x 1.8 cm it had 80% granular tissue and 20% slough and was improving. -The left scrotum abscess measured 2.0 cm x 1.0 cm x 0.1 cm it had 100% granular tissue and was improving. -The right posterior thigh abrasion measured 1.0 cm x 1.6 cm x 0.2 cm it had 100% granular tissue and was unchanged. -The left great toe abrasion measured 6.0 cm x 3.5 cm x 0.3 cm in had 80% slough and 20% of granular tissue and was stable. 4. Personal care The skin integrity care plan, initiated 6/25/19 and revised on 7/1/19 revealed the resident had pressure ulcers and history of surgical flap. Interventions included to have an air mattress and pressure relieving/reducing cushion to the wheelchair. The ostomy care plan, initiated 6/25/19 and revised on 7/1/19 revealed the resident had a [MEDICAL CONDITION] bladder. Interventions included to assist the resident with toileting and peri-care. The ADL care plan, initiated 6/25/19 and revised on 7/1/19 revealed the resident required extensive assistance with mechanical lift transfer, extensive one-person assistance with bed mobility and repositioning, and required assistance to manage his indwelling catheter and ostomy. 5. Physician orders [REDACTED]. The (MONTH) 2019 medication administration records (MARs) and treatment administration records (TARs) revealed the following pertinent physician orders: -[MEDICATION NAME] Solution 10 units subcutaneously at bedtime for diabetes mellitus. -[MEDICATION NAME] Solution 10 units subcutaneously four times a day, hold for blood sugar less than 120 for diabetes mellitus. -Left ischium, left scrotum, and right thigh cleanse with normal saline and apply calcium alginate and cover with a foam dressing change daily and as needed. -Cleanse left great toe with normal saline apply calcium alginate, ABD (absorbent pad), wrap with kerlix and change every evening shift. -Catheter care every shift. III. Staff interviews The director of nursing (DON) and social services director (SSD) were interviewed on 7/25/19 at 10:20 a.m. They provided documentation of Resident #3's behaviors of non-compliance with wound treatment and leaving the facility for extended periods of time, documentation of education on his high risk behaviors, and the discharge AMA form dated 7/23/19 which they said the resident refused to sign. They said they did not issue Resident #3 a 30-day discharge notice but made Resident #3 aware his pass privileges were lost and if he left the facility he would be discharged AMA. The physician assistant was interviewed on 7/25/19 at 10:40 a.m. He said he worked with the physician caring for Resident #3 and had assessed Resident #3 through-out his entire stay. He said over-all Resident #3 was non-compliant with care and treatment. He said they had always provided education to Resident #3 surrounding his substance abuse, smoking, leaving the facility for extended periods, non-healing wounds, and risks for re-hospitalization and infection. He said Resident #3 would admit he was drinking and doing drugs, and from the providers standpoint they could assume when he went on pass he was doing illicit drugs since he openly admitted it. He said Resident #3's, 7/1/19 toxicology screen was the only one completed during his stay. He said it would be costly to run a toxicology report for Resident #3 every time he returned from pass and the illicit drugs could have been out of his system by the time the screen could be completed. He said when Resident #3's toxicology report came back positive for substance abuse Resident #3 was told his pass privileges were taken away and if he left he would be discharged AMA. He said he did not know who gave the discharge order to discharge Resident #3 AMA on 7/23/19, but he was made aware of the discharge by the DON. The NHA, DON, and assistant director of nursing (ADON) were interviewed on 7/25/19 at 12:45 p.m. They acknowledged the resident was not given a right to appeal the involuntary discharge to the Social Services Director (SSD), the facility's grievance committee and, if necessary, the Colorado Department of Public Health and Environment. They acknowledged their responsibility to discharge a resident to a safe environment and to give proper notice of discharge to residents who were not following facility rules.

Based on resident and staff interviews, observations and record review, the facility failed to ensure five of five residents (#43, #63, #58, #65 and #70) out of 30 sampled residents received adequate supervision to prevent accidents. Specifically: Residents #70, #63, #43, and #65 all resided on the same unit and residents #70, #63, #43 and #58 ate in the same dining room. The facility, after receiving notice of abusive behavior by resident #70 toward residents #43, #63, and #58 that included unwanted touching, unwanted intrusion into their personal space and verbal abuse, failed to take sufficient steps to protect residents #43, #58, #63, and at risk resident #65 from abuse and fear of abuse by resident #70. Resident #63, who, per interview, said resident #70 was "all the time touching her and rolling up behind her in her wheelchair," expressed fear, verbally and nonverbally, of resident #70. Resident #43, too, expressed fear of resident #70. The facility failed to ensure resident #70's care was individualized and effective and his supervision adequate to protect these and other residents on the unit. This failure created a situation of immediate jeopardy with the potential for serious harm. Findings: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Interviews with alert and oriented residents #43 and #58 on 9/4/14 at 10:35 a.m. and 3:45 p.m., and resident #63 on 9/5/14 at 1:35 p.m., revealed the residents had experienced abusive behavior - unwanted touching and/or unwanted intrusion into their personal space, as well as verbal abuse - by resident #70. Residents #58 and #63 expressed and reported their fear of resident #70 to the facility administration. The facility failed to put adequate and effective measures in place to protect residents from further abuse by resident #70, creating a situation of immediate jeopardy with the potential for serious harm for residents #63, #43, #58 and other residents on the unit, including at risk resident #65. On 9/5/14 at 4:15 p.m. the nursing home administrator (NHA) and the facility operations manager were notified of the situation of immediate jeopardy. B. Plan to Remove Immediate Jeopardy At approximately 6:00 p.m. on 9/5/14 the facility submitted the first draft of the plan to abate the immediate jeopardy. This draft was rejected 9/5/14 at 6:15 p.m. and a second plan was submitted at 7:10 p.m. 9/5/14 and accepted at 7:15 p.m. The facility abatement plan read: The facility put in place 1:1 monitoring of resident #70. This monitoring would be 24/7 (24 hours) and would continue until the IDT (interdisciplinary team) determines that it is safe to discontinue the 1:1 monitoring. A schedule of monitoring was done that included meal and break coverage. The facility planned to monitor the psychosocial status of residents #43 and #63 every shift and as needed. The facility identified all residents on the first floor as being at risk. All first floor residents and staff were interviewed to identify if any incidents had occurred with resident #70. The interviews were concluded by 9/6/14. Any allegations were to be reported to the Administrator for investigation immediately. The Medical Director held in-services for staff prior to the beginning of the staff's next shift. The in-service covered behavior monitoring and abuse reporting. Department head staff would be present in the building 7 days per week to determine the effectiveness of behavior monitoring and 1:1. Agenda of the in-service and sign in sheets were reviewed. On 9/7/14 at 4:10 p.m. an unannounced visit was made to the facility to verify implementation of the facility's plan of abatement. -Interview with licensed practical nurse (LPN) LPN #3 at 4:15 p.m. revealed the LPN understood why 1:1 monitoring of resident #70 was being done. LPN #3 said he had been in-serviced prior to beginning his first shift on 9/6/14 on behavior monitoring and reporting abuse. The in-service had been presented by the Medical Director. -Interview with certified nurse aide (CNA) CNA #2 at 4:20 p.m. revealed the CNA was knowledgeable about resident #70 and the current situation. The CNA said she also had been in-serviced by the Medical Director regarding behavior monitoring and abuse reporting. -Interviews with residents #43 and #63 at approximately 4:30 p.m. revealed both residents expressed satisfaction with the actions the facility had taken. Resident #43 stated, "I slept well last night for the first time in a long time." Both residents said they were not fearful of resident #70 now. On 9/8/14 the NHA was asked to provide a second plan of abatement that specified their ongoing plan to protect the residents. This plan was submitted on 9/8/14 at approximately 1:05 p.m. and accepted at 1:16 p.m. C. Removal of Immediate Jeopardy On 9/8/14 at 2:50 p.m. the NHA was informed of their plans for abatement had been accepted and the immediate jeopardy removed. However, deficient practice remained at a G level, actual harm that is isolated. II. Failure to Protect Residents from Resident #70's Inappropriate Behaviors A. Environmental Characteristics 1. Dining The facility had two main dining areas; one dining room on the second floor and the other on the first floor. Residents #58, #63, #43 and #70 ate meals, when present in the building, in the first floor dining area on a daily basis and sat in close proximity to one another. 2. Room Location (as observed on 9/8/14 at 9:08 a.m.) Residents #63, #65, #43 and #70 resided on the same floor. The residents' rooms were approximately 5' and 45' apart. Residents #43 and #63 were roommates. 3. Visibility of rooms from the nurses' station On 9/5/14 at 5:40 p.m., while sitting at the nursing station (the chair by the wall), there was no visibility of resident #65 or resident #43 and #63's rooms. Staff's visibility of resident #70's room was limited to partial viewing (of an upper 1/3 of the doorway). Observation during survey (9/2 - 9/12/14) revealed nursing staff completed their charting at the station due to computer accessibility. B. Resident #70 Resident #70, age 60, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. 1. Resident Status The resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as having adequate hearing, clear speech, the ability to make himself understood and understand others. He was assessed as severely cognitively impaired (BIMS score 3 of 15 points), but as requiring limited physical assistance for mobility and activities of daily living. The resident was 5' 8' tall and weighed 195 pounds. Review of physician orders [REDACTED]. 2. Inappropriate and aggressive behaviors toward residents and staff 9/13 - 3/14 - Facility response - Failures in facility response a. Documented behaviors Review of the resident #70's record revealed a history of inappropriate behavior toward staff and residents 9/13 - 3/14. -A notification of room change 9/11/13 documented the resident was moved from the second floor to the first because of "behaviors" toward residents on the second floor. -Progress notes by the resident's physician and staff (nursing and social services) 1/14 to 3/14 documented "inappropriate behavior" (1/28/14), "groping towards female staff and other residents" (2/14/14), hitting residents, wandering in other residents' room, calling resident a '[***] ' and residents expressing fear of resident #70 (3/15, 3/16, 3/23, and 3/24/14). b. Facility response Review of resident #70's record revealed the resident was evaluated by mental health 3/24/14; mental health's recommendation was to return the resident to facility. Upon his return, resident #70 was placed on 1:1 supervision (discontinued 4/8/14) and Seroquel (antipsychotic) was initiated. (Paxil, an antidepressant, was ordered to replace Celexa, but the order was cancelled due to insurance.) c. Failures in facility response Record review revealed no evidence the interdisciplinary team investigated the cause of the resident's behaviors, what they represented, what need he was attempting to express, how the behaviors might be triggered and how they could be managed. There was no evidence of a care plan with resident specific intervention for staff addressing the resident's behaviors. Review of the Behavior Monitor Flowsheet (BMF) for March, 2014, revealed staff was directed to track resident #70 for physical, verbal abuse and sexual inappropriateness. Despite documentation of such behaviors in the progress notes (see above), there were no entries on the BMF prior to 3/24/14. Thereafter, one entry was made on 3/27/14 for the month. Record review revealed no plan to ensure the resident, who was independently ambulatory in his wheelchair, would be adequately supervised after 1:1 supervision was discontinued 4/8/14. Although 15 minute checks were to be implemented, there was no documentation how long such checks would continue. 3. Inappropriate and aggressive behaviors toward residents and staff 4/14 - 6/14 - Facility response - Failures in facility response a. Documented behaviors Review of records (resident #70, resident #43, resident #58's records and facility reports) revealed resident #70's behaviors continued. -Resident #43's 4/18/14 progress notes by nursing and the staff development coordinator documented when resident #43 propelled past resident #70 at the nurses' station, resident #70 stated to her "you need to die." -Resident #70's 4/28/14 progress note documented the resident had been very intently trying to go into other resident rooms and a social service note dated 5/2/14 read the resident has had inappropriate sexual behaviors/comments toward female residents and staff, physical aggression, and verbal abuse, as well as history of seeking out other residents and initiating altercations. -Resident #70's 5/6/14 progress note documented the resident had attempted twice to enter a female resident's room and 5/15/14 progress note documented the resident grabbing staff's 'buttock.' -Resident #70's 6/20/14 physician progress notes [REDACTED].#70) "continues to have some behaviors, recently running his wheel chair into people and last night went into another resident's room, returns to areas that he has been asked to stay out of after a minute or so." -Resident #70's 6/24/14 progress note read in pertinent part, "This nurse was called into dining room by another patient (resident #58). Patient states that "Res 70 just grabbed her boob." "This nurse explained to resident that his actions were inappropriate and that he could not do that. Res stated "he didn't care." "Removed resident from dining room. MD on site and notified..." BMF for May documented one behavior on 5/15/14 (see above). The June BMF was requested but not provided. b. Facility response Care plans were initiated 6/18/14 and 6/19/14 to address the resident's depression and behaviors. -A care plan was developed 6/18/14 to address the resident's risk for depression related to dementia. -Two other care plans were initiated 6/19/14 for the resident's potential to demonstrate physical behaviors as well (i.e. striking out) verbally abusive behavior related to dementia. Pertinent interventions for physical behavior included to guide the resident away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. Pertinent interventions for verbally abusive behavior included to analyze key times, places, circumstances, triggers and what de-escalates behavior and document and provide positive feedback for good behavior. -A fourth care plan, also initiated 6/19/14 addressed the resident's history of being sexually inappropriate. Interventions included, in pertinent part, to document behaviors and resident response to interventions; intervene as necessary to protect the rights and safety of others. Approach calmly and divert attention. Remove from situation and take to alternate location as needed. The resident was assessed by the physician following the 6/24/14 incident, medication changes, and the resident's care plan was updated. Specifically: -Resident #70's physician progress notes [REDACTED]. Similar events in past. Pharmacy recommending change ... to Paroxetine (Paxil), possibly due to greater anticholinergic side effects which might control his behavioral events." Treatment, in pertinent part: "Stop Celexa tablet, 20 mg, 1 tablet orally once a day. Start paroxetine tablet, 10 mg, 1 tab in the morning, orally, once a day, 30 days ... Remains on Seroquel 12.5 mg BID for agitation." -Resident #70's care plan was updated to read that staff would increase monitoring until (resident #70) could be redirected. The facility investigated the 6/24/14 incident and review of the facility investigation summary revealed (resident #70) grabbed another resident "inappropriately." -The facility concluded the resident was not capable of forming intent, and the corrective action was to change resident #70's antidepressant medication. -Staff interviews conducted 6/24/14 revealed no sexually inappropriate behaviors recently, but such behaviors in the past. -Resident interviews conducted 6/24/14 revealed two residents (#58 and #63) expressed fear of resident #70. Resident #58 was interviewed and stated she has fear of resident #70. Per the interview, the resident was told measures have been taken to protect her. "Resident provided with reassurance." Resident #63's interview revealed "she feared (resident #70) but says, "he's been good this week," adding, she "knows he goes on rampages (verbal, not physical)." c. Failures in facility response See care plans above; resident #70's care plan for behaviors, even when updated, included vague and non-specific directions to staff. The care plans contained no resident specific information in an attempt to understand his behaviors, in particular, what need he was expressing, what circumstances might trigger them. "Increased monitoring until redirected" provided no direction to staff on the frequency and duration of this intervention. Moreover, there was no documentation in the resident's record, as care planned, of an analysis of key times, places, circumstances, triggers for resident #70's behaviors, as well as what de-escalates the behavior. On 9/10/14 at 3:34 p.m. an interview was conducted with the Social Services Director (SSD). The SSD had worked in the facility under the previous ownership, left to work at another facility and returned 6/2/14. The SSD said resident #70 was monitored for fighting and sexually inappropriate behavior. The SSD said the care plans dated 6/18 and 6/19/14 were written to replace paper care plans. (However, no paper care plans were found in the resident's purged records.) The SSD said the care plans done 6/18 and 6/19/14 were not written in response to any events occurring at that time. See facility investigation summary above; the facility failed to follow up on investigation findings that residents #58 and #63 were afraid. Specifically: Resident #58: Review of resident #58's electronic record and paper chart (6/21/14 - 9/10/14), revealed no reference to the incident on 6/24/14. There was no additional monitoring of the resident's psychosocial status after the event. There was no assessment of her psychosocial needs to ensure she felt safe after the 6/24/14 event. Staff was monitoring for behaviors such as restlessness/anxiety and delusions/paranoia in June 2014 related to her daily prescribed medications; however, no abnormal events were noted on 6/24/14 through 6/30/14. On 9/9/14 at 3:24 p.m., the Social Service Director (SSD) was interviewed. She stated she did not personally interview this resident after the 6/24/14 event and was not part of the team that worked on the 6/24/14 investigation. She could not recall if she'd been asked to follow up with the resident. The SSD said that when she participates in such an investigation, after interviewing residents and establishing a safety plan, she likes to follow up (monitor) with the resident for 72 hours and look for any changes, body actions/non-verbal actions of the resident. She said if a resident expressed fear, she would initiate one to one oversight. (See care plan intervention above for "increased," but not one to one, level of supervision initiated 6/24/14). On 9/5/14 at 1:38 p.m. the Director of Nurses (DON) and Nurse Consultant (DCS) were interviewed about the 6/24/14 incident. -The DON said that although the incident was not witnessed, they did not have any reason to believe it didn't happen. She said this was resident #70's first sexual incident since the facility came under new management (6/1/14 when a corporation change occurred in the facility. New administrative staff was placed but many nursing staff transitioned form the previous to the new corporation). The resident's medication was changed and there have been no incidents since then. (But see below; interviews with residents #63 and #43 and resident council minutes 9/7/14.) -The DON said she did a lot of "one to ones" with resident #58 and sat with her after the 6/24/14 incident. In addition, she said she checked with the resident three to four times a day and contacted the resident's mental health worker. But see interview and record review above; there was no documentation of the incident in resident #58's record and the SSD indicated she had not been involved in the incident or follow up after the incident. (Resident #58, who was alert and oriented, was interviewed on 9/4/14 at 3:45 p.m. She recalled the 6/24/14 incident when asked about abuse. Although initially afraid of resident #70, she said was not currently fearful of him.) Resident #63: Record review of the electronic charting/paper chart (6/8/14 - 9/9/14) for resident #63 revealed no additional monitoring of resident #63's psychosocial status after the 6/24/14 incident. There was no assessment of her psychosocial needs to ensure her safety needs were met after she expressed fear of resident #70. The DON, during an interview with the DCS on 9/5/14 at 1:38 p.m. said that in response to resident #63's expression of fear, "We put frequent monitoring of (resident #70) (in place) and asked family to come and spend more time with him. Resident #63 has not expressed any fear of him." The DON said resident #70 has not been on 1:1 monitoring since they took over management in early June. See resident #63's interview below; the resident expressed current fear of resident #70. 4. Current inappropriate and aggressive behaviors toward residents and staff - Continued failure in facility response a. Reports of ongoing inappropriate behavior by resident #70 (1) Resident #63 Record Review: Resident #63, [AGE] years old, was admitted to the facility on [DATE] and re-admitted on [DATE] from the hospital. The face sheet of the same date documented [DIAGNOSES REDACTED]. The resident resided in the first floor unit with her roommate, resident #43. Observations 9/4/14 revealed the resident ate in the main first floor dining room. The resident either utilized a wheelchair or walker. The quarterly MDS dated [DATE] documented that the resident had no cognitive impairments (score of 15/15 of the brief mental status exam). A further review of the document indicated that the resident had no documented rejection of cares, history of hallucinations or delusions or was taking any psychoactive medications. The 4/4/14 quarterly assessment also indicated the resident had no cognitive impairments. Residents height was 5'2" and weighed 115 pounds. A review of the resident's care plans indicated that the resident was not care planned for the use of psychoactive medications. A further review of the resident's care plan indicated that the resident was not care planned for any psychosocial issues or concerns until the IJ (prior to the recertification survey 9/2/14 - 9/12/14). See above; record review of the electronic charting/paper chart (6/8/14 - 9/9/14) revealed no additional monitoring of the resident's psychosocial status after 6/24/14 when she expressed fear of resident #70. A 7/15/14 quarterly social service assessment indicated there were no significant changes in the resident's condition. The resident was pleasant and social. A 7/15/14 care conference occurred with the resident and no concerns were expressed. An 8/26/14 social service re-admission assessment, signed and completed by SSD on 9/5/14, indicated the resident was not unhappy with other residents and did not have anxiety. Resident Interview: Contrary to the social service assessments above, resident interview revealed she expressed verbally and nonverbally, fear of resident #70. On 9/5/14 at approximately 10:35 a.m., resident #63 was observed and interviewed in her room. The following observations were made prior to the interview: -The resident was sitting in a large overstuffed personal chair and was watching television. Her legs were elevated and she was smiling and invited the surveyor to come in and sit down. The resident was cordial and smiling when she turned her television off and faced the surveyor. -The resident stated she had told a surveyor on 9/4/14 that she had a concern with a resident (resident #70) in the facility. The resident stated that resident #70 was "all the time touching her and rolling up behind her in his wheelchair." -The resident stated resident #70 would lower his voice "as low as it would go" and whisper in the curve of her neck "what is your problem and why don't you like me?" -The resident stated that these repeated and continuous events made her anxious and nauseous to her stomach. She stated that sometimes the nausea would last for a week. -The resident stated that resident #70 had touched her inappropriately on more than one occasion. She stated the last time was on 8/5/14. -The resident stated that she had reported the sexual inappropriateness of resident #70 to the NHA and the DON in June 2014. -The resident said when she inquired as to why nothing was being done and resident #70 was in the common areas such as the dining room and continued harassing her, the DON informed her that she could not tell her any information about resident #70 because of HIPPA (legislation that requires protection of confidential information). (In an interview on 9/10/14 at 4:39 p.m., the DON confirmed the facility tried to be cautious on what information was relayed to the female residents. She said 'we let them know that we took dramatic measures to ensure resident safety and ... keeping a closer eye on him. We could not let them know specific information due to HIPPA regulations.') -The resident stated that she continued to be hesitant to dine in the dining room or go outside of her room much anymore because of the constant state of anxiety that resident #70 gave her. -The resident stated that at night she was "scared to death that she would wake up and resident #70 would be standing over her." She further stated "I pray so hard that the staff doesn't let him in our room at night." The resident said resident #70 had come into her room in the middle of the night and pulled his pants down and would not leave. She said, "the resident knew exactly what he was doing" because he said "I am not leaving until I am done using the bathroom." (See interviews below; administration did not investigate this incident.) -The resident said no one from the facility has come to update her or her roommate (resident #43) about what they are doing so that she and her roommate don't have to be worried about when resident #70 is going to touch them or sneak up behind them and whisper terrible things in their ears. -The resident stated that she was in a constant state of anxiety and that the anxiety made her sick to her stomach and nervous all day long after she sees resident #70 anywhere in the facility. At the end of the interview, the resident was observed sitting in her arm chair, staring at the wall in front of her. Her right hand was observed picking in a nervous manner at a doilie that was draped over the arm area of the chair. The resident appeared tearful until the subject (resident #70) was changed to a common interest between the resident and surveyor. At that time, the resident's face was observed to be smiling and cheerful as observed at the beginning of the interview process. Review of Resident Council minutes from a meeting held during survey (9/7/14) revealed the following statements by resident #43 when residents were asked if they felt safe in the facility: Resident #43 stated that "(resident #70) ...blows breath on the back of her neck when he is near her. Residents (#63 and #43) feel that even though they had informed staff in the past, that nothing has been done in the way of preventing these things from occurring ..." (2) Resident #43 Resident #43 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the first floor in a room with resident #63. A 12/5/13 note by social services shortly after the resident's admission read, "Res(ident) is alert and oriented. Res is able to make her own decisions. Res has not had any recent physical or cognitive changes ...Res does not have any behaviors but does have increased anxiety at times surrounding concerns r/t (related to) care provided to herself and others. Res has a healthy level of psychosocial well-being, overall ... A 4/7/14 (physician monthly note) read, in part: "[AGE] year female ...Pt (patient) with good appetite ...no change in functional status, health status, mental status ...Anxiety level: mildly anxious/nervous ...propels W/C (wheelchair) per self throughout facility ...spoke in person, pt agrees to pain management consultation ..." A quarterly 5/28/14 MDS assessment revealed the resident was cognitively intact, (score of 15 out of 15 on the brief interview for mental status exam). The resident was 5"4" tall and weighed 211 pounds. Resident Interview: During an interview on 9/5/14 at 1:35 p.m., the resident was asked if she had problems with other residents. She responded: "It's (resident #70). He will not let us alone. He touches (resident #63) ...He's come down here to our room several times. Finally I held my foot on the door." She said one night, a couple of months ago resident #70 entered her room. She said, "I told him to leave but he went into the bathroom. I hollered as loud as I could...No one could get him to leave until he was done..He tries to sit at the table with us ...I don't trust him. I'm afraid of him ....The night before last he tried to sit at our table." She stated, "He touches (resident #63) all the time. She says, "Get your hand off of me." We were told they were looking for another place for him - that "We'll watch him" and that's about it. ...I don't trust him and I don't know what he'll do. He says in a soft voice like this, "Diiieee [***] ." He's said that several times ...He gives me the creeps ..." Record Review: See above; on 4/18/14, resident #70 was overheard when passing resident #43 to saying to her, "you need to die." Further review of progress notes revealed an 8/4/14 physician monthly note that read the resident reported episodes of feeling very "anxious," stating her stomach feels "knotted" up. The note read the resident consented to counseling. An 8/21/14 psychological diagnostic interview documented, " Client appears anxious and irritable ..." Review of Resident Council Meeting minutes from 9/7/14 (see above in reference to resident #63) documented the following statements by resident #43: "(Resident #43) stated that a fell ow resident (resident #70) bothers both herself and her roommate daily. The resident tries to sit with them at their table which is already full and also antagonizes both herself and her roommate by speaking obscenities in front of them - "Die [***] " or asks "Why don't you like me?" ....(Resident #43) also stated that (resident #70) knocks on their bedroom door and tries to enter and about a month and a half ago said resident actually succeeded in entering the room and using the restroom ...(Resident #43) stated that "Yes, she does fear for her safety." Residents feel that even though they had informed staff in the past, that nothing has been done in the way of preventing these things from occurring ..." b. Additional resident at risk - Resident #65 Resident #65 was re-admitted to the facility on [DATE] from the hospital. She was originally admitted on [DATE]. According to the admission record and physician notes, the pertinent medical [DIAGNOSES REDACTED]. A 6/26/14 physician note documented the resident was unresponsive to voice and had a severe brain injury. A 7/9/14 MDS indicated the resident was non-verbal and required extensive assistance from staff with all activities of daily living. Record Review: Record review revealed a history of sexual assault and physical and mental conditions that placed the resident at risk for harm. Specifically, review of the resident's care plans revealed: -A plan (7/17/14) that noted the resident was unable to use a call light due to decreased independent mobility related to head injury. Staff was directed to make frequent checks and provide a room close to nurses' stations for frequent monitoring. -A plan (7/14/14) that the resident was at risk for communication problems related to TBI (traumatic brain injury), [DIAGNOSES REDACTED]. Pertinent interventions included to ensure and provide a safe environment. -A plan (7/29/14) that the resident had limited physical mobility related to TBI, [DIAGNOSES REDACTED], seizure, contracture and weakness. -A plan (7/16/14) for activities that identified the resident was bed bound. On the CNA care kardex, staff was directed to provide a safe environment and provide a room assignment close to the nursing station. Interview: On 9/5/14 at approximately 6:10 p.m., the DON stated a safety intervention for this resident included keeping a STOP sign in place across the door when staff or family was not visiting. The DON said the STOP sign would deter any residents from entering. Observations and Interview: Observations revealed the STOP sign to deter residents from entering resident #65's room was not in place. -On 9/4/14 at 8:24 a.m., the resident was lying in bed, eyes closed. The STOP sign was not present across the door: -On 9/4/14 at 11:20 a.m., the resident was lying in bed, eyes closed. The STOP sign was not present across the door. -On 9/5/14 at 9:45 a.m., the resident was lying in bed, eyes closed. The STOP sign was not present across the door. On 9/5/14 at 5:40 p.m. and 7:01 p.m., the resident was lying in bed, eyes closed. The STOP sign was not present across the door. -On 9/8/14 at 7:42 a.m., the resident was lying in bed, eyes closed. The STOP sign was not present across the door. On 9/8/14 at 7:42 a.m., the Registered Nurse (RN#2) was asked where the STOP sign was located. The RN stated the right side Velcro attachment was broken and the STOP sign could not be applied correctly. The RN was uncertain how long the Velcro attachment had been missing and the sign not used. The RN stated the STOP sign was to be in place at all times when staff or family was not present. The STOP sign could not be located in the resident's room. The day RN (RN#3), also confirmed at 7:45 a.m., the Velcro STOP sign was to be in place at all times. The DON, interviewed at this time, stated she was not aware of the Velcro STOP sign being unusable. Additional interviews: On 9/9/14 at 2:32 p.m., the DON and nurse consultant (DCS) were interviewed about monitoring resid

Based on observations, interviews and record review, the facility failed to keep one of 5 sample residents (#1) free from physical abuse and/or mistreatment. Evidence from a video tape indicated resident #1 was sexually assaulted by certified nurse aide (CNA) #1. Findings include: 1. Resident #1 Resident #1, age 30, was admitted to the facility from the hospital on [DATE]. The resident had five readmission's from the hospital to the facility with the last readmission on 12/13/13. The face sheet of the same date indicated the following admission Diagnoses: [REDACTED]. The quarterly minimum data set (MDS), dated [DATE], indicated the resident was totally dependent on staff for all cares, including bed mobility, dressing, eating and personal hygiene. The resident received enteral tube feedings as the primary source of nourishment as indicated in Section K of the MDS. The resident was non-verbal and unable to communicate using sign language or any other means of written communication. The resident was totally dependent on staff anticipating her cares and needs. The resident's care plan, dated 7/4/13 and updated 11/13/13, documented the resident was care planned for little or no activity involvement related to physical limitations, immobility and inability to verbally communicate, write or respond with sign language. Interventions included frequent staff monitoring related to the inability to use a call light, staff to give at least two sponge baths weekly and staff to check and change frequently for incontinence. The resident resided in a private room on one of the two halls on the second floor, along with 22 other residents. Her room was at the very end of the hall. Interview with the resident's family member on 2/24/14 at 1:30 p.m., revealed the family had placed a video camera in a stuffed animal in the resident's room to record the resident #1's sounds and behaviors when they were not with her. 2. Events 1/14/14 A physician telephone order, dated 1/14/14 at 8:00 p.m., read to send resident #1 to the emergency room for evaluation. The telephone order was signed by the facility evening charge nurse. An emergency room report, dated 1/14/14 at 11:26 p.m., revealed the resident was brought to the hospital by ambulance. The chief complaint was "sexual assault" after family members viewed a video indicating the resident was orally and vaginally assaulted by a facility staff member. -The resident was examined and evaluated by the hospital sexual assault nurse examiner (SANE), a registered nurse who has had additional training and education specifically for the purpose of investigation rape and sexual assaults. -The resident was administered three different types of antibiotics to "help prevent sexually transmitted infections caused by bacteria" and a pregnancy test was conducted. The primary [DIAGNOSES REDACTED]." Review of the police report, dated 1/15/14 at 1:13 p.m., revealed the video tape showed a male CNA (CNA #1) in resident #1's room engaged in actions consistent with sexual intercourse on 1/2/14 at approximately 9:31 p.m., and oral intercourse on 1/7/14 at approximately 9:47 p.m. The CNA was arrested and taken into custody. Two facility nurses, the charge nurse and the second floor nurse, who were working 1/14/14, were interviewed in the presence of the regional nurse consultant (RNC) on 2/7/14 at approximately 11:30 a.m. -They stated resident #1's family entered the facility on 1/14/14 at approximately 6:00 p.m., and asked to speak to the nursing staff. The two nurses responded to the family's request. -The family provided the nurses with a video tape of the resident and the resident's room and surroundings. The video tape revealed two incidents of alleged sexual abuse/misconduct. The tape had two time-stamps on it; the time-stamps indicated the first incident was taped on 1/2/14 at 9:13 p.m., and the second incident was taped on 1/7/14 at 9:47 p.m. -The nurses said after viewing the video tape, they immediately called the police department and the nursing home administrator (NHA). 3. Failure of the facility to keep resident #1 free from sexual abuse a. Facility expectations (1) The facility policy titled "Abuse" (POL: 504-01, released 8/31/12, reads in pertinent part: -All alleged violations involving mistreatment, neglect, or abuse ... are reported immediately to the administrator... -Components to prevent abuse include: --Screening staff. Investigations into the past histories of a potential employee include: inquiry of the state nurse aide registry, previous and/or current employers, and completion of criminal background checks, "reasonable efforts" to uncover information about any past criminal prosecutions. --Identification of patients most at risk of neglect and abuse (may include but not limited to): patients who have dementia; no or infrequent visitors, psychosocial, interactive, and/or behavioral dysfunction; and patients who are bedfast and totally dependent on care." (2) The facility policy titled "Abuse Prevention" (PRO ), dated 4/28/09, reads in pertinent part: "Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur through analysis of: -Features of the physical environment that may make abuse and/or neglect and/or misappropriation of resident property more likely to occur, such as secluded areas of the facility. -Deployment of staff on each shift in sufficient numbers to meet the needs of the residents ... -Monitoring residents, visitors and staff to identify inappropriate behaviors ... -Assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. b. Failure to adequately screen CNA #1, contrary to facility expectations Cross-reference F225. CNA #1 began employment 5/22/13. Review of CNA #1's file revealed no evidence of reference checks. Final disposition to hire was made prior to printing the criminal background check which revealed active warrants relating to two misdemeanor charges. The active warrants were not further investigated. Finally, licensure verification was dated 1/15/14, eight months after date of hire. See F225 for further details. c. Failure to timely identify resident #1 as at risk for abuse, contrary to facility expectations Review of the resident's care plan (see above) revealed it was updated on 1/16/14, two days after the facility viewed the family's video tape, to reflect the resident had been identified as a high risk resident and she was to be monitored for symptoms of agitation or distress especially during and immediately after receiving hands on care. She also was to have two caregivers present for all cares. Interview on 2/7/14 at 11:00 a.m., with the social services director (SSD), who had worked at the facility since 6/13, revealed that since 1/14/14, she was asked to put together a care plan/behavior plan for resident #1 for 'increased agitation and sleep restlessness,' that included all the resident's care was to be conducted by two caregivers. Interview on 2/7/14 at 11:30 a.m., with the two nurses who worked 1/14/14 (see above) revealed that on 1/15/14, the facility developed a plan to identify all residents who were at risk for abuse. Risk factors included those who were unable to verbalize need/abuse with staff assistance. The facility identified five residents as being at risk and they were care planned to have two caregivers present during all cares. Based on the resident's care plan and interviews above, the facility did not identify resident #1 at risk for abuse until after the abusive incidents were identified by the video tape. d. Failure to analyze features of the physical environment that might make abuse more likely to occur, such as secluded areas of the facility, contrary to facility expectations On 2/6/14 at approximately 9:00 a.m., an observation of resident #1's room was completed. Resident #1's room was not visible from the nursing station. The door to the resident's room was left slightly ajar and the resident was not visible unless one entered the room. In an interview on 2/7/14 at 11:30 a.m., with the two nurses who worked 1/14/14 (see above), the nurses revealed that after 1/14/14, no environmental changes were made to the resident's room or the second floor nursing station. In an interview with the Director of Nurses (DON) on 2/7/14 at 1:00 p.m., the DON acknowledged none of the resident rooms on resident #1's hall could be seen from the nursing station. He confirmed, moreover, that no changes had been made to resident #1's room or the nursing station on the second floor. The DON stated, in pertinent part, "We feel like (the incidents revealed on the video tape) are opportunistic and (we) did not recognize environmental concerns with the resident's room or the nursing stations." In an interview on 2/18/14 at approximately 8:15 p.m., the floor nurse on the night shift where resident #1 resides said he has worked the second floor of the facility for approximately six months and was familiar with resident #1 and her care needs. -He said the resident's room is not visible from the nursing station or the south side of the unit where the nurses are required to be when delivering medications to approximately 11 residents; there are no concave mirrors at the end of the hallways for the nursing staff to visualize the residents or the back stairwell of the unit. -He said if staff was seated at the nursing station, there would be no way of know what was going on because you cannot see past what is in front of you. Based on observations and the interviews above, the facility failed, both prior to and after 1/14/14, to consider features of the physical environment that had the potential to create secluded areas of the facility. e. Failure to monitor staff to identify inappropriate behaviors and failure to report inappropriate behaviors to the administrator, contrary to facility expectations Interview with a facility staff member on 2/7/14 at 3:10 p.m., revealed unreported allegations of sexually suggestive comments and gestures directed toward and/or within hearing distance of facility residents by CNA #1 prior to 1/14/14. -The staff member stated CNA #1 frequently made sexually inappropriate comments and gestures while serving in the dining room and while working on the unit with residents. The staff member stated that one evening CNA #1 told staff in the dining room he was taking male enhancements which he indicated was having a positive effect. The staff member said no one took the CNA seriously because he frequently made lewd remarks that were not appropriate for the work environment; staff just ignored his behavior. -The facility staff member reported a second interaction with CNA #1 when she noticed a dark brown stain on his scrub top. Thinking it might be fecal material, she brought it to the attention of CNA #1. He proceeded to make a sexually suggestive licking motion while lifting his shirt toward his face. -The staff member said one time s/he was talking with another resident seated in their wheelchair in the hallway. CNA #1 walked up behind the resident as he sat in the wheelchair and made several sexually suggestive licking motions behind the resident's ear while looking directly at the facility staff member. -The staff member confirmed these incidents were not reported to facility administration. According to the staff member, people frequently ignored CNA #1's comments including him/her. Interviews with the NHA on 2/6/14 at 9:00 a.m. and the DON on 2/6/14 at 9:00 a.m., revealed facility staff training was conducted between 1/15/14-1/22/14 on identifying and reporting abuse, neglect, or mistreatment. However, review of the attendance rosters revealed not all facility staff received the abuse training between 1/15/14-/22/14. Multiple requests were made of the DON, RNC and NHA for evidence that the facility had provided abuse training to facility staff prior to the reported sexual assault on 1/14/14, no such evidence was provided prior to exit on 2/20/14. Based on staff interviews above, a number of staff was aware of CNA #1's inappropriate behavior around facility residents. No staff, however, identified the behavior as potentially abusive and no staff reported it to administration. f. Failure to ensure staff on each shift was deployed in sufficient numbers to meet the needs of the residents On 2/18/14 beginning at approximately 7:30 p.m. until 8:05 p.m., an observation of the resident common area on the second floor was conducted. The observation revealed ten residents seated in wheelchairs in the common area of the facility second floor. There was no staff visible on the unit at the time of the observation. The residents were not supervised, attended or observed by facility staff during the observation time. In an interview with the DON on 2/7/14 at 1:00 p.m., the DON stated that approximately one month before (1/14/14), the staffing office expressed concerns over all the overtime going to one employee, CNA #1. The former employee had accumulated over 1000 hours of extra time worked. The NHA had voiced concerns over the same employee consistently being allowed to sign up and work so much overtime (but no action had been taken prior to 1/14/14). In an interview on 2/18/14 at approximately 8:15 p.m., the floor nurse on the night shift stated that he knew CNA #1 and had worked with him often. He said CNA #1 worked a lot of hours, was always at the facility, and often took care of resident #1 when working. He said the CNA had worked a lot of shifts because the facility needed help and the CNA was willing to constantly work. Based on observations and interviews, the facility failed to evaluate staffing patterns to ensure resident safety.

Based on record review and interviews, the facility failed to ensure one facility staff member, certified nurse aide (CNA #1) was fit for service as a nurse aide and that potential allegations of abuse were identified and promptly reported to administration. These failures contributed to sexual abuse of resident #1. The findings include: I. Evidence of Sexual Abuse of Resident #1 Reported 1/14/14 A physician telephone order, dated 1/14/14 at 8:00 p.m., read to send resident #1 to the emergency room for evaluation. -Resident #1, a [AGE] year old female, was admitted to the facility from the hospital on [DATE]. The face sheet indicated the following admission Diagnoses: [REDACTED]. -The quarterly minimum data set (MDS), dated [DATE], indicated the resident was totally dependent on staff for all cares, including bed mobility, dressing and eating (tube feedings were the primary source of nourishment). The resident was non-verbal and unable to communicate using sign language or any other means of written communication. An emergency room report, dated 1/14/14 at 11:26 p.m., revealed the resident was brought to the hospital by ambulance. The chief complaint was "sexual assault" after family members viewed a video indicating the resident was orally and vaginally assaulted by a facility staff member. -The resident was examined and evaluated by the hospital sexual assault nurse examiner (SANE), a registered nurse who has had additional training and education specifically for the purpose of investigation rape and sexual assaults. -The resident was administered three different types of antibiotics to "help prevent sexually transmitted infections caused by bacteria" and a pregnancy test was conducted. The primary [DIAGNOSES REDACTED]." Review of the police report, dated 1/15/14 at 1:13 p.m., revealed the video tape showed a male certified nurse aide (CNA) #1 in resident #1's room engaged in actions consistent with sexual intercourse on 1/2/14 at approximately 9:31 p.m., and oral intercourse on 1/7/14 at approximately 9:47 p.m. The CNA was arrested and taken into custody. Cross-reference F223 for further details. II. Facility Failures in Abuse Prevention - Employee Screening - Abuse Identification and Reporting A. Employee Screening 1. Facility Expectations The facility Abuse policy, dated 8/31/12, states components to prevent abuse include screening staff. Investigations into the past histories of a potential employee include: a) inquiry of the state nurse aide registry or licensing authority, b) inquiry of previous and/or current employers, c) completion of criminal background checks, and d) reasonable efforts to uncover information about any past criminal prosecutions. The facility Employee Background and Screening policy, dated 4/28/11, regarding staff screening included the following in pertinent part: -Successful completion of a pre-employment background check is required before a candidate is granted regular employment with the company. -Background checks are completed prior to the first day of work and include one or more of the following checks as determined by senior human resources management - Search against the National Wants and Warrants database in accordance with State requirements. -Employment reference checks may be conducted by telephone or written correspondence and employment is conditional upon successful completion of the reference checks. The manager's guide to human resources regarding reference requests dated 8/2008 reads in pertinent part: Prior to making an offer of employment verify at a minimum two work references, including the most recent and current employer. 2. Failure to ensure CNA #1's background was thoroughly screened and licensure timely verified Review of CNA #1's file revealed an online application for employment was submitted on 5/7/13, listed references for 2 previous employers, and one educational program coordinator. The CNA began working at the facility 5/22/13 at 8:30 a.m. a. Record Review Review conducted on 2/7/14 of CNA #1's file revealed no evidence that reference checks were conducted, as required by facility policy prior to the first day of work. In an interview on 2/7/14 at 1:00 p.m., the Director of Nurses (DON) stated reference checks were completed for CNA #1 prior to employment and included two previous employers (one of which did not remember him), and his nurse aide training instructor. A second interview with the DON regarding reference checks was completed on 2/18/14 at 4:45 p.m., in which copies of the reference checks were requested. Copies of two reference check forms were received on 2/18/14 at approximately 7:00 p.m. The forms were partially completed and neither form was dated or signed by the person completing them. The references included the most recent employer and nurse aide clinical instructor of CNA #1. The employer verified dates of employment, position, and rehire status. The CNA instructor reference revealed no "red flags," and included that CNA #1 was enthusiastic, personable, and required little supervision-nothing but "praise." According to timeline documentation on CNA #1's on-line application: -CNA #1's application status was changed to 'rejected' on 5/14/13, with details indicating the new applicant has a poor or inappropriate work history entered by the regional hiring recruiter who no longer works for the organization. -The facility submitted a background check through an outside vendor for CNA #1 on 5/14/13, after the hiring recruiter had updated the candidate's status to 'rejected.' The background check revealed the CNA had pled guilty to two misdemeanor charges (out of state); one misdemeanor charge dated 5/16/11 included a one year summary probation with special conditions and another dated 1/19/12, included a three year summary probation with special conditions. An active warrant was issued for the first misdemeanor 4/24/12, and for the second misdemeanor on 8/17/12. The background investigation report revealed the report was printed from the background search vendor's web portal on 5/22/13, the same day CNA #1 reported for orientation at 8:30 a.m. Review of the background check revealed a final disposition status of meets hiring criteria with a QA (quality assurance) date of 5/21/13 at 4:50 p.m., EST which was prior to the printing of the background search vendor's report (see above) on 5/22/13. There was no evidence after printing the report that the facility investigated the nature of the misdemeanors, the special probation conditions, or the active warrants and the CNA's probationary status at time of hire. CNA #1's file revealed a copy of license verification printed from the Department of Regulatory Agencies (DORA) website on 1/15/14, indicating an active certification originally issued on 5/16/13 and an effective date of 2/01/14 without discipline or board actions on file. There was no evidence in the file to show the facility had verified the certification of CNA #1 prior to 1/15/14. b. Staff Interviews On 2/18/14 at 5:30 p.m., the regional nurse consultant (RNC) and the benefits coordinator (HR liaison) were interviewed regarding the application, background and reference screening and pre-employment process. Their interview revealed the following in pertinent part: -The regional hiring recruiter screens applicants for educational requirements, work history, and preliminary data gathering. Then the application is forwarded to the hiring manager. -The regional hiring recruiter (no longer employed by the organization) changed CNA #1's status to ineligible on 5/14/13, and would not have changed the information he received unless he had good reason. -The hiring manager has access to the employee application profile, including comments entered by the regional hiring recruiter, but is not able to make any changes to the information that has been entered by another user. -The hiring manager is responsible for conducting a pre-employment screening and interview. If the hiring manager wishes to proceed with making an offer, they submit the background check and complete the reference checks and make a contingent offer of employment. The hiring manager makes the final decision whether a candidate is a good fit for the job. On 2/18/14 at 4:45 p.m., an interview with the Director of Nursing (DON) and the RNC revealed in pertinent part: -At the time CNA #1 was interviewed and hired, the DON held the position of Staff Development Coordinator, and was responsible for assisting with completion of pre-employment and on-boarding processes. -The DON stated the CNA #1's reference checks had been completed prior to hire, although the reference checks were not located in the CNA's file during initial review 2/6-2/7/14, as required by facility policy. -The DON acknowledged that active warrants would raise "red flags." However, an arrest record does not rule out their consideration for hire, as long as they are not violent crimes or felony offenses. On 2/18/14 at approximately 7:30 p.m., interview with the NHA revealed, in pertinent part, that she was unaware CNA #1 had active warrants on his criminal background check at the time of hire. She said she has recently begun to review all criminal background checks, including looking for active/outstanding warrants for all potential candidates and signs off prior to employment. She said that had she known about CNA #1's background, she would not have hired him. B. Identifying and Reporting Abuse 1. Facility Expectations The facility Abuse policy further provides that all alleged violations involving abuse, mistreatment, or neglect will be reported immediately to the administrator. Components to prevent abuse include identification (of abuse) and reporting (of abuse). 2. Failure to ensure staff identified and reported potentially abusive behavior to administration Interview with a facility staff member on 2/7/14 at 3:10 p.m., revealed unreported allegations of sexually suggestive comments and gestures directed toward and/or within hearing distance of facility residents by CNA #1 prior to 1/14/14. -The staff member stated CNA #1 frequently made sexually inappropriate comments and gestures while serving in the dining room and while working on the unit with residents. The staff member stated that one evening CNA #1 told staff in the dining room he was taking male enhancements which, he indicated, were having a positive effect. The staff member said no one took the CNA seriously because he frequently made lewd remarks that were not appropriate for the work environment; staff just ignored his behavior. -The facility staff member reported a second interaction with CNA #1 when she noticed a dark brown stain on his scrub top. Thinking it might be fecal material, she brought it to the attention of CNA #1. He proceeded to make a sexually suggestive licking motion while lifting his shirt toward his face. -The staff member said one time s/he was talking with another resident seated in their wheelchair in the hallway. CNA #1 walked up behind the resident as he sat in the wheelchair and made several sexually suggestive licking motions behind the resident's ear while looking directly at the facility staff member. -The staff member confirmed these incidents were not reported to facility administration. According to the staff member, people frequently ignored CNA #1's comments including him/her. Interviews with the NHA on 2/6/14 at 9:00 a.m. and the DON on 2/6/14 at 9:00 a.m., revealed facility staff training was conducted between 1/15/14-1/22/14 on identifying and reporting abuse, neglect, or mistreatment. However, review of the attendance rosters revealed not all facility staff received the abuse training between 1/15/14-1/22/14. Multiple requests were made of the DON, RNC and NHA for evidence that the facility had provided abuse training to facility staff prior to the reported sexual assault on 1/14/14; however, no such evidence was provided prior to exit on 2/20/14. Based on staff interview above, a number of staff was aware of CNA #1's inappropriate behavior around facility residents. No staff, however, identified the behavior as potentially abusive and no staff reported it to administration.