Every finding on record at Life Care Center of Casper

Based on medical record review, observation, staff and resident interview, facility incident review, and policy and procedure review, the facility failed to ensure hot liquids were at a consumable temperature to prevent accident hazards for 1 of 5 sample residents (#59) reviewed for accident hazards. This failure resulted in actual harm to resident # 59 who received a burn from hot liquid that was provided by staff. The failure resulted in a determination of immediate jeopardy due to a lack of implementation of preventative measures. The census was 70. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #59 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included difficulty swallowing, diabetes mellitus, peripheral vascular disease, anxiety, depression, and a history of bilateral below the knee amputation. Further review showed the resident was dependent upon staff for bed mobility such as, sitting on the side of the bed from a lying position. Review of the care plan last revised on 12/30/24 showed the resident was independent with eating. The following concerns were identified: a. Review of the incident report dated 7/12/26 and timed 11 AM showed the resident .was eating a bowl of green chili, and tried to adjust in bed and spilled on [his/her] right thigh. Further review showed s/he had obtained redness and a nickel sized blister to the right thigh. b. Interview with resident #59 on 7/14/26 at 9:02 AM confirmed s/he had spilled a cup of green chili on him/herself while eating in bed on 7/12/26 which caused a blister on his/her right thigh. S/he revealed the chili had been served in a Styrofoam cup and while holding it, his/her thumb went through the cup, which resulted in the resident dropping the cup, and spilling the contents on his/her lap.c. Observation on 7/14/26 at 9:10 AM showed a dressing on the resident's right thigh dated 7/12/26. d. Interview with RN #1 on 7/14/2026 at 6:03 PM revealed she had made her own green chili at home, and would often bring it into the facility in a crock pot to share with the residents. She revealed she left the crock pot on the warm setting at 6 AM and did not check the temperature prior to serving it to the resident at 11 AM. Further interview confirmed she had served the green chili in a Styrofoam cup and when she returned to the resident's room at 11:15 AM she observed the green chili had spilled on the resident's thigh, which caused redness and blistering. 2. Review of the policy titled Food Safety last revised 5/1/24 showed The facility must .store, prepare, distribute and serve food in accordance with the professional standards of food service safety. 3. Review of the policy titled Hot Liquids last revised 5/4/26 showed The food provided by the facility should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction, while minimizing the risk for scalding and burns. and Liquid Temperature and Burn Considerations .burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reaction time), decreased cognition or dementia, decreased mobility and decreased ability to communicate. The degree of injury depends on factors including water temperature, the amount of skin exposed, and the duration of exposure. 4. Interview with the DON on 7/14/26 at 11:53 AM revealed the facility was monitoring the resident's burn following the incident, however denied implementation of interventions for reoccurrence or that an investigation had been completed. 5. On 7/14/26 at 3:40 PM the regional vice president, the facility administrator, the regional director of clinical services, and the facility director of nursing were informed of an immediate jeopardy related to a failure to identify and remove accident/hazard risks to residents. 6. The facility submitted a removal plan on 7/15/26 at 9:40 AM which included: a. A root cause analysis was performed regarding the incident and identification of non-adherence to outside food temperature policy and microwave food safety serving temperatures was identified on 7/14/26. b. All at risk residents, including resident #59 were reviewed and assessed for adaptive equipment and the ability to manage self-feeding. Residents who required adaptive equipment were referred to occupational therapy for further evaluation on 7/14/26.c. An ADHOC Quality Assurance/Performance improvement meeting was held with the medical director in attendance on 7/14/26. d. 1 to 1 education was provided to RN #1 on 7/14/26. e. Education was provided for nursing staff on 7/14/26 regarding the facility policy and procedures related to outside food brought into the facility, safe food temperatures not exceeding 155 degrees Fahrenheit for consumption, and reheating hot liquids. Further education included, serving food in appropriate containers to meet the residents needs and allowing food to cool to 155 degrees Fahrenheit prior to serving to residents. f. Temperature logs and thermometers were posted at each unit microwave on 7/14/26. g. All remaining nursing staff would be educated prior to their next scheduled work shift. 7. The removal plan was accepted on 7/15/25 at 9:49 AM. 8.The implementation of the removal plan was verified and immediacy was removed on 7/15/26 at 2:42 PM; however, deficient practice remained at a scope and severity of G.

Based on resident and staff interview, grievance form review, and policy and procedure review, the facility failed to ensure the views of a resident or family group were considered and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The census was 70. The findings were:1. Interviews with 15 residents who attended resident council meeting on 7/14/26 at 2:10 PM revealed most residents felt staff did not follow up on their grievances with a resolution.2. Review of 22 grievance forms regarding missing personal items, water temperature, nursing, and staffing concerns over the last 4 months revealed 7 of the 22 grievances lacked documentation showing a resolution or follow-up outcome with the resident or representative.3. Interview with the administrator revealed no specific timeline for grievance resolution. The administrator stated the facility allowed the laundry department additional time to locate missing clothing, but attempted to resolve nursing or missing money concerns immediately. During the interview, this surveyor presented the administrator with several unresolved grievance forms dating back to 3/13/26 that lacked documented resident or representative follow-up. Upon this surveyor's request for these forms, the administrator immediately resolved two grievances regarding missing blankets, one from 3/13/26 and one from 5/13/26 by purchasing a replacement blanket for one resident that day and agreeing to reimburse another resident's daughter for reordering a replacement. The administrator reviewed the remaining grievance forms and confirmed that staff did not always resolve grievances in a timely manner. 4. Review of the facility policy titled Grievance Program (Concern and Comment) last revised 6/15/22 showed .1. b. A reasonable expected time frame for completing the review of the grievance . Following up with resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction.Executive Director and/or Designee is responsible for the following: .Ensuring that all grievances and Concern & Comment Reports have been reviewed and addressed in a timely and appropriate manner and that concerned individuals feel that some type of resolution has been communicated, achieved and maintained.

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 1 of 5 sample residents (#4) observed for resident care. The findings were: 1. Observation on 7/15/26 at 3:56 PM showed CNA #2 and CNA #1 entered resident #4's room with a mechanical lift. The CNAs attached the lift sling to the mechanical lift and without applying gloves or other personal protective equipment. CNA #2 used her ungloved left hand to lift the resident's catheter drainage bag. The CNA hung the drainage bag on the mechanical lift and CNA #1 lifted the resident out of the recliner and positioned the lift over the resident's wheelchair. Without performing hand hygiene, CNA #2 grabbed the resident's wheelchair handles to reposition and stabilize the chair. At that time, CNA #1 lowered the resident into the wheelchair and without wearing gloves, CNA #1 used her ungloved hand to remove the drainage bag from the mechanical lift and positioned it under the resident's wheelchair. Without performing hand hygiene, the CNAs prepared the resident to exit the room by touching his/her pants, shirt, wheelchair foot pedals, and the mechanical lift controls. Observation showed CNA #2 exited the room pushing the resident's wheelchair and CNA #1 pushed the mechanical lift into the hall. Further observation showed no hand hygiene was performed before exiting the room. 2. Interview with the infection preventionist on 7/16/26 at 10:17 AM revealed enhanced barrier precautions should have been used when providing care to a resident with a catheter, even during a mechanical lift transfer. She revealed she expected hand hygiene to be performed after touching a catheter drainage bag and before exiting a resident's room. 3. Review of the policy titled Indwelling Urinary Catheter (Foley) Management last revised on 9/4/25 showed .General Urinary Catheter Maintenance Guidelines .3. Use personal protective equipment, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collection system . 4. Review of the policy titled Hand Hygiene last revised on 7/15/22 showed . When to perform proper hand hygiene with (ABHR) and with soap and water; Before and after all resident contact; After contact with potentially infectious material; After contact with objects in the resident's room; It is important to make sure that hand hygiene is performed at the appropriate times before and after touching a resident, between residents and frequently during care .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a pharmaceutical services procedure related to accurate acquiring, receiving, dispensing and administration of medications for 1 of 3 sampled residents (#17) reviewed for medication availability. The findings were: 1.Review of the admission MDS assessment dated [DATE] showed resident #17 had a (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included urinary tract infection, heart failure, high blood pressure, anemia, atrial fibrillation, anxiety disorder, respiratory failure, and shortness of breath. Further review of the nursing progress note dated 4/14/26 and timed 3:53 PM showed the resident was sent to the emergency room for shortness of breath and low oxygen saturation. The following concerns were identified: a. Review of the medical record showed the resident was admitted on [DATE] at 4:30 PM. Review of the progress note dated 4/13/26 and timed 5:29 PM showed the resident did not receive his/her diltiazem, gemfibrozil, and methocarbamol because it wasn't available. Review of the nursing progress note dated 4/13/26 and timed 6:15 PM showed the facility did not have any of [his/her] medications at this time and [s/he] verbalized understanding. Review of the progress note dated 4/13/26 and timed 11:34 PM showed the resident did not receive his/her Bactrim [antibiotic] because it wasn't available. Review of progress note dated 4/13/26 and timed 11:35 PM showed the resident did not receive his/her simvastatin because it wasn't available. Review of progress note dated 4/13/26 and timed 11:36 PM showed the resident did not receive his/her propranolol or primidone because it wasn't available. Review of a progress note dated 4/13/26 and timed 11:37 PM showed the resident did not receive his/her pantoprazole or methocarbamol because it wasn't available. Review of progress note dated 4/13/26 and timed 11:38 PM showed the resident did not receive his/her famotidine because it wasn't available. Review of progress note dated 4/13/26 and timed 11:39 PM showed the resident did not receive his/her AZO cranberry or apixaban because it wasn't available. Review of progress note dated 4/13/26 and timed 11:41 PM showed the resident did not receive his/her diltiazem because it wasn't available. Review of progress note dated 4/13/26 and timed 11:45 PM showed the facility was unable to give medications as not available, outside pharmacy did not bring any .and would not add [him/her]. Resident aware. Review of the progress note dated 4/14/26 and timed 9:04 AM showed the resident did not receive his/her AZO cranberry or gemfibrozil because it was On supply from the pharmacy. Review of the medication administration record confirmed the resident had not received the medications. b. Interview with the DON on 7/15/26 at 4:07 PM revealed the resident was admitted with medication orders which should have been sent to the contracted pharmacy. He confirmed the resident had missed medication doses, but could not provide a rationale. Further interview revealed nursing staff were expected to pull medications from the facility's emergency 'kit located in the Omnicell (An automated, computerized cabinet or system used in hospitals and healthcare facilities to securely store, manage, and dispense medications and medical supplies) if the contracted pharmacy had not sent them to the facility. c. Interview with the DON on 7/16/26 at 2:17 PM revealed the facility admissions team was responsible for sending medication orders to the primary pharmacy, but could not provide evidence the admissions team had sent the orders. Further interview revealed if the pharmacy couldn't deliver the medications to the facility, the prescriptions should have been sent to a local contracted pharmacy until the primary pharmacy could deliver them to the facility. d. Interview with the admissions director on 7/16/26 at 2:24 PM revealed the resident's medication orders should have been faxed to the primary pharmacy prior to the resident's admission and a call should have been placed to verify the pharmacy had received them, but she could not provide evidence the orders were faxed. e. Interview with LPN #1 on 7/16/26 at 4 PM confirmed the facility had not received the resident's medications from the pharmacy and she did not pull the medications from the emergency kit located in the Omnicell. 2. Review of the policy titled Medication Shortages/Unavailable Medications last revised 8/1/24 showed .3. If a medication is unavailable or discovered after normal pharmacy hours.A facility nurse should obtain the ordered medication from the Emergency Medication Supply, the licensed facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include.Emergency delivery or use of an emergency (back-up) third party pharmacy.

Based on medical record review and staff interview, the facility failed to implement resident centered care plans for 2 of 5 sample residents (#6, #9) reviewed for development and implementation of care plans. The findings were:1.Review of the quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included non-Alzheimer's dementia, debility, depression, adjustment disorder with mixed anxiety and depressed mood. Further review of the 5/30/24 care plan showed the resident was to receive care with a minimum of 2 staff members present while providing care. The following concerns were identified:Review of an incident report dated 8/16/25 showed CNA #1 provided cares for resident #6 without another staff member present.Interview with CNA #1 on 4/21/26 at 3:40 PM confirmed cares were provided to the resident without another staff member present.Interview with RN #1 on 4/22/26 at 5:26 PM revealed staff had often provided cares to residents who were pairs in cares without a second staff member present.Interview with the DON on 4/22/26 at 4:50 PM revealed staff were expected to follow resident care plans, including pairs in cares.2. Review of the 3/25/26 quarterly MDS showed resident #9 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included paraplegia and muscle weakness. Further review of the 3/25/26 care plan showed resident #9 was at risk for malnutrition and had interventions which included monthly, weekly, or as needed weights. The following concerns were identified:Review of the residents weights showed s/he was weighed at a minimum of once a month until 3/13/26. Further review showed there were no documented weights between 3/13/26 and 4/22/26.Review of the 4/10/26 dietician note showed .No monthly or weekly weight obtained due to scale broken. Will continue to request weekly and monthly weights as needed.Interview with the dietician on 4/23/26 at 10:16 AM confirmed the resident wasn't weighed.Interview with the DON on 4/23/26 at 10:30 confirmed there was a broken scale; however, staff were expected to use the other facility scale and follow the residents care plan to the best of their abilities.Review of the document titled Weight monitoring, long term care last revised 9/15/25 showed .Weighing a patient in a long-term care facility is an important part of assessing a residents health, following a routine weighing schedule helps detect weight changes. Unless otherwise specified, record a resident's weight at the time of admission, weekly for 4 weeks, and then monthly.3. Review of the policy titled Person Centered Care Planning last revised 8/29/25 showed .Each resident will have a person-centered care plan developed and implemented to meet.and address the resident's medical, physical, mental and psychosocial needs.

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for 2 of 2 resident units. This failure affected resident #30, #50, #52, #67, and #73. The census was 81. The findings were: 1. Review of the 8/23/24 quarterly MDS assessment for resident #30 showed s/he had a suprapubic catheter and a diagnosis of neurogenic bladder. Observation on 10/16/24 at 9:44 AM of the resident's room showed no EBP (enhanced barrier precautions) signage or PPE (personal protective equipment) was present. 2. Review of the 8/21/24 admission MDS assessment for resident #50 showed s/he had a suprapubic catheter with a diagnosis of progressive neurological conditions. Observation on 10/16/24 at 9:44 AM of the resident's room showed no EBP signage or PPE was present. 3. Review of the Order Summary Report for resident #52 showed s/he had an indwelling catheter, a PICC (peripherally inserted central catheter) line for receiving antibiotics, and required wound care to his/her left heel. Observation on 10/14/24 at 2:17 PM, 10/15/24 at 9:23 AM, and 10/16/24 at 11:50 AM of the resident's room showed no EBP signage or PPE was present. 4. Review of the 9/20/24 admission MDS assessment for resident #67 showed the resident had a stage 3 decubitus ulcer to the coccyx which required routine wound care. Observation on 10/16/24 at 9:44 AM of the resident's room showed no EBP signage or PPE was present. 5. Observation on 10/15/24 at 1:35 PM showed RN #1 was performing wound care on resident #73 using gloves; however, the RN was not wearing a gown. Further observation of the room showed EBP signage was on the wall and PPE was hanging on the inside of the resident's door; however, no gowns were present. 6. Interview with RN #1 on 10/15/24 at 2:02 PM revealed resident #73 was no longer on EBP because his/her PICC line had been removed. In addition, EBP was only indicated for residents with Foley catheters, lines, or wounds with multi drug resistant organisms (MDRO). 7. Interview with the infection preventionist (IP) on 10/15/24 at 2:06 PM revealed EBP were used when residents have Foley catheters, lines, or MDRO wounds. Further, resident #73 was removed from EBP due to his/her PICC line being removed. An additional interview on 10/16/24 at 9:35 AM with the IP revealed residents on EBP were identified with a pink star on their room number/name plate, EBP signage should be present in the room, and PPE available. 8. Review of the policy and procedure Enhanced Barrier Precautions, revised 3/21/24, showed .the indications for EBP are for residents with wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on medical record review, staff interview, and review of the RAI (resident assessment instrument) manual, the facility failed to ensure MDS assessments were accurately completed for 3 of 5 (#34, #35, #71) sample residents reviewed for falls. The findings were: 1. Review of a 5/4/24 Event Note showed resident #34 had a witnessed fall with bilateral knee soreness, pain to the right lateral thigh, and bruising to the left knee and right lateral thigh. Review of a 6/15/24 Event Note showed the resident had an unwitnessed fall and had no signs or symptoms of pain or distress. The following concerns were identified: a. Review of 5/15/24 and 8/13/24 quarterly MDS assessments showed the resident was coded as not having any falls since admission or the prior assessment. 2. Review of a 3/20/24 Event Note showed resident #35 had an unwitnessed fall and was transported to the emergency department for evaluation. Further review of the medical record showed the resident had fractured his/her left hip. The following concerns were identified: a. Review of the 3/26/24 significant change MDS assessment showed the resident was coded as not having any falls since admission or the prior assessment. 3. Review of the medical record showed resident #71 was admitted on [DATE]. Review of Event Notes from 4/26/24, 6/23/24, and 8/27/24 showed the resident had unwitnessed falls with no injury noted. The following concerns were identified: a. Review of the 6/6/24 and 9/5/24 quarterly MDS assessments showed the resident was coded as not having any falls since admission or the prior assessment. 4. Interview with the MDS coordinator on 10/17/24 at 10:51 AM confirmed falls were incorrectly coded on the MDS assessments. 5. Review of the CMS RAI 3.0 User's Manual, October 2023, showed .Determine the number of falls that occurred since admission/entry or reentry or prior assessment and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury.

Based on observation, resident and staff interview, grievance review, and policy and procedure review, the facility failed to ensure residents were treated with dignity and respect on 1 of 2 resident units (unit 1). The census was 81. The findings were: 1. Interview with 9 residents during resident council on 10/15/24 at 10:40 AM revealed at times residents had to wait between 45 minutes and 2 hours for call lights to be answered. The residents revealed they had observed staff walking by rooms or sitting at the nurses' station while call lights were sounding. Further interview revealed the number of staff answering call lights during the survey was increased compared to the number of staff who normally answered call lights. 2. Observation on 10/16/24 at 9:35 AM showed the call light for resident #20 was turned on. Continued observation until 9:48 AM showed 18 staff members passed by the resident's room. The staff included 3 activities staff members, 4 CNAs, an LPN, and 2 laundry staff members which walked past the resident's room a total of 18 times without entering the resident's room or offering assistance. At 9:49 AM LPN #1 entered the resident's room to answer the call light and asked if she could assist the resident. At that time, the resident stated they forgot to shut it off. 3. Observation on 10/16/24 showed the call light for resident #72 was turned on for 42 minutes from 9:55 AM to 10:37 AM. Further observation showed staff walked past the resident's room without entering to assist the resident. 4. Review of a Concern & Comment Form dated 3/20/24 showed resident #11 reported on 3/19/24 his/her call light was on from 6:45 AM to 9 AM and the resident expressed frustration with call light times (outside of this one event). Review of a Concern & Comment Form dated 5/18/24 showed the resident reported Call lights taking too long to be answered. Review of a Concern & Comment Form dated 7/15/24 showed the resident reports frustration with call light response times. [S/He] states they are taking 1 to 1 1/2 hours to be answered, especially around 6:30 AM. Reports nursing won't help answer them and defer to the aide to need to help instead. Reports [s/he] filled out a previous card re: [regarding] this with no improvement. 5. Interview with the DON on 10/17/24 at 10:19 AM revealed everyone was expected to answer call lights and the lights should be answered between 3 and 5 minutes for an emergency light or 5 and 7 minutes for a regular light. 6. Review of the policy titled Resident Call System, last revised 1/4/2023, showed .Procedure: 1. Facility associates should always be aware of call lights. 2. Associates should answer call lights whether they are assigned to provide care to that resident .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure as needed (PRN) psychotropic medication was limited to 14 days or the physician provided a rationale for extended use for 1 of 5 sample residents (#43) reviewed for unnecessary medications. The findings were: 1. Review of the physician orders for resident #43 showed the resident had an order for lorazepam (antianxiety) 0.5 milligrams to be given every 2 hours as needed for anxiety and restlessness related to end of life care ordered on 8/16/24 and no stop date. The following concerns were identified: a. Review of a progress note dated 10/17/24 and timed 9:33 AM showed Per [RN name] with Dr. [name] re: [regarding] Lorazepam usage: The dx [diagnosis] palliative care for its use of Lorazepam is for [facility] comfort care and the behavior could occur at any time and so its [sic] for the benefit of the patient. The benefit outweighs the risk of continuing the medication for the life of resident. 2. Interview with the DON on 10/17/24 at 10:19 AM confirmed the facility did not have a stop date or rationale for the lorazepam prior to 10/17/24. 3. Review of the facility policy titled Psychotropic Medication Use last revised on 11/28/16 showed .5. PRN orders for psychotropic drugs should be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the order to be extended beyond 14 days, he or she should document their rationale in the resident's record and indicate the duration for the PRN order .

Based on medical record review, staff interview, and review of the MDS 3.0 RAI (Resident Assessment Instrument) manual, the facility failed to ensure a significant change assessment was completed for 1 of 18 (#35) sample residents. The findings were: 1. Review of the medical record for resident #35 showed s/he had fallen on 3/20/24 which resulted in a fractured hip. Review of the 3/26/24 significant change MDS assessment showed the resident was coded as dependent for toileting hygiene, lower body dressing, putting on and taking off footwear, toilet transfers, and tub/shower transfers. The resident was coded as requiring substantial/maximal assistance for showering or bathing self, personal hygiene, rolling left to right, sitting to lying, sitting to standing, and chair/bed-to-chair transfers. In addition, the resident was coded as requiring partial/moderate assistance for eating, oral hygiene, upper body dressing, lying to sitting, and moving a manual wheelchair. The resident was not assessed for walking due to safety reasons. 2. Review of the 9/11/24 quarterly MDS assessment showed the resident was coded as being independent with moving his/her manual wheelchair and rolling left and right. The resident required setup or clean-up assistance for eating, oral hygiene, toileting hygiene, and personal hygiene. The resident was coded as requiring supervision or touching assistance for upper body dressing, sitting to lying, lying to sitting, sitting to standing, chair/bed-to-chair transfers, and could walk for 150 feet. 3. Interview with MDS coordinator on 10/17/24 at 10:07 AM confirmed a significant change assessment had not been completed. 4. Review of the CMS RAI 3.0 User's Manual, October 2023, showed .03. Significant change in status assessment (SCSA) (A0310A=04) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline .An SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement .Improvement in two or more of the following: Any improvement in an ADL (activities of daily living) where a resident is newly coded as Independent, setup or clean-up assistance, or supervision or touching assistance which last assessment and does not reflect normal fluctuations in that individual's functioning .

Based on medical record review, resident interview, staff interview, and review of incident investigation documentation, the facility failed to ensure residents were free from sexual abuse for 1 of 5 sample residents (#1). The findings were: The facility had implemented the corrective action prior to the survey and was determined to be in substantial compliance as of 3/29/24. The facility was in past non-compliance. 1. Review of resident #1 (victim) medical record showed a significant change MDS assessment dated [DATE], which showed the resident had a BIMS score of 12 out of 15 (moderately cognitive impaired). The diagnoses included non-Alzheimer's dementia, hemiplegia, dysarthria following cerebral infarction, blindness right eye, seizure disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of the care plan showed Risk for elopement. Disoriented to place, Impaired safety awareness, resident wanders aimlessly dated 9/15/23. The Vision status showed the resident as legally blind in [his/her] right eye and adequate vision to the left eye. Further review showed under communication status .able to verbalize [his/her]needs albeit mod (sec) cognitive loss per BIMS. Status post S/P WMC admit for urinary tract infection with associated Acute Kidney Injury (AKI) and metabolic encephalopathy which has not completely cleared - per family (resident name] is alert and orientated times 3, and cognitive intact at baseline - staff reports frequent confusion, disorientation - Risk for unmet needs dated 9/13/24. 2. Review of resident #2 (perpetrator) medical record showed a quarterly MDS assessment dated [DATE], which showed the resident had a BIMS score of 13 out of 15 (moderately cognitive impaired). The functional limitation in range of motion showed no impairment for the upper extremities, and impaired on both sides for the lower extremities. The diagnoses included non-Alzheimer's dementia, Parkinson's disease, cognitive communication deficit, unspecified voice and resonance disorder, adjustment disorder with anxiety, and insomnia. Review of the care plan showed, the resident was noted to wander the facility. No pattern was noted in regard to time of day. S/he on multiple occasions had been reported to attempt to enter the room of other residents and get in their beds. [Resident name] has on two occasions entered the room of female residents uninvited and attempted to behave in a sexual manner towards them. [S/he] often makes sexual comments towards female staff. [Resident name] at times may become physically aggressive towards staff when attempts at redirection are provided. Date Initiated: 03/22/2024. Document all behaviors, interventions, and communication with resident's spouse in progress note. Frequent checks, noting location within the facility and activity. Date Initiated: 03/22/2024. 3. The following concerns were identified: a. Review of the incident report dated 3/15/24 at 7:15 PM showed the perpetrator was in the victims room with his/her pant down around the ankle. The perpetrator told the nurse they were just talking as s/he was escorted out of the room. b. Review of the 3/19/24 at 4:55 PM, event note showed during the evening med pass the RN went to resident #1 room, knocked on door and upon opening saw [resident #2] in his/her room off to the side of [resident #1] wheelchair. S/he was standing up out of his/her wheelchair facing [resident #1] and his/her pants were down around his/her ankles, his/her back to the door. From what the nurse could see his/her brief was still up. When the nurse announced herself and entered the room resident #2 quickly pulled up his/her pants and sat back down in his/her wheelchair stating she's fine, she's right here, she's fine. When the RN questioned what s/he was doing in resident #1 room with the door shut s/he claimed they were just talking. Resident #2 was immediately escorted out of resident #1 room, educated that s/he was not allowed to enter other resident's rooms and of the inappropriateness of his/her behaviors. S/he was then returned to his/her appropriate hall to be further monitored by the assigned nurse. Upon removal of resident #2, resident #1 was asked if s/he was ok and what the resident was doing when RN had entered his/her room. Resident #1 verbalized that the resident did expose his/her genitalia to him/her and told him/her that s/he wanted to stay. Resident #1 also stated more than once that the resident needed to leave and was out of control. During an interview with a police officer, resident #1 stated that resident #2 had masturbated in front of him/her (did not finish) and stopped when s/he told him/her to stop. S/he stated I don't know why s/he is like this. Resident #2 corroborated these statements when the police officer spoke with him/her about the incident. Resident #2 was returned to his/her room, where s/he opted to get in bed for the night. The on call Manager, DON and Executive Director were immediately notified of incident at 7:20 PM and multiple attempts to notify resident #2 spouse were made. Several messages left with no return call until the next day. Copy of this note will also be faxed to resident #2 doctor. Further monitoring placed on resident #2 to prevent re-occurrence of any future incidents in facility. Police investigation started and resident #2 corroborated events as resident #1 had stated them. c. Attempted to interview the victim multiple times during the survey without success. The resident was either not in the room or was asleep. d. Interview with the perpetrator on 4/8/24 at 10:10 AM revealed s/he felt safe in the facility. The resident stated in regards to the allegation that s/he was not touching myself. It was a joke grabbing my crotch, I did not drop my drawers or grabbed my nuts. During the interview this surveyor observed staff checking on the resident. e. Review of resident #2's location checks every 15 minutes showed on 3/14/24 the facility failed to show the resident location from 6:30 AM until 2 PM (7.5 hours). On 3/15/24 the facility failed to show the resident location from 4:15 PM through 7:15 PM (3 hours). f. Interview with LPN #1 on 4/8/24 at 10:17 AM revealed the perpetrator was on frequent checks 15 minutes to make sure s/he was not where s/he should not be. 4. Review of the facility investigation showed the initial allegation was verbal between residents, and was not reported as abuse to the administration. The allegation was reviewed by the IDT team and saw that it was instead a physical abuse and reported it right away. The facility contacted the physician, the spouse, and the police. 5. The residents were separated at the time of the incident. The staff then again started monitoring resident #2's location. Other residents were interviewed related to their safety. Staff were interviewed related to the resident. 6. The facility investigated the incident appropriately. The facility implemented daily audits of the 15 minute check sheet by the DON. The audits were taken to the QAPI committee.

Based on medical record review, resident and staff interview, concern form review, and policy and procedure review, the facility failed to ensure residents received services to maintain good personal hygiene for 4 of 9 sample residents (#1, #6, #7, #9) reviewed for bathing. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #9 had a BIMS score of 13 out of 15 (cognitively intact). Review of the care plan last revised on 11/21/23 showed the resident has a self-care deficit related to new onset of confusion. Further review showed the resident had showers scheduled twice per week on Tuesday and Friday and required staff supervision and set-up help. The following concerns were identified: a. Review of the 30 day look back for the showers task showed the resident went 7 days without a shower from 1/2/24 through 1/9/24, and 1/9/24 through 1/16/24. Further review showed the resident went 8 days without a shower from 1/16/24 through 1/24/24 and refused a shower once during that time. b. Interview with the resident on 1/25/24 at 1:05 PM revealed s/he was not getting showers like s/he was suppose too. 2. Review of the annual MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15 (cognitively intact), and had range of motion impairment of one side of his/her lower extremities with a prosthesis. Review of the care plan last revised on 12/12/23 showed the resident had a self-care deficit related to a below the knee amputation. Further review showed the resident had scheduled showers on Monday and Friday and required assistance of 1 staff member. The following concerns were identified: a. Review of the 30 day look back for the showers task showed the resident went without a shower for 14 days from 1/5/24 through 1/19/24, and 5 days without a shower from 1/19/24 through 1/24/24. b. Interview with the resident on 1/24/24 at 12:35 PM revealed s/he was not getting his/her baths like s/he was suppose too. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 15 out of 15 (cognitively intact). Review of the care plan last revised on 12/6/23 showed the resident had a self-care deficit related to progressive cognative loss from underlying dementia and multiple sclerosis. Further review showed the resident had showers scheduled twice per week on Monday and Friday and required assistance of 1 staff member. The following concern was identified: a. Review of the 30 day look back for the showers task showed the resident went 7 days without a shower from 1/5/24 through 1/12/24, and 7 days from 1/12/24 through 1/19/24. 4. Review of the MDS assessment dated [DATE] showed resident #6 had a BIMS score of 14 out of 15 (cognitively intact), and had upper and lower extremity impairment on one side. Review of the care plan last revised on 1/18/24 showed the resident had a self-care deficit related to hemorrhagic stroke resulting in left non-dominate hemiplegia/neglect, dysphagia, left hemianopsia, and loss of ability to independently manage ADLs. Further review showed the resident had showers scheduled twice per week on Tuesday and Saturday and required moderate assistance of 1 staff member. The following concerns were identified: a. Review of the 30 day look back for the showers task showed the resident went 7 days without a shower from 1/13/24 through 1/20/24. b. Interview with the resident on 1/25/24 at 10 AM revealed s/he was not getting his/her baths like s/he wanted. 5. Review of a Concern & Comment Form dated 11/1/23 and timed 3 PM showed a resident representative wanted a resident to get 2 showers a week- minimum! 6. Review of a Concern & Comment Form dated 1/23/24 and timed 3:10 PM showed resident reported not having showers enough and being itchy. 7. Interview with the DON on 1/25/24 at 2:18 PM confirmed the facility expected the residents to get bathed per the care plan. 8. Review of the Lippincott procedures - Tub baths and showers hand delivered on 1/25/24 at 2:18 PM by the DON showed .Bathing Frequency - Tub baths or showers will be scheduled at least two (2) times per week based on resident preferences .

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure a call device was readily available for 1 of 18 residents (#68) reviewed for accommodation of needs. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #68 had a brief interview for mental status (BIMS) score of 13 out 15, which indicated the resident was cognitively intact, and had diagnoses which included pneumonia, malnutrition, respiratory failure (acute and chronic), history of malignant neoplasm of bronchus and lung, and acquired absence of lung. Further review showed the resident required limited physical assistance of 1 person for bed mobility, transfers, and toilet use. Review of the Activities of daily living (ADL) care plan dated 8/2/23 showed the resident required standby assistance of one person for transfers, supervision for bed mobility, and setup and supervision for toileting. The following concerns were identified: a. Observation on 8/22/23 at 9 AM showed resident #68 was in bed, asleep, facing the window with the call device clipped to the handle of the bedside cabinet. The call device was not in reach of the resident. b. Observation on 8/24/23 at 8:17 AM showed resident #68 was in bed asleep and the call device was on the floor behind the recliner, on the other side of the room. c. Interview with the resident on 8/22/23 at 11:21 AM revealed the resident never knew where the call device was located. d. Interview with CNA #1 on 8/24/23 at 8:29 AM revealed the call device should be attached to the bed, within reach of the resident. Further interview revealed if the resident was in the recliner, the call light should be attached to the arm of the recliner. e. Interview with the unit care coordinator #1 on 8/24/23 at 8:40 AM revealed it was the expectation that the call device be within reach of the resident. It should be attached to the bed or the recliner. f. Review of the policy titled Resident Call System provided by the unit care coordinator on 8/24/23 at 8:40 AM showed .The call light should be positioned within reach of the resident .If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative .

Based on observation, resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure timely toileting assistance was provided for 1 of the 5 sample residents (#5) who required assistance with activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, idiopathic normal pressure hydrocephalus, muscle wasting and atrophy of the right shoulder, periodic limb movement disorder, obesity, age-related osteoporosis without current pathological fracture, unspecified abnormalities of gait and mobility, and constipation. Further review showed the resident required extensive physical assistance of 2 or more people for transfers and toilet use, was not on a toileting program, and was frequently incontinent (7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding). Review of the Activities of daily living (ADL) care plan last revised on 6/8/23 showed the resident had interventions which included the use of a [NAME] lift with a 1/2 sling and the assistance of 2 staff members for toileting. The following concerns were identified: a. Observation on 8/21/23 at 3:23 PM showed the resident's room had a strong smell of urine detectable from the hallway. b. Interview with the resident on 8/22/23 at 9:28 AM revealed s/he was frequently incontinent of urine due to staff not providing assistance to the bathroom in a timely manner. The resident revealed Sometimes I wait all day or after lunch before anyone helps me to the bathroom. The resident revealed his/her roommate was assisted to the bathroom; however, the roommate required less assistance. The resident revealed s/he attempted to stay out of the room all day, worked hard with therapy so s/he would not have to ask staff for help, and s/he can pretty much count on being wet. Further interview revealed the resident felt call lights were never answered. c. Observation on 8/23/23 at 10:05 AM showed the resident left the nursing unit in his/her wheelchair and traveled around the facility. d. Observation on 8/23/23 at 3:19 PM showed the resident was resting in his/her wheelchair in his/her room. Interview with the resident at that time revealed s/he had not asked or been asked to use the restroom since before breakfast. Further interview revealed the resident did not want to lay down, because it was nice to have the bed made and clean. e. Observation on 8/23/23 at 3:22 PM showed the resident activated the call light. Interview with the resident at that time revealed s/he had to use the bathroom really bad and s/he was wet and it's going to get worse if they don't come fast. Further interview revealed s/he thought it would be too late when staff answered the light and s/he would be incontinent of urine because the staff will need to get the machine so it will be too late and I will pee my pants. Observation at 3:29 PM showed CNA #2 answered the call light, 7 minutes after it was turned on. At that time, the resident requested to use the bathroom and the CNA stated she needed to get the mechanical lift and left the room. The CNA returned with a mechanical lift and RN #1 at 3:33 PM, 11 minutes after the call light was turned on. The staff members applied the lift sling and assisted the resident out of the wheelchair which resulted in the release of a stronger urine smell. The staff members assisted the resident into the bathroom and removed the resident's brief which was visibly wet and yellow in color. The resident reported feeling very constipated and felt it was due to waiting so long to use the toilet. The staff members assisted the resident onto the toilet and the CNA told the resident she knew the resident did not get toileted when s/he needed and the CNA apologized. Further observation showed the CNA told the resident she knew the resident had not been toileted all day and has been wet for a while, she was still trying to learn the assignment, and was struggling all day. The CNA told the resident she had 13 people to care for, it was her first time working the assignment, and she wished she could tell the resident it was going to get better, but there was nothing she could do to help. f. Interview with CNA #3 on 8/22/23 at 3:27 PM revealed the resident did not refuse to be changed, was incontinent, and needed frequent care. Further interview revealed if the resident was changed routinely, it helped prevent the smell of urine in the resident's room. 35081 2. Interview with DON on 8/24/23 at 12:13 PM revealed his expectation was for residents to be toileted before and after meals; however, there was no set time frame for toileting. 3. Review of facility's policy titled Activities of Daily Living (ADLs) last reviewed on 8/22/2022 showed .The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in their ability to perform ADLs will be documented and reported to the licensed nurse .to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observation, staff interview, review of the 2017 U.S. Public Health Service Food Code, and policy and procedure review, the facility failed to ensure sanitary meal service during 1 of 2 meal observations. The census was 86. The findings were: 1. Observation on 7/27/22 at 11:34 AM showed dietary aide #1 used his right hand to grab the front of his mask and pull it away from his face to talk with another staff member. The dietary aide returned the mask to his face and used the same hand to grab a plate from the plate warmer. At that time, the dietary aide's thumb wrapped over the top of the plate and touched the food surface of the plate. No hand hygiene was performed. 2. Observation on 7/27/22 at 11:35 AM showed the dietary aide #1 grabbed the front of his face mask, with his right hand, and pulled it down to position it below his chin. At that time, he left the mask under his chin and continue to place food on trays. No hand hygiene was performed. 3. Observation on 7/27/22 at 11:36 AM dietary aide #1 used his right hand to grab the front of his mask and pull it away from his face and returned the mask to his face, covering his mouth and nose. The dietary aide used the same hand to grab a plate from the plate warmer. At that time, the dietary aide's thumb wrapped over the top of the plate and touched the food surface of the plate. No hand hygiene was performed. 4. Observation on 7/27/22 at 11:39 AM showed dietary aide #1 grabbed 2 plates from the plate warmer with his right hand. At that time, his hand touched the center of the plate, which he then placed pizza on. Continued observation showed the dietary aide left the service line, opened the door to the walk-in cooler with his right hand, obtained a salad, placed it on a plate, and pushed a cart into the walk-in cooler. The dietary aid returned to the service line without performing hand hygiene. 5. Observation on 7/27/22 at 11:43 AM showed dietary aide #1 went to the walk-in cooler and opened the door with his right hand, returned to the service line with items obtained from the cooler, left the service line, and opened the walk-in cooler with his left hand. The dietary aide obtained some bowls of food, went to the microwave, opened the microwave door with his right hand, and placed one of the bowls in the microwave. The dietary aide returned to the service line with packages of crackers in his right hand, and placed the crackers on a resident tray. The dietary aide returned to the microwave, opened the door with his right hand, removed the bowl from the microwave, and placed another bowl in the microwave. No hand hygiene was performed. 6. Observation on 7/27/22 at 11:51 AM showed dietary aide #1 grabbed 2 plates from warmer, touching the food surface area of the top plate with his right thumb, and placed pizza on the plate. The dietary aide cut one slice of pizza with a fork and knife, during which time his right hand came in contact with the pizza. The dietary aide walked over to an area of the service line where there were breadsticks, obtained two breadsticks and placed them on the plate. The dietary aide returned to the other plate, placed a slice of pizza on the plate, and with an ungloved right hand, grabbed one of the breadsticks from the first plate, and placed it next to the pizza on the second plate. No hand hygiene was performed. 7. Interview with dietitian #1, dietitian #2, and the dietary manager on 7/27/22 at 12:24 PM revealed hand hygiene should be performed when staff changed tasks or picked items up off the floor. Further interview confirmed staff should not touch food or food surfaces with hands and hand hygiene should be performed after touching items like the external portion of a face mask. Further interview revealed it was not facility policy to wash hands each time a staff member left the service line, as it would slow meal service and staff should use serving utensils during meal service which would prevent them from contaminating food. 8. Review of the policy titled Personal Habits and Infection Control provided by the facility on 7/28/22 at 9:50 AM showed .Required Personal Practices Wash your hands properly and frequently .Personal Practices to Avoid .Unsanitary personal practices, such as scratching the head, placing the fingers in or about the mouth or nose, sneezing or coughing in the area of food or clean dishes, or incorrectly sampling food can contaminate food and spread foodborne illness. Careless handling and unnecessary contact with soiled surfaces of dishes, glasses, cups, and tableware or with soiled napkins may expose associates to needless health hazards .Wash your hands thoroughly after completing each task to protect yourself and avoid contaminating the items you handle next .Good Habits to Practice keep your hands off the eating surfaces or plates .Use tongs, a scoop, or a spoodle when serving food. Do not use your hands or contaminated gloves . 9. Review of the facility policy titled Sanitary Food Handling provided by the facility on 7/28/22 at 9:50 AM showed Hands should always be washed upon entering the kitchen and immediately after touching your head, hair, or face .When food is served, a separate serving utensil should be used for each item. Fingers and hands should not be used for serving . 10. According to Food Code 2017, U.S. Public Health Service: 2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLE and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on observation and staff interview, the facility failed to post the daily nurse staffing information in a prominent location; readily accessible to residents and visitors, and in a clear and readable format. In addition the facility failed to include the daily census on the daily staff postings. The census was 86. The findings were: 1. Observation on 7/27/22 at 2:37 PM showed the daily nurse staffing information was located in the lobby area behind the receptionist's desk which was enclosed with a plastic infection control shield. The daily nurse posting was attached to the wall 5 feet from the floor. The posting consisted of an 8.5 by 11 inch page behind a plastic protector on which green numbers were entered with an erasable marker. The posting was not legible. 2. Interview with receptionist #1 on 7/27/22 at 2:37 PM confirmed the information on the daily nurse staff posting was not legible or in a location easily accessible to residents or visitors. 3. Review of the Nursing Staff Directly Responsible For Resident Care postings for the dates of 7/8/22 through 7/26/22 showed the daily census was not included on the posting. 4. Interview with the DON on 7/27/22 at 2:55 PM revealed the facility was not aware the census information was required on the daily postings.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents or residents' representatives received written information on the bed-hold policy for 5 of 5 sample residents (#1, #19, #56, #73, #173) reviewed for hospitalization . The findings were: 1. Review of a progress dated 7/16/22 and timed 5:06 PM showed resident #1 had not been at his/her baseline, had a left leg which was red and hot with a red line, was running a fever of 101.7 degrees Fahrenheit, and had wheezing. Further review showed the nurse sent the resident to the hospital. The following concerns were identified: a. Review of the medical record showed no evidence written bed-hold policy information was provided to the resident or resident's representative on the day of hospital admission. 2. Review of the medical record showed resident #19 was transferred to the hospital on 4/12/22 for an acute change of condition and readmitted to the facility on [DATE]; transferred to the hospital on 5/7/22 for an acute change of condition and readmitted to the facility on [DATE]; and transferred to the hospital on 6/10/22 for an acute change of condition and readmitted to the facility on [DATE]. Further review showed no evidence the facility issued written information on the bed-hold policy to the resident or the resident's representative at the time of the hospitalization s. 3. Review of a progress note dated 6/23/22 and timed 10:59 PM showed resident #56 had nausea, vomiting, and diarrhea, was weak, and fatigued easily. The resident was sent to the hospital for evaluation and treatment. Review of a progress note dated 6/28/22 and timed 9:37 PM showed no concerning issues after being readmitted in previous shift . The following concerns were identified: a. Review of the medical record showed no evidence written bed-hold policy information was provided to the resident or resident's representative on the day of hospital admission. 4. Review of the medical record showed resident #73 was transferred to the hospital for an acute change of condition on 6/2/22. Further review showed no evidence the facility issued written information on the bed-hold policy to the resident or the resident's representative at the time of the hospitalization . 5. Review of the medical record showed resident #173 was transferred to the hospital on 5/23/22 for an acute change of condition and readmitted to the facility on [DATE]. Further review showed no evidence the facility issued written information on the bed-hold policy to the resident or the resident's representative at the time of the hospitalization . 6. Interview with the DON on 7/27/22 at 5:01 PM revealed written bed-hold policy information was not provided to the residents or residents' representatives. 7. Review of the Bedhold/Reservation of Room policy, effective 5/2/19, showed .Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents or residents' representatives received a written transfer notice for 5 of 5 sample residents (#1, #19, #56, #73, #173) reviewed for hospitalization . The findings were: 1. Review of a progress dated 7/16/22 and timed 5:06 PM showed resident #1 had not been at his/her baseline, had a left leg which was red and hot with a red line, was running a fever of 101.7 degrees Fahrenheit, and had wheezing. Further review showed the nurse sent the resident to the hospital. The following concerns were identified: a. Review of the medical record showed no evidence a written transfer/discharge notice was provided to the resident or resident's representative. 2 Review of the medical record showed resident #19 was transferred to the hospital on 4/12/22 for an acute change of condition and readmitted to the facility on [DATE]; transferred to the hospital on 5/7/22 for an acute change of condition and readmitted to the facility on [DATE]; and transferred to the hospital on 6/10/22 for an acute change of condition and readmitted to the facility on [DATE]. Further review showed no evidence the facility issued a written transfer notice to the resident. 3. Review of a progress note dated 6/23/22 and timed 10:59 PM showed resident #56 had nausea, vomiting, and diarrhea, was weak, and fatigued easily. The resident was sent to the hospital for evaluation and treatment. Review of a progress note dated 6/28/22 and timed 9:37 PM showed no concerning issues after being readmitted in previous shift . The following concerns were identified: a. Review of the medical record showed no evidence a written transfer/discharge notice was provided to the resident or resident's representative. 4. Review of the medical record showed resident #73 was transferred to the hospital on 6/2/22 for an acute change of condition. Further review showed no evidence the facility issued a written transfer notice to the resident or the resident's representative. 5. Review of the medical record showed resident #173 was transferred to the hospital on 5/23/22 for an acute change of condition and readmitted to the facility on [DATE]. Further review showed no evidence the facility issued a written transfer notice to the resident or the resident's representative. 6. Interview with the DON on 7/27/22 at 5:01 PM revealed the written transfer/discharge notices were not provided to the resident or resident representatives. 7. Review of the Transfers and Discharges policy and procedure, last revised 6/3/20, showed .Before a facility transfers or discharges a resident, the facility must---(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman .

Based on medical record review, staff interview, and review of policy and procedure, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 2 of 5 sample residents (#1, #34) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had diagnoses which included [CONDITION(S)], non-Alzheimer's dementia, anxiety disorder, and depression. Review of the physician orders for July 2022 showed the resident received [MEDICATION(S)] (antidepressant) 20 mg (milligrams) by mouth at bedtime, [MEDICATION(S)] (antidepressant) 20 mg by mouth daily, and [MEDICATION(S)] (antipsychotic) 100 mg by mouth at bedtime. The following concerns were identified: a. Review of the behavior monitoring sheet provided by the facility on 7/28/22 showed a target symptom/behavior of physical aggression for [MEDICATION(S)] and visual hallucinations for [MEDICATION(S)]; however, there was no identified target symptom or behavior for the use of [MEDICATION(S)]. b. Review of the behaviors care plan last revised on 7/21/22 showed the resident experienced exit seeking behaviors, physical aggression towards staff, a history of feeling confused, and hallucinations. Further review showed no specific target symptom identified for the use of [MEDICATION(S)] and no non-pharmacological interventions identified for identified behaviors. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had diagnoses which included anxiety disorder and depression. Review of the physician orders for July 2022 showed the resident received [MEDICATION(S)] (antianxiety) 0.5 mg by mouth daily at bedtime, [MEDICATION(S)] (antidepressant) 15 mg by mouth twice per day, and [MEDICATION(S)] [MEDICATION(S)] (antidepressant) 3 mg by mouth daily at bedtime. The following concerns were identified: a. Review of the [CONDITION(S)] RX [prescription] care plan last revised on 6/14/22 showed the resident suffered from chronic anxiety, depression with recent exacerbation due to loss of family member, and friend's daughter with cancer. Further review showed there were no non-pharmacological interventions identified. 3. Interview with the social services director on 7/28/22 at 8:45 AM confirmed there were no identified target symptom/behaviors identified for some of the medications and revealed it would be difficult to identify the effectiveness of medications without knowing the target symptom/behaviors for each medication. 4. Review of the policy titled Behavioral Health Management last revised 8/2/21 showed .Procedure .3. Initiate Behavior Monitoring, Behavior Management Care Plan, and Kardex as indicated by assessment findings, use of psychoactive medications, resident/responsible party conversations, and observations .The facility must provide necessary behavioral health care and services which include: .Ensuring that pharmacological interventions are only used when nonpharmacological interventions are ineffective or when clinically indicated .

Based on medical record review, and staff and resident interview, the facility failed to ensure health care treatments were scheduled in accordance with residents' preferred sleeping schedules for 1 of 18 (#44) sample residents reviewed. The findings were: 1. Review of the 6/16/22 admission MDS assessment showed resident #44 was admitted to the facility on [DATE] and had a BIMS score of 15/15 which indicated the resident was cognitively intact. Further review showed the resident was admitted with two stage 4 pressure ulcers, and one unstageable pressure ulcer. Review of a 7/14/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, on 7/5/22 the resident was prescribed one 5-325 milligram tablet of [MEDICATION(S)]-acetaminophen (a narcotic for pain relief) to be administered 30 to 45 minutes prior to dressing changes. The following concerns were identified: a. Interview with the resident on 7/26/22 at 9:56 AM revealed s/he had a pressure ulcer which required a dressing change every 12 hours, and she was given pain medication 30 to 45 minutes before the procedure. The resident stated s/he had informed the nurses that s/he preferred to go to sleep around 9:30 PM to 10 PM, however felt there was not any continuity of care and s/he was at the bottom of the totem pole because the dressing change often occurred later than 9:30 PM. In addition the resident revealed s/he had to either wait until the second dressing change of the day had been completed or be woken up to have it done. Further the resident stated it was hard to go back to sleep after being woken up. b. Review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Interview with RN #1 on 7/27/22 at 11:47 AM revealed the resident was scheduled for a dressing change between 6 AM and 10 AM and again between 6 PM and 10 PM. RN #1 confirmed the resident received medication for pain 30 to 45 minutes before the procedure. d. Interview with RN #2 on 7/27/22 at 6:25 PM revealed she worked the 6 PM to 10 PM shift and would do the resident's dressing change if she had time; otherwise she would leave it for the night shift nurse. e. An additional interview with the resident on 7/28/22 at 9:47 AM revealed s/he had been given the pain medication around 10 PM the previous evening; the dressing change was started at approximately 10:40 PM and was completed at 11 PM. f. Interview with the DON on 7/28/22 at 11:43 AM revealed it should be the resident's choice as to what time the dressing changes should occur.

Based on observation, medical record review, review of the facility investigation report, staff interview, and review of facility policies, the facility failed to ensure a safe transfer was provided for 1 of 5 sample residents (#7) reviewed for falls during staff assistance. This failure resulted in actual harm to resident #7 who was dropped during a full body transfer. The resident suffered a skull fracture and subdural hematoma. The findings were: 1. Review of a nurse's note dated 6/12/19 and timed 3:12 AM revealed CNA #1 had dropped resident #7 on the floor at approximately 7:50 PM on 6/11/19. The CNA told the nurse the resident had slipped out of the sling from above the height of the wheelchair at approx (approximately) 3 feet. The nurse asked the CNA if she had transferred the resident without assistance and was told she could not find any help. The nurse wrote the CNA had not personally asked me nor had I seen her talking to other CNAs during her shift. The nurse also noted there was not a full sling in the room at the time. The CNA told the nurse the resident's head hit the floor first and then his/her back. The resident was transferred to the emergency department on 6/11/19 at 8:29 PM. 2. Review of the radiology report dated 6/11/19 showed the resident had an acute subarachnoid and subdural hematoma . and a nondisplaced [MEDICAL CONDITION] calvarium and skull base . 3. Review of the ADL care plan last revised 4/18/19 for resident #7 showed the resident required a Hoyer (a full-body mechanical lift) for transfers using a blue full sling. Review of the Kardex (located in the resident's room) showed the resident required the assistance of 2 staff members for transfers using a Hoyer lift and a full sling. 4. Review of the facility's investigation showed an interdisciplinary team (IDT) summary which included Upon review of the resident's medical record, diagnoses, MDS and care plan, eMAR (electronic medication administration record) and eTAR (electronic treatment administration record), as well as staff/resident and family interviews, by the IDT, this investigation reveal (sic) that the CNA involved in incident did knowingly transfer the resident with one person instead of two, used the wrong type of sling and applied the sling used in an improper manner. 5. Interview with the ED and the DON on 6/19/19 at 2:43 PM revealed corrective actions were implemented on 6/12/19 to prevent re-occurrence. The actions taken by the facility included: a. The CNA involved was suspended and subsequently terminated. b. The nursing staff was re-educated in regard to the policy regarding mechanical lift transfers, proper sling, and the proper application of the sling. The DON stated the staff development coordinator had educated all of nursing staff, however 14 PRN (as needed) staff remained, and would be educated before they worked their next shift. c. The therapy department evaluated the resident's transfer status and informed staff of the proper lift and size of the sling required to safely transfer the resident. d. The staff were educated as to where the information regarding transfer status was located. e. The facility provided individual slings for all residents, labeled with the resident's name, and stored on a hook in the bathroom. f. The facility was promoting a teamwork approach to keep residents safe. g. The DON stated audits would be conducted on a weekly basis to ensure the proper slings were available and functional in the resident's rooms. 6. Review of the facility investigation report showed education was provided to nursing staff on 6/13/19 and 6/14/19. However, due to the date of the incident and the survey timeframe, audits and quality assurance monitoring had not yet been completed. 7. Observation on 6/18/19 at 9:13 AM showed CNA #2 and CNA #3 transferred resident #74 with a Hoyer lift from the bed to his/her wheelchair. Observation on 6/18/19 at 9:36 AM showed CNA #2 and CNA #4 transferred resident #7 from his/her wheelchair to the bed. Interview with the CNAs at that time revealed all transfers were to be done with 2 staff members present. 8. Review of the policy Mechanical Lift Use dated 11/97 showed General Guidelines .3. Two (2) persons are required to perform this procedure.

Based on staff interview, medical record review, and policy and procedure review the facility failed to complete a post-fall assessment for 1 of 5 sample residents (#3) with a fall. The failure to conduct a post-fall assessment resulted in a delay in treatment and a lack of adequate pain relief. The findings were: Review of the quarterly MDS (minimum data set) assessment with an assessment reference date of 4/24/18 showed resident #3 had [DIAGNOSES REDACTED]. Further, the resident required the extensive assistance of 2 or more staff members for transfers. Review of the care plan showed the resident was dependent with all cares and required a mechanical lift for transfers. The following concerns were identified: a. Review of the nursing progress note dated 4/30/18 at 6:31 AM showed the CNA assisted the resident to sit on the edge of the bed, when the resident slid to the floor, and landed softly onto left leg/hip. The resident complained of hip/leg pain and [MEDICATION NAME] (opiod pain medication) was administered. The physician, the director of nursing (DON) and the daughter/power of attorney (POA) were notified. b. Review of the nursing progress note dated 4/30/18 at 9:08 showed .Resident was sent to Wyoming Medical Center (WMC) this morning at 9:00 AM related to the fall that s/he had this morning. Resident has been complaining of left leg pain his/her POA wanted him/her to go and get his/her leg further checked out. c. Review of the incident follow-up and recommendation form dated 4/30/18 showed the resident sat on the edge of the bed and slid to the floor landing on the left hip. Further review showed the resident was . 1) assessed for injury 2) pain med given 3) changed to hoyer lift 4) boat mattress in place. Further review showed the resident continued to have anxiety and was given an anxiety pill and a half hour later was given pain medication. Further review showed .the resident was less anxious but continued to complain about leg pain . d. Review of the witness interview form dated 5/3/18 detailed events of the incident that occurred on 4/30/18 at 5:00 AM. The form showed the resident was positioned onto his/her back where the nurse checked for injury, legs appeared to be the same length, no sign of knee injury although resident kept complaining of leg pain there was no sign of bruising or injury . e. Interview with the DON on 5/10/18 at 5:23 PM revealed the expectation after a fall was for the nurse to do a head-to-toe assessment for injury, check vital signs and notify the DON, the physician and the resident representative. The DON revealed the nurse completed an assessment which was documented in the witness interview form. The DON further stated the resident was usually anxious at that time of day and they did not suspect an injury until the morning wore on and his/her pain level increased. The DON felt the impact of the fall was not enough to sustain an injury. She further stated they transferred the resident to the hospital via wheelchair in their facility van, instead of calling an ambulance. f. Review of the fall management policy dated 11/2016 showed, .With the event of a patient fall a complete nursing assessment will be performed by the nurse . Review of the nursing progress notes failed to show a complete nursing assessment was done. g. Review of the WMC emergency triage notes dated 4/30/18 at 9:34 AM showed the resident arrived to the department in a wheelchair via the facility van. Further review showed the resident complained of pain, was agitated and moaning, and left leg swelling was present. h. Review of the WMC emergency room physician history and physical dated 4/30/18 showed the resident was found to have a distal femur fracture (periprosthetic) on the left side.

Based on observation, medical record review, review of policy and procedure, and resident and staff interview, the facility failed to implement effective measures to control the spread of a known outbreak of infectious respiratory disease. This failure resulted in an immediate jeopardy situation. The census was 107. In addition the facility failed to ensure staff practices minimize the potential for cross contamination and the spread of disease during one random observations of staff and visitors handling ice, 1 of 6 observations of lack of hand hygiene between glove changes (resident #37), and 1 of 6 observations of inappropriate perineal care (resident #76). The findings were: Regarding the facility's failure to implement effective measures to control the spread of a known outbreak of infectious respiratory disease: 1. Observation on [DATE] from 2 PM through 2:35 PM revealed no PPE by any resident rooms, or signs on any resident doors during a tour of the entire facility, which would alert staff and visitors of an influenza outbreak. Interview on [DATE] at 2:25 PM with MDS coordinator #1 revealed she advised the state survey agency staff to consider wearing a mask in the facility due to an influenza outbreak. Random observations at that time showed no staff or visitors, which included the MDS coordinator, wore PPE at any time. 2. Observation on [DATE] at 2:45 PM revealed the front door to the facility lobby had two signs posted that requested if any visitor showed signs or symptoms of illness they should not enter the facility. No signage was present at that time which would alert visitors to avoid the facility due to an influenza outbreak. 3. Interview with the facility administrator, staff development coordinator and DON on [DATE] beginning at 3:45 PM revealed the following: a. The facility identified 4 residents with influenza on [DATE]. These residents included resident #110, who was hospitalized on [DATE] and tested positive for influenza; resident #45, who was hospitalized on [DATE] and tested positive for influenza; resident #80, who tested positive for influenza in the facility; and resident #111, who tested negative for influenza at the facility, but was subsequently hospitalized and tested positive for influenza. Additionally, resident #62 was symptomatic, but tested negative for influenza at the facility. b. On [DATE], the facility identified an additional resident, resident #83, who tested positive for influenza, as well as employee #1 who also tested positive for influenza. c. The DON stated the facility's actions in response to the influenza outbreak included "following the protocol and testing anyone with symptoms," putting a sign on the facility's front door discouraging people with signs and symptoms of illness from visiting the facility, increasing handwashing and cleaning, and having symptomatic residents go to "Cowboy Dining" (the dining room on unit 2) or remain in their rooms for meals. The DON further stated employees had "the option to wear a mask." The masks were kept at the nurses' station. d. On [DATE], the facility administrator attempted to contact the Wyoming Department of Health, Infectious Disease Epidemiology Unit to report the influenza outbreak, and left a message. On [DATE], the Epidemiology Unit returned the call and spoke to the staff development coordinator. The Epidemiology Unit also provided the facility with guidance from the Centers for Disease Control (CDC) on management of influenza outbreaks in long term care facilities. e. The DON stated that, after reviewing the CDC guidelines, she spoke to the facility's medical director. According to the DON, the medical director said the facility was "doing everything they needed to," and as a result the facility did not institute droplet precautions as outlined in the facility's own policy and procedure. The DON further stated "we thought we had it (the outbreak) under control." f. On [DATE] an environmental services worker #1, and LPN #2 tested positive for influenza. g. On [DATE] resident #82 tested positive for influenza. Additionally, resident #98 was symptomatic, but tested negative for influenza at the facility. h. On [DATE] resident #51, resident #81 and resident #54 all tested positive for influenza at the facility. 4. Review of the facility's policy and procedure entitled, "Protocol to Manage a Flu Outbreak" showed interventions to be implemented in the event of an influenza outbreak included the following: a. "Provide notification to families to discourage visitation until flu has cleared up in the facility or in the community." b. "Initiate droplet precautions for care of the symptomatic residents." c. "Stop group activities and group dining during the outbreak." 5. Review of the facility's policy and procedure for "Droplet Precautions" revealed droplet precautions were to be instituted for influenza, and included the following: a. "Stop" sign on door. b. "Visitors are instructed to wear a mask and wash hands when entering and leaving room." c. "Gloves." d. "Mask." e. "Resident Transport - Limit transport of resident to essential purposes only. During transport, resident must wear a mask." 6. CDC recommendations, found in "Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities" include implementing standard and droplet precautions for residents with suspected or confirmed influenza. 7. On [DATE] at 5:01 PM the administrator and DON were informed of an immediate jeopardy situation in the area of infection control. The facility's action plan included the following immediate changes: a. 100% of Family members of residents positive for Influenza were notified between ,[DATE]-,[DATE]. All residents who test positive in the future were to have family member(s) notified immediately. b. Signs illustrating influenza is present were to be posted on all facility entrance doors on [DATE]. c. Training of all facility staff re: Flu precautions, droplet precautions related to PPE were scheduled for 1:30 - 2:30 & 9:30 PM on [DATE] and training was to continue prior to each shift until all staff have been trained. Staff were not to be eligible to work until they had been trained. d. The DON was designated as the individual responsible for facilitating all Flu-related education, surveillance and monitoring. e. Every shift auditing of appropriate use of PPE was to be conducted until influenza has been mitigated in the facility. Audits have begun on all applicable units. f. The criteria for determining whether residents are still infectious will be according to CDC Guidelines, i.e. asymptomatic 7 days after onset of symptoms or 24 hrs (hours) after afebrile for those treated. g. "No terminal outcomes are reported for all residents positive for flu." 8. The action plan was accepted on [DATE] at 6:07 PM. 9. Interview with the infection preventionist and the ADON on [DATE] beginning at 10:45 AM confirmed droplet precautions were not put in place at the facility on [DATE] when the first cases of influenza were identified, or thereafter until the immediate jeopardy was declared on [DATE]. 10. Review of nursing notes for resident #81 dated [DATE], timed 12:45 PM, revealed the resident was febrile, had a cough and had tested positive for influenza. Observation on [DATE] at 3:30 PM showed the resident was lying in bed with a [DEVICE] attached to his/her lower extremity. There were no precautions posted anywhere in the room, nor any notice on the door into the room advising of the resident's infectious status. Interview at that time with CNA #7 revealed she was unaware of the resident's positive influenza status. 11. Observation on [DATE] at 6 PM showed the unit 2 nurse manager assisted resident #83 (positive for influenza on [DATE]) to the bathroom. Neither the resident nor the manager wore a mask. Immediately after the observation, the manager stated the resident no longer had signs or symptoms of the flu. However, the manager posted a sign on the resident's door at that time which stated, "Please ask the nurse before entering this room." Observation on [DATE] at 6:15 PM showed CNA #5 entered the resident's room without donning a mask. Interview with the aide at that time showed she believed the sign was for the resident's roommate. Interview with the resident on [DATE] at 6:25 PM showed the resident felt better. However, the resident stated, "I still have somewhat of a cough. They said I have Influenza A." After the interview, the resident transported him/herself via wheelchair in the hallway without donning a mask. 12. Observation on [DATE] at 8:05 AM in the main dining room showed resident #83 and roommate resident #4 eating breakfast and not donning a mask. 13. Observation on [DATE] at 8:15 AM showed resident #45 in the Cowboy dining room without a mask. The dining room was open to the hallway near Nursing Station II, and staff and residents were present. 14. Observation on [DATE] at 9:15 AM showed CNA #6 transporting resident #80 from the Cowboy dining room in his/her wheelchair. The resident was coughing frequently at that time; however, neither the resident nor the aide donned a mask. Interview with the aide at that time outside of the resident's room revealed the resident did not like to wear a mask. 15. Review of the [DATE] hospital progress note for resident #51 revealed the resident was admitted to the hospital on [DATE] with "acute-on-chronic hypoxemic respiratory failure likely secondary to influenza A." Interview with the ADON on [DATE] at 11:05 AM revealed the resident returned briefly to the facility on [DATE] before transferring to hospice, where s/he died on [DATE]. 16. Review of nursing notes dated [DATE], timed 4:09 PM, revealed resident #108 began antibiotic treatment for [REDACTED]. Nursing notes dated [DATE], timed 1:24 PM, showed charting for the [DATE] night shift and revealed the resident was suffering an exacerbation of chronic obstructive pulmonary disease with acute bronchitis, and continued antibiotic treatment. Nursing notes dated [DATE], timed 1:45 PM, showed charting for the [DATE] evening shift, and revealed the resident was "in cowboy dining due to behaviors..." Nursing notes dated [DATE], timed 10:02 AM, revealed the resident was started on [MEDICATION NAME] 75 mg once daily for 2 weeks. Nursing notes dated [DATE], timed 10:35 AM, revealed the resident's [MEDICATION NAME] had been increased to 75 mg twice daily for 5 days, and the resident had been put on droplet precautions. Interview with the ADON on [DATE] at 11:05 AM revealed the resident died on [DATE]. 17. Review of nursing notes dated [DATE], timed 11:56 PM, revealed resident #54 tested positive for influenza on [DATE] (not [DATE] as was stated in interview). Nursing notes dated [DATE], timed 1:54 PM, revealed an intravenous line was started in the resident's right wrist to administer fluids. 18. Review of nursing notes dated [DATE], timed 6:31 PM, showed resident #79 had a non-productive cough and complained of not feeling well. The resident was treated for [REDACTED]. Nursing notes dated [DATE], timed 5:50 PM, revealed the resident continued to have a non-productive cough, but was "feeling well enough to go to dining room for meals." Review of the nursing notes dated [DATE], timed 7:37 PM, revealed the resident continued to complain of not feeling well, had a non-productive cough, and further revealed the resident was "going to dining room for meals, but requests that (s/he) be assisted to and from meals." Interview with the medical director on [DATE] beginning at 11:07 AM revealed the resident had tested negative for influenza at the facility, and was treated for [REDACTED]. There was no laboratory confirmation of the negative result. The resident's condition declined, and s/he was sent to the hospital on [DATE] where a test for influenza was positive. Review of the hospital progress note dated [DATE] revealed the resident was suffering "Acute-on-chronic hypoxemic and hypercarbic respiratory failure probably secondary to influenza A on top of a mixed obstructive and restrictive lung disease with chronic respiratory failure." Interview with the ADON on [DATE] at 12:25 PM revealed the resident had died that day. 19. Review of nursing notes dated [DATE], timed 6:34 PM, revealed resident #24 had a fever of 101.8 degrees Fahrenheit, and was started on [MEDICATION NAME] (an antiviral medication used to treat flu symptoms caused by influenza). Nursing notes dated [DATE], timed 6:36 PM, revealed the resident had upper respiratory symptoms, oxygen saturations in the 60's (below 90% is considered abnormal) on room air, a non-productive cough, and shortness of breath. 20. Based on implementation of the facility's plan, the immediate jeopardy was removed on [DATE] at 8:52 AM. However, deficient practice remained at a scope and severity of H (actual harm that is not immediate jeopardy). 21. Interview with the infection preventionist on [DATE] at 11:50 AM revealed resident #52 had been put on droplet precautions. Interview with the ADON on [DATE] at 11:05 AM revealed the resident was treated with [MEDICATION NAME] and died at the facility on [DATE] 22. Interview with LPN #3 on [DATE] at 2:45 PM revealed resident #5 had been put on droplet precautions due to symptoms. 23. Interview with LPN #4 on [DATE] at 2:02 PM revealed the following residents were on droplet precautions due to symptoms of influenza: resident #52, resident #10, resident #17, resident #41, resident #93, resident #109, resident #85, and resident #37. The LPN further revealed resident #35 had experienced respiratory distress that morning and had been transported to the hospital where s/he tested positive for influenza. 24. Interview with a Surveillance epidemiologist at the Wyoming Department of Health, Infectious Disease Epidemiology Unit on [DATE] at 1:15 PM revealed he contacted the facility on [DATE] and spoke with the facility SDC. He provided the CDC's "Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities" to the facility and urged the facility to take the influenza outbreak very seriously, due to the currently circulating strain of influenza A being "very detrimental" to persons greater than [AGE] years of age. Additional findings regarding the facility's failure to minimize the potential for cross contamination and spread of disease were noted during the following observations: 1. Observation on [DATE] at 6:05 PM showed a visitor used an ice scoop to fill a resident's mug; while holding the mug over the filled ice chest located at the nurses' station, dirty water ran into the ice chest. The visitor returned to the resident's room. Interview at that time revealed the visitor performed this action "every night" for the resident, and staff had not provided any education about filling the resident's mug with ice and water. Interview on [DATE] at 6:15 PM with the rehabilitation director revealed staff members should be filling the resident's mug with ice water, and she would ask a staff member to clean the ice chest. Interview on [DATE] at 6:30 PM with the admission coordinator revealed she rinsed the ice chest and filled it with ice, then returned it to the nursing station to be used. Additionally, she was not educated on how to clean and sanitize the ice chest when contaminated. Interview at that time with the DON revealed she was unaware of how the CNAs clean the ice chest when contaminated. Interview on [DATE] at 7:10 PM with the staff development coordinator revealed staff should clean the contaminated ice chests with a 10 percent (%) bleach solution. 2. Review of the [DATE] annual MDS assessment showed resident #76 had [DIAGNOSES REDACTED]. Observation on [DATE] at 4:50 PM showed CNA #1 and CNA #2 provided care to the resident. During the observation CNA #2 removed the resident's wet brief and completed the following tasks without performing hand hygiene: wiped the resident's abdomen and perineum, removed her soiled gloves, donned clean gloves, wiped the resident's buttocks, reused the same visibly soiled wipe to clean the resident's perineum, removed soiled gloves, donned clean gloves, pulled up the resident's clean brief and pants, then positioned the resident in his/her wheelchair. Interview on [DATE] at 6 PM with the Staff Development Coordinator revealed the expectation is to perform perineal care with a clean wipe and throw away the visibly soiled wipe. 3. Review of the [DATE] quarterly MDS showed resident #37 had severe cognitive impairment and required extensive assistance with ADLs. On [DATE] from 12:05 PM to 12:20 PM CNA #4 and CNA #8 were observed providing toileteting assistance and personal hygiene care for resident #37. During the observation CNA #4 changed gloves 4 times before completing the task of cleaning the resident's perineal and rectal areas. Further observation revealed the CNA did not perform hand hygiene between the glove changes. Interview with the staff educator on [DATE] at 10:35 AM revealed the education and in-services provided for the staff did not included hand hygiene between glove changes. According to the CDC "Guidelines for Hand Hygiene in Health-Care Settings", published 2002, ..."hands should be decontaminated or washed after removing gloves..."

Based on observation, staff and resident interviews and medical record review, the facility failed to ensure 1 of 9 sample residents (#79) identified with swallowing problems was provided adequate supervision while eating. As a result, the potential for serious avoidable injury to sample resident #79 was identified and a determination of immediate jeopardy was made. In addition, the facility failed to ensure adequate supervision/education for 1 sample resident using a gel pack for heat therapy (#114), which resulted in burns to the resident's ankle. The findings were: 1. Review of a physician's note dated 11/7/13 showed resident #79 had [DIAGNOSES REDACTED]. Further, the note showed the resident reported problems with food sticking in his/her throat and having to cough the food up. A physician's note dated 12/2/13 showed the resident had moderate dementia. Review of a physician's note dated 12/16/13 revealed a swallow study was completed with the following recommendations from speech therapy: "...small drinks, double swallows with thin liquids. If pulmonary compromise occurs, consider nectar thick liquids..." Review of the quarterly nutrition assessment dated [DATE] showed the resident received a mechanical soft diet due to it being easier to swallow. Further, the resident remained in his/her room for most of the meals. Review of the care plan for nutrition dated 12/6/13 showed the licensed nursing staff was to observe the resident for signs and symptoms such as "chewing/swallowing problems, worsening of tremors that affect ability to hold utensils." Further, the care plan showed the CNA staff was to report any signs and symptoms of chewing/swallowing or other problems consuming meals to include: choking, coughing while eating or drinking, nose dripping or eyes tearing while eating, pocketing food or excessive drooling. Review of the 12/8/13 MDS assessment showed the resident required one person assistance with eating. Review of the nurses' notes showed the following entries: 1. On 9/30/13 the resident was observed having problems eating while in the dining room with food sticking in his/her throat. 2. On 11/7/13 the resident felt (s/he) was more shaky. Review of the physician notes dated that same day showed the resident had food stuck in his/her throat during breakfast. 3. On 11/25/13 a family member notified the facility the resident was choosing inappropriate food due to his/her dementia and as a result was choking on the food. The family member reported the resident called "frequently" reporting s/he was choking on food. 4. On 11/28/13 a family member reported, while out of the facility for a meal,the resident had an episode of difficulty with swallowing. 5. On 12/19/13 the note showed the resident was oriented to person and sometimes to place. Further, it showed the resident was forgetful and easily confused. a. Observation on 1/7/14 at 1:40 PM showed resident #79 was brought to his/her room in a wheel chair and placed next to the foot of the bed with his/her back to the door, facing the window. A staff member brought the resident's meal into the room and then left after setting up the tray. At 1:55 PM the surveyor entered the room and the resident stated s/he was having difficulty swallowing. S/he was tearing and drooling; however, it was not evident the resident was having difficulty from the hallway due to having his/her back to the door. The resident's call light was located on the bed and out of reach of the resident. Assistance was requested from the nursing staff at that time. The following concerns were identified: b. Observation on 1/8/14 at 5:50 PM showed the resident was again sitting on the side of the bed with his/her back to the door. CNA #8 brought the resident's meal tray and left the room. Continuous observation until 6 PM did not show staff entered the resident's room until s/he had completed his/her meal. An interview with the resident at 6:10 PM revealed s/he was not supervised during meals when eating in his/her room, only when in the dining room. c. An interview with CNA#8 on 1/8/14 at 6:45 PM revealed she was not aware the resident had problems with eating and was to be observed for swallowing difficulty. Additional interviews with CNA #9 and CNA #10 on 1/8/14 at 6:20 PM and 6:30 PM respectively revealed they were not aware of any precautions related to swallowing for this resident. d. An interview with RN #1 on 1/8/14 at 7:25 PM revealed she was aware the resident had swallowing problems. She was not aware the CNAs did not know the resident was to be observed for swallowing difficulty while eating. On 1/8/14 at 7:10 PM, the administrator was informed of an immediate jeopardy situation in the area of patient safety related to lack of supervision of residents with known swallowing issues. The facility's action plan included the following: 1. Resident #79: 100% of all care staff has been in-serviced with respect to the nutrition-related component of the 1/8/2014 current care plan. Resident #79 Nutrition Care Plan was updated to include interventions summarized below: a. Report to nurse any signs and symptoms of chewing and/or swallowing or other problems consuming meals, included but not limited to: i. Choking ii. Coughing during eating or drinking iii. Nose dripping iv. Eyes tearing while eating v. Pocketing of food vi. Excessive drooling vii. Eats less than 50% of meal (and) b. Resident #79 will be supervised during all meals. 2. Resident #79: An inspection of resident room was conducted at 7:30 PM on 1/8/14, to ensure that no food items were present in the room. The resident affirmed there were no food items present in the room. 3. Resident #79: Diet was downgraded on 1/9/14 to puree, pending further assessment(s). Patient expresses agreement with the downgrade. Resident #79 is on thin liquids. 4. A whole house audit was conducted on 1/9/14 to identify other residents at risk as Resident #79. This audit was completed by utilizing the: a. CMS-802. b. Identified list of residents with mechanically altered diet. c. Identified list of residents with like diagnoses. 5. A total of three residents were identified with similar risks of choking/swallowing. 6. The care plan of each of those three residents identified with the same risk as Resident #79 was reviewed on 1/9/14. 7. The care plans for those 3 identified residents were amended on 1/9/14 to ensure individualized interventions were included. 8. All care staff on 1/9/14 will be inserviced, prior to their shift on the Care Plan(s) of those three residents identified in #5 above. 9. The three identified residents (as well as Resident #79) will be supervised/monitored during each meal to ensure that the Care Plan related to their swallowing risk is being followed. 10. Individuals assigned to monitor these residents (i.e. Restorative Aide and/or CNA) during their meals will complete a Meal Monitoring Tool designed to capture evidence of compliance with the residents' Care Plan. 11. The tool(s) will be turned into the Director of Nursing (or her designee) each day for review and action if necessary. 12. The Director of Nursing will summarize the results of the Meal Monitoring Tools each month at the facility's Performance Improvement Committee. The action plan was accepted on 1/9/14 at 3:10 PM, and based on verified implementation of the plan, the immediate jeopardy was abated on 1/9/14 at 6:30 PM. However, deficient practice remained at a scope and severity of D. 2. Review of the medical record for resident #114 revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] showed the resident was cognitively intact, ambulated under supervision with the assistance of a walker, required limited assistance with most ADLs, and had almost constant pain that limited day to day activities. Review of the physical therapy plan of treatment dated 10/3/13 showed the resident received therapy five times a week for difficulty walking and muscle weakness. The following concerns were identified: a. Review of a PT (physical therapist) Daily Treatment Note dated 10/15/13, timed at 3:41 PM, showed "Therapist saw the patient walking in the hall by him/herself without his/her walker, s/he said s/he heated up a gel pack in the microwave, she was just on his/her way back to his/her room. (Resident) agreed to therapy, was complaining of being hot and needed a drink. Therapist thought if the (resident) is getting more steady on his/her feet, s/he should trial a SPC (single point cane). (Resident) was only able to go ~15' (approximately 15 feet) with CGA (contact guard assist), had the (resident) sit down because s/he was too unsteady. EDUCATION: Instructed the patient to use his/her walker if s/he is by him/herself. (Resident) then performed the Tinetti Balance Assessment, scored 22/28 which put him/her in the moderate risk for falls category. (Resident) performed the assessment without an assistive device. This intervention is medically necessary in order to determine the (resident) fall risk." No evidence of a safety assessment for the gel pack, or resident education on hot pad safety was found in the record. b. Review of a non-pressure skin condition record dated 10/22/13 revealed the resident had four blisters on his/her right ankle. Review of the facility's investigation report dated 10/22/13 revealed the resident had heated a gel pack in a microwave, and applied it to his/her right ankle. The investigation report did not show where the resident obtained the gel pack, information about who authorized the hot gel pack as an effective treatment modality, or whether the resident and/or staff had received instructions regarding safe usage. c. Interview with the DON on 1/9/14 at 4:30 PM revealed the facility had been unaware the resident was using the gel pack, and the facility usually did not use gel packs due to the potential for injury. The DON stated the therapist should have reported the resident was using the gel pack so staff could have removed it or provided instructions on safe use. The DON was not aware of the gel pack being part of therapy treatment or a doctor's order, and assumed the resident had brought the gel pack from home. d. Interview with the rehabilitation director on 1/10/14 at 9:40 AM revealed the facility had, at one time, used gel packs, but only for cold therapy. She said the facility no longer used gel packs. The rehabilitation director further confirmed no assessment for the safety of the resident while using the gel pack was made, and no resident education on gel pack usage and safety was performed.

Based on observation, medical record review, and staff interview the facility failed to monitor and treat skin breakdown for 2 of 3 sample residents (#77, #105) identified as being at risk of pressure ulcers. This failure resulted in an unstageable pressure ulcer for resident #77. The findings were: 1. Review of the medical record for resident #77 revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment dated [DATE], revealed s/he required extensive assistance from staff for bed mobility, toilet use and hygiene, and was totally dependent on staff assistance for transfers. The resident was assessed as being always incontinent of both bowel and bladder. The following concerns were identified: a. Nursing notes dated 12/16/13, timed at 3:46 PM, revealed "Resident has an open area on (his/her) sacrum that is moisture acquired at this time. Has good blood flow on the borders. Resident already has a draw sheet in place on (his/her) bed. Needs excellent pericare and keep area dry. Will leave open to air and apply blue top remedy cream with barrier protection to heal. Will continue to monitor weekly and as needed." No other assessment of the wound, such as measurements, was included in the nursing note. b. Review of the weekly skin integrity data collection forms revealed nursing skin assessments were completed on 12/26/13 and 1/2/14. Both assessments noted the resident had an open area on his/her coccyx, as well as a shear injury to the right buttock. Neither assessment included any further description of the wounds, such as measurements. c. The next time these wounds were addressed in the nursing notes was in the nursing notes dated 1/5/14, timed at 1:44 PM, which revealed "Resident has 2 unstageable pressure areas - 1) to coccyx measures 4.5 cm in length by 1.5 cm in width by 1.5 cm in depth covered entirely in slough at 100% - 2) to right hip area measures 1 cm in length by 5 cm in width with 10% slough noted to distal end - will request physical therapy screen for closed pulse irrigation 5 X week - will implement medi-honey to both areas after cleansing with sterile normal saline and apply [MEDICATION NAME] dressings to both areas twice daily - MD notified and family notified. Will continue to monitor." d. Review of a physician's record of visit dated 1/7/14 revealed the resident had a "sacral decubitus unstageable but at least a stage III." A physician's interim order dated 1/8/14 revealed orders for physical therapy to provide closed pulse irrigation five times weekly for twelve weeks to help facilitate wound healing. e. Observation of a dressing change on 1/9/14 at 10:10 AM showed the resident received closed pulse irrigation to cleanse the wound. At that time, the wound as measured by the physical therapy aide was 4 cm in length, 3 cm in width, 2 cm in depth, with 2.2 cm deep tunneling noted at the 12 o'clock position. The wound bed was entirely covered in yellow slough. f. Interview with the facility wound care nurse on 1/10/14 at 3:10 PM revealed that he was the nurse that assessed the initial open area on 12/16/13, and confirmed the pressure ulcer discovered on 1/5/14 was in the same location as the open area documented on 12/16/13. He stated when wounds were assessed as being moisture-related they were not tracked by the wound team. He further revealed that non-pressure wounds were supposed to be assessed and tracked to resolution by nursing staff on a "non-pressure report." He was unable to explain why no such report existed for this wound, and uncertain why there were no measurements of this wound before 1/5/14. g. According to Perry, Potter and Elkin, "Nursing Interventions & Clinical Skills" 5th ed. St. Louis, MO: Mosby, 2012, page 585 "Wound assessment is essential in wound management. The assessment of the following factors: location, dimensions, undermining, drainage, tissue type, exudate, wound edges, and pain, plays an important role in correct [DIAGNOSES REDACTED]. A uniform approach to wound assessment that uses measurements can identify the appropriate treatment plan and appropriately evaluate progress to healing." 2. Review of the 12/22/13 quarterly MDS assessment showed resident #105 was at risk for the development of pressure ulcers. In addition, the resident had one unhealed ulcer. Review of the 2014 treatment administration record showed s/he had [DIAGNOSES REDACTED]. Review of the resident's care plan for skin dated 8/7/13 showed the resident was at risk for skin breakdown related in part to cognitive loss, functional mobility decline, incontinence and weakness. Approaches included: the CNA was to inspect skin surfaces daily during care and report signs and symptoms of skin irritation as soon as possible. The following concerns were identified: a. An observation on 1/7/14 at 1:10 PM showed CNA #2 and CNA#7 transferred resident #105 from the wheelchair to bed with the use of a total lift in order to provide incontinence care. During the care, it was revealed the resident had 2 areas of skin breakdown on the right buttock. In addition, there were 2 areas of skin breakdown noted on the resident's sacrum. The CNAs completed perineal care and applied Remedy cream to include the areas of breakdown. The resident was left on his/her back after the CNAs completed the care. An observation of these wounds, with the wound care nurse, on 1/7/14 at 4:20 PM, 3 hours 10 minutes after they were initially observed, revealed he was not aware of the skin breakdown. He confirmed there were two stage II pressure ulcers measuring 0.5 by 0.5 cm (centimeters) and 1.0 by 1.0 cm located on the sacrum. The areas of skin breakdown on the right buttock were identified, but he did not measure them. Interview with the wound care nurse at that time revealed he would expect CNAs to notify the nurse of any skin breakdown. In turn, the nurse would notify the wound care nurse to assess and recommend treatment. b. Review of the facility's policies and procedures for pressure ulcer prevention dated 10/7/10 showed; "The facility's procedures are such that all disciplines are alerted immediately if the resident either has skin breakdown or is at risk for the development of skin breakdown."

Based on observation, medical record review, and resident and staff interview, the facility failed to provide effective pain management for 1 of 9 sample residents (#83) identified as having moderate to severe pain. The lack of effective pain management likely compromised the resident's ability to attain the highest practicable level of physical, mental, and psychosocial well-being. The findings were: Review of the medical record for resident #83 showed the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] showed the resident was mildly cognitively impaired, required extensive to total assistance with ADLs and had pain that s/he was unable to rate. Review of the CAA dated 2/21/13 showed the resident had pain that "adversely affects mood, disturbs sleep", and included behaviors such as, "screaming, kicking, babbling, cursing, and repetitive questions." The care plan updated on 11/9/13 showed the resident had chronic daily pain associated with back, shoulder, hip and leg discomfort. Interventions included administering PRN pain medication, observing for non-verbal and behavioral signs of pain such as facial grimacing, aggression, agitation, vocalizations, complaints of pain, and crying. Interventions also included providing ice packs, massage, exercise, repositioning, touch, and music and to notify the physician for changes in pain or if pain was not reduced after one hour of receiving the first intervention. Review of the recapitulation of physician's orders [REDACTED]. Review of the MAR for the resident from 11/1/13 through 1/6/14 showed the resident received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg on 11/2/13, 11/3/13, and 12/25/13. Review of the TAR 11/1/13 through 1/6/14 showed the resident had not received any non-pharmacological interventions including applying warm packs to the left leg as needed for cramping pain or massaging the left lower extremity or bilateral lower extremities as needed for cramping pain. The following concerns with pain management were identified: a. Continuous observation on 1/7/14 from 8:40 AM until 11:10 AM revealed the resident was lying in bed with his/her door open. At 8:50 AM the resident yelled out "nurse." At 9 AM when the resident called out, "nurse," again, CNA #2 entered the resident's room and the resident complained of his/her "leg hurting and burning." The CNA informed the resident she would notify the nurse. CNA #2 then exited the resident's room and entered another resident's room to answer a call light without informing the nurse about the resident's pain as she said she would. At 9:15 AM CNA #3 entered the resident's room and delivered the resident's breakfast tray. The resident informed this CNA that his/her leg was hurting. CNA #3 exited the resident's room and continued to deliver trays; again without telling the nurse the resident was in pain. Observation at 10:16 AM showed an unidentified staff member entered the resident's room and the resident again said, "my legs are hurting and burning." That staff member replied she would inform the nurse. Between 10:16 AM and 10:30 AM the resident yelled out, "nurse please help", 3 more times. LPN #1 entered the resident's room at 10:30 AM (1 hour and 50 minutes after the first observation of the resident yelling out for nurse help) and informed the resident s/he had brought a "pain pill," which the resident took whole with water. Review of the January 2014 MAR indicated [REDACTED]. However, there was no evidence this resident's pain was assessed as to severity or intensity. In addition, there was no evidence PRN pain medication or non-pharmalogical interventions for pain were documented as being administered the morning of 1/7/14. Finally, there was no evidence the resident's pain was re-assessed with [REDACTED]. b. Continuous observation on 1/7/14 from 12:40 PM until 2:45 PM revealed the resident continued to yell out, "nurse help" and/or, "help" a total of 19 times. At 12:40 PM the resident was yelling, "nurse" and continually bouncing his/her left leg. The DON went into the resident's room and the resident complained of "hurts from my catheter to my (genitals) and my legs are hurting and burning." The DON assessed the resident's suprapubic catheter, urinary drainage bag and (genitals), and informed the resident she would tell the nurse s/he needed something for pain. The DON exited the room and walked to the nursing station several feet away and informed LPN #1 the resident had complained of pain. Again, there was no evidence staff assessed the resident's pain or provided pharmacological or non pharmacological interventions to address the resident's pain. The resident continued to yell out, "nurse help" 6 times until an unidentified CNA entered the resident's room at 1:05 PM. The resident informed the CNA, "I need to be cleaned up and my legs still hurt." At 1:12 PM the resident was yelling, "nurse help" and CNA #4 entered the resident's room. At that time the resident complained, "I need to be cleaned up and my Goddamn leg hurts." CNA #4 informed the resident it required 2 people to assist him/her and s/he would get another CNA and come back. CNA #4 did not address the resident's complaint of pain, she then exited the room and walked down the hall and entered another resident's room to answer a call light. At the nursing station at 1:18 PM the resident could easily be heard yelling, "nurse, help" 2 additional times. LPN #1, who was sitting at the nursing station, looked up towards the resident's room and commented, "there's nothing wrong with (his/her) lungs so (s/he) shouldn't get pneumonia." However, the LPN did not assess the resident for pain or offer any pain management interventions. From 1:19 PM until 1:40 PM the resident yelled out "nurse" 3 times, and "help" 2 times and bounced his/her left leg. Staff were observed walking up and down the hall and sitting at the nursing station, however, no staff entered the resident's room until 1:40 PM when CNAs #2 and #4 entered to perform incontinent care. During incontinent care from 1:40 PM until 2:07 PM, the resident asked, "please get me something for pain my Goddamn leg is on fire, it hurts so bad." CNA #2 informed the resident s/he had told the nurse earlier but would tell the nurse again. c. Review of the January 2014 MAR indicated [REDACTED]. Interview with CNAs #2 and #4 at the time of the observation, on 1/7/14 from 1:40 PM to 2:07 PM, revealed the resident always yelled out whether s/he was in pain or not. d. Interview with the resident on 1/7/14 at 9:30 AM and again between 2:07 PM and 2:20 PM revealed the resident had been in the facility since 2008. The resident stated, "I hurt every damn day, mostly my leg (points to left leg), sometimes my back, and sometimes just all over." The resident further stated, "I quit using my call light and started yelling because nobody answers the call light but if I yell long enough and loud enough eventually somebody will come." The resident also revealed staff, "tell me nothing will help the pain in my leg." The resident further revealed, "I just lie here, can't get up anymore." The resident denied being offered ice packs or massage for leg pain, and stated, "sometimes they prop it up with pillows but that doesn't help for long." e. Interview with the DON on 1/9/14 at 4:40 PM revealed she expected staff to assess and administer pain medication, and notify the physician as needed to manage pain. f. Interview with the resident's physician on 1/10/14 at 10:00 AM revealed the physician was aware the resident had chronic pain. The physician verified he had ordered scheduled [MEDICATION NAME]es and [MEDICATION NAME]/[MEDICATION NAME] as needed every 4 to 6 hours (2 narcotic pain medications) and [MEDICATION NAME] 3 times a day to manage the resident's pain. The physician also revealed he expected staff to administer PRN pain medication when a resident had complaints of pain and to notify him if the medications were not effective or the resident had worsening pain. g. According to the American Geriatrics Society, titled, "Pharmacological Management of Persistent Pain in Older Persons" August 2009-Vol.,57, NO.8 copyright 2009.."Persistent pain or its inadequate treatment is associated with a number of adverse outcomes in older people, including functional impairment, falls, slow rehabilitation, mood changes (depression and anxiety), decreased socialization, sleep and appetite disturbance.."