Every finding on record at Life Care Center of North Glendale

Based on observation, staff interviews, and facility policy and procedure the facility failed to ensure that food items were stored, dated, and labeled in accordance to professional standards. The deficient practice could lead to food borne illnesses.Findings Include:Observation of freezer on June 9, 2026 at 8:21 A.M. with Food Service Director (staff #45) revealed two personal size pepperoni pizzas and four burritos were not covered, open to air and not dated. Observation of #1 refrigerator on June 9, 2026 at 8:23 A.M. revealed a tray of individual clear cups with lids containing tartar sauce and coleslaw that were not dated. Also, a gallon container of relish that was half full did not have an open date.Observation of dry storage area on June 9, 2026 at 8:35 A.M. revealed a box of rainbow sprinkles open and no date of when opened. Bread crumbs were in a large container and it was dated January 2, 2026 and the use by date was June 2, 2026. Also, a large container of salt was dated January 2, 2026 and the use by date was June 2, 2026. In addition, Corn Flakes were in a container dated January 2, 2026 and use by date June 2, 2026, and Raisin Bran dated January 2, 2026 and use by date June 2, 2026. Also, Caramel sauce and chocolate syrup which were both opened were not labeled with date opened or use by dates.Observation of the #2 refrigerator on June 9, 2026 at 8:50 A.M. revealed individual cups of liquid that were not dated. Also, 18 pitchers with tea and lemonade were on a cart unrefrigerated and open to air with no label or date. Observation on June 10, 2026 at 1:12 P.M. revealed a 3rd floor hydration cart with a blue cooler on top of the cart and an ice scoop that was lying next to the blue cooler on the cart and was not in the ice scoop holder. An interview on June 10, 2026 at 1:15 P.M. with staff #45 stated that the ice scoop should be in the scoop holder and not on the top of the cart. This could cause cross contamination or bacteria in the beverages. Staff #45 stated that she does weekly checks on food items placed in the refrigerators, freezers, and dry storage areas, to ensure that food items are labeled, dated, and stored correctly. She stated that the risk of the food items not labeled, dated, and stored correctly could cause food contamination and someone could get sick. Staff #45 stated she completes training with her staff every year and as needed if a new staff member starts or if there is a concern that she notices.An interview was conducted with the Administrator/ Executive Director (Staff #160) on June 11, 2026 at 9:25 A.M. to review food storage and labeling, expired foods, and sanitation practices for the ice scoop. Staff #160 stated the food items should be labeled and dated and thrown away if expired, and the ice scoop should be in the holder at all times.The facility policy on food safety and sanitation revised May 26, 2026 states food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Pre-packaged food is placed in a leak-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). The use by date is noted on the label or product when applicable. Food is labeled with the date received if not already indicated on the item. Opened packages of food are resealed tightly to prevent contamination of the food items and use by date will be used when applicable.

Based on review of the clinical record, resident and staff interviews, observations, facility documentation, and policy and procedure, the facility failed to ensure respiratory care was provided with professional standards of practice for one resident (#59). The deficient practice could result in care or services that do not meet residents' needs. The universe was 125 and the sample size was 1.Findings includeResident #59 was admitted on [DATE], with diagnoses including pneumonia, chronic respiratory failure with hypoxia, and congestive heart failure.A care plan dated April 29, 2026, revealed a focus for oxygen therapy. Interventions include observing for signs and symptoms of respiratory distress and reporting to the medical doctor as needed, monitor for respiratory distress including respiratory rate, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, and changes in skin color.A quarterly Minimum Data Set (MDS) assessment date May 5, 2026 included a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment revealed the resident had no indicators for mood or behavior. Further review of the MDS revealed the resident was on oxygen therapy while a resident.Review of the Electronic Health Record (EHR) from May 11, 2026 to June 10, 2026 revealed no pulse oximeter readings.A physician's order dated June 9, 2026 revealed an order for oxygen to be administered at 2 liters per minute (LPM) via nasal cannula, as needed. During initial screening, an interview was conducted on June 9, 2026 at 9:56 am with resident #59. The resident stated he relies on oxygen for breathing support during the night. He further stated he had not been receiving oxygen and his oxygen tubing had not been re-applied after his shower the previous night. During the interview, the resident's oxygen tubing was observed lying on the floor beneath the bed and was not within residents reach. No label or date was observed on the oxygen tubing. The oxygen concentrator was on and set to 3.5 LPM.A second observation was conducted on June 9, 2026 at 10:52 am with Licensed Practical Nurse (LPN/staff #108). Staff #108 observed the nasal cannula lying on the floor underneath the resident's bed. She picked up the oxygen tubing from beneath the bed, removing it from the concentrator and disposed of it in the garbage can. She stated the risk of the nasal cannula being on the floor places the resident at risk of infection. She further stated that having the oxygen tubing out of the resident's reach placed the resident at risk of not being able to access oxygen therapy if needed.A physician's order dated June 10, 2026 revealed an order to check oxygen saturation rates every eight hours.An observation was conducted on June 10, 2026 at 9:23 am of resident #59. There was no oxygen tubing connected to the oxygen concentrator located in the resident's room. The resident stated he experienced difficulty breathing the night before because staff had not replaced his oxygen tubing from the night before, nor had the checked on his oxygen needs.An observation was conducted on June 10, 2026 at 12:26 pm of resident #59. The resident was sleeping and wearing a nasal cannula. The oxygen tubing was connected to the oxygen concentrator which was set to a flow rate of 2.6 LPM.An interview was conducted on June 10, 2026 at 1:34 pm with staff #108. She stated upon entering the resident's room at lunchtime, she observed the resident's oxygen saturation level was at eight-eight percent and noted the resident was wheezing. She stated she was unable to provide documentation of the oxygen level check, as the information had not been entered into the resident's records. Staff # 108 stated she contacted the physician to request new orders to increase the oxygen levels and to conduct a chest x-ray. She stated there were no standing orders to check the resident's pulse oximetry. She further stated facility policy states oxygen saturation levels should be monitored each shift and documented during observations. She stated nurses are responsible for placing orders for oxygen saturation checks, and stated the oxygen saturation checks had not been completed for this resident.An observation was conducted on June 10, 2026 at 1:40 pm by staff #108. She assessed the resident's oxygen level, and stated she originally set the oxygen concentrator to 3 LPM, but the concentrator was now set to 2.6 liters. She further stated the resident had a continuous oxygen order for 3 LPM. Staff # 108 stated it is the responsibility of nursing staff to adjust oxygen flow rate or monitor oxygen saturation levels could result in shortness of breath or respiratory issues for the resident.An interview was conducted on June 10, 2026, at 2:00 pm with the Certified Nursing Assistant (CNA/staff #71). She stated CNAs are not permitted to adjust the oxygen flow rate for any resident. She further stated if a resident's oxygen tubing falls off, the CNA is supposed to replace the tubing and reapply the nasal cannula to the resident.An interview was conducted on June 12, 2026, at 11:39 AM with the Director of Nursing (DON/staff # 14). The DON stated oxygen tubing should be disposed of properly and replaced to prevent risk of infection. She stated nurses must ensure that oxygen tubing is not left on the floor. The DON further stated vital signs for oxygen therapy are dependent on physician orders, including saturation levels. If oxygen is prescribed on an as needed basis, the resident should have an order for pulse oximetry checks, which allows the nurse to determine if the oxygenation level is therapeutic for the resident. She stated if nurses do not have an order to check oxygenation saturation levels, they should contact the provider to obtain one. The DON stated there is no facility policy specifying when oxygen saturation levels should be checked, but nurses are expected to regularly assess the resident's skin color and level of orientation. She stated failure to monitor pulse oximetry readings and maintain the ordered oxygen flow rate could result in residents experiencing shortness of breath.A review of the facility policy titled Oxygen Administration (Infection Control, Safety, and Storage) revised 03/03/2026 states to ensure that oxygen is administered and storedOxygen supplies weekly and when visibly soiled, equipment should be labeled with resident name and dated when set up or changed out.Store oxygen and respiratory supplies in bag labelled when not in use.A review of the facility policy titled A review of the facility policy titled Pulse Oximetry revised 10/14/2021 and reviewed 09/24/2025 states:The facility will provide pulse oximetry in accordance with professional standards of practice as outlined by Lippincott procedures.

Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that Preadmission Screening and Resident Review Screening (PASRR) was completed for one of two residents (#6), the universe was 125, with a diagnosis of a serious Mental Illness (MI) was referred to the appropriate state-designated authority and determination received. The deficient practice could result in residents not receiving the necessary specialized services that they require. Findings Include:Resident #6 was admitted to the facility on [DATE], with diagnoses that included schizophrenia, major depressive disorder, anxiety disorder, type 2 diabetes mellitus, heart failure and renal failure.The physician order dated included following:-Rexulti (Brexpiprazole) 1 mg give one tablet by mouth one time a day for schizoaffective disorder ordered August 19, 2025.-Prozac (Fluoxetine HCI) 40mg give 2 capsules by mouth one time a day for depression ordered on September 6, 2022.-Trazodone 100mg give 1 tablet by mouth at bedtime for anxiety ordered on May 9, 2026.A Minimum Data Set (MDS) assessment dated [DATE] for resident #6, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the individual's cognitive abilities are fully intact with no significant impairment. The resident #6 was administered high risk medication that included Rexulti (Brexpiprazole) 1mg 1 tablet by mouth one time a day for Schizophrenia.A review of care plan dated April 7, 2026 revealed resident #6 had the potential of psychosocial wellbeing problem and change in mood or behavior related to diagnosis of anxiety disorder, major depressive disorder and schizoaffective disorder. The resident #6 is to be monitored every shift for sedation, drowsiness, dry mouth, blurred vision, tardive dyskinesia, and seizure disorder.Further review of the medical record revealed a PASSR Level 1, dated April 8, 2026, completed for resident #6 had no determination results received by the state-designated authority.A Pre-admission Screening and Resident Review (PASRR) Level 1, dated April 15, 2025, for resident #6 revealed the resident had a Mental Illness (MI) that included Schizophrenia. The screening was completed by the facility with no determination results received by the stated-designated authority.An interview was conducted on June 11, 2026 at 10:20 A.M. with the Social Services Assistant (staff #116) who stated that it was her responsibility to complete PASRR Level 1 and send it to the state-designated authority and track the determination results. She stated that on admission she ensures that all residents have a PASRR Level 1 completed and she then sends to the state-designated authority by email. If she receives a determination result she prints it out and places it in her PASSR binder. She stated that resident #6, there was a Level 1 PASRR dated April 15, 2025, which had no response indicating state review or determination results were received. Furthermore, she stated a PASSR Level 1 was completed for resident #6 on April 8, 2026 and no response indicating state review or determination results were received.An interview was conducted on June 11, 2026 1:44 pm the Director of Nursing (DON/staff #14) and Executive Director (ED/staff #160) who stated a PASSR Level 1 is sent to the state-designated authority for review for all residents and determination results should be received. The DON stated the risk of not receiving the Level 1 determination could result in the resident not receiving the appropriate level of care and services.An interview was conducted on June 12, 2026 with staff #116 at 8:23 A.M. who confirmed that she was not able to find determination results for resident #6 for PASSR dated April 15, 2025 and April 8th, 2026.The facility policy on pre-admission screening and resident review (PASARR), reviewed on 9/26/25 states the facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as a PASARR Level I. A negative Level I screen permits admission to proceed and ends the PASARR process. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level 2. The record of the pre-screening should be retained in the resident's medical record.

Based on a review of clinical records, staff and resident interviews, and facility policies and procedures, the facility failed to ensure that pain medication for one (Resident #132) of nineteen sampled residents was administered in accordance with physician orders. The facility census was 125. This deficient practice had the potential to result in overmedication, adverse drug effects, impaired pain management, and inaccurate assessment of the resident's pain status.Findings include:Resident #132 was admitted to the facility on [DATE], with diagnoses that included cellulitis of the left and right lower extremities, muscle weakness, cognitive communication deficit, psychoactive substance abuse, and alcohol abuse in remission.Resident #132's care plan dated May 16, 2026, revealed a focus stating that the resident experienced pain related to infection of the bilateral lower extremities. Interventions included administering pain medication as ordered and attempting non-pharmacological interventions prior to pain medication administration.Review of a physician's order dated May 17, 2026, revealed Hydromorphone HCl Tablet 2 mg was to be administered by mouth every four hours as needed for pain levels of 6-10 on a 0-10 pain scale.Review of the Medication Administration Record (MAR) for May 2026 revealed Hydromorphone was administered four times when the documented pain level was below the physician-ordered parameter of 6-10. These administrations included: May 21, 2026 - Pain level 4; Hydromorphone administered at 10:39 a.m. May 21, 2026 - Pain level 4; Hydromorphone administered at 2:49 p.m. May 28, 2026 - Pain level 1; Hydromorphone administered at 4:53 p.m. May 29, 2026 - Pain level 3; Hydromorphone administered at 7:49 p.m.Review of the Medication Administration Record (MAR) for June 2026 revealed Hydromorphone was administered three times when the documented pain level was 0. These administrations included: June 5, 2026 - Pain level 0; Hydromorphone administered at 7:49 a.m. June 5, 2026 - Pain level 0; Hydromorphone administered at 12:51 p.m. June 5, 2026 - Pain level 0; Hydromorphone administered at 5:27 p.m.On June 12, 2026, at 9:57 a.m., an interview was conducted with Licensed Practical Nurse (LPN/Staff #25). Staff #25 stated that when a resident has an as-needed order for pain medication, the nurse should ask the resident to rate their pain on a scale of 1 to 10 and attempt non-pharmacological interventions, such as repositioning. Staff #25 stated that pain medication should only be administered within the physician-ordered pain scale and time parameters.On June 12, 2026, at 12:21 p.m., an interview was conducted with the Director of Nursing (DON/Staff #14). Staff #14 stated it was her expectation that when a resident reports pain, the nurse should assess the resident's pain level using a 1-to-10 pain scale, implement non-pharmacological interventions when appropriate, and administer medication according to the physician's order. Staff #14 stated that medications should only be administered as ordered. Staff #14 further stated that administration of pain medication outside physician-ordered parameters could negatively affect pain management and place the resident at risk for adverse outcomes associated with inappropriate medication administration.Review of the facility policy titled Administration of Medications, reviewed September 9, 2025, revealed that the facility must ensure medications are administered safely and appropriately in accordance with physician orders to address residents' diagnoses, signs, and symptoms.

Based on observations, clinical record reviews, facility documentation, staff and resident interviews, and policy and procedures, the facility failed to ensure that medications were secured in a locked storage area and were accessible only to authorized personnel for Residents #27 and #66. The universe was 125, and the sample size was 2. Findings include: -Regarding Resident #66: Resident #66 was admitted on [DATE], with diagnoses that included type 2 diabetes mellitus, venous insufficiency, and end-stage renal disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. The assessment revealed no indicators for mood or behavior. Further review revealed the resident is at risk for developing pressure ulcers and skin injuries. The resident was always incontinent of bowel and bladder. During initial screening, an observation conducted on June 9, 2026, at 10:27 a.m. revealed a container of Coloplast Hydrophilic Wound Dressing Ointment located at the resident's bedside on the windowsill. An observation was conducted on June 9, 2026, at 10:42 a.m. A Certified Nursing Assistant (CNA/Staff #142) was observed entering the resident's room to provide care. An interview was conducted on June 9, 2026, at 10:51 a.m., with Licensed Practical Nurse (LPN/Staff #108). Staff #108 observed the wound dressing ointment at the windowsill. She stated the wound dressing ointment should not be kept at the resident's bedside and should only be administered by a nurse. She stated the risks associated with leaving the ointment in the room are that a Certified Nursing Assistant (CNA) may accidentally use the dressing as a barrier cream and place the resident at risk for infection. A physician's order dated June 11, 2026, at 9:55 a.m. revealed an order for TRIAD cream application to the wound bed on the right buttock and cover with bordered foam dressing. The Medication Administration Record and Treatment Administration Record (MAR/TAR) for June 2026 revealed that the TRIAD cream treatment was administered by licensed nursing staff. An interview was conducted on June 11, 2026, at 11:20 a.m. with a Wound Care Nurse (Staff #74). Staff #74 stated that Hydrophilic Wound dressing is used for treating open wounds, particularly those that are draining. She stated that the medication is used to dry out the wound and promote healing. She stated that this should be applied by nursing staff only. The medication should not be kept at the resident's bedside. She further stated the resident is currently receiving treatment for a skin tear and abrasion on the right lower leg. She stated that the hydrophilic dressing was not included in the current orders. She stated that most wound care is scheduled during the day shift, Monday through Friday. She further stated that wound care medications are stored in the medication cart, which is locked. She stated access to these medications is limited to authorized personnel. She also stated nurses are to return the supplies and medications to the medication rooms. She stated that all nurses are responsible for applying wound care treatments and providing comprehensive care to all residents within the facility. She further stated that the risk associated with leaving medication at the resident's bedside could lead to improper application, and the medication must be applied by nursing staff to ensure safety and effectiveness. An interview was conducted on June 11, 2026, at 10:21 a.m., with (LPN/Staff #61). She stated nurses administer topical medications and store them in the medication storage room. She stated medications should never be stored in a resident's room. She stated the risks associated with medications being left in resident rooms included rashes, overmedication, sickness, and medication interference. An interview was conducted on June 11, 2026, at 10:35 a.m., with a Certified Nursing Assistant (CNA/Staff #57). Staff #57 stated that medications should never be stored in resident rooms. He stated that if staff observed medication in a resident's room, they would notify nursing staff. He stated risks included another resident taking the medication or accidentally dropping the medication on the floor. An interview was conducted on June 12, 2026, at 11:25 a.m., with the Director of Nursing (DON/Staff #14). The DON stated that medications and treatments are not to be left at the bedside and that nursing staff routinely monitor resident rooms. She stated residents may only self-administer medications if a physician order is obtained and an interdisciplinary team assessment determines the resident is capable of safe self-administration. The DON stated that medications and treatment supplies are expected to be stored in the medication cart or medication room. She further stated wound care products, ointments, and similar treatment items should not be kept in resident rooms, and staff would be expected to remove them if found. She stated the risks of having ointments or medications at the bedside could result in a resident taking the medication by mouth and could cause a stomachache. -Regarding Resident #27: Resident #27 was admitted on [DATE], with diagnoses including acute embolism and thrombosis, quadriplegia, and osteoarthritis. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment revealed no indicators for mood or behavior. Further review of the MDS revealed the resident had frequent pain, which occasionally interfered with sleep and daily activities, and a reported pain intensity of 7 out of 10. A care plan dated April 30, 2026, revealed no care area for medication self-administration. Further review of the care plan revealed a focus area for knee pain and chronic arthritis. Interventions included observing and reporting complaints of pain and administering analgesics as ordered by the physician. A review of the resident's electronic health record (EHR) indicated no assessment for self-administration. During initial screening, an observation was conducted on June 9, 2026, at 10:45 a.m., in resident #27's room. A container of Icy Hot topical analgesic was observed on the resident's bedside table. The resident stated she used the product for aching bones, applied it herself, and believed staff were aware she had it. An interview was conducted at 10:48 a.m. with Licensed Practical Nurse (LPN/Staff #108). Staff #108 observed the Icy Hot ointment at the resident's bedside and stated the resident was not supposed to have the Icy Hot ointment in her room. She stated the risks of having the ointment at the bedside are that the resident could put too much on, become confused, and eat the ointment. She further stated the ointment is to be kept by nursing staff and requires a physician's order. She stated that if the resident wanted to use Icy Hot, the nurse would need to administer it. A physician's order dated June 9, 2026, at 11:15 a.m. revealed an order for Icy Hot PM External Lotion 7.5% Menthol Topical Analgesic application to the lower back topically every 12 hours as needed for pain. A review of the Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed that the resident had no documented administration of Icy Hot in June 2026. An interview was conducted on June 11, 2026, at 10:21 a.m., with (LPN/Staff #61). She stated nurses administer topical medications and store them in the medication storage room. She stated medications should never be stored in a resident's room. She stated the risks associated with medications being left in resident rooms included rashes, overmedication, sickness, and medication interference. An interview was conducted on June 11, 2026, at 10:35 a.m., with a Certified Nursing Assistant (CNA/Staff #57). Staff #57 stated that medications should never be stored in resident rooms. He stated that if staff observed medication in a resident's room, they would notify nursing staff. He stated risks included another resident taking the medication or accidentally dropping the medication on the floor. An interview was conducted on June 12, 2026, at 11:25 a.m. with the Director of Nursing (DON/Staff #14). The DON stated that medications and treatments are not to be left at the bedside and that nursing staff routinely monitor resident rooms. She stated residents may only self-administer medications if a physician order is obtained and an interdisciplinary team assessment determines the resident is capable of safe self-administration. The DON stated that medications and treatment supplies are expected to be stored in the medication cart or medication room. She further stated wound care products, ointments, and similar treatment items should not be kept in resident rooms, and staff would be expected to remove them if found. The DON stated that if a resident possessed Icy Hot, nursing staff would be expected to secure the product and obtain appropriate physician orders if its use was indicated. She stated that having ointments or medications at the bedside could lead a resident to take the medication by mouth, causing a stomachache, or to apply the ointment to their face, which could cause numbness and require saline drops to reduce it. Review of the facility policy titled Self-Administration of Medication, revised 10/01/2021 and reviewed on 09/15/2025, revealed the facility will ensure each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications. The facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications that are requested from a central location, or the resident is able to safely store the medication in a secure area in their room, and safely administer the medication as prescribed. Review of the facility policy titled Administration of Medications, revised on 02/13/2023 and reviewed on 09/09/2025, revealed the facility will ensure medications are safely and appropriately administered per physician order to address residents' diagnoses and signs and symptoms.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported immediately and within 2 hours to mandated entities for one resident (#2). The deficient practice could result in continued abuse of a resident.-Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses that included displaced fracture of medial malleolus of right tibia, displaced fracture of lateral condyle of left femur, urinary tract infection, and acute kidney failure.A Cognitive Patterns note dated October 30, 2025, revealed Resident #2 had a brief interview for mental status (BIMS) assessment score of 12, indicating moderately impaired cognition.An incident report dated October 30, 2025, revealed that on the evening of October 31, 2025, Resident #2's family came to the nurses' station and told the nurse on duty that Resident #2 told the family member that the resident was raped. When the nurse entered the resident's room and asked the resident what happened, the resident claimed that a night shift male staff member came into her room and touched her inappropriately in her genital area with his knuckles. The report also revealed that Resident #2 was assessed head to toe for injury, with no injuries observed. The report revealed that the family member was notified of the incident on October 31, 2025 at 10:15 P.M., the provider and the local police were notified on October 31, 2025, at 10:30 P.M., and the State Agency was notified on November 1, 2025, at 1:18 P.M.A Nursing note dated October 31, 2025, revealed the nurse (Staff #29) was alerted by Resident #2's family that Resident #2 was claiming abuse. The note revealed that nursing management, administration, and the local police department were notified. Additionally, the police came to the facility and investigated, staff were interviewed, and an assessment of Resident #2 was performed.An Event Note dated October 31, 2025, revealed Resident #2 made an allegation of abuse against a male staff member from the night shift of October 30, 2025. The note revealed that Resident #2 was assessed by a female registered nurse (RN) right away, and no signs of any injury were noted. The alleged male staff member was placed on suspension pending investigation, and all authorities and agencies were notified. Additionally, the note revealed that the resident's family was present at the time.A Report of Allegation of Neglect, Abuse, Misappropriation of Property, and Exploitation Form revealed the alleged incident occurred on October 30, 2025, at 10:00 P.M. The report revealed that the local police were notified on October 31, 2025, at 10:30 P.M., the State Agency was notified on November 1, 2025, at 1:18 A.M., and Adult Protective Services (APS) was notified on November 1, 2025 at 1:30 A.M.An email to the facility Administrator (Staff #6) from the online APS submission portal, revealed a confirmation of submission of intake #599415 on November 1, 2025 at 1:30 A.M.An email dated November 1, 2025, at 1:39 A.M. from the facility Administrator (Staff #6) to the State Agency, revealed that the facility staff attempted to submit the self-report of alleged abuse on November 1, 2025, at 1:18 P.M., but could not due to a server error. The facility self-report complaint attached to the email revealed that on October 31, 2025, at around 10:00 P.M., Resident #2 reported to her nurse that yesterday a night male nurse raped her.An interview was conducted with the Social Services Director (Staff #19) on November 4, 2025, at 1:56 P.M. Staff #19 stated that if there was an allegation of abuse, that it would be reported to the Administrator (Staff #66), who is the abuse coordinator, and then Staff #19 would notify APS and the ombudsman of the allegation. Regarding Resident #2, Staff #19 stated that the resident's allegation of abuse came to staff's attention over the weekend, so the Administrator completed the reports to APS and the ombudsman.A telephonic interview was conducted on November 4, 2025, at 1:48 P.M. with an RN (Staff #22), who stated that he was a nurse on duty on October 31, 2025, and was first notified of Resident #2's allegation on October 31, 2025, at around 10:00 P.M., when the resident's family member approached Staff #22 in the hallway and stated that Resident #2 had been raped the night before. Staff #22 stated that he then went to Resident #2's room and took the resident's statement that she had been touched inappropriately by a male staff. Staff #22 stated that he notified nursing management, the local police, and the Administrator immediately, and that the Administrator came to the building within 20-25 minutes. Staff #22 stated that the Administrator started the investigation process right away, and the local police interviewed Resident #2.An interview was conducted with a certified nursing assistant (CNA / Staff #31) on November 5, 2025, at 9:51 A.M. Staff #31 stated that if there is an allegation of abuse of a resident, that staff would be expected to immediately inform the nurse, the charge nurse, and the Administrator. Staff #31 stated that the importance of immediate notification to facility management would be to ensure the safety of the resident by investigating the allegation right away.An interview was conducted with a licensed practical nurse (LPN / Staff #57) on November 5, 2025, at 9:54 A.M. Staff #57 stated that if there was an allegation of abuse of a resident, that staff are expected to report the allegation immediately to the Administrator. Staff #57 stated that the importance of immediate reporting is to ensure residents are safe and to investigate what is going on, and if abuse is ongoing, to stop it immediately.An interview was conducted with the Director of Nursing (DON / Staff #4) on November 5, 2025, at 10:34 P.M. Staff #4 stated that if staff heard an allegation of abuse of a resident, that she would expect staff to report the allegation right away to the abuse coordinator (Staff #66). Staff #4 stated that then, the facility is required to report the allegation of abuse immediately, and within 2 hours, to the State Agency, APS, the police, and the ombudsman. Staff #4 stated the purpose of immediate reporting to outside entities is to makes sure there is an immediate response, and that the resident is attended to immediately.An interview was conducted with the Administrator (Staff #66) on November 5, 2025, at 10:41 A.M. Staff #66 stated that if staff heard an allegation of abuse of a resident, that staff should notify her, and then Staff #66 would make the determination if the allegation is going to be reported to outside entities. Staff #66 stated that allegations of abuse must be reported to outside entities within 2 hours. Also, Staff #66 stated that during normal business hours, Staff #66 would make the report to the State Agency, nursing management would call the local police, and the Social Service Director would notify APS and the ombudsman. Regarding Resident #2, Staff #66 stated that since the allegation was first brought up to the nurse late at night, that Staff #66 did all the reporting to the mandated entities. Staff #66 stated that she was first notified of the allegation between 10:00 and 10:15 P.M. on October 31, 2025. Staff #66 stated that it was 1:18 A.M. on November 1, 2025, when she tried to submit the report to the State Agency on the online portal, however there was a server error, so she scanned the report and sent it by email instead. Staff #66 stated that she was a little over the mandated timeframe for reporting to the State Agency.Review of the facility policy titled Area of Focus: Abuse & Neglect, reviewed November 19, 2024, revealed that each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone. In response to allegations of abuse, the facility must ensure that all alleged violations involving abuse, are reported immediately but not later than 2 hours after the allegation is made, to the Administrator and to other officials, including to the State Survey Agency and adult protective services.

Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to ensure sufficient staffing to provide for the needs of the residents. The deficient practice could result in residents not receiving the assistance required to complete care tasks. Findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, depression, and anxiety. The care plan dated November 29, 2024 revealed that the resident had bowel incontinence. Interventions included to assist with toileting as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 which indicated that the resident was cognitively intact. -Resident #33 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, vascular dementia, and an overactive bladder. The care plan dated February 10, 2023 revealed that the resident had bowel incontinence. Interventions included assist with toileting as needed. The care plan dated February 10, 2023 revealed that the resident had an activity of daily living (ADL) self-care performance deficit related to impaired mobility, and a recent right tibia/fibia fracture. Interventions included to assist with: bathing/shower, bed mobility, dressing, eating, personal hygiene, toilet use, and transfers. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 which indicated that the resident was cognitively intact. -Resident #44 was admitted to the facility on [DATE] with diagnoses that included colostomy status, generalized weakness, and an overactive bladder. A care plan dated January 20, 2025 included that the resident is at risk for injury related to falls. Interventions included to assist with all ADLs. The care plan dated January 20, 2025 revealed the resident had an ostomy. Interventions included to provide ostomy care as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 which indicated that the resident had a moderate cognitive impairment. The care plan dated March 11, 2025 revealed that the resident has a Foley catheter and interventions included to provide catheter care each shift. -Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included irritable bowel syndrome, chronic stage III kidney disease, and paroxysmal atrial fibrillation. The care plan dated July 30, 2017 revealed that the resident had weakness and poor endurance due to heart failure, neuropathy, chronic pain syndrome, mobility and ADL deficits. Interventions included to encourage the resident to use the bell for assistance. The care plan dated July 30, 2017 revealed that the resident was at risk for falls due to weakness, pain meds, psychotropic meds, occasional bladder incontinence, cardiovascular disease, cardiovascular meds, and diuretics. Interventions include to anticipate and meet the resident's needs and to assist with ADLs as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. -Resident #22 was admitted to the facility on [DATE] with diagnoses that included paraplegia unspecified, generalized muscle weakness, and disorder of muscle unspecified. The care plan dated May 27, 2024 revealed that the resident is incontinent of bowel. Interventions include to assist with toileting as needed. The care plan dated June 12, 2024 included a self-care performance deficit related to paraplegia. Interventions include to assist with ADLs as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. -Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included morbid obesity chronic obstructive pulmonary disease, and Diverticulosis. The care plan dated November 11, 2021 revealed mobility and ADL deficits due to weakness, decreased balance, left foot drop, decreased range of motion in the left hip and knee, and pain. Interventions included that the resident needs one to two staff for transfers. Use the Hoyer lift as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. -Resident #99 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure, unspecified dementia, and generalized weakness. The care plan dated June 7, 2022 revealed that the resident has an ADL self-care performance deficit related to dementia, disease process, and impaired balance. Interventions included a mechanical lift with two staff assistance for transfers. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. Resident #110 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, generalized muscle weakness, and irritable bowel syndrome with diarrhea. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. The care plan dated August 12, 2024 revealed an ADL self-care performance deficit related to activity intolerance. Interventions included to assist with ADLs. Review of the staffing schedules, daily staff posting, and time cards for staff working on Hall 200 for the months of February and March 2025, revealed that the facility was short staffed. Review of the resident council meeting notes: -August 13, 2024 revealed a concern regarding call-light response time and staff turning off the call-light without helping the resident if the resident is asleep. -October 12, 2024, DON came to the resident council meeting and addressed issues. She will be doing an in-service for all issues that were brought up. -November 16, 2024, requesting help on the second floor (Hall 200) with trays as soon as they come out because by the time they are served, the food is cold, which is a food safety concern after twenty-three minutes. -January 14, 2025, no resident council meeting due to COVID outbreak. -February 17, 2025, food trays on the second floor are not being passed in a timely manner, needing more aides on the floor, issues with getting up for activities and the aides are not bringing them to activities. An interview was conducted on March 11, 2025 at 9:34 a.m. with resident #55, who stated that she has had to wait up to two hours for her call-light to be answered and this mostly happens during the night shift. She has waited up to three hours for continence care and has a rash. She has asked certified nursing assistants (CNAs) why it is taking so long to answer the call-lights and was told that that staff have too many patients. She stated that she had to wait a couple of hours yesterday to be changed. She also stated that the food is often cold by the time it is served. An interview was conducted on March 11, 2025 at 9:45 a.m. with resident #33, who stated that she has had to wait up to four hours for staff to answer her call-light and provide continence care. She stated that her roommate (resident #55) had to wait for four hours to be changed and it was reported. She stated that sometimes there is only one CNA. She stated that the food is always cold by the time it is served and the CNAs will heat it if asked, but begrudgingly, because they are so busy. An interview was conducted on March 11, 2025 at 9:55 a.m. with resident #44, who stated that that she has waited forty-five minutes for her call-light to be answered more than once. She stated that this morning she was supposed to get up at 6:00 a.m. and waited for staff until 7:15 a.m. with the call-light on. She asked staff what took so long and staff told her that she was too busy. She stated that one time her colostomy bag was leaking, got all over her clothes, and she waited 30 minutes to be taken to the toilet and change her clothes. An interview was conducted on March 11, 2025 at 10:25 a.m. with resident #66, who stated that she waits twenty to thirty minutes on a good day for her call-light to be answered and sometimes staff don't come. She stated that about 50% of the time, staff don't answer her call-light and she has to get in her wheelchair and go find staff to assist with things like taking her tray away, get ice water and to get clean sheets and linens. She has complained to the Resident Council President. She stated that the food is always cold by the time it is served. An interview was conducted on March 11, 2025 at 10:38 a.m. with resident #22, who stated that he has waited two hours for his call-light to be answered. He stated that one time he had a bowel moment and urinated, and when the CNA answered the call light, she told him that he would have to wait for his CNA to return from lunch. He referred to his binder and stated that on - February 21, 2025, a CNA came and told him that she had to help other residents and left. He waited one and a half hours to be changed and he also had waited from 11:30 a.m. to 1:30 p.m. for a CNA to bring him ice water. He stated that there were only two CNAs working. -On February 23, 2025, the CNA answered his call-light and told him that she needed to help other residents; she returned after an hour and a half to get him some ice water and to dump his pee bottle. -On February 24, 2025, his call-light was on and the CNA told him that he had to wait because the CNA was helping other residents. He stated that he waited from 3:30 p.m. to 5:30 p.m. to be changed and he got a rash around his groin area. -On February 27, 2025, he had a bowel movement at 7:40 p.m. and wasn't changed until about 11:00 p.m. and he had diarhea. He stated that the CNA told him that she had to go down the line because other residents needed to be changed. -On March 1, 2025, his call-light was on at 10:00 a.m. because he needed to be changed and the light was not answered until 10:45 a.m. -On March 5, 2025 his call-light was on at 9:00 a.m. and was answered at 11:00 a.m. and he needed to be changed. Staff told him that she was sorry, but they were short staffed again and there were other residents ahead of him. -On March 10, 2025, he stated that he waited two hours to get changed. An interview was conducted on March 11, 2025 at 11:46 a.m. with resident #88's spouse, who stated that he asked a female staff to get the resident up out of bed. The resident was observed lying in bed. He stated that the staff told him that she would help the resident after serving the lunch trays. He stated that they have waited twenty to thirty minutes for the call-light to be answered and needed assistance with getting and being changed. An interview was conducted on March 11, 2025 at 11:52 a.m. with resident #99, who stated that she had placed the call-light on about 10:30 a.m. because she wanted staff to help her get up and staff did not respond until about 11:30 a.m. She stated that staff got her up right before lunch. She stated that had waited for thirty minutes for her call-light to be answered when she needed to use the toilet and ended up having a incident in her brief. Staff has told her that she is not the only one here. She stated that sometimes there is only one CNA working on the hall. An interview was conducted on March 11, 2025 at 1:15 p.m. with resident #110, who stated that the food is often cold because staff are very busy, so residents may have to wait for food trays to be served for fifteen to twenty minutes after the food cart has been delivered to the hall. She also stated that there are plastic covers for the food carts, but they aren't being used, so food may lose heat faster. She stated that residents are complaining about call-light response time and say that they are waiting more than an hour. She stated that the Director of Nursing (DON/staff #1) came to a resident council meeting that the facility is trying to hire more staff, but right now the facility doesn't use registry staff and the current staff are working doubles, so staff are getting burnout, look physically tired, seem apathetic, and lack enthusiasm. She stated that she doesn't have the stamina to stay up all day and has waited up to an hour for staff to transfer her to bed. An interview was conducted on March 11, 2025 at 2:06 p.m. with the Staffing Coordinator (staff #33), who stated that she is responsible for the staffing schedules and there are three shifts for the CNAs: 6:00 a.m. to 2:30 p.m., 2:00 p.m. to 10:30 p.m., and 10:00 p.m. to 6:30 a.m. She stated that there are two shifts for the nurses, 7:00 a.m. to 7:30 p.m. and 7:00 p.m. to 7:30 a.m. She stated that Hall 200 is long-term care, so the census basically stays the same, which is approximately 56 and in order to provide care the facility needs: -two nurses and a unit manager from 7:00 a.m. to 7:30 p.m, two nurses 7:00 p.m. to 7:30 a.m. -five to six CNAs from 6:00 a.m. to 2:30 p.m. -five to six CNAs from 2:00 p.m. to 10:30 p.m. -three CNAs from 10:00 p.m. to 6:30 a.m. Staff #33 reviewed that the staffing schedules, the daily staff postings, and hours worked by staff for Hall 200 and stated: -February 1, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. because she was not able to find anyone to work. -February 1, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 2, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 4, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 5, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 11, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 15, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 17, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 18, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 21, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 24, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 25, 2025, there were only four CNAs on Hall 200 from 6:00 a.m. to 2:30 p.m. -February 1, 2025, there were only two CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then two CNAs came at 6:00 p.m. -February 3, 2025, there were only three CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 5, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. -February 6, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 11, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. -February 12, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 13, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 14, 2025, there were only three CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 14, 2025, there were only three CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 15, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 17, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 18, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. -February 19, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. and then one CNAs came at 6:00 p.m. -February 20, 2025, there were only four CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. -February 21, 2025, there were only two CNAs on Hall 200 from 2:00 p.m. to 10:30 p.m. One CNA from the day shift stayed about two hours and one CNA came in around 8:00 p.m. -February 22, 2025, there were only one CNAs on Hall 200 from 2:00 p.m. to 10:00 p.m., one CNA from the day shift stayed about two hours, one CNA worked from 2:00 p.m. to 6:00 p.m. and two CNAs worked from 6:00 p.m. to 10:30 p.m. -February 23, 2025, there were three CNAs from 2:00 p.m. to 10:00 p.m. on Hall 200 and one CNA from CNA from 6:00 p.m. to 10:30 p.m. -February 24, 2025, there were four CNAs from 2:00 p.m. to 10:30 p.m. and one CNA from 6:00 p.m. to 10:30 p.m. -February 25, 2025, there were four CNAs from 2:00 p.m. to 10:30 p.m. -February 14, 2025, two CNAs worked the 10:00 p.m. to 6:30 a.m. on Hall 200 and she couldn't find anyone else to work the shift. -February 16, 2025, there were only two CNAs on Hall 200 from 10:00 p.m. to 6:30 a.m. -February 22, 2025, there were only two CNAs on Hall 200 from 10:00 p.m. to 6:30 a.m. -February 23, 2025, there were only two CNAs on Hall 200 from 10:00 p.m. to 6:30 a.m. -February 24, 2025, there were only two CNAs on Hall 200 from 10:00 p.m. to 6:30 a.m. -March 1, 2025, there were four CNAs from 2:00 p.m. to 10:30 p.m. and the fifth CNA was scheduled from 6:00 p.m. to 10:30 p.m. but five CNAs are needed for the shift. -March 5, 2025, there were four CNAs from 6:00 a.m. to 2:30 p.m. on Hall 300 because one CNA was on vacation, so she pulled the fifth CNA from Hall 200, which left Hall 200 short staffed. -March 6, 2025, there were four CNAs scheduled for Hall 200 because one CNA was on vacation and she couldn't get anyone to cover the shift. -March 9, 2025, there were only two CNAs from 10:00 p.m. to 6:30 a.m. because the third CNA was on FMLA and she couldn't get anyone to pick up the shift. After reviewing the above staffing ratios, staff #33 stated that the facility is short staffed. She stated that she is scheduling interviews, but people are not showing up and she cannot use registry staff. She can have restorative staff (RNA) help, but then the restorative program doesn't get done. She stated that the (DON/staff #1) supervises the staffing and they go over the schedules together; they have discussed the above staffning needs. She stated that there is a risk of skin breakdown if residents aren't being changed timely and residents have a the right to get up and get out of bed when they want to get up. An interview was conducted on March 12, 2025 at 9:50 a.m. with a certified nursing assistant (CNA/staff #3), who stated that there are a lot of residents who need assistance with bowel movements on Hall 200; she has one resident in room [ROOM NUMBER] who always needs something, so she takes a lot of her time and she has explained that she needs to care for other residents. She stated that sometimes they are short staffed, but there are usually two to three CNAs on Hall 200 during the evening shift and one to two CNAs during the NOC shift. She stated that it takes her approximately fifteen minutes to answer a call-light and she tells the resident that she will come back after helping another resident, which takes twenty minutes or less for her to return, but it is possible that residents are waiting thirty to forty minutes while she is changing other residents. She stated that the supervisors know that they are short staffed and say that they are trying to hire more CNAs. An interview was conducted on March 11, 2025 at 3:34 p.m. with the Director of Nursing (DON/staff #1), who stated that together with the Executive Director are responsible for monitoring the staffing ratios and sufficient staffing is determined by the number of residents and the the acuity, the needs of each resident. She stated that the second floor (Hall 200) is long-term care and the Staffing Coordinator (staff #33) knows how many staff, CNAs, are needed on each floor and lets her know when they are not able to cover a shift. They are trying to hire more CNAs, it is an ongoing process. She stated that resident complaints regarding staffing is nothing new and when residents make a complaint, she tells them that they are trying to hire more staff. She thinks that a 15-minute response time for care is appropriate. An interview was conducted on March 12, 2025 at 10:29 a.m. with (CNA/staff #79), who stated that she has answered call-lights and told the resident that she is finishing up with another resident and will be right back. She stated that if she is in the middle of giving another resident a shower, the resident is going to have to wait for at least twenty to thirty minutes before she can provide care. She stated that residents have complained about waiting all morning, up to three hours for care, but this was mostly before she has arrived for her shift and she reported it to the nurse. She stated that she thinks there is supposed to be five CNAs scheduled to work, but there have been days when there were only four CNAs for the 6:00 a.m. to 2:30 p.m. shift on Hall 200. The facility policy, Staffing revealed that the facility maintains adequate staff on each shift to meet residents' needs.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that residents are free from abuse from other residents. The deficient practice could result in residents being physically and emotionally injured. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, chronic kidney disease, liver disease, atherosclerotic heart disease, and other specified disorders of bone density and structure unspecified site. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. A progress note dated August 13, 2024 revealed that this writer was at the nurse station at 6:40 p.m. when a certified nursing assistant (CNA) yelled out, no don't hit her, while rushing toward the incident. The CNA noticed the resident #37 with left hand balled onto a fist hitting the resident #11 by her left forearm. Nursing staff were immediately present at the incident, and both resident were separated. The Executive Director, Director of Nursing, medical doctor, the power of attorneys, and authorities were notified. This writer didn't notice any injuries upon the initial assessment of both residents. Nursing will continue to follow up with a psych assessment and present medication orders. Safety measures were put in place, both residents are in their rooms resting, and watching TV. Call-lights and bedside tables are within reach. The care plan dated August 14, 2024 revealed that the resident is/has the potential to be verbally/physically aggressive related to dementia, ineffective coping skills. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. -Resident #37 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and depression unspecified. The minimum data set (MDS) dated [DATE] revealed that the resident is not able to complete a brief interview for mental status. A progress note dated August 13, 2024 revealed that the resident got in verbal argument with another resident and punched her in the arm. Residents were separated, and the medical doctor and family made aware. The progress note dated August 13, 2024 revealed that the resident is to move rooms. The resident's son is aware and in agreement. New orders for labs were received. A progress note dated August 15, 2024 revealed that at approximately 6:43 p.m. a CNA witnessed this resident and another resident raising voices in the hallway. The CNA walked quickly to separate them both and before she could get to them, the CNA witnessed this resident took her left fist and hit the other resident in her left arm. The other resident grabbed this resident's hand and CNA got to them and separated them immediately. Residents were separated immediately, no injuries bruises/redness noted to this resident's arm. The Executive Director, Director of Nursing, medical doctor, and the family were notified. This resident was moved to station 4, and the family was notified of the transfer. The care plan dated August 16, 2024 revealed that the resident is/has the potential to be physically aggressive related to anger, dementia. Interventions included that the resident needs personal space. The resident reacts to touch. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of a written statement dated August 13, 2024 by a certified nursing assistant (CNA/staff #7), revealed that resident #11 was in the hall and resident #37 stopped her and they started arguing. Resident #37 took left fist and struck resident #11 on the left forearm. Resident #11 grabbed resident #37's arm and when the CNA got to the residents, resident #11 let go of resident #37's arm. Review of a written statement dated August 13, 2024 revealed that a licensed practical nurse (LPN/staff #41) revealed that she heard the two residents raising their voices in the hallway. A (CNA) went to separate the residents, but before she could get to them, resident #37 raised her hand and grabbed/hit the other resident #11 in the arm. The CNA separated them right away, and no injuries were noted on either resident. Then resident #37 was moved to the fourth floor. Review of a written statement dated August 13, 2024 revealed that (CNA/staff #54) was standing by room [ROOM NUMBER] when she saw resident #37 hit resident #11's chair and says something to resident #11 in her language, while making gestures with her hands. Resident #11 had resident #37's right arm very tightly, because she could see the force that resident #11 was exerting on resident #37's arm and then (CNA/staff #7) screams, they are fighting. Staff #54 stated that they all know that resident #11 doesn't share her space with anyone, and since resident #37 hit her chair, she was angry and became aggressive with resident #37. An interview was conducted on August 27, 2024 at 12:16 p.m. with a licensed practical nurse (LPN/staff #23), who stated that she has received training on abuse and physical abuse includes striking, grabbing, and pulling. She stated that resident #11 needs supervision because she wanders. She stated that she did not witness the altercation, but knows that one of the residents was transferred to the fourth floor. An interview was conducted on August 28, 2024 at 9:05 a.m. with the Director of Nursing (DON/staff #1), who stated that abuse occurs when harm is inflicted on a resident and can be physical, mental, misappropriation, isolation, restrained, and sexual. She stated that a 5-day investigation was completed and the allegation of abuse was substantiated. The two residents didn't like each other, which only became apparent during the incident. The facility policy, Abuse Prevention revised June 17, 2024 states that it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on observation, interviews, and records review the facility failed to ensure the physician was notified of a change of condition for one resident (#5). The deficient practice could result in delayed treatment. Findings include: Resident #5 was initially admitted to the facility on [DATE] with diagnoses of muscle weakness, anemia, chronic kidney disease and paroxysmal atrial fibrillation. The care plan initiated on July 12, 2021 revealed that resident #5 was on anticoagulant therapy. The goal was that the resident will be free from discomfort or adverse reactions related to anticoagulant use. Interventions included to administer anticoagulant medications as ordered by physician, monitor for side effects and effectiveness, observe for and report, as needed, adverse reactions of anticoagulant therapy including mental status and significant or sudden changes in vital signs. A progress note dated August 2, 2021 revealed the resident was sent to the hospital for a CT (Computerized Tomography) scan due to increase pain. The clinical record review revealed the resident was readmitted at the facility on August 9, 2021. A physician order dated August 10, 2021 included an order for warfarin sodium (anticoagulant) give 2.5 milligram (mg) by mouth at bedtime every Monday, Tuesday, Wednesday, Friday, and Sunday. The physician order summary for August 2021 revealed an order to monitor for signs and symptoms of bleeding including black tarry stools, bleeding gums, bruising/nose bleed related to anticoagulant use every shift, to document positive (+) if signs and symptoms were present and negative (-) if not present. A progress note dated August 10, 2021 at 11:44 A.M. revealed the resident was alert and oriented to situation and surrounding, was pleasant, and was not in acute distress. It was also noted that the resident was readmitted to the facility for coagulopathy and elevated INR. Review of the progress note dated August 10, 2021 at 5:18 P.M. revealed resident had a fall and was found sitting on the floor next to her bed. The documentation included that neuro checks were started per policy; and that, the physician and family member were notified. The progress note dated August 10, 2021 at 11:32 P.M. revealed resident was alert and oriented x 3 with confusion and was able to verbalize need. Further, it included neuro checks were continued status post of unwitnessed fall; and that, the resident was very confusing at night and weak while night. The Fall Risk Evaluation dated August 10, 2021 revealed that the resident had 1-2 falls and had no cognitive change in the last 90 days. There was no documented response for questions on resident behaviors such as easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive and resists care. However, in another Fall Risk Evaluation dated August 10, 2021 documented that the resident had no falls and had a cognitive change in the last 90 days. The documentation also included that the resident was easily distracted, had periods of altered perception or awareness of surroundings, had episodes of disorganized speech, had periods of restlessness, had periods of lethargy; had mental function that varied over the course of the day, wanders; was abusive and resisted care. Review of the clinical record revealed that Neurological Checks were completed; and the initial neurological check was August 10, 2021 at 4:45 P.M. Subsequent assessments were conducted on every 15-, 30-, and up to 60-minute intervals; and, the documentation revealed the resident had clear speech. The neurological check dated August 11, 2021 at 2:00 A.M. the speech evaluation section was left blank. At 8:00 A.M. and 2:00 P.M., the documentation included that the resident had slurred speech. Review of the Fall Risk Evaluation dated August 11, 2021 revealed that resident had 1-2 falls and had no cognitive change in the last 90 days. The documentation also included that the resident was not easily distracted, had no periods of altered perception or awareness of surroundings, had no episodes of disorganized speech, periods of restlessness, no periods of lethargy, had a mental function that varied over the course of the day, did not wander, was not abusive and did not resist care. The physician order with a start date August 12, 2021 included for warfarin 1.5 mg by mouth at bedtime every Thursday and Saturday. However, there was another physician order with a start date of August 12, 2021 to continue to hold coumadin (brand name for warfarin) and recheck INR in the morning one time only until August 12, 2021. The neurological check dated August 12, 2021 at 6:00 A.M. revealed the resident had clear speech. At 8:00 A.M, the resident was documented to have slurred speech. Review of a progress note dated August 12, 2021 at 3:14 P.M. revealed resident was laying in a recliner chair with eyes closed holding a cellphone to ear talking to the air and had slurred slow speech, nonsensical, and was not able to be redirected; and that, a family member was in the room with the resident. It also included that the resident was lethargic, confused, and was hitting, kicking, and pulling at oxygen tubing, screaming without cause in a high-pitched manner. The documentation also included that all narcotics had been discontinued due to the resident's mental status. Despite documentations that the resident had slurred speech on August 11 and August 12, 2021, there was no evidence found that the physician was notified. The physician orders for warfarin sodium was transcribed in the Medication Administration Record (MAR) for August 2021. The documentation in the MAR revealed that warfarin 2.5 mg was held on August 10, 2021 and given on the August 11, 2021. Despite the hold order for warfarin, the MAR documentation for August 12, 2021 revealed that warfarin was administered to the resident. Review of a progress note dated August 13, 2021 revealed that a registered nurse (RN) contacted the resident's family member regarding the resident's increasing confusion and the medication changes to include the discontinuation of all narcotics. Further, the documentation included that the family member requested to contact the doctor. A physician order with a start date of August 13, 2021 included to continue to hold coumadin and recheck INR in the morning one time only until August 13, 2021 at 10:59 A.M. Another progress note dated August 13, 2021 revealed that a nurse practitioner (NP) saw the resident and ordered for the resident to be sent the hospital for a CT scan of the head without contrast second to altered mentation. It was further noted that the resident was transported to the Emergency department at approximately 12:00 P.M. An interview was conducted on June 14, 2024 at 12:44 P.M. with a licensed practical nurse (LPN/staff #85) who stated that if a resident had an unwitnessed fall or was found on the floor and it was unknown whether the resident hit their head, the RN would perform a neurological assessment and notify the physician and family. The LPN stated that the doctor will also be notified that the resident was on a blood thinner; and, the doctor would give instructions. The LPN said it was the doctor's decision to send the resident who fell to the hospital for a CT scan. Further, the LPN stated that it was a change in condition and the doctor would be notified if a resident who had clear speech prior to a fall then developed slurred speech after the fall. The LPN said the resident who was on coumadin (anticoagulant) and had a fall would be at risk for a brain bleed; and that, not notifying the physician of any changes can put the resident at risk for internal bleeding. An interview with a RN (staff #61) was conducted on June 14, 2024 at 1:30 P.M., the RN stated that when a resident had an unwitnessed fall, she will assess the resident and the physician was notified; and that, a neurological check would be done to include vital signs, checking the resident's pupils, speech, orientation and upper and lower extremity movement. The RN said the neurological checks were completed at every 15 minutes x 4, then every 30 minutes x 4, then every 2 hours x 4, every 4 hours x 4, every 8 hours x 4, etc. The RN stated that neurological assessments allowed the nurses to see any changes and if there was a decline in the resident's status. The RN said that if there were changes from the resident's baseline during the neurological assessments then the physician was notified right away; and that, if the physician was not notified right away of any changes the resident may have had a stroke and the resident was not attended to right away. The RN further stated that residents on blood thinners like coumadin were at a higher risk for bleeding. The RN said that physicians relied on the neurological assessments to determine the next course of action, whether to hold coumadin or to continue giving it. A telephone interview was conducted on June 14, 2024 at 1:55 P.M. with a physician (staff #300) who said that staff notifies him for every resident that had a fall. The physician stated that the expectation was to indicate and let him know whether the resident hit their head or not; and the staff can volunteer to let him know if the resident was on a blood thinner. The physician stated that he does not hold medications for just any fall because of the risk versus benefits of the medications. The physician said some residents fall all the time but if they had atrial fibrillation he might not hold the medication. Further, the physician stated his expectation was that he was notified of any changes after a resident fell because the resident could have a subdural hematoma (brain bleed) that show up three days later; and, because subdural hematoma is slow it could take days to show signs/symptoms. He said that the resident would require a scan of the head. Further, the physician said that if a resident had clear speech then suddenly developed slurred speech after a fall, he would send the resident to the hospital and in his experience, any other doctor would do the same. During an interview with the Director of Nursing (DON) conducted on June 24, 2024 at 2:13 P.M., the DON stated that if a resident had an unwitnessed fall and was on blood thinner, the staff would notify the RN right away so the resident could be assessed. The DON said that the RN would assess the resident paying close attention to the neurological assessment and any obvious bleeding, then notify the physician and family. The DON stated that the RN would let the physician know if the resident was on blood thinner like coumadin because of the risk of bleeding. The DON said that there could be slow and subtle bleeding which was why neurological assessments were done. The DON added that the neurological assessment included checking for pupil changes, drooping, headache, pain, and slurred speech; and that, if resident who was assessed to have clear speech and suddenly changed to a slurred speech, the physician would be notified. The DON said most doctors would want the resident to have a scan; and, it was important to notify the physician right away if there were changes in the neurological assessment because it was a critical situation to provide appropriate care. The DON stated that if the physician was notified by staff, it would be documented in the resident's clinical records. A review of the clinical record was conducted with the DON who stated that the physician was notified after the resident experienced a fall on August 10, 2021; and that, the neurological assessment on August 10, 2021 that resident had clear speech but on August 21, 2021 the resident had slurred speech. The DON stated that her assumption was that the physician was notified, which was why the narcotics were held. The DON stated that slurred speech would be concerning if it was new; and, based on what was documented in the clinical record, there was a change in the resident's condition. The DON said the expectation was that the physician was notified of the slurred speech; and that, she did not find any documentation in the clinical record that the physician was notified of the slurred speech of resident #5. The DON further stated that sometimes the signs of impairment were so subtle that it was hard to pick up, which was why neurological assessments were stretched out for a period of time. Review of the facility's policy titled, Neurological Assessment reviewed on August 10, 2023 revealed that neurological assessment shall be initiated by a written physician's order for neurological checks or when indicated by resident assessment (e.g. head injury, post fall, neurological decompensation). The noted procedure revealed that the nurse documents and reports any pertinent changes in the resident's neurological status immediately to the physician.

-Resident #92 was admitted to the facility on [DATE] with diagnoses that included sepsis, bipolar disorder and depression. Review of the Level I PASRR dated 3/09/2023 included the diagnoses of bipolar disorder and depression. Per the documentation, the resident had not exhibited any interpersonal symptoms or behaviors (not due to a medical condition) and she received antidepressant medication daily. However, review of the physician's orders dated 03/09/2023 included: -Risperidone (antipsychotic) 2 milligrams (mg). Give 1 tablet via G-tube at bedtime for bipolar disorder with a target behavior of striking out. -Sertraline HCL (antidepressant) 50 mg. Give 1 tablet daily for depression with a target behavior of lack of motivation. A risk for change in mood or behavior care plan dated 03/10/2023 related to her medical condition had a goal to allow staff to assist her with basic needs. Interventions included a psychiatric consult as indicated. On 03/28/2023 a PASRR Level I screening was completed. The screening revealed the resident's diagnoses included bipolar disorder, depression and anxiety disorder. The assessment included that she had exhibited no interpersonal symptoms or behaviors, including difficulty interacting with others and that she had displayed no symptoms related to adapting to change such as physical violence and or excessive irritability. The screening indicated that no Level II referral was necessary. The admission MDS assessment dated [DATE] revealed the resident was rarely/never understood and scored 99 on the BIMS assessment, indicating severely impaired cognition. According to the assessment the resident displayed no behaviors. Review of the April 2023 Medication Administration Record (MAR) revealed medications were administered in accordance with the physician's orders. According to the record, the resident displayed no symptoms of depression and she had 2 episodes of striking out. The May 2023 MAR indicated the resident received medications per physician's orders. Review of the MAR revealed the resident displayed no symptoms of depression. According to the MAR, she displayed behaviors of striking out on 5 occasions. According to the June 2023 MAR, the resident was administered medications as ordered. Per the MAR, the resident displayed symptoms of depression on 1 occasion and she displayed behaviors of striking out on 5 occasions. However, despite the resident's escalated behaviors, the resident was not referred to the State authority for PASRR Level II evaluation and determination. On 06/30/2023 at 12:29 PM, an interview was conducted with Social Service Director (staff #99). After review of resident #92's Level I PASRR, she stated that based on the resident diagnosis of bipolar and the prescribed antipsychotic medication, a Level II evaluation was needed. She stated the risk to the resident would include not identifying the resident's needs and getting services in place. 47910 -Resident (#3) was admitted to the facility on [DATE] with the diagnosis that included paraplegia, bipolar disorder and major depressive disorder. Review of the PASRR Level I screening dated 02/04/2020 revealed that the resident had diagnoses of bipolar disorder and depression but that a Level II referral was not required. Further review revealed no behaviors were identified in the document. A behavior problem care plan revised on 02/19/2022 related sexual impropriety had a goal for the resident not to experience behaviors that were harmful to himself or others. Interventions included to intervene as necessary to protect the rights and safety of others. Review of the physicians orders dated 09/07/2022 included: -Sertraline HCL 50 mg. Give one time a day for depression for a target behavior of verbalization of sadness. -Trazodone HCL (antidepressant) 25 mg. Give by mouth at bedtime for depression with a target behavior of inability to sleep. The quarterly MDS assessment dated [DATE] revealed the resident scored 15 on the BIMS assessment, indicating intact cognition. The behavioral assessment indicated the resident had displayed no presence of symptoms. Review of the April 2023 through June 2023 MARs revealed the resident received medications in accordance with the physician's orders. Behavior monitoring included verbalization of sadness and inability to sleep. However, sexual behaviors were not identified as having been monitored on the MAR. An interview was conducted on 05/30/2023 at 12:29 p.m. with the Social Services Director (staff #99). She stated that based on the resident's current diagnosis for bipolar disorder, a Level II PASRR evaluation was required, but that the evaluation request had not been submitted to the appropriate state agency. Staff #99 stated the risk of not referring a resident for a Level II evaluation would mean the resident's needs would not be identified and ensure, if needed, additional services were in place for that resident. A review of the facility policy titled Pre-Admission Screening and Resident Review (PASARR) revised October 6, 2022 included that the facility will strive to verify that a Level I PASRR screening has been conducted, in order to identify Serious Mental Illness (MI) and/or an Intellectual Disability (ID) prior to initial admission of individuals to the facility. PASRR Level 1 screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for MI or ID. If the resident is positive for a potential MI or ID, a Level II screening referral must be submitted. A positive Level I screen necessitates an in-depth evaluation of the individual by the State designated authority, known as PASRR Level II. 48087 Based on clinical record review, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated appropriately for one resident (#94) and that two residents (#92 and #3) were referred to the State designated authority for evaluation and determination of a Level II PASRR. The sample size was 4 residents. The deficient practice could result in specialized services not being identified and provided to residents. Findings include: -Resident #94 was admitted to the facility on [DATE] with diagnosis including disorder of the autonomic nervous system, Parkinson's disease, dementia and psychosis. A Level I PASRR screening completed on 02/14/2023 included the attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services and that the nursing facility must update the Level I at such a time it appeared the resident's stay would exceed 30 days. However, review of the clinical record did not indicate an updated PASRR had been completed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. On 06/30/2023 at 12:20 p.m. an interview was conducted with the Admissions Assistant (staff #124) who stated that prior to admission, a Level I PASRR was always required. Staff #124 stated that a Level I PASRR will be completed by the referring facility or hospital, and that every page of the documentation was reviewed. She stated that if it looked incomplete, then the facility would do one themselves. An interview was conducted with Social Service Director (staff #99) on 06/30/2023 at 12:29 p.m. Staff #99 stated that during the social service assessment process, residents' information was gathered and reviewed by medical records. In addition, staff #99 stated that a Level I PASRR was always completed by the Social Service Department either way because sometimes the hospital will send an incomplete PASRR. Staff #99 stated that the PASRR screening is primarily the Social Service Department duty. Staff #99 reviewed resident #94's PASRR and stated that an updated Level I PASRR should have been completed after the 30-day convalescent care was exceeded.

Based on resident and staff interviews, and facility policy and procedure review, the facility failed to ensure multiple residents were able voice grievances without fear of discrimination or reprisal. The deficient practice could result in residents not able to exercise their right to voice grievances. Findings include: -During interviews conducted from May 2 through 5, 2022, multiple residents stated they did not want to report concerns about care they received because of fear of staff retaliating back at them and as a result, they will not receive assistance when they need them. One resident stated that she once made a comment regarding one certified nursing assistant (CNA) to facility management and it was not even a complaint. The resident stated the CNA then told her that the CNA could be caring for the resident as instructed by management; and that, if the CNA did not, the CNA will get fired. The resident also stated that the CNA never provided her with assistance after the incident; and, even if the CNA was the only staff on shift in the unit. The resident said there was one time when she and her roommate pressed the call button at the same time and the CNA was on shift that day. The CNA came into their room and assisted her roommate but not her. The resident further stated that she felt she was retaliated on because she made a comment about the CNA; hence, since then she did not and will not say any concerns about the care received; and the resident put her right thumb and index finger together and ran it across her lips to indicate that she was zipping her lips sealed. Another resident stated that the previous night, a CNA assisted the resident with a brief change and the CNA rushed her and did not allow her time to move. The resident told the CNA to slow down a bit but the CNA just yanked her. The resident said she required assistance with activities of daily living (ADLs) all the time. She stated she was concerned that if she reported the incident, staff would be mad at her and she would not receive the assistance she needed. Another resident stated that she told the facility about her concerns regarding not having enough staff to answer the residents call for assistance. However, the resident said that the facility administration just ignored her. One staff member stated there were times when residents were all wet or did not receive their pain medications because there was only one staff in the unit. However, she stated she does not want to voice this concern to management because she will probably lose her job. Further, she stated that she might lose her job if seen talking to the survey team. Another staff member stated that she had been the only staff for the entire hall that had several residents that required two staff assistance and/or use of Hoyer lift. The staff member stated that this had been going on for a while; and that because of this issue, there were residents who were not provided with showers as scheduled. The staff member stated there was an issue related to resident care but she wanted to remain anonymous for fear that she would lose her job. Further, she stated that she was unsure whether she will lose her job or not if management sees her talking to the survey team. -During interviews conducted between May 3 through May 5, 2022 it was revealed grievance concerns were not shared with the facility by a resident and a staff member because of fear of retaliation from the staff and management. An interview was conducted on May 3, 2022 with a resident who stated she heard a particular CNA yell at other residents before, and that did not report the incident because she was afraid of retaliation from the staff. The resident stated this particular CNA has been very moody, any little thing that was not the CNA's way can set the CNA off. The resident stated, for example, if the bedside table was not cleared for this particular CNA to place a meal tray, the CNA will show frustration by grunting, huffing and having discontent on the CNA's face. A follow up interview was conducted on May 5, 2022 with the resident. The resident stated the resident did not feel safe filing a grievance. The resident stated that after speaking about concerns about a particular CNA, the resident felt like the staff were retaliating by being overly nice, which was weird. The resident stated she feels safe for now because the head nurse was frequently checking on the resident. An interview was conducted on May 4, 2022 with a staff member. The staff member was hesitant to speak and asked not to put their name on record because the staff member did not want to be in trouble. The staff member stated that during their shifts, the residents were complaining of not getting showered because the previous shift were working short, and that the staff tells the residents they are working short. The staff member also stated the residents complained of waiting for a long time for their call lights to be answered and to receive pain medications. The facility policy on Resident Rights included that at the time of admission and periodically throughout their stay, the facility will inform each resident, orally, and in writing, of their rights. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required. The resident has the right to voice grievance to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal.

Based on observations, clinical record reviews, resident and staff interviews, the Facility Assessment, and review of policy and procedures, the facility failed to ensure there was sufficient staff to ensure resident safety and to meet the residents' needs. The deficient practice could result in residents not receiving the assistance they need to promote their rights, physical, mental and psychosocial well-being. Findings include: The Facility assessment dated [DATE] and reviewed by the QAPI (Quality Assurance Performance Improvement) on 3/17/2022 revealed the facility was licensed for 208 beds with an average census of 120. The average admissions or discharges were 2-4/day during weekdays and 1-3/day on the weekend. The type of care that residents required and that facility provided included ADLs (activities of daily living), mobility, pain management, skin integrity, therapy, and providing opportunities for social activities. Per the assessment, staffing ratio may vary from average number during COVID pandemic and was listed as follows: -Licensed nurses: 1.25-1.5 PPD (per patient day); -Nurse aides: 1.2-1.6 PPD; -Other nursing personnel: 0.13 -0.18 PPD; -In addition to nursing staff, other staff needed for behavioral healthcare and services (list other staff position/roles): 0.03 PPD; -Dietician: 0.09 PPD; -Food and nutrition services staff: 0.50 PPD; and, -Respiratory care: N/A -During interviews conducted with residents during the survey, a resident stated she pressed the call button last night and did not get the help needed until this morning. The resident stated she was in pain and wanted her pain medications but she did not receive it until this morning. The resident stated the staff did not tell the resident why she was not given the pain meds when requested nor why the call light button was not answered. The resident stated that this happens a lot and that there is not enough staff to care for the residents. The resident stated that this usually happens on the night shift most of the time, because staff on schedule does not show up. The resident stated as a result, there is usually only one CNA (certified nurse assistant) to assist the residents in the hall. The resident said that she used to have a roommate who could not use the call light and she had to press her call light so that staff would come into the room to help her roommate. However, the resident stated that no staff came to help even if she did that. The resident also stated she has orders for RNA (restorative nursing) and was supposed to receive showers twice a week. However, the resident stated since the facility did not have enough staff, she has not received RNA services and stated that she was lucky if she gets one shower per week. Further, the resident stated that she voiced these issues/concerns but the administration ignored her concerns. Immediately following the resident interview, an interview with a staff member was conducted. The staff member stated there was only CNA last night in the unit and they had to get the CNA from another unit. She stated the residents in the unit were all wet and some residents did not get their pain meds. In an interview with another resident, the resident stated there was no regular CNA in the unit and the CNA that works in the unit will answer the call light and tell the resident that she will return but the CNA does not return. The resident stated that she has not received the twice a week showers as scheduled because the facility is short staffed. The resident also said that last night there was only the nurse and no CNA in the unit; and she asked to use a bedpan but she did not receive it until this morning. During an interview with another resident, the resident stated the previous night, the CNA rushed her and did not allow her time to move during the process of getting changed. The resident told the CNA to slow down a bit but the CNA just proceeded on to changing her very quickly and left the room. The roommate who overheard the conversation stated that the resident statement was true because she wanted to ask for assistance as well but the next thing she knew the CNA was out of the room. During an interview with another staff member, the staff member stated that there had been only one CNA during the night shift since the regular night shift CNA took a leave. The staff member stated that last night there was only one nurse and no CNA in the unit. The staff member stated that the unit has residents who require two-person assistance and/or Hoyer lift. The staff member also said that yesterday, showers were not provided to a couple of residents, because there was only one CNA in the unit and that sometimes there is no time to wash the resident's hair. The staff member stated that there were times when they would receive reports from the outgoing staff that residents were all soaking wet in the morning because there was no staff to change the residents. Also, the staff member stated it takes a long time to answer the call light if there is only one staff member in the unit and that this staff member would just apologize for the wait. An observation was conducted on May 4, 2022 at 5:11 a.m. There were no staff present in the unit. The medication cart was parked by the entrance to the dining room located at the side of the unit nurse station. There were approximately 3-5 rooms with the call light turned on. Located at the nurse station was a call light monitor with individual room numbers mounted on the wall, that had red lights on for specific rooms and had continuous short beeping sound. Most residents were asleep and there was one resident who was awake, sitting in the wheelchair getting some ice from the ice machine. The resident then proceeded to her room. At 5:19 a.m., a staff member came into the unit and stood at the area where the call light monitor was and proceeded to put a note in a binder by the counter at the nurse station. Despite seeing the lights turned on in the call light monitor and hearing the continuous short beeping sound, the staff left the unit without answering the call light. At 5:26 a.m., a CNA was located at the end of the hall charting residents' vitals in the electronic record. The CNA stated that she does not usually work in the unit and the staff assigned to the unit called off. The staff further stated that she was the only CNA that worked the shift. At 5:36 a.m., a nurse arrived at the unit and stated she worked the night shift and there was only one CNA last night. The nurse stated that she thinks there should be more than one CNA in the unit and remarked that she was not a scheduler. However, the nurse stated that it was crazy last night because a resident (#22) had a fall incident. The nurse stated there were no injuries and the nurse stayed a few times with the resident last night to make sure the resident was okay. At 5:45 a.m., another CNA came to the unit and one of the rooms that had the call light on was turned off. At 6:01 a.m., another CNA came on shift and at 6:04 a.m. (approximately 50 minutes from the time the call lights were observed to be on), all the rooms that had the call light on were turned off and answered. An interview with a registered nurse (RN) was conducted on May 4, 2022 at 6:10 a.m. The RN stated that she was the wound nurse and she usually covers for the nurses on the morning shift lately because of the facility's staffing shortage. She stated that there seemed not enough nurses applying at the facility. She stated that there is usually only one nurse and about 2-3 CNAs on the morning shift and referred to a CNA to answer about the number of staff members on the night shift. The CNA stated that they were lucky if there were 2 CNAs assigned in the unit. In an interview conducted with a resident (previously interviewed), the resident stated that the resident pressed the call light this morning and waited for about 30 minutes before a staff came in to assist. The resident stated that the resident only needed a tablet; however, could not reach it because it was placed on the table directly across from the resident's bed. An interview was conducted with resident #22 on May 4, 2022 at 8:20 a.m. Resident #22 stated that she sleeps on her right arm, can push herself up to try to move from her bed to her wheelchair and she gets changed at night. She said the regular CNA assigned to the unit would know to put her wheelchair by the end of her bed because she could scoot to her wheelchair when she wants to in the middle of the night. She also said the regular CNA would also know to leave her door open because she hollers or calls for help when needed. However, she stated that the CNA on shift last night was new to her care, placed her wheelchair far from her bed and left the doors closed. Resident #22 said that last night she was trying to move from her bed to her wheelchair and her right arm fell asleep on her resulting in her slipping from her bed. The resident stated she pressed the call light but she did not see the time she did it and thought it was long because she was hanging on to dear life. She stated she was yelling and calling for help but nobody could hear her because her door was closed. She stated that as soon as the CNA heard and saw her, the CNA called the nurse. The resident stated both staff members tried to move her back to the bed using the Hoyer lift but was not successful. Resident #22 stated that 911 was called and the firefighters transferred her from the floor to her bed. Further, resident #22 stated that it was her fault for not telling the CNA what to do with her wheelchair and door. She stated she should have known to do so since she knows there are staffing issues at the facility and there are usually floaters who are not familiar with her care assigned in the unit all the time. An interview was conducted with restorative nurse assistant (RNA/staff #34) on May 4, 2022 at 12:45 p.m. Staff #34 stated that she was the only RNA providing RNA services to the residents at the facility; but, she currently has been working as a CNA. Staff #34 stated there were at least 20 residents on the RNA program. She stated that two of their units had almost all residents in that unit requiring RNA service. However, staff #34 said RNA services were put on hold at the beginning of the pandemic due to staffing shortage. Further, she stated that when she works as a CNA in the unit, the facility was short-staffed for a while and that sometimes, showers were not provided to the residents. During an interview with a licensed practical nurse (LPN/staff #18) conducted on May 5, 2022 at 10:39 a.m., the LPN stated that when they are short-staffed, it is usually the showers that get missed. In an interview conducted with another staff member, the staff member stated that the facility was short-staffed and as a result the residents miss the twice a week showers; and that, residents had complained about it. The staff member stated restorative services are provided by RNA (staff #34) who now works as a CNA resulting in residents not receiving RNA services. This staff member stated that when reporting for shift, a report was given from other staff members that the residents were not changed by the previous shift and were left soaking wet. The staff said that when a resident complained about showers, this staff member would just do what they could because when a resident needs assistance staff should provide it. During an interview with the DON (director of nursing) with a corporate staff present conducted on May 5, 2022 at 12:57 p.m., the DON stated she was aware of the staffing challenge and she does not encourage staff to tell residents that the facility is short-staffed because this may upset the residents. She stated if showers cannot be provided to a resident, the staff may tell the resident that showers cannot be done today but can be done the next day. She said the reason why showers were not provided include resident refusal and staffing issues. She stated the facility has RNA services offered to residents and the facility had 2 RNAs. However, one RNA got sick and the second RNA (staff #34) was being pulled to the floor for CNA coverage. The DON said the RNA program has not been provided to residents and was put on hold for about a year. The DON further stated that with all the things going on with the pandemic, the provision of RNA to residents was pushed back because the facility was concentrating on the residents' immediate needs. -An interview was conducted with a resident, who stated that staffing was a concern, especially at night when the residents need help to get into their beds. The resident stated that one evening not long ago, the resident put their call light on to be assisted to bed, as the resident cannot get into the bed without staff assistance. The resident stated the call light was turned on at approximately 8:00 p.m. and no staff arrived until after midnight. The resident stated that when the staff arrived after midnight, the resident explained that the resident had been waiting since 8:00 p.m. for assistance to get into bed for the night. The resident stated that this was an ongoing problem and that the facility definitely needed more aides on the floor to assist residents. -During the initial phase of the survey, residents reported that they have waited up to 2.5 hours for call lights to be answered to get medicated for pain, for assistance with a brief change, and to be able to reach drinking water. An observation was conducted of a resident on May 3, 2022 at 8:46 a.m. The resident's bathroom was wide open, and the resident appeared to be struggling with putting on a clean gown. The resident's one hand was holding onto the grab bar, the other hand was holding the hospital gown. Soiled linens, towels, clothing, and a soiled brief were observed on the bathroom floor. The resident stated the resident needed help with dressing and changing briefs, but was not able to get help because staffing was always short or staff were too busy to offer help even if the resident pressed the call light. During an observation conducted on May 4, 2022, a call light was observed to be pressed on at 5:49 a.m. and was answered at 6:03 a.m., 19 minutes later. During the observation, one licensed nurse was passing medication, and another staff was observed passing supplies in different halls. An interview was conducted with a resident who stated pain medication was difficult to get in the facility. The resident stated one day recently, the resident pressed the call bell at about 4:30 p.m. and the staff did not respond to the call light until the following morning. The resident stated the pain was 10 on a scale of 0-10, and that the resident was not medicated for pain until the following morning. An interview was conducted with a resident, who stated the call light had been answered timely that morning. The resident stated the resident was embarrassed because the resident had a fall last night. The resident stated that the resident had to go to the bathroom really badly, got up without asking for help, because the resident had to wait for a long time for the call bell to be answered before. The resident stated while in the bathroom, the resident had a urine accident and slid on the urine on the floor and fell . The resident stated the resident pulled the emergency bathroom light immediately, and that the resident laid on the bathroom floor for about 20 minutes or so before someone answered the emergency bathroom light. An interview was conducted with a resident's family member who stated the resident was assisted to bed but unable to reach the water. The family member stated the resident pressed the call bell and waited over 2 hours but no one answered. The family member stated the resident phoned the family member to ask for help in the middle of the night. The family member then called the facility several times but no one answered the phone. The family member stated the family member was afraid that someday, the resident would press the call bell for emergency reasons, and they will find the resident already dead because the call bell was not responded to timely. The family member stated she reported the incident to the facility administrator. During an interview conducted with a staff member, the staff member stated that the staff member passed medications on one station and moved to another station at about 2:00 a.m. to finish the shift. The staff member stated that usually there are two licensed nurses on one of the stations and one CNA for 46 residents, however, there was only one licensed nurse scheduled. The staff member also stated that sometimes the staff member also works as a CNA. The staff member stated most residents' complaints were related to call light not being answered timely because of not enough staff working. The staff member stated that pain medications not being given timely depended on who the licensed nurse was that was working. The staff member also stated the staff member overheard the challenges the other staff brought up already, and those are the same issues the staff member has experienced. An interview was conducted with a CNA, who stated the CNA was assigned 35 residents and that 43 residents was the most the CNA had been assigned to take care of. The CNA conducting rounds every 2-3 hours was impossible. The CNA stated when reporting for the beginning of the shift, the residents were already upset because the residents stated they had been waiting over two hours for their call bell to be answered. The CNA stated the residents were waiting for brief change, water, and pain pills. The CNA stated at the beginning of the shift, the CNA had to clean up the mess from the previous shift because they were working short staffed also. The CNA stated it is overwhelming, there were a bunch of call lights on, and residents were already upset. The CNA stated working alone has been the norm at least twice a week, and on weekends. The CNA stated the past Sunday there was no CNA and one LPN for 27 residents for one floor. The CNA stated the CNAs from the other two floors took turns helping the residents on that floor. The CNA stated a few residents were found to be soaked in urine, to a point they had to do complete bed changes. The staff member stated some of the residents were upset because they were sitting in urine for a long time, and the call light was left on and not answered for a long time. An interview was conducted on May 5, 2022 at 9:23 a.m. with the facility administrator (staff #140). The administrator stated the facility staffing assessment was based on census multiplied by the number of hours in each position (PPD). He stated he thinks the average census last month was 124.5, so the facility assessment was adjusted accordingly. He stated if the facility has low census, he does not cut nursing staff, instead he cuts other departments that do not provide direct care to the residents. He stated he was doing everything he could including offering bonuses and that it is getting a little better but it is still a challenge. An interview was conducted on May 5, 2022 at 9:55 a.m. with the staffing coordinator (staff #35), who stated staffing has been a challenge and the DON (Director of Nurses) and the administrator knew about it. Staff #35 stated she also works on the floor as CNA but it has been two weeks ago since she worked the floor. The staffing coordinator reviewed the staffing schedule for Sunday May 1, 2022 and Monday May 2, 2022. Staff #35 stated station 1, 2, and 3 has licensed nurses and CNAs on those dates. However, station 4 only had one LPN and no CNA for the night shift. Staff #35 stated that on station 4, the licensed nurse who was passing the medications was also responsible for monitoring all the call lights until the CNAs from station 3 and 4 were able to come up to station 4 to do rounds. She stated for the meantime, there is no CNA in station 4, only one LPN. Staff #35 stated she thinks the census in station 4 was about 32 on May 2, 2022. Review of the facility Staffing policy revealed the facility maintains adequate staff on each shift to meet residents' needs. The facility utilizes the Facility Assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that restorative services were provided for one sampled resident (#8) with limited mobility as ordered. The deficient practice could result in residents not being provided with services they need. Findings include: Resident #8 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The functional goal care plan dated July 27, 2020 included the resident had limited physical mobility related to weakness, right Charcot foot and [CONDITION(S)]. The goal was that the resident would remain free from complications related to immobility. Intervention included nursing rehabilitation or restorative program twice a week for 30 minutes for ambulation and sit to stand activities to maintain current level of functioning. The physical therapy (PT) Evaluation and Plan of treatment dated February 23, 2021 revealed the resident demonstrated proximal instability, core and lower extremity weakness due to prolonged inactivity. Per the documentation the resident reported that she stood with RNA only 3 times since December. The reason for skilled services included the resident required skilled PT to increase transfer skills to decrease burden of care; and that the resident wished to at least transfer without assistance. The PT discharge summary dated April 5, 2021 included discharge recommendations for the RNA (restorative nursing) program for standing when able. The documentation also included that the restorative and transfer program were established. It also included that the transfer program was for sit to stand in parallel bars when the ankle pain subsides. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The rehabilitation services multidisciplinary screening tool dated May 3, 2021 included that the resident was ambulatory, was recently on the therapy caseload and was continuing standing parallel with RNA. Further, the documentation included that RNA was for sit to stand and exercising. The nursing monthly summary dated January 20, 2022 included the resident was alert and oriented, required assistance with ambulation and was bed or chair bound. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have restorative nursing programs performed for at least 15 minutes per day in the last 7 calendar days of the assessment. The treatment administration record for January 2022 revealed for sit-to stand activities with the use of a gait belt, walker and that the resident has special shoes for standing every shift for bilateral lower extremities weakness. According to the documentation, the order date was February 2, 2021. The TAR also revealed that the treatment was documented as administered as ordered from January 1 through 31, 2022. The nursing monthly summary dated February 22, 2022 included the resident was alert and oriented and was bed or chair bound. The TAR for February 2022 revealed that the sit to stand activities were administered as ordered. The rehabilitation services multidisciplinary screening dated March 8, 2022 revealed there was no change in the resident's ROM (range of motion) and strength. It also revealed that the resident was not appropriate for skilled therapy intervention at this time. The nursing monthly summaries dated March 22 and April 22, 2022 included the resident was alert, easily distracted, required assistance with ambulation and was bed or chair bound. The quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. The assessment also revealed there were no restorative nursing programs performed for at least 15 minutes per day in the last 7 calendar days of the assessment. The TAR for March., April and May 2022 revealed that the sit to stand activities were administered as ordered from March 1 through May 3, 2022. The certified nurse assistant (CNA) documentation from January 1 through May 3, 2022 revealed no evidence that RNA services were one of the CNA tasks/services provided to the resident. In an interview conducted on May 2, 2022 at 2:23 p.m., resident #8 stated that she was on therapy but has orders for RNA. However, she stated that she has not received restorative nursing service for approximately 2 years because the facility had only one RNA; and that the one RNA that provides the services to the residents is now working as a CNA. An interview was conducted with the medical records director (staff #51) on May 4, 2022 at 12:18 p.m. Staff #51 stated that resident #8 have not had RNA services since it was put on hold during the pandemic. She stated that she could not tell when the last time resident #8 had RNA services provided. In another interview with resident #8 conducted on May 4, 2022 at 12:20 p.m., she stated that she has not had any restorative nursing services and has not received any sit-to-stand activities for a long time. During the interview, the resident pulled out her little notebook that contained the list of dates she received RNA services. She stated that based on her notes, the last restorative nursing service she had was on June 24, 2021. Further, the resident said that no one has come to her to provide RNA services since. An interview with a restorative nursing assistant (RNA/staff #34) was conducted on May 4, 2022 at 12:45 p.m. Staff #34 stated that currently, there were no residents receiving RNA services because it was put on hold at the beginning of the pandemic due to staffing issues. She stated there were approximately at least on the average 20 residents on or that required RNA; and there used to be 5 RNAs at the facility. She said she was the only RNA at the facility and is the only one who provides ROM exercises and sit-to-stand activities to residents at the facility. However, she stated she had been working as a CNA lately. She stated that if RNA services were provided, it would be documented in the electronic record. During an interview with a registered nurse (RN/staff #18) conducted on May 5, 2022 at 10:39 a.m., the RN stated that the restorative nursing program is provided by staff #34 and that CNAs do not provide this service. She stated that there are residents in the unit that receive a restorative nursing program. However, the RN stated resident #8 does not have an RNA program. A review of the clinical record was conducted with the RN who stated that resident #8 has not had RNA services since 2020. In an interview with a CNA (staff #101) conducted on May 5, 2021 at 11:28 a.m., she stated that the RNA program is provided by staff #34 who was working as a CNA because of staffing. She stated that a CNA cannot provide a restorative nursing program unless the CNA gets certified. She also stated that resident #8 does not have RNA services at this time. In an interview conducted with the Director of Nursing (DON/staff #7) on May 5, 2022 at 12:57 p.m., the DON stated that the RNA program had been on hold for 1 year due to staffing issues. She stated that the facility had planned to start it this week but it was pushed back because of the survey. She stated that the RNA program was scheduled to start on May 15, 2022. She stated the facility had RNA services that were offered to the residents and the facility had 2 RNAs. However, the DON stated one RNA got sick and the second RNA (staff #34) was being pulled to the floor for CNA coverage. The DON said the RNA program had not been provided to residents and was put on hold for about a year. The DON further stated that with all the things going on with the pandemic, the provision of RNA to residents was pushed back because the facility was concentrating on the residents' immediate needs. A review of the clinical record was conducted with the DON during the interview. However, the DON did not comment regarding the sit-to-stand activities documented as administered to resident #8 as ordered. The facility policy on Restorative Nursing revealed a purpose that the facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome. The policy also revealed that to promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Nursing assistants must be trained in the techniques that promote resident involvement in restorative activities.

Based on observations, clinical record review, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure that two residents (#257 and #8) received consistent showers, per the facility shower schedule. The sample size was 3. The deficient practice could result in residents' hygiene needs not being met. Findings include: -Resident #257 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for ADL (activities of daily living) assistance and therapy services needed to maintain or attain the highest level of function dated April 28, 2022 revealed the intervention to assist with mobility and ADLs as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. It revealed that the resident required extensive assistance with bed mobility, transfers, and bathing did not occur within the 7-day look-back period. The ADL self-care performance deficit related to the disease process, impaired balance dated May 5, 2022 did not reveal an intervention for bathing. Review of the bathing tasks documentation did not reveal any documentation that the resident had received assistance with bathing, showers, or a bed bath. During an interview conducted on May 2, 2022 at 1:42 p.m. with resident #257, the resident stated that she cannot shower without assistance. It was observed that the resident's hair was uncombed and appeared greasy. The resident stated that no one has offered her shower or a bed bath since she was admitted to the facility. An interview was conducted on May 5, 2022 at 11:47 a.m. with a certified nursing assistant (CNA/staff 125). She stated that each resident is scheduled for a shower twice a week, but she was told that she did not need to follow the schedule. She said that she is to see if the resident looks clean and if not offer a shower. She said that she documents when a resident receives a shower and also if the resident refuses a shower. The CNA reviewed the shower schedule and stated that the resident is scheduled for a shower on Tuesday and Friday from 2:00 p.m. to 10:00 p.m. She said that the resident refused to shower last week and she had assisted the resident with a shower last Friday, April 29, 2022. Then, she reviewed the resident's shower documentation and observed that there was no documentation that a shower had occurred or that the resident had refused to shower and stated that she must have forgotten to document. On May 5, 2022 at 11:55 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #119), who stated that the residents are scheduled for showers, baths, or bed baths twice a week, but do not have to do it twice a week. The ADON stated staff are to make sure the resident looks clean. She said that there is no paper chart and if the resident refuses a shower, the CNA is to report it to the nurse and the nurse is supposed to figure out what is going on. The ADON also stated that showers, baths, and refusals, are documented by the CNA. -Resident #8 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADL care plan revised on February 18, 2022 revealed the resident needed extensive to total assistance with bathing or showering. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident was cognitively intact. The assessment also included the resident required one-person physical assistance with bathing and extensive assistance with personal hygiene. The orders for showers were transcribed onto the MAR (medication administration record) and revealed that showers were documented as provided Mondays and Thursdays from January 1 through May 3, 2022. However, review of the CNA documentation from January 1 through May 3, 2022 revealed that for this period of time, the resident had approximately 13 sponge baths, 2 bed baths and 2 refusals. The documentation also revealed that it was documented approximately 19 times that the activity did not occur. During an observation conducted on May 4, 2022 at 12:05 p.m., a shower schedule was located in one of the binders found at the nurse station. According to the written schedule, resident #8 was scheduled for Monday and Thursday. In an interview conducted with resident #8 on May 2, 2022 at 2:20 p.m., the resident stated she is supposed to receive a shower on Monday and Thursday; however, she is not receiving a shower twice a week as scheduled. During the interview, resident #8 pulled out her personal calendar book and stated that she had recorded the showers/bed bath she received as follows: February 3 and 7, March 3 and 21, and April 10, 2022. In another interview with resident #8 conducted on May 3, 2022 at 1:31 p.m., she reported that she received a sponge/bed bath yesterday and that the staff stayed until late around 10:30 p.m. last night so she could have at least a bed bath. She said that she has received only bed baths/sponge baths when staff are able to provide her that; and, she has not been showered in the bathroom for about 2 years now because her wheelchair does not fit into the bathroom door. An interview was conducted with a CNA who wanted to remain anonymous for fear of losing job. The staff stated that there is a sheet of paper located at the nurse station that contains the schedule for showers which are provided only by the CNA and documented under bathing tasks in the electronic record. The CNA stated that if a resident refuses showers/bed baths/sponge baths, it is documented in the electronic record as well. The CNA also said if a resident was not offered a shower/bed bath/sponge bath, this CNA will document it as N/A (not applicable) in the electronic record. Further, the CNA stated that if the resident's hair is washed, it is considered showers; hence, this CNA only code for sponge bath or bed bath when there is no time to wash the resident's hair. The CNA further stated that because there is only one CNA in the unit most of the time and there are residents that require two-person assistance or use of a Hoyer to provide showers, there are some residents who do not receive their showers as scheduled. During an interview with the RNA (restorative nursing assistant) conducted on May 4, 2022 at 12:45 p.m., the RNA stated that she currently has been working as a CNA because of the facility's staffing issues. She further stated that because of the staffing issues, sometimes staff are not able to provide showers to the residents as scheduled. An interview was conducted with a licensed practical nurse (LPN/staff #18) on May 5, 2022 at 10:59 a.m. The LPN stated residents are provided with twice a week showers as written on the shower schedule. She stated if residents refused showers, the CNA will report it to her. She said the CNA provides showers and documents it in the electronic record. She said that she can look at their system to check whether the resident received showers or not. Further she stated that residents had complained about showers often and would call the administrator and/or the Director of Nursing (DON). The LPN further stated that when the facility is short staffed, it is usually resident showers that get missed. In an interview with another CNA conducted on May 5, 2022 at 11:52 a.m., she stated that CNAs receive a schedule of showers for residents in the unit. She stated each resident has a twice a week schedule which is distributed between the am and the pm shifts. However, the CNA stated that when the facility is short staffed, resident showers get missed. She stated that most of the time there is only one CNA in the unit on shift and that the facility had been having issues with staffing. During an interview with the DON (staff #7) conducted on May 5, 2022 at 12:57 p.m. with the corporate staff present, the DON stated residents have 2 showers scheduled per week and the resident can also have bed baths. She stated if the resident refuses showers and even bed baths, the CNA reports this to the nurse. She stated that resident refusal and staffing issues may affect the provision of showers to the residents. She stated when the facility is short-staffed, the CNAs and the nurse would assess and determine which resident needs the shower more. The DON also said that the facility does not encourage staff to tell residents that there is staffing shortages because it may upset the residents. The DON said that the staff may say that showers cannot be done as scheduled today but the resident can have showers the following day. Further the DON stated that she is aware that residents are reporting not being given showers. The facility policy on Activities of Daily Living (ADL) reviewed on July 17, 2021 stated the purpose is to ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. The policy revealed the resident will receive assistance as needed to complete ADLs; and that, the facility must provide care and services in accordance with the comprehensive assessment and consistent with the resident's needs and choices for bathing, dressing, grooming and oral care.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure infection control procedures were followed during mealtime, and for one resident (#59) during medication administration. The deficient practice could result in the spread of infection. Findings include: During the entrance conference conducted with the Executive Director (staff #140) on 05/02/2022 at 10:46 AM, the ED stated that there were 3 residents with COVID-19 in the facility and that two staff had tested positive for COVID-19 in the last week. -An observation was conducted on 05/05/22 at 12:40 PM during lunch service to resident's rooms. A Licensed Practical Nurse (LPN/staff #18) was observed delivering food and was not wearing goggles or a face shield. Staff #18 stated that she knows the policy states that eye protection must be worn at all times in the facility. Staff #18 stated that she was just not thinking and should have been wearing goggles. An interview was conducted on 05/05/22 at 1:53 PM with the Director of Nursing (DON/staff #7). The DON stated that staff are to wear goggles and face shield at all times. She added that it is her expectation that all staff follow these rules as there is COVID in the building. The DON stated We need to protect our residents and staff. The DON also stated that they educate staff constantly and have in-services on PPE (personal protective equipment), but apparently, they still need more. -Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a physician order dated February 8, 2022 for [MEDICATION(S)] 100 milligrams by mouth every 8 hours for pain. A medication observation was conducted on May 3, 2022 at 1:38 PM with a Licensed Practical Nurse (LPN/staff #18). Staff #18 was observed preparing medications for resident #59. During the observation, the LPN was observed to take out the resident's [MEDICATION(S)] 100 mg capsule. The medication was in a blister pack/card. The LPN was observed to pop one tablet into a medication cup. The medication cup fell over and the medication fell on top of the medication cart. The nurse was then observed to pick up the tablet that fell on top of the medication cart without gloves and place it back in the medication cup. She then called another nurse to complete the narcotic waste process. The nurse was observed to remove the medication from the medication cup without gloves, and place the medication in the waste receptacle. The nurse was then observed to pop another [MEDICATION(S)] capsule from the blister card, and place it into the original medication cup where she had previously placed the contaminated pill and then removed it for waste. The nurse was observed to take the medication and administer the [MEDICATION(S)] capsule to the resident. During the medication administration observation, the medication cart was not observed to be sanitized. Following the observation, the nurse was asked about resident #59's [MEDICATION(S)] 100 mg capsule. The nurse stated that when she placed the capsule in the medication cup, it fell over and the capsule fell on to the top of the medication cart. She stated that she placed the capsule back into the medication cup, and called another nurse to assist with the narcotic waste process. She further stated that when the waste documentation was completed, she removed the [MEDICATION(S)] from the medication cup without gloves on her hand, and placed it into the waste container. She then stated that she placed a new [MEDICATION(S)] back into the same medication cup. The LPN also stated that this did not meet the facility policy regarding infection control, and the risk was contamination of the medication. An interview was conducted on May 5, 2022 at 9:55 AM with the Infection Preventionist (IP/staff #31), who stated that the process for medication administration is to wash/sanitize hands before/after administration of medications, sanitize the medication cart before/after shifts, and if it is soiled. The IP also stated that it is not following proper infection protocol to place a medication in a medication cup in which the nurse had previously touched the inside with her bare fingers, and that the risk could be possible exposure to infection. An interview was conducted on May 5, 2022 at 10:09 AM with the Director of Nursing (DON/staff #7), who stated that nurses perform hand hygiene before and after each resident contact, and should not have direct contact with any medication with their hands. The DON further stated that if the nurse touches the inside of the medication cup, then places a new medication in the same cup, it is breaking infection control protocol. She also stated that the risk would be possible infection/contamination. Review of the facility policy titled, Hand Hygiene, revealed that hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. 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. Review of the facility policy titled, Administration of Medications, revealed that the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy titled, Infection Prevention and Control Program (IPCP) and Plan, revealed that methods to reduce the risks associated with procedures included appropriate disposal of supplies and equipment and no reuse of supplies and equipment designated by the manufacturer as disposable in a manner that is consistent with regulatory and professional standards. Review of the facility policy titled, Cleaning and Disinfection of Non-Critical Patient Care Equipment, revealed that any equipment that cannot be identified as clean or soiled should be presumed dirty.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#38) who was receiving a [CONDITION(S)] medication was monitored for behaviors. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #38 was admitted on [DATE] with diagnoses that included pneumonia, [CONDITION(S)] and depression. A care plan dated 2/24/2022 revealed the resident used an antidepressant medication. The goal was for the resident to remain free of drug related complications such as hallucinations, tremors, muscle cramps, suicidal thoughts and social isolation. A physician's order dated 5/4/22 included for [MEDICATION(S)] (antidepressant) 10 mg (milligram) one tablet by mouth one time daily for depression. The above physician orders did not include monitoring for behaviors indicated to the use of the antidepressant. Review of the May 2022 Medication Administration Record (MAR) for resident #38 revealed the resident received the medication as ordered. Further review of the MAR for May 2022 and the clinical record revealed no evidence that the resident was being monitored for behaviors related to the use of the antidepressant. An interview was conducted on 05/04/22 at 9:30 AM with the resident's Licensed Practical Nurse (LPN/staff #36). The LPN stated that all antidepressant medications should include behavior monitoring. The LPN added that the lack of behavior monitoring must be an oversight on someone's part. An interview was conducted on 05/04/22 at 10:57 AM with the Director of Nursing (DON/staff #7). The DON stated that she was surprised to find that the resident was not being monitored for a specific behavior. She added that all residents on an antipsychotic/antidepressant medication are required to have the behaviors monitored. The DON stated they are also required to have documentation of monitoring for side effects and have the Pharmacy monitor and make recommendations for the medication. She stated the physician needs to see the behaviors so that he or she can perform a GDR (gradual dose reduction) or increase the medication as necessary. The DON included that it is ultimately her responsibility to verify that behavioral monitoring is in place. Review of the facility policy [CONDITION(S)] Medication Use (revised 1/1/22) stated that a [CONDITION(S)] drug is any medication that affects brain activities with a mental process or behavior. [CONDITION(S)] medications that are used to treat behaviors will be used to treat specific underlying behaviors symptoms. All medications used to treat behaviors should be monitored for efficacy, risks, benefits, and harm or adverse consequences.

Based on clinical record reviews, staff interviews, and facility policy and procedures, the facility failed to ensure multiple medications were administered as ordered for two of five sampled residents (#22 and #56). The deficient practice could result in residents receiving unnecessary medications. Findings include: -Resident #56 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on November 23, 2021 revealed resident #56 expressed pain and discomfort related to phantom pain. The goal was that the resident would express pain relief. Interventions included evaluating the effectiveness of pain interventions and pain medications as ordered. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on May 5, 2022 at 10:45 AM with a Licensed Practical Nurse (LPN/staff #6). She stated pain assessment includes asking the resident to describe the type of pain such as stabbing, throbbing, or aching. She stated that she would ask where the location of the pain is and how long it has been occurring and to rate the pain on the pain scale 1-10. Further, she clarified that 10 is the highest level of pain, while 1 is the lowest level of pain. The nurse stated that she would try non-pharmacological interventions prior to medicating the resident, such as repositioning or ice. The nurse explained that if non-pharmacological inventions did not work, then she would review the resident's medication orders. The nurse stated that administering pain medication for a pain reported of 0 is not ok unless the physician was notified and an order was given to do so. Additionally, the nurse stated that giving an opioid pain medication for someone with no pain is not necessary for the resident. An interview was conducted on May 5, 2022 at 11:02 AM with the Director of Nursing (DON/staff #7). The DON stated that she expects the nurses to assess pain by asking the resident for the location of the pain, the numerical number for the reported pain on the pain scale, and then to look at physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the MAR for resident #56 and stated that the nurses had been documenting the pain number reported by the resident. -Resident #22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order also stated to hold the medication for SBP (systolic blood pressure) below 110. A provider note dated February 15, 2022 included the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the documentation, the resident's SBP's were all below 130, and that the resident had controlled hypertension. The current comprehensive care plan revised on February 18, 2022 included the resident was at risk for cardiac complications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal included that the resident will have no complications related to CHF. Interventions included administering medications as ordered. The order for [MEDICATION(S)]-[MEDICATION(S)] was transcribed onto the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence found in the clinical record of any changes in the order for [MEDICATION(S)]-[MEDICATION(S)]. The order for [MEDICATION(S)]-[MEDICATION(S)] continued to be transcribed onto the MAR for March and April 2022. Review of the MARs revealed there were multiple dates that the resident's BP were not documented and multiple dates when the SBP was documented below 110. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed no evidence the physician was notified the medication was administered outside the ordered parameter on multiple occasions from February through April 2022. An interview was conducted on May 5, 2022 at 10:45 a.m. with an LPN (staff #26). The LPN stated that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She also said there could be an increased risk to the resident if their blood pressure is too high or too low as a result of administering blood pressure medication outside of the ordered parameters. The LPN further stated that if the medication was held or not given to the resident, the nurse will document it in a progress note and notify the physician. During an interview with the DON (staff #7) conducted on May 5, 2022 at 2: 16 p.m., the DON stated that the nurses are expected to administer the medications and follow the ordered parameters. The DON stated that orders for blood pressure medication should have parameters and the nurse should document the resident's blood pressure prior to administering the medication. The facility policy Administration of Medication revealed the facility will ensure medications are administered safely and appropriately per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff who are responsible for medication administration will adhere to the following 10 rights of Medication Administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation and right education and information.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure discharge planning included developing a discharge care plan that included ensuring that one resident (#260) was discharged to a safe environment. The sample size was 3. The deficient practice could result in residents not receiving the care and services needed post discharge. Findings include: Resident #260 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's profile revealed that resident #260 was responsible for self and the resident's spouse was the emergency contact. Review of the care plan initiated on February 17, 2021 and stated discharge plan to be developed for the resident. The goal stated will develop and follow a full discharge plan with comprehensive. Intervention/Tasks stated the resident wishes to return home. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 9 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately impaired cognition. The assessment revealed the resident required extensive assistance of two+ persons for bed mobility, transfer, walking in room, toilet use, and dressing; and extensive assistance of one person for personal hygiene and eating. The assessment also included the resident expected to be discharged to the community and that the information was obtained from the family or significant other, the resident participated in the assessment, and that no referral was needed to the Local Contact Agency. The Discharge Planning Evaluation completed by a case manager Licensed Practical Nurse (LPN/staff #19) dated [DATE] revealed that the resident was to be discharge to home. The note also revealed the resident did not have a caregiver capable of and willing to provide assistance with post discharge, and that the resident will likely need post discharge physical assistance. Review of a progress note dated [DATE] completed by staff #19 revealed that staff #19 told the resident's spouse the discharge date was [DATE]. The note revealed the spouse told staff #19 that the spouse had spoken to the resident and had explained to the resident that the resident may have to go to a group home and stay until the resident gets better before coming home. The note stated staff #19 gave the spouse the number to a placement agency and educated the spouse about how much care the resident would need. The note further revealed the spouse reached out to the agency. The note stated the agency told staff #19 that the spouse had stated the spouse had no money to take the resident to a group home, so the spouse will be taking the resident home. A plan of care note dated [DATE] stated the care plan was reviewed by the interdisciplinary team (IDT). The resident/family declined to attend the care plan conference. Will continue with the current plan of care and discharging plan as appropriate. A progress note dated [DATE] at 5:29 a.m. completed by the Social Services Director (staff #3) stated the spouse is insisting on taking the resident home. The note included it was explained to the spouse how important it was that the spouse follow through with ALTCS (Arizona Long Term Care System) and that the spouse stated an appointment via phone is scheduled for Thursday, [DATE]. The spouse was told to ask an adult child for assistance and that the spouse indicated the adult child was helping to find someone to help care for the resident. Again, the importance of really working with ALTCS to get some assistance with caring for the resident was reiterated with the spouse. The spouse stated that the spouse will do what the spouse has always done when the resident comes home from the hospital, and that is take care of the resident as the resident's family never helps or asks how they can help. Review of a progress note dated [DATE] at 2:14 p.m. completed by staff #19, revealed staff #19 had spoken with the spouse via phone and the spouse has an appointment with ALTCS on Tuesday at 10:00 a.m. via phone. The note also revealed the spouse stated the spouse did not want the resident to stay at the facility and will be picking up the resident on Friday and taking the resident home. The note included staff #19 told the spouse that staff #19 wanted to make sure that the spouse understands the resident is a maximum assistance with transfers and toileting, and asked the spouse who would help get the resident up and out of bed. The spouse said the spouse has friends and family that will help. The Request for Orders Discharge Notice dated [DATE] completed by the case manager (LPN/staff #19) revealed the resident was being discharged home with the spouse, which included a wheelchair, home health, physical therapy evaluation and treatment, occupational therapy evaluation and treatment, bath aide, social worker, and a home health registered nurse (RN). Review of the NRSG: Section GG (Functional Status) form dated [DATE] revealed: -Toileting, the resident was dependent upon a helper providing all the effort or 2 staff members were required. -From sitting to lying, the resident required substantial/maximum assistance. -From lying to sitting on the side of the bed, the resident required substantial/maximum assistance. -Sit to stand, the resident was dependent upon a helper providing all the effort or 2 staff members were required. -Transfers, the resident required substantial/maximum assistance. -Walking 50 feet was not attempted due to medical conditions or safety concerns. The physical therapy (PT) discharge summary completed by a registered physical therapist (staff #99) dated [DATE] revealed that the resident's discharge destination was home and the resident was discharged from therapy because the highest practical level was achieved. Prognosis: initial discharge plan was for the resident to stay in the facility for long-term care due to the level of assistance that the resident required, but the spouse took the resident home. The resident demonstrated some functional gains in all areas, but still required ,d+[DATE] able bodied caregivers for all mobility. The discharge recommendations included ,d+[DATE] able bodied caregiver, home health physical therapy, remain at this facility or go to another facility where the resident can receive the physical assistance the resident required. The occupational therapy (OT) discharge summary dated [DATE] revealed that the resident's destination was home with support from others. Discharge recommendations revealed the resident still required significant cues for safety and assistance. The resident is going home with family, who can assist with activities of daily living (ADL) and perform ADL. The summary included it was recommended for ,d+[DATE] care, four-wheeled walker, 3 in 1 commode as well as home health to safely ease transition to home. The discharge MDS assessment dated [DATE] included a BIMS score of 9 which indicated the resident had moderate cognitive impairment. It also included that the resident required extensive assistance with bed mobility, transfers, walking in the room, walking in the corridor, dressing, toilet use, and bathing. The assessment stated the resident was always incontinent of urine and frequently incontinent of bowel. The assessment also stated the resident was discharged to the community and a referral was not made to the local contact agency. Review of a progress note dated [DATE] at 11:41 a.m. revealed the resident was discharged home with spouse. All paperwork and scripts were reviewed and given to the resident. A progress note dated [DATE] by staff #19 stated received a call was received from a sibling and adult child of the resident accusing staff #19 of sending the resident home with no care and that staff #19 had told them that it was unsafe for the resident to go back home where the spouse could not take care of the resident. Staff #19 said that the spouse was told to take the resident to a group home and also to file for ALTCS for the resident. The spouse, who would be the power of attorney (POA), said the spouse could not afford for the resident to go to a group home. The note included they were demanding to know why staff #19 did not file an Adult Protective Services (APS) report. Staff #19 told them the resident was issued a notice and the wife was given all the information about caregivers in the home, group homes, and ALTCS. Staff #19 told them that they knew how much help the resident needed and none of them reached out to help. Review of the clinical record did not reveal evidence identifying the spouse as the resident's power of attorney (POA), that the caregiver (spouse) had received training on safely providing ADLs, or that a report to Adult Protective Services had been made. An interview was conducted on [DATE] at 9:22 a.m. with the Director of Social Services (staff #3) and the Social Services Assistant (staff #127). Staff #3 said therapy and case management are responsible for ensuring the family member receives the education and training needed to provide care for the resident, and documenting that the training occurred. She stated therapy is very aware of who is going to be at home with the resident and would assess if the family member is frail. She said they would not discharge a resident if the POA/family member was not able to provide a sufficient level of care or was refusing to pay money for in-home services because it would not be a safe discharge. Staff #3 reviewed the Discharge Summary and the MDS Discharge assessment section G, and stated that based on the information, the resident would have needed extensive assistance, which required 2 persons. Staff #127 also reviewed the discharge MDS assessment and stated that the resident was an extensive assistance with two persons, so the resident would need two-persons to assist with care. Staff #3 also stated that if the POA says they cannot afford the level of care being recommended, it would be documented and she would verify that the person was the POA and would file an APS report. Staff #3 was not able to find documentation confirming an APS report was filed. On [DATE] at 10:27 a.m., an interview was conducted with the Director of Rehabilitation (staff #17), who said before he meets with the IDT team to discuss discharge, therapy completes a discharge summary which includes the reason for the discharge, location of discharge, and recommendations. Staff #17 stated that if a resident is being discharged home, he would provide the training to the POA/family members to ensure level of care can be provided safely and documents that the training was provided. He stated that his team determines the DME (durable medical equipment) needed and the number of people needed to provide care. He reviewed the resident's notes and stated the resident required ,d+[DATE] able body care for bed mobility and transfers, and needed 1 to 2-person assistance. He said that prior to discharge, the facility would determine if other/secondary persons were available to assist. He referred to the resident's progress notes and stated the grandchildren and children were to provide for transportation and he assumed they would help with ADL care, but did not have documentation showing it was discussed with them. He stated that the spouse would have needed training on how to assist with transfers, repositioning, bathing, dressing and toileting, but does not have any documentation that the spouse was provided any type of training. He stated that if the spouse had been provided training, it would be documented in the progress notes. He also said that the weight, size, strength, cognition, and physical ability of the resident along with the spouse's ability to assist the resident with ADL care would be determined when training was provided to the spouse. He said that maximum assistance is extensive assistance and requires 75% of caregiver assistance. Staff #17 stated risk is created if the appropriate training is not provided to the caregiver, and the training for family members/caregivers is a part of ensuring a safe discharge. He said, originally, the resident was offered group home care because of the level of care needed and the spouse declined because the spouse said they could not afford it. On [DATE] at 11:18 a.m., an interview was conducted with the case manager lead (LPN/staff #19), who stated that the IDT team, which consists of PT, OT, case management, and social services decides what level of care is needed when a resident is discharged . She said therapy recommended ,d+[DATE] care in a group home, but the spouse said they could not afford a group home. Staff #19 stated that the facility applied for ALTCS on the resident's behalf because ALTCS would pay for a group home, but the spouse said she did not want to apply for ALTCS because the resident made more money and the resident's social security money would go towards the group home placement and the spouse would not have enough money to live on. Staff #19 also said that she also told the spouse that ALTCS would pay for up to 30 hours of in-home health care services, but the spouse did not go to the meeting with ALTCS, so it was never approved. Staff #19 said the resident did not have a POA, but the resident also stated that the resident wanted to go home. Staff #19 stated that the spouse would have needed training on transfers and dressing, if taking the resident home, and therapy should have provided the caregiver training, but she did not know if this occurred. She stated it is her expectation that staff offer training and if the family refuses the training, it is documented. She stated that if they did not provide training on ADL care and if the family was not able to provide the level of care needed and cannot afford to pay for in-home services, this was not a safe discharge. Staff #19 stated that when there is an unsafe discharge, Social Services would file the report with APS. During the interview, she reviewed the resident's clinical record and could not find documentation stating that an APS report had been submitted by the facility. On [DATE] at 12:41 p.m., an interview was conducted with the Director of Nursing (DON/staff #7) with a regional support staff (staff #142) present. Staff #7 stated that discharge planning begins the day the resident is admitted . She stated the IDT team meets at least twice a week and discusses the resident's progress, which includes discharge goals. The DON stated therapy completes a discharge summary with recommendations that includes the level of care needed, if the resident is going to be safe at home or if the resident needs ,d+[DATE] care. She said that therapy recommends group home level of care because care may not be available at home or the family cannot afford to pay for caregivers at home. She reviewed the clinical record and stated the resident required extensive assistance and that therapy recommended a group home. She said when it is not a safe discharge, the facility would file an APS report. The DON stated a CNA receives training on ADL care, which includes transfers to ensure ADL care is provided safely and that the spouse/family member would also need training to ensure safety. A second interview was conducted on [DATE] at 9:26 a.m. with the Director of Social Services (staff #3), who said that she believes the spouse was the one that made the decision regarding the resident's discharge to home, but would have to look it up. She reviewed the resident's record and stated that the resident was responsible for making decisions and the wife was the emergency contact. A second interview was conducted on [DATE] at 9:36 a.m. with the case manager lead (LPN/staff #19). After reviewing the Initial Discharge Planning Evaluation form dated [DATE] signed by her, she acknowledged that she had documented that the resident did not have a caregiver capable of and willing to provide assistance post discharge. She stated she did not remember or know why she did this. She stated that when she completed the form, she interviewed the resident and then called the spouse to complete the interview as family is a part of the process. She stated she thinks the resident and spouse lived alone and had family that lived in the same complex, but had no documentation that she asked these questions. Staff #19 stated it was her understanding that the spouse was going to provide care and be the main care provider. She said the resident's sibling and adult child did not agree with the resident going home with the spouse and they said they would help find a group home. On [DATE] at 9:59 a.m., a second interview was conducted with the Director of Rehabilitation (staff #17). Staff #17 stated the resident was voicing to go home pretty much daily and they were trying to explain/educate the resident that it was not safe due to the level of assistance that was needed. During the interview staff #17 contacted the physical therapist (staff #99) via phone and she said it is her expectation that if the resident is a maximum assistance, the caregiver is responsible for cuing and monitoring the resident's mechanics during transitions. The facility's policy, Discharge Plan, reviewed [DATE] stated this requirement intends to ensure that the facility has a discharge planning process in place which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan. Involve the resident and resident representative. Consider the resident's support/caregiver's availability, capacity, and capability to perform required care when identifying discharge needs. Document the resident/resident representative involvement in the discharge plan development. The discharge plan will identify the discharge destination, and ensure it meets the residents' health and safety needs as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs or appears unsafe, the facility must determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral will be made at the time of discharge, if appropriate.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure a written notice of transfer/discharge was sent to the Office of the State Long Term Care Ombudsman regarding one resident's (#260) discharge. The sample size was 3. The deficient practice could result in the Ombudsman not receiving a copy of residents' transfers/discharges. Findings include: Resident #260 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge care plan initiated on February 17, 2021 stated discharge plan to be developed by the resident and the resident wishes to return home. Review of a progress note dated March 12, 2021 at 11:41 a.m. revealed the resident was discharged home with spouse and that all paperwork and scripts were reviewed and given to the resident. However, no evidence was revealed that a copy of the discharge was sent to the Ombudsman. During an interview conducted on May 5, 2022 at 8:26 a.m. with the regional support staff (staff #142), she stated that the facility is still looking for documentation that the Ombudsman was notified when the resident was discharged . On May 5, 2022 at 9:26 a.m., an interview was conducted with the Director of Social Services (staff #3). She stated the Ombudsman is contacted via email at the end of each month showing who has been discharged and the discharge location. Staff #3 stated that she does not have any records to show if the Ombudsman was contacted when resident #260 was discharged . She said she started working at this facility on March 8, 2022 and that the Administrator may have documentation showing when the Ombudsman was contacted. During an interview conducted on May 5, 2022 at 9:36 a.m. with the case manager lead (staff #19), she stated that she does not have any records regarding Ombudsman notification. The facility policy, Transfers and Discharges, reviewed May 11, 2021 stated before a facility transfers or discharges a resident, the facility must 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 clinical record review, staff interviews, and the facility's policy and procedure, the facility failed to ensure one resident (#87) was treated with respect, and in a dignified manner. The sample was 25. The deficient practice could result in residents not being treated with respect. Finding include: Resident #87 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan with a revision date of February 23, 2022 included an ADL (Activity of Daily Living) self-care performance deficit related to impaired mobility, infections, and bilateral foot wounds/[CONDITION(S)]. The goal included the resident will not have complications related to ADL self-care deficit. The interventions revealed the resident required physical staff assistance with bathing/showering, and for staff to use short, simple instructions such as hold your washcloth in your hand; put soap on your washcloth; wash your face; to promote independence. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Summary Mental Interview Status score of 15, which indicated the resident was cognitively intact. The MDS stated the resident needed extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS assessment also revealed the resident used a wheelchair for mobility. During an interview conducted with the resident on May 3, 2022 at 8:52 a.m., the resident stated that she was showered by a male CNA (Certified Nursing Assistant) yesterday morning. Resident #87 stated she attempted to shower herself, to maintain her independence, but the water started going under the door. Resident #87 stated the CNA yelled at her, and she felt scared because the CNA was very aggressive. She stated after the shower, the CNA was very distant. An interview was conducted on May 4, 2022 at 11:57 a.m. with the CNA (staff #42) via phone. Staff #42 stated he has worked in the facility for [AGE] years and is normally assigned in the hall where resident #87 resides. Staff #42 stated he worked a double shift on Monday, May 2, 2022, a morning shift and an evening shift. He stated he was familiar with resident #87. The CNA stated that resident #87 was assigned to his care and he provided the resident a shower on May 2, 2022 at about 1:30 p.m. Staff #42 stated the resident has a shower in her room and that the resident only needed help with transfer on the shower chair with one-person assistance. Staff #42 stated resident #87 was able to shower her upper and lower body independently. Staff #42 stated while the resident was showering, he started fixing the resident's bed, and that the bathroom door was half way opened. He stated that resident #87 called his name, he looked and noticed the shower head was facing the bathroom door. He stated he yelled at the resident but then clarified his statement and said that he yelled at the resident or raised his voice. The CNA stated he entered the bathroom and moved the shower head and turned the water off. During the interview, the staff spoke with an elevated tone, loud enough for other personnel in the conference room to hear his voice without being placed on the speaker phone. An interview was conducted on May 4, 2022 at 12:47 p.m. with an LPN (Licensed Practical Nurse/staff #6). Staff #6 stated if a resident was bathing and the water was getting on the door, she would go into the resident's bathroom and explain to the resident about the hazard of the water getting on the door, and then she would ask the resident if she could shut the door. Staff #6 stated there is never a right time or situation that makes it ok to yell at the resident. She stated the facility is the resident's home, and the staff are the visitors. Another interview was conducted on May 4, 2022 at 12:55 p.m. with another CNA (staff #60). Staff #60 stated if a resident was taking a shower and the water was getting on the door, she would tell the resident to be careful, and speak to the resident with respect, in a soothing voice. Staff #60 stated she would also ask the resident if she needed any help to complete the shower. Staff #60 stated there is never a situation where a staff member should yell at the resident. She stated even if a resident was yelling at her, she would not yell back, she stated she would walk out the room and report the situation to the nurse immediately. Review of the facility policy, Resident Rights, stated a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality.

Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#99) was free from neglect. Findings include: Resident #99 was admitted to the facility on (MONTH) 21, (YEAR) and readmitted on (MONTH) 29, (YEAR). [DIAGNOSES REDACTED]. A Fall Risk assessment dated (MONTH) 15, (YEAR) revealed the resident was at risk for falls. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, (YEAR) revealed a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. The MDS included the resident had sustained a fall with injury since the previous assessment. The MDS also included the resident required extensive assistance with bed mobility, transfers, toilet use and was frequently incontinent of bowel and bladder. Review of a care plan revealed the resident was at risk for injury related to falls. A goal included that the resident would not sustain a serious injury requiring hospitalization . Interventions included call light in reach, toilet after meals, and do not leave resident unattended while toileting. Review of the CNA (Certified Nursing Assistant) Care Guide revealed toileting directives which included to assist the resident with toileting as needed and do not leave resident unattended on the toilet. Review of the nursing progress note dated (MONTH) 4, (YEAR) at 6:37 p.m., revealed the nurse was told by another resident that resident #99 was on the floor. The resident complained of pain in her legs and right hip and the right leg was slightly rotated inward. The on call nurse practitioner was notified and orders were received for a right hip x-ray. Per the note, the x-ray was done, which revealed a [MEDICAL CONDITION] hip. Orders were received to send the resident to the emergency room for evaluation and treatment. The resident left the facility via gurney at 9:15 p.m. A nursing progress note dated (MONTH) 5, (YEAR) revealed the resident was admitted to the hospital. Review of the hospital History and Physical report dated (MONTH) 5, (YEAR) revealed the resident was brought to the emergency room for further evaluation for hip pain, which happened after a fall. The x-ray showed an acute comminuted, displaced right femoral neck and intertrochanteric femur fracture. The plan included to admit the resident to the medical floor and for an orthopedic evaluation in the morning. Review of the facility's investigative report revealed the resident sustained [REDACTED]. A CNA (staff #118) reported that the resident needed to use the restroom, so she assisted the resident to the bathroom. She said that she told the resident to turn on the call light when she was done, because she was going to grab some towels for her shower. The report further included that the resident was left unattended in the bathroom while a CNA (staff #118) stepped out of the room to gather towels and the resident fell landing on her right side, resulting in a [MEDICAL CONDITION] hip. The report also included that staff #118 was educated on (MONTH) 4, (YEAR) by the RN regarding strict adherence to Kardex directives, which included that the resident is not to be left unattended while toileting. In an interview with the Director of Nursing (DON/staff #45) on (MONTH) 26, (YEAR) at 11:30 a.m., the DON stated that she and the nursing supervisor investigated this accident and completed a Quality Assurance Improvement Plan for this issue. She stated that it was one CNA who left the resident unattended on the toilet, when she stepped just outside the door to get some linens, in preparation for the resident's shower. She further stated that it was clearly noted on the Care Guide that the resident was not to be left unattended in the bathroom. The DON stated that the CNA was educated on the spot and that all of the CNA's were in-serviced, and that follow up observations of care were done. Review of the facility's Quality Assurance Performance Improvement Plan revealed that after the incident, staff #118 and all nursing staff were educated regarding following resident's care plans and supervision of residents. The documentation also included monitoring of CNA practices by the licensed nurses and nursing administration over several weeks. A telephone interview was conducted on (MONTH) 26, (YEAR) at 12:07 p.m., with a Licensed Practical Nurse (LPN/staff #77), who was on duty at the time of the resident's fall. Staff #77 stated that she thought resident #99 told her that she was trying to get up from the toilet and fell . Staff #77 stated that she notified the nursing supervisor of the fall. A telephone interview was attempted with staff #118 however, the CNA was on leave and did not return any calls. Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect revised (MONTH) (YEAR), revealed that each resident has the right to be free from abuse and neglect. The policy included that neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. The policy further included that all residents will be protected from all types of abuse and neglect. The facility will have structures and processes in place to provide the needed care and services to all residents.

Based on clinical record review, hospital record review, observation of current facility practice, staff and complainant's interviews, review of facility policy and procedure and review of facility documentation, the facility failed to ensure an outside patio, located near the the resident elevators, was safe for use, and one resident (#482) sustained a fall resulting in actual harm. The sample size was five. Findings Include: Resident #482 was readmitted to the facility April 23, 2010, with [DIAGNOSES REDACTED]. Clinical record review revealed that the resident was alert and oriented with some periods of confusion. Also documented was that the resident used a wheel chair for ambulation. Review of the nurse's notes dated January 3, 2011, revealed that the resident had sustained a fall on the outside patio. Additional review of the nurse's notes dated January 3, 2011, included that two residents from the first floor called for help. Review of portable diagnostic X-ray results documented that the resident had not sustained a fracture, but that these portable diagnostic results could not rule out a nondisplaced fracture of the femoral neck. Further documented was that if the patient remained clinically symptomatic to consider further diagnostic evaluation. Additional review of the clinical record revealed the resident continued to have complaints of pain and was transported to a local hospital for further evaluation. Review of the hospital records revealed that the resident sustained [REDACTED]. Observation of the facility patio area on August 23 through 25, 2011, included that residents were free to come and go and that the facility had a system in place to identify residents needing supervision while on the patio. This system utilized a flag on their wheel chairs to identify the need for more supervision. Observations of the facility patio from August 23 through 25, 2011, included that the patio was a large concrete area as well as a grass covered area and rocky landscaped areas at the base of several trees. Visual observations included that the transition from the concrete surface area to the grass and rocky areas revealed a difference in elevation. Further observation revealed that there was no railing or protective barrier to prevent ambulatory residents, including those in wheel chairs, from inadvertently getting from the concrete surface area on to the unstable grassy and rocky areas. Review of facility documentation included that at the time of the fall, the resident was turning around her wheel chair and tipped over into the grassy area. In an interview conducted August 25, 2011, a CNA (certified nursing assistant) stated she would assist residents to the outside patio as needed. She reported that the activities department was responsible for communication with staff about which residents required additional supervision while on the patio. In an interview conducted August 25, 2011, the activities director stated that residents that needed extra supervision while on the outside patio had a flag or a beeper on their wheelchair. The activities director also stated that residents who were at risk for falls were not left alone on the patio. In an interview conducted August 25, 2011, the DON (director of nursing) stated that resident #482 was able to propel herself around on the unit and to the outside patio. The DON also stated that the resident had attempted to turn around in her wheel chair when she went off onto the grass and the wheel chair tipped over. In an interview conducted August 25, 2011, the facility's environmental director observed the transition or drop off from the concrete surface to the grassy area of the patio. The maintenance director measured the drop off from the concrete surface to the grassy area and in one area it was measured to be four inches. In response to a specific surveyor question about the drop off from the concrete to the grass, the environmental director acknowledged that it could be a potential hazard. The environmental director also stated that he was a long term employee of the facility and he was unable to recall any other incidences of the drop off contributing to accidents. Review of facility policy "Falls Management" included "...The IDT (Interdisciplinary Team) will determine the need for development of any additional facility-wide or resident specific interventions, staff, resident and/or family education and training, or other follow up measures that may be needed to reduce the risk of recurrence..." Review of facility policy titled Courtyard/Secured Patio Access states, "...each facility should provide for periodic monitoring of residents in courtyards and secured patios to provide assistance..."