Every finding on record at Life Care Center of Sandpoint

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen was cleaned, the resident freezer was cleaned, and staff food was not stored with resident food. These deficiencies had the potential to affect the 71 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:1.FDA Food Code Section 3-303.12 Storage or Display of Food in Contact with Water or Ice, documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water.FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils, documented: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned: (4) In equipment such as ice bins . and enclosed components of equipment such as ice makers. (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.On 7/21/25 at 9:55 AM, and 7/24/25 at 10:55 AM, during the initial and follow-up kitchen inspection, the walk-in freezer was observed to have water droplets on the ceiling, some frozen, some dripping, with a layer of ice on the open boxes of ice cream sandwiches and other closed boxes of food. Ice droplets had accumulated to 2-inch ice piles on the floor. On 7/21/25 at 9:57 AM, the DM stated maintenance had been working on fixing the condenser for the past month, but it had yet to be resolved. She stated water should not be dripping onto the food boxes or the floor creating a coating of ice. 2. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented: Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. On 7/21/25 at 9:55 AM, and 7/24/25 at 10:55 AM, during the initial and follow-up kitchen inspection, the walk-in refrigerator was observed to have a layer of dust particles blowing from the fan covers and hanging from the ceiling. On 7/24/25 at 10:56 AM, the DM stated maintenance had been in to clean the dust from the refrigerator fans and replaced the filters on 7/23/25, but they had missed areas of the refrigerator ceiling and fans which were visibly covered in dust. On 7/24/25 at 3:05 PM, during the follow-up kitchen inspection, it was observed the main ice machine for the facility had an accumulation of black residue on the inner upper area of the ice machine. On 7/24/25 at 3:07 PM, the DM stated quarterly cleanings are completed by facility maintenance for both the fans and ice machine, and the last cleaning for the ice machine was in June 2025. The ice machine should not have any black residue. On 7/24/25 at 3:25 PM, the Facility Manager stated the ice machine had been cleaned on 6/4/25, and it should not be dirty.On 7/24/25 at 3:20 PM, the LTC Resident Refrigerator was observed to have physical food residue in the freezer area. On 7/24/25 at 3:20 PM, the Housekeeping Supervisor stated the LTC Resident freezer should have been cleaned more frequently. He did not know when it was last cleaned. 3. FDA Food Code Section 6-403.11 documented areas designated for employees to eat, and drink . shall be located that so that food . [is] protected from contamination. On 7/24/25 at 3:20 PM, the LTC Resident Refrigerator was observed to have leftover fried chicken in the refrigerator drawer belonging to facility staff. On 7/24/25 at 3:25 PM, the RCM stated staff food is not to be stored with resident food and should not have been in the LTC Resident Refrigerator.

Based on observation, policy review, record review, CDC guidance review, and interviews it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment, and to help prevent the transmission of communicable diseases and infection. Specifically the facility did not perform a facility wide testing for COVID 19 as advised by their local Health Department, personal protective equipment (PPE) was not don properly, hand hygiene was not performed during residents' cares, and medical equipment was not stored in a sanitary manner. Findings include:1.On 7/21/25 at 12:14 PM, the IP together with the DON present stated the facility had residents who tested positive for COVID-19. The IP stated Resident #6 and Resident #60 tested positive for COVID-19 on 7/12/25 and were placed on isolation. The DON stated Resident #6’s roommate and Resident #60’s roommate was informed of their COVID positive results and were encouraged to wear mask. The DON stated there were no rooms available for Resident #6 and Resident #60 to move them to. Since their roommates have already been exposed, they were kept in the same room. On 7/21/25 at 12:29 PM, the SDC stated she informed their local health department of their positive COVID results via email. On 7/22/25 at 2:22 PM, the DON, IP and SDC were present and a copy of the local Health Department email, dated 7/16/25 at 12:07 PM was provided to the Surveyors and it documented “Your facility is in COVID outbreak as of 7/12/25.” The email also documented the facility should be testing facility - wide (both staff and residents) and to wear a mask or respirator at all times while in the facility at any time they could come into contact with another staff or resident. The IP with the ADON and SDC present stated 100 Hall was divided into Team 3 and Team 4. Resident #6 and Resident #60 were in Team 3, and all residents in Team 3 were tested for COVID 19 on day 1, 3 and 5. The IP stated residents on Team 4 were not tested for COVID 19. When asked why the residents on Team 4 were not tested for COVID 19, the ADON stated a decision was made to test only the residents on Team 3. When asked if all the staff were tested for COVID 19, the SDC stated only those staff who had contact with residents with COVID 19 and symptomatic were tested for COVID 19. When asked why the facility wide testing for COVID 19 was not conducted as per their local Health Department advised on the email, SDC stated, We did not look at the email until today. 2. The CDC website article titled Sequence for Donning Personal Protective Equipment (PPE) accessed on 7/29/25, documented the gown should fully cover the torso from neck to knees to end of wrist, wrap around the back and fasten in back or neck and waist. The facility’s Personal Protective Equipment (PPE) for SARS-COV-2 policy reviewed 7/12/24, documented the facility will provide and utilize the appropriate PPE for the care of residents with COVID-19 in accordance with CMS and CDC guidance. The policy documented the following should be worn before entering the patient’s room with suspected or confirmed COVID-19, N95 respirator, eye protection such as goggles or face shield, gloves, and gown. The N95, eye protection, gloves and gown should be removed and discarded after exiting the patient’s room. On 7/22/25 at 10:03 AM to 10:11 AM, Housekeeper #1 wearing a facemask, gloves and disposable gown which was tied only around her neck was observed entering and collecting the dirty linen in rooms #s 119, 110, 114 and 104 on isolation due to COVID 19. Housekeeper #1 was also observed entering the Day room which was being used by COVID 19 positive residents for their activity and dining. Housekeeper #1 was not observed to remove her gown and mask as she exited the resident’s room on isolation, and she was not observed to change her facemask and disposable gown as she entered the rooms on isolation. She was observed changing her gloves and put on new gloves without performing hand hygiene as she exited Room #s 119 and 110. On 7/22/25 at 10:15 AM, Housekeeper #1 stated she often put her gown on and did not think of tying it completely around her waist. When asked if she removed her gown as she exited the resident’s room on isolation and put on a new gown and mask as she entered the isolation room. Housekeeper #1 stated she did not know she was supposed to remove/put on gown and facemask when she exited/entered the resident’s room on isolation. Housekeeper #1 was also informed by the surveyor that she was not observed to perform hand hygiene when she changed her gloves upon exiting room #s 119 and 110. Housekeeper #1 stated, “Yes, I am supposed to perform hand hygiene when I change my gloves.” 3. The facility’s Hand Hygiene policy, revised 12/8/20, documented the facility should assist either physically or through reminders to residents to perform hand hygiene after toileting and before meals. On 7/21/25 between 11:55 AM and 12:35 PM, it was observed in the main dining hall residents were not offered hand hygiene before being given their drinks, soups, or main meal. On 7/24/25 at 12:02 PM, the DON and the ADON stated residents should be offered hand hygiene before meals. The ADON, who was in the dining room on 7/21/25 at 11:55 AM, stated she was unsure whether residents had been offered hand hygiene before receiving their first course, soup. 4. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a mental health condition characterized by a combination of schizophrenia symptoms [like hallucinations and delusions] and mood disorder symptoms [like depression or mania]), PTSD, depression, and cognitive communication limitations. On 7/21/25 at 2:35 PM, the DON and the IP verified Resident #18 tested positive for COVID-19 on 7/19/25. Resident #18’s care plan, initiated on 7/21/25, documented she had a COVID-19 respiratory infection precautions and treatment plan including requiring the resident’s room door to remain closed, and to encourage her to wear a mask when out of her room. On 7/21/25 at 3:10 PM, Resident #18 was observed leaving her room with a face mask placed below her nose, walking down the hallway to the nurses’ station, and then returning to her room. Facility staff did not stop Resident #18 to properly adjust her face mask. On 7/22/25 at 11:37 AM, Resident #18 was observed leaving her room without a face mask, walking down past the nurses’ station, and drinking from the community water fountain. Staff did not approach Resident #18 to encourage a face mask or to discourage her from using the community water fountain. From 7/21/25 through 7/25/25, it was observed Resident #18’s room door was left open. On 7/24/25 at 10:42 AM, in a joint interview with the DON and the ADON, they stated Resident #18’s care plan was not followed. No information was provided regarding why the community water fountain was still in use during the COVID-19 outbreak. 5. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including right side paralysis following a stroke, diabetes, and dysphagia (a medical condition characterized by difficulty or discomfort in swallowing.) On 7/21/25 at 9:32 AM, Resident #49 was listed as Resident #6’s roommate. On 7/21/25 at 11:15 AM, Resident #49 stated he has been Resident #6’s roommate since Resident #6 tested positive for COVID-19. Resident #49 then left his room, without a mask, and proceeded to the dining room to eat lunch, where he stated he has eaten all of his meals over the past two weeks. Between 7/21/25 and 7/25/25, Resident #49 was observed eating in the dining room multiple times. He was not wearing a mask, nor was he approached by staff to be encouraged to wear a mask. On 7/21/25 at 2:35 PM, the DON and the IP verified Resident #6 tested positive for COVID-19 on 7/12/25. They stated there were no other rooms to move Resident #49, so they kept him in the same room with Resident #6. The DON and the IP stated all facility residents and representatives were notified about the COVID-19 outbreak in the building. 6. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dissection of thoracoabdominal aorta (a severe medical emergency characterized by a tear in the inner lining of the aorta, the main artery that carries blood from the heart through the chest and abdomen), asthma, and dementia. On 7/24/25 at 2:23 PM, it was observed with the RCM, Resident #8's nebulizer mask was face down on his side table, next to a portable urinal with a yellow residue inside and around the top of it. On 7/24/25 at 2:25 PM, the RCM stated the nebulizer mask should have been attached to the nebulizer stand, but it was broken so the mask was placed face down on the side table. She stated the nebulizer mask should not be near a portable urinal.

Based on policy review, record review, and staff interviews, it was determined the facility failed to ensure residents were offered and/or administered the appropriate pneumococcal vaccine as indicated. Additionally, the facility failed to ensure residents' refusals to receive pneumococcal vaccinations were addressed each year. This was true for 5 of 5 residents (#3, #7, #8, #60 and #78) reviewed for pneumococcal immunizations. This deficient practice placed residents at risk of developing pneumococcal pneumonia a potentially life-threatening condition. Findings include:The facility's Pneumococcal Vaccine policy for Residents reviewed 7/8/25, documented the following:- Each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized.- The facility should re-address the refusal with the resident and/or resident representative each year to ensure they have not changed their decision. These conversations should be captured in the medical record.- Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine and/or whose previous vaccination history is unknown.-If PCV15 is used, administer a dose of PPSV23 one year later, if needed. Then their vaccinations are complete.-If PCV20 or PCV21 is used, a dose of PPSV23 is not indicated. Regardless of which vaccine is used (PCV20 or PCV21), their pneumococcal vaccinations are complete.-Adults 65 years or older have the option to get PCV20 or PCV21 if they have received PCV13 at any age and PPSV23 at or after the age of [AGE] years old.The facility's Informed Consent for Pneumococcal Vaccine PCV13, PCV20, or PCV21 (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide) included the following sections:-You are being offered the following vaccine (check one): PCV15, PCV20, PCV 21 PPSV23 with a space to write the date.-The vaccine information statement provided to you is:This section has a check box for the VIS (Vaccine Information Sheet) on what type of pneumococcal vaccine was being offered to the resident, and space to write the date of the VIS and when it was provided to the resident.1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including bipolar disorder (a mental health condition that causes extreme swings. These include emotional highs also known as mania or hypomania, and lows, also known as depression). Resident #7 was over the age of 65 at the time of admission.Resident #7's immunization history on his EMR did not document he had received the pneumococcal vaccine.Resident #7's Informed Consent for Pneumococcal Vaccine dated 3/26/24, documented he refused to receive the pneumococcal vaccine.There was no documentation in Resident #7's record he was offered the pneumococcal vaccine after 3/26/24.2. Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dissection of thoracic abdominal aorta (a condition in which a tear occurs in the inner layer of the body's main artery - aorta) and asthma. Resident #8 was over [AGE] years old on admission.Resident #8's immunization history on his EMR documented she had refused the Pneumovax 1 and 2 vaccines.There was no documentation Resident #8 was offered the pneumococcal vaccine. An Informed Consent for Pneumococcal Vaccine was not found in his record.On 7/24/25 at 5:12 PM, MDS Coordinator #2 stated she was unable to find documentation Resident #8 was offered the pneumococcal vaccines.3. Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including dementia and depression. Resident #60 was over [AGE] years old on admission.Resident #60's immunization history on her EMR documented she had received the PCV13 on 4/10/23.Resident #60's Informed Consent for Pneumococcal Vaccine dated 6/27/24, documented she refused to receive the pneumococcal vaccine.There was no documentation in Resident #60's record she was offered the pneumococcal vaccine after 6/27/24.4. Resident #78 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy and dementia. Resident #78 was over [AGE] years old on admission.Resident #78's immunization history on his EMR did not document he had received the pneumococcal vaccine.Resident #78's Informed Consent for Pneumococcal Vaccine dated 8/10/23, documented the pneumococcal vaccine was refused. Resident #78's consent form had a handwritten note which documented, Family states he has both series, but they don't have documentation.There was no documentation in Resident #78's record he was offered the pneumococcal vaccine after 8/10/23.On 7/24/25 at 11:00 AM, the IP stated pneumococcal vaccines were offered to the residents upon admission. The IP stated she would check the IRIS (Idaho Immunization Reminder Information System) a portal to find out what pneumococcal vaccine the resident needed and would offer it to the resident.On 7/24/25 at 4:27 PM, the MDS Coordinator #2 reviewed Resident #7, Resident #8, Resident #60 and Resident #78's Informed Consent for Pneumococcal Vaccine. When asked if the consents were filled out completely, MDS Coordinator #2 stated, It was not. When asked if the consent should indicate the appropriate vaccines for the residents upon their admission, MDS Coordinator #2 stated, Yes, it should indicate what type of pneumococcal vaccines was offered to the residents.There was no documentation in Resident #7, Resident #8, Resident #60 and Resident #78's record pneumococcal vaccine was offered to them a year after they initially refused the pneumococcal vaccine administration.

Based on record review, CDC guidance and interviews, it was determined the facility failed to ensure COVID vaccinations were offered, administered, and re-offered to the residents. This was true for 4 of 4 residents (#7, #8, #60 and #78) whose COVID vaccinations were reviewed. This deficient practice placed residents at risk of severe illness, hospitalization, and death due to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus - the virus that cause the COVID-19 illness) and had the potential to all affect all residents in the facility. Findings include:The CDC website article titled: Staying Up to Date with COVID-19 Vaccines dated 6/6/25 and accessed on 7/30/25 documented:- Protection from COVID -19 vaccine decreases over time.- Immunity after COVID-19 infection decreases with time.-2024 -2025 vaccine is especially important if you:a. Never received a COVID-19 vaccine,b. Are ages 65 years and olderc. Are at high risk for severe COVID-19d. Are living in a long-term care facility.1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including bipolar disorder (a mental health condition that causes extreme swings. These include emotional highs also known as mania or hypomania, and lows, also known as depression). Resident #7 was over the age of 65 at the time of admission.Resident #7's COVID-19 Vaccination consent dated 3/26/24, documented he refused the administration of COVID-19 vaccine.Resident #7's record did not include documentation the COVID-19 vaccine was reoffered to him after he refused on 3/26/24.2. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including dissection of thoracic abdominal aorta (a condition in which a tar occurs in the inner layer of the body's main artery - aorta) and asthma. Resident #8 was over the age of 65 at the time of admission.Resident #8's record did not include documentation the COVID-19 vaccine was offered to him.An Informed Consent for COVID -19 Vaccine was not on his record.3. Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including dementia and depression. Resident #60 was over the age of 65 at the time of admission.Resident #60's immunization history on her EMR documented she last received the COVID-19 vaccine in 10/22/21.Resident #60's Informed Consent for COVID-19 dated 6/27/24, documented she refused the administration of COVID-19 vaccine.Resident #60's record did not include documentation the COVID-19 vaccine was reoffered to her after she refused on 6/7/24. 4. Resident #78 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy and dementia. Resident #78 was over 65 years on admission.Resident #78's immunization history on his EMR documented he last received the COVID-19 vaccine in 8/25/23.Resident #78's Informed Consent for COVID-19 dated 8/23/24, documented his POA consented for him to receive the COVID-19 vaccine.Resident #78's record did not include documentation he received the COVID-19 vaccine in 2024.On 7/24/25 at 11:00 AM, the IP stated COVID-19 vaccine was offered to the residents on admission and if the resident declined the COVID-19 vaccine she would reoffer it to the residents. When asked when she is going to reoffer the COVID vaccines to the residents after they initially refused, the IP stated, I don't have a set time when to offer it, I don't have the clinic schedule yet.On 7/24/25 at 4:45 PM, MDS Coordinator #2 with the ED present reviewed Resident #78's record and stated she did not find documentation COVID-19 vaccine was administered to Resident #78. The MDS Coordinator stated she did not know why Resident #78 did not receive the COVID-19 vaccine in 2024. The ED stated the COVID vaccine was on back order at that time.On 7/25/25 at 9:30 AM, the ED was asked via email when the facility's last COVID vaccine clinic was held. The ED responded that the last COVID clinic was held in 2022 -2023.

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure residents were treated with dignity when eating in the dining room. This was true for 1 of 16 resident's (Resident #49) observed during dining observation. This deficient practice had the potential to cause psychosocial harm if the resident felt he was not as important as other residents, and physical harm if his nutritional needs were not met. Findings include: The facility's Dignity Policy, reviewed 9/26/24, documented 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 his or her quality of life, recognizing each resident's individuality. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including right side paralysis following a stroke, diabetes, and dysphagia (a medical condition characterized by difficulty or discomfort in swallowing.) On 7/24/25 the following was observed: -At 8:22 AM, Resident #49 was seated at the same table as Resident #29 and Resident #78. Resident #29 and Resident #78 received their meals at 8:22 AM. Resident #49 was not served a meal. -At 8:38 AM, Resident #49 looked at Resident #29 and Resident #78's meals while they were eating. He turned his wheelchair around, looked at the other residents eating their meal, shook his head and left the dining room. -At 8:43 AM, Resident #49 returned to the dining table to receive his meal. On 7/24/25 at 8:45 AM, the DM stated she prepares fried egg orders at the same time, and by the time they are finished and served, residents at Resident #49's table have already been served meals, and he receives his meal afterward. On 7/24/2025 at 11:53 AM, the ED stated residents seated at the same table were supposed to be served at the same time. It was not the facility's policy to have a resident served later than other residents. Resident #49 should have been served when the other residents at his table were served.

Based on observation and staff interview, it was determined the facility failed to ensure residents had a homelike environment. This was true for 1 of 18 resident's (Resident #32) who were observed for homelike environment. Resident #32's room was observed to be soiled and unkept. This deficient practice created the potential for psychosocial harm if residents were not provided with the same homelike environment as other residents, and potential harm if the residents lived in unsanitary conditions. Findings include: The facility's Resident Belongings and Homelike Environment policy, reviewed 5/15/25, documented the resident has a right to a safe, clean, comfortable and homelike environment. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including protein-calorie malnutrition, right-sided paralysis after a stroke, failure to thrive, and dementia. On 7/24/25 at 2:18 PM, the following was observed with the RCM in Resident #32's room: - [NAME] liquid was pooled on the floor between Resident #32's bed and her roommate's bed. - Her roommate's trashcan was overflowing with wadded tissues.- A wadded tissue was observed on the floor near the brown liquid pool.- Resident #32's bedding was wadded up and piled at the end of her bed. On 7/24/25 at 2:20 PM, the RCM stated housekeeping had not cleaned the room at the time of the observation. Resident #32's bedding should not have been left wadded up and not tidied. The RCM stated Resident #32's roommate frequently puts food on the ground and housekeeping is aware to clean the room more frequently. On 7/24/25 at 2:50 PM, the Housekeeping Manager stated all rooms are cleaned daily; however, Resident #32's room is cleaned twice per day as the room gets dirty with food particles after lunch. He stated housekeeping had not yet been to the room to clean up after lunch, and they should have planned to clean it earlier in the afternoon.

Based on the review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents' Minimum Data Set (MDS) assessment included accurate information. This was true for 2 of 3 residents (#7 and #10) who were reviewed for accuracy of assessments. This deficient practice had the potential for negative consequences if residents were not monitored due to inaccurate assessments. Findings include:The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded “Yes” when a PASRR level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia, anxiety, and depression. Resident #10’s PASRR level II, dated 6/15/23, documented he had a primary diagnosis of schizophrenia with medication management. An Annual MDS assessment dated [DATE], documented “No” at A1500 a PASSR level II was not completed. On 7/23/25 at 2:44 PM, the MDS Coordinator #1 stated, “The MDS is inaccurate as Resident #10 does have a PASSR level II.” She stated the MDS should have been marked “Yes” at A1500 a PASSR level II was completed. 2. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including bipolar disorder (a mental health condition that causes extreme swings. These include emotional highs also known as mania or hypomania, and lows, also known as depression). Resident #7’s PASRR Level 1, dated 5/14/24 documented he had a diagnosis of “Bipolar and depression.” Resident #7’s PASRR Level II, dated 5/15/24 documented he had been diagnosed with bipolar and depression and supporting documents suggested his mental illness was being managed with medication, and no further evaluation was needed. Resident #7’s Annual MDS dated [DATE], documented on section A1500 PASRR “Has the resident been evaluated by Level II PASRR and determined to have serious mental illness and/or mental retardation or a related condition?” The answer for this question was documented as “No.” On 7/23/25 at 2:35 PM, the MDS Coordinator #1 reviewed Resident #7’s Annual MDS assessment and stated Resident #7’s Annual MDS assessment was not accurate and should have been answered “Yes” on section A1500.

Based on record review and staff interview, it was determined the facility failed to refer residents with a diagnosed mental disorder to the appropriate state-designated authority for a re-evaluation and determination. This was true for 1 of 3 residents (Resident #3), reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including PTSD (Post Traumatic Stress Disorder), and anxiety.Resident #3's PASRR level I dated 6/14/23, documented she did not have any mental illnesses.An admission MDS assessment dated [DATE], documented No Resident #3 did not have an MMI. No other PASRR's were found in Resident #3's medical record.On 7/23/25 at 3:42 PM, the ED stated Resident #3's PASRR level I was inaccurate and should have been updated when Resident #3 was admitted . She said Resident #3 should have had a PASRR level II completed.

Based on record review, staff interview, and observation it was determined the facility failed to update resident's care plans and provide care conferences. This was true for 2 of 18 residents (#6 and #11), whose care plans were reviewed for accuracy and care conference planning. This deficient practice had the potential to cause harm if a resident's care plan was not updated to reflect current medical conditions, or if their care plan was not discussed with residents or their representatives. Findings include: 1.Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including a brain injury with brain bleeding and right-side paralysis. On 7/21/25 at 2:35 PM, the DON and the IP verified Resident #6 tested positive for COVID-19 on 7/12/25. A review of Resident #6’s care plan did not document he had a respiratory infection. On 7/24/25 at 10:50 AM, in a joint interview with the DON and the ADON, they stated Resident #6’s care plan was not updated when he tested positive for COVID-19 on 7/12/25, and it should have been. 2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including cancer of duodenum (part of the small intestine) and heart failure. On 7/21/25 at 3:36 PM, Resident #11 stated she did not think she had attended a care plan conference meeting. Resident #11 stated, “I don’t remember any meeting at all. I never had a meeting with the staff.” Resident #11’s record documented care conferences were held on 3/28/24 and 11/21/24. There were no other care conferences held between December 2024 to July 2025. On 7/23/25 at 2:57 PM, the DON stated care conferences were being held quarterly and as needed. The DON stated she would look for other documentation of Resident #11’s care conferences. On 7/24/25 at 10:21 AM, the DON stated Resident #11 should have had two more care conferences after the 11/21/24 care conference. The DON stated she was unable to find documentation a care conference was held after the 11/21/24 care conference.

Based on observation, record review, Incident and Accident report, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 18 sampled residents (Resident #35) reviewed for quality of care. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include:Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, right hip fracture, and cognitive communication deficit.Resident #35's care plan documented she expressed pain related to chronic back pain, right hip fracture and impaired mobility; including a goal that resident will express pain relief.On 7/21/25 at 5:00 PM, Resident #35 stated she was in pain 99% of the time in her back and right hip, and pain medication was inconsistent with relief. Resident #35's physicians orders were as follows:-Administer 5 mg Oxycodone (an opioid pain medication) every 4 hours as needed for pain-Administer 10 mg Oxycodone every 4 hours as needed for pain-Administer 15 mg Oxycodone every 4 hours as needed for pain The physician orders did not include parameters for when to administer the 5mg, 10mg, and 15mg doses of Oxycodone. Resident #35's MAR documented she received the Oxycodone as follows: Oxycodone 5 mg administered with pain level rated as a 5 out of 10.Oxycodone 10 mg administered with a pain level rate ranging between 4-6 out of 10.Oxycodone 15 mg administered with a pain level rate ranging between 2-8 out of 10. On 7/24/25 at 2:03 PM, the ADON reviewed Resident #35's records and confirmed the nurses were inconsistent when administering these medications and they should have contacted the physician for parameters to be added to the orders.

Based on observation and staff interview, it was determined the facility failed to provide respiratory care for 1 of 2 residents (Resident #8) reviewed for respiratory care. This deficient practice created the potential for harm if respiratory care was not provided. Findings Include:Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dissection of thoracoabdominal aorta (a severe medical emergency characterized by a tear in the inner lining of the aorta, the main artery that carries blood from the heart through the chest and abdomen), asthma, and dementia. On 7/24/25 at 2:23 PM, it was observed with the RCM, Resident #8's humidifier reservoir was empty, his nebulizer tubing was not stored correctly, and his oxygen tubing was not dated. On 7/24/25 at 2:25 PM, the RCM stated oxygen tubing was replaced weekly, and should have been dated when it was changed. She also stated she was not sure when the humidifier reservoir had last been changed, but it was supposed to be monitored every shift and should not be empty. The RCM stated the nebulizer tubing should have been stored in the plastic bag.

Based on record review, policy review, and resident and staff interviews, it was determined the facility failed to ensure post dialysis assessments were completed and accurate. This was true for 1 of 2 residents (Resident #15) who received dialysis. This created the potential for Resident #15 for adverse outcomes such as blood loss and infection from the access site. Findings include:The facility's policy revised 3/18/20, documented the facility should provide immediate monitoring and documentation of the status of resident's access site upon return from the dialysis treatment to observe for bleeding or other complications such as redness or edema. Obtain vital signs of resident upon return from dialysis and complete the Pre/Post dialysis Communication Form.Resident #15 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including Wegener's Granulomatosis (swelling also called inflammation of small blood vessels, mainly affecting the blood vessels in the nose, sinuses throat, lungs and kidneys) with renal involvement and morbid obesity.Resident #15's Pre/Post Dialysis Communication Form documented on the Post Dialysis Section (Completed by SNF [Skilled Nursing Facility] of the form the following assessments to be completed: Vital Signs, Condition of the Access Site, Bruit Present, and Change of Site.Resident #15's Post Dialysis section of his Dialysis Communication form dated 6/2/25, 6/4/25, 6/6/25, 6/11/25, 6/13/25, 6/16/25, 6/23/25, 6/25/25, 7/4/25, 7/7/25, and 7/15/25, did not include documentation the appropriate assessments were completed.On 7/24/25 at 10:48 AM, the ADON reviewed Resident #15's Pre/Post Dialysis Communication form. The ADON stated the post dialysis sections were not completed by the staff and should have included the vital signs and condition of Resident #15's access site upon her return from dialysis.

Based on record review and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 3 of 7 residents (#9, #15, and #81) reviewed for medication errors. This deficient practice created the potential for harm if residents received the wrong dosage of medications. Findings include:The online Nursing 2025 Drug Handbook accessed on 7/30/25, stated the eight rights of medication administration were: - Right drug - Right patient - Right dose - Right time - Right route - Right reason - Right response - Right documentation 1. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including fracture of right femur, pain and cognitive communication deficit. Resident #9’s record documented a physician's order for Oxycodone (an opioid pain medication) with the following instructions: -Oxycodone 2.5 mg every 4 hours as needed for pain rated at (3-6/10) -Oxycodone 5 mg every 4 hours as needed for severe pain rated at (6-10/10) Resident #9's July 2025 MAR documented the following: -7/6/25 at 1:54 PM, pain was rated at a 5/10 and was administered Oxycodone 5 mg. -7/6/25 at 8:20 PM, pain was rated at 2/10 and was administered Oxycodone 2.5 mg. -7/14/25 at 4:17 PM, pain was rated at 5/10 and was administered Oxycodone 5 mg. On 7/24/25 at 2:11 PM, the ADON confirmed Resident #9 was administered the incorrect dose of Oxycodone twice on 7/6/25 and again on 7/14/25 when the physician's order was not followed regarding pain scale and dosage. 2. Resident #81 was admitted to the facility on [DATE], for orthopedic aftercare, with multiple diagnoses including diabetes and cognitive communication deficit. Resident #81’s record documented a physician's order for Oxycodone with the following instructions: -Oxycodone 5 mg every 4 hours as needed for moderate pain rated at (4-6/10) -Oxycodone 10 mg every 4 hours as needed for severe pain rated at (7-10/10) Resident #81's July 2025 MAR documented the following: -7/11/25 at 8:23 PM, pain was rated at 5 and was administered 10 mg. -7/12/25 at 5:33 PM, pain was rated at a 4 and was administered 10 mg. On 7/24/25 at 2:11 PM, the ADON confirmed Resident #81 was administered the incorrect dose of Oxycodone on 7/11/25 and on 7/12/25 when the physician's order was not followed regarding pain scale and dosage. 3. Resident #15 was admitted to the facility on 10/2524 and readmitted [DATE], with multiple diagnoses including Wegener’s Granulomatosis (swelling also called inflammation of small blood vessels, mainly affecting the blood vessels in the nose, sinuses throat, lungs and kidneys) with renal involvement and morbid obesity. A physician’s order dated 4/24/25, documented Resident #15 was to receive 5 mgs of Midodrine (a low blood pressure medication) HCL (hydrochloride) two times a day for low blood pressure. Hold for systolic blood pressure (the top number in blood pressure reading) greater than 120. Resident #15’s June - July 2025 MAR documented she was administered Midodrine 5 mg tablet when her systolic blood pressure was greater than 120 as follows: June 2025 AM (day shift): - 6/5/25: 134/68 - 6/10/25: 128/60 - 6/11/25: 128/55 - 6/17/25: 152/72 - 6/22/25: 138/62 - 6/29/25: 195/55 June 2025 HS (at bedtime): -6/15/25: 148/84 - 6/16/25: 128/60 - 6/17/25: 152/72 - 6/28/25: 130/72 July 2025 AM (day shift): -7/3/25: 122/60 - 7/14/25: 125/60 - 7/18/25: 133/60 - 7/20/25: 130/70 July 2025 HS (night shift) -7/11/25: 129/60 On 7/24/25 at 10:18 AM, the DON reviewed Resident #15’s record and stated “Yes” Midodrine was administered to Resident #15 when her systolic blood pressure was greater than 120 systolic and it should not have been administered.

Based on observation and staff interview, it was determined the facility failed to ensure pharmacy labels matched the physician's order. This was true for 1 of 8 residents (Resident #15) whose medications administration was observed. This failure created the potential for harm should Resident #15 be administered the wrong dose of her medications. Findings include:On 7/24/25 at 7:39 AM, LPN #1 was observed as she administered one tablet of Sevelamer Carbonate to Resident #15. The Sevelamer Carbonate pharmacy label documented Sevelamer Carbonate 800 mgs two tablets before meals and at bedtime LPN #1 stated the physician's order was changed to administer one tablet of Sevelamer Carbonate to Resident #15. LPN #1 stated the label on the bottle should have been changed to match the physician's order.On 7/24/25 at 10:29 AM, the DON stated Resident #15's Sevelamer Carbonate order came from the dialysis center and Yes the label should have been changed to match the physician's order.

Based on record review and staff interview, it was determined the facility failed to ensure accurate clinical records were maintained for each resident. This was true for 1 of 18 residents (Resident #42) whose record was reviewed. This deficient practice created the potential for Resident #42 to experience harm if she received inappropriate care and/or treatment. Findings include:The State Operations Manual Appendix PP issued 4/25/25 documented the facility must maintain medical records of each resident that are complete and accurate.Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness) and diabetesA physician's order included the following:- Insulin Glargine 100 units/ml, inject 30 units subcutaneously one time a day for diabetes, ordered 12/9/24.- Insulin Glargine 100 units/ml, inject 5 units subcutaneously at bedtime for diabetes, ordered 12/9/24.-If blood glucose is greater than 360, give the highest sliding scale dose and recheck in one hour.-If blood glucose greater than 360 for 2 consecutive tests, call the physician and document unless otherwise directed by the physician, ordered 9/7/22.The physician's order did not include an order for the sliding scale for insulin.On 7/23/25 at 11:49 AM, the DON with the ADON present stated Resident #42 was no longer on sliding scale dose of insulin because she refused the injections when needed. Resident #42 was placed on long-acting insulin. The DON stated Resident #42's record should have been updated to reflect the current physician's order.

Based on record review, facility job description review, and staff interview, it was determined the facility failed to ensure there was a qualified dietary manager. This failed practice created the potential to negatively affect all residents in the facility who ate food which was prepared in the facility's kitchen. Findings include: The facility's Food Service Director - Certified Dietary Manager Job Description, dated 5/1716, stated the Education, Experience, and Licensure/Certifications as: must have completed a CDM or State-approved course in food services; must have a current certification as a Certified Dietary Manager in applicable state; must maintain an active certification in good standing throughout employment; must have one year experience in post-acute food service; and must have a minimum two years' supervisory experience. During an interview on 7/9/24 at 11:22 AM, DM stated she completed the coursework for certification but had not scheduled a time to take the test. During an interview on 7/9/24 at 2:40 PM, the Administrator stated the DM moved from the position of cook to the manager of the facility's dietary services on 5/10/23. During a a telephone interview on 7/10/24 at 1:51 PM, the RD, who was employed on a weekly basis prior to survey, said she was helping out with assessments until the new dietician started. The RD said she was in the facility once a week to complete assessments and follow-up on recommendations and/or questions regarding resident diets. The RD stated she checked the kitchen once a month. In an interview on 7/11/24 at 8:40 AM, the Administrator confirmed the DM's lack of certification, for over a year (5/10/23). The Administrator stated, Yes, you're right, she is not certified, I'm going to sit down with her today to schedule the test. In an interview on 7/11/24 at 9:44 AM, the DM stated, I know I had a Serve Safe certificate, but I can't find it. When asked if her certificate could be located online, the DM stated, the online says I have to take the test again. Review of the DM's personnel file did not include documentation of a Serve Safe certificate.

Based on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure a resident was assessed for safety to self-administer an over-the-counter supplement medication. This was true for 1 of 1 resident (Resident # 32) reviewed for self-administration of medications. This failure created the potential for adverse outcomes if Resident #2 received too much or too little of the medication. Findings include: The facility's policy titled Self-administration of Medications, revised 8/29/23 stated .Each resident has the right to self-administer medications after the Interdisciplinary Team has assessed the resident and determined the resident can safely complete the task .If a resident expresses a desire to self-administer medications the DON, Interdisciplinary Team and resident physician must be notified before allowing the resident to self-administer the medication .This request will be documented in the Interdisciplinary Notes of the resident's medical record .A physician's order .allowing .self- administration of medications will not be honored until the Interdisciplinary Team has assessed the resident for the ability to administer the medication (s) safely .Medications will be administered by the licensed nurse or certified medication aide until the Interdisciplinary Team determines the resident can safely store and /or self-administer medication (s) in a safe manner . Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, paroxysmal atrial fibrillation (a type of irregular heartbeat), chronic kidney disease, heart failure, and muscle weakness. A quarterly MDS assessment, dated 5/15/24, documented Resident 32 was cognitively intact. During an interview and observation on 7/8/24 at 10:49 AM with Resident #32 in her room, an observation was made of a 4-ounce brown bottle that was approximately 90 percent used and labeled Chanca [NAME] on the resident's bedside table. Resident #32 was asked what was in the bottle and she stated, I have cancer and my doctors are trying something new to treat my pain. The resident continued to share that she uses the supplement daily. During an observation on 7/9/24 at 10:55 AM the Chanca [NAME] supplement remained on the bedside table as observed on 7/8/24. The Healthline website, updated 3/24/23, accessed on 7/24/24, and located at https://www.healthline.com/nutrition/chanca-[NAME], states, As a supplement, chanca [NAME] is reported to help with a variety of conditions related to the digestive system, liver, and kidneys. Supposedly, it contains phytochemicals or plant compounds that can increase urine flow, kill harmful bacteria and viruses, and relieve inflammation. Resident #32's physician orders, dated 7/2024 did not include an order for Resident #32's self-administration of Chanca [NAME]. Resident 32's MAR, dated 7/2024 did not include an order for self-administration of Chanca [NAME]. Resident #32's comprehensive care plan, did not include a plan for Resident #32 to self-administer the Chanca [NAME]. Resident #32's record did not include a self-administration for medication administration assessment. During an interview on 7/9/24 at 2:04 PM, CNA #3 stated she was not aware of residents in the facility who self-administered medications, nor did she know of any over-the-counter medications on a resident's bedside table. During an interview and observation on 7/9/24 at 2:15 PM, LPN #1 stated she was not aware of residents who had been assessed to self-administer medications. LPN #1 then observed and removed the bottle of Chanca [NAME] in Resident #32's room and locked it in the medication storage room. LPN #1 continued to share the facility was not aware Resident #32 was using an over-the-counter supplement. During an interview on 7/9/24 at 2:22 PM, the Administrator stated residents had the right to self-administer medication after they were assessed by a nurse, the Interdisciplinary Team, and a physician. She stated once the resident was assessed and found safe, then the resident would be allowed to self-administer the medication. The Administrator stated she expected all residents were assessed and if there were over-the-counter medications located in the residents' rooms her staff immediately removed the over-the-counter medication until the resident was assessed and the over-the-counter medication was determined to have no negative drug interactions with the resident's current medication regimen.

Based on observation, record review, and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 17 residents (Resident #24) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments. Findings include: Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, Chronic Obstructive Pulmonary Disease (COPD - a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), hearing loss, and hemiplegia and paraplegia (weakness and paralysis on one side of the body) following a stroke. Quarterly MDS assessments, dated 3/11/24 and 6/10/24, documented Resident #24 had adequate hearing and clear speech. Resident #24's care plan, initiation date 2/15/23, included a focus for a communication problem related to Resident #24's chronic hearing impairment from a childhood illness. During an observation and interview on 7/8/24, Resident #24 was unable to hear when her name was called and a touch to her shoulder caught her attention. When spoken to, Resident #24 pointed to a white board to write on to be asked questions. When the Resident #24 attempted to speak, the words were garbled sounds and no complete words. During an interview on 7/10/24 at 12:56 PM, the MDS Coordinator reviewed the quarterly MDS assessments dated 3/11/24 and 6/10/24 and stated the information was incorrect. She stated Resident #24 was not able to hear, and speech was unrecognizable. During an interview on 7/10/24 at 12:46 PM, the DON stated the quarterly MDS assessments dated 3/11/24 and 6/10/24 were not correctly coded as Resident #24 was deaf and typed on a tablet, used sign language, or a white board to let her needs be known.

Based on observation, policy review, record review, and resident and staff interview, the facility failed to ensure a resident was provided toileting assistant and incontinence care. This was true for 1 of 1resident (Resident #44) reviewed for activities of daily living. This failure had the potential to lead to urinary tract infections, skin rashes, skin infections, pressure sores or increased incontinence. Findings include: The facility's policy titled Activities of Daily Living (ADLs), revised 2/12/24, stated, Residents will receive assistance as needed to complete activities of daily living (ADLs).A resident who is unable to carry out activities of daily living receives the necessary services to maintain .grooming and personal .hygiene. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), scoliosis (curvature of the spine), muscle weakness, and abnormality of gate and mobility, and segmental and somatic disfunction (impaired or altered functions of related components of the body framework) of lower extremity. A quarterly MDS, dated [DATE], documented Resident #44 was independent with toileting hygiene and in need of supervision or touching assistance for shower/bathing and she was cognitively intact. Resident #44's care plan, with a revision date of 5/23/23, documented Resident #44 had an ADL self-care performance deficit related to Parkinson's disease, Scoliosis, Radiculopathy (injury or damage to nerve roots in the area where they leave the spine), Lumbosacral (tailbone) region. The interventions for toileting documented Resident #44 needed the assistance of one person for toileting. During an interview on 7/8/24 at 12:12 PM, Resident #44 stated on one occasion during the evening it took staff one and half hours to respond to her call light and assist her to the bathroom. Resident #44 further stated that she was assisted to the bathroom after her son called the nurse's station and informed the nursing staff his mother needed assistance to the toilet. Resident #44 further stated during the wait time she had a urine incontinent episode. When asked how she knew it took 1.5 hours, Resident #44 pointed to a clock that was hanging on the wall directly in front of her bed. During an interview on 7/10/24 at 12:11PM with CNA #5, stated she had just started her shift on 6/19/24. At approximately 6:10am, when she answered a telephone call from the son of Resident #44 who stated his mother had her call light on and was lying wet in bed and had not been assisted. CNA #5 further stated Resident #44 was flustered when she went to assist her. During a follow up interview with Resident #44 on 7/11/24 at 3:43 PM regarding the 1.5-hour call light response, Resident #44 stated she was angry and felt disgusted and ashamed.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 3 residents (Resident #41) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful activities throughout the day. Findings include: The facility's policy titled, Care of the Cognitively Impaired (Dementia Care), reviewed 8/22/23, stated, The facility will provide dementia treatment and services . Utilizing individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's wellbeing. The facility's policy titled, Person Centered Care Plan, reviewed 8/26/23, stated, The facility will develop a person-centered care plan that addresses the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline. Resident #41 was admitted on [DATE], with multiple diagnoses including Alzheimer's Disease, dementia, and cognitive communication deficit. An admission MDS assessment, dated 5/10/23, documented in section D the questions for mood assessment including little interest or pleasure in doing things, was not assessed for Resident #41. A significant change MDS with ARD of 01/25/24, documented in section D the questions for mood assessment including little interest or pleasure in doing things, was answered no. A quarterly MDS assessment, dated 4/26/24, documented Resident #41 was severely cognitively impaired. An Admission Activities assessment, with a completion date of 10/6/23, 5 months after Resident #41 was admitted , documented Resident #41 preferred the nickname Deedle. Activity interests included pets/animals, arts and crafts with current small group interests were very important, and board games in small groups were very important, to name a few. Resident #41's record did not include documentation of his preferred nickname or participation in activities. Resident #41's care plan did not include documentation or interventions for a nursing focus about her participation in activities. During an interview on 7/10/23 at 12:58 PM, the MDS Coordinator confirmed there was not a care plan for activities for Resident #41 and there should be a care plan focus specific to activities for a resident with dementia. During an interview on 7/10/24 at 12:32 PM, the DON confirmed Resident #41 should have had a care plan focus for activities. During an interview on 7/11/24 at 12:22 PM, the DON verified the admission assessment was completed five months after admission and should have been completed during the initial admission process.

Based on record review, observation, Incident and Accident (I&A) report review, policy review, and staff interview, it was determined the facility failed to ensure residents received the level of supervision necessary to prevent falls, resident-to-resident abuse, and elopement. This was true for 4 of 11 residents (#1, #2, #3, and #5) reviewed for supervision and accidents. Resident #2 was harmed when he fell and fractured three ribs. Resident #3 was harmed when she experienced a fall resulting in a fractured tibia (one of the two long bones in the lower leg) The facility failed to ensure Resident #1 received the supervision necessary to prevent her from phyisically abusing other residents. The facility failed to implement and maintain supervision measures to prevent elopement and potential physical and/or psychosocial injury of Resident #5. Findings include: 1. The facility's Fall Management policy, reviewed [DATE], stated the facility maintained an environment free of accident hazards and ensured residents received adequate supervision and assistance to prevent accidents. In addition, the policy stated that the facility must accurately and thoroughly assess the indicators for potential falls. This policy was not followed. a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], dementia, and a delusional disorder. Resident #2's MDS assessment dated [DATE], documented he was severely cognitively impaired. Resident #2's care plan, dated [DATE], documented he was a high fall risk related to medication use, lack of bowel and bladder control, lack of balance, lack of mobility, poor trunk control, hallucinations and pain. It stated he frequently placed himself on the floor by getting himself down on his knees, stating he is looking for something or trying to fix something. Resident #2's care plan documented interventions for falling, as follows: - Assist Resident #2 with ADLs. - Use a body pillow while Resident #2 is in bed. - Ensure Resident #2's call light is within reach. - A fall risk assessment will be completed after each fall. - Do not leave resident unattended in the dayroom. - A fall mat will be placed at the right side of the bed. - Frequent rounding (when the nurse or CNA goes to see the residents they are responsible for) - If Resident #2 is leaning down while in his chair, assist him to the floor to fix things. - Offer to toilet when awake, before and after meals, and before bedtime. - Monitor for trauma for 72 hours after a fall. - Complete a neurological assessment for 3 days after fall. - Offer Resident #2 his calculator, phone, or a car part when he is distracted by his hallucinations. Resident #2's I&A reports, [DATE] to [DATE], documented he had a total of 13 falls in 4 months, as follows: * [DATE]: Resident #2 was found sitting on the floor next to his bed. He stated he was going out to talk with someone. The nurse assessment documented he had pink marks on his knees and right lower ribs. The Incident and Accident investigation documented the facility would initiate frequent rounding on Resident #2 related to this fall. * [DATE]: Resident #2 attempted to change his brief without assistance, slipped on urine in the floor and slid to the floor from his bed. It documented he was confused and had been yelling for help. There was no documentation his non-skid socks were being worn when he fell as directed by his care plan. There was no documentation indicating frequent rounding was occurring on Resident #2 when he fell . * [DATE]: Resident #2 was found with his knees at the base of his wheelchair by his bathroom door. His forehead had a red mark on the skin, and he complained his feet hurt. He stated he dropped something in the toilet. There was no documentation of the last time he had been assisted to the restroom by staff in the Incident and Accident report as his care plan instructed. * [DATE]: Resident #2 was found on the hallway floor outside of his bedroom. He stated he was trying to get up. The interventions in the care plan regarding this fall were documented as call light within reach, floor safety mat, low bed and frequent rounding. Resident #2 was in his wheelchair in the hallway when he fell . None of those interventions were appropriate to this fall as Resident #2 was out of his room in a wheelchair independently moving about in the facility when he fell . * [DATE]: Resident #2 was found on the floor in the hallway of the unit outside another resident's room door. He stated there was a hole in the floor he was trying to get around. He had been checked on by staff 2 minutes before the fall. The intervention was to refer to occupational therapy to assess wheel chair for appropriate positioning. There were no new interventions documented to address prevent further falls. * [DATE]: Resident #2 was found on the hallway floor. He stated he was getting stuff off the ground. The Incident and Accident report documented there were no witnesses to this fall, and he had refused an activity lap blanket and plastic nuts and bolts. There was no documentation he was offered a calculator, phone, or car part to distract him from his hallucinations. * [DATE]: Resident #2 was found sitting outside a room picking up and fixing things he hallucinated were on the floor. He was offered activities and refused. Interventions were documented as occupational therapy would continue to work on a wheelchair for Resident #2's leaning. A Social Worker note dated [DATE], documented the social worker left a message for Resident #2's son about the transfer of Resident #2 to another facility as he had exceeded this facility's level of care. * [DATE]: Resident #2 was found on the floor in the day room by staff when other residents alerted staff he had fallen. He was not attended by staff in the day room as directed in his care plan when he fell . An intervention documented in the Incident and Accident report documented staff were attempting to keep Resident #2 in view at the nurse's station for safety. * [DATE]: Resident #2 slid from his wheelchair onto his knees. A CNA witnessed the fall. The CNA stated Resident #2 was leaning to the right from his wheelchair to get things on the floor he thought he saw. The Incident and Accident report documented Resident #2's care plan interventions would not be updated for this fall. * [DATE]: Resident #2 was found on the floor at the nurse's station. He stated he was trying to pick up a picture on the floor. There was no picture on the floor. There was no documentation he was being rounded on during this time. An X-ray report from [DATE], five days later, documented Resident #2 had rib fractures of the ,d+[DATE] ribs. It stated there was also evidence of previous rib fractures of his upper ribs from an earlier time. A Physician Progress Note, dated [DATE], documented Resident #2 has had yet again another fall from his wheelchair. There have been almost innumerable falls and actually some of them may be his attempt to get to the ground to pick something off the ground as he seems to be hallucinating things on the ground that he needs to pick up .everything tried seems to have failed, including [CONDITION(S)] medications. A Physician Progress Note, dated [DATE], documented Resident #2 had multiple falls. Some of them seem to be related to seeing things on the floor and trying to reach down and grab them an X-ray was obtained yesterday and does confirm evidence of an 8 through 10th right sided rib fractures. * [DATE]: Resident #2 was found on the floor next to his bed on a fall mat talking to himself. The Incident and Accident report documented he had been rounded on by a CNA ten minutes before the fall, had on non-skid socks, and did not have to use the bathroom. * [DATE]: Resident #2 was found sitting on the floor of his room with his back against his bed. He stated he had been in bed but wanted to get up. There was no documentation he was assisted out of bed by staff. * [DATE]: Resident #2 was found on the floor of the day room by staff. There was no documentation that he was attended by staff in the day room. A Physician Progress Note, dated [DATE], documented Resident #2 was experiencing visual hallucinations that are characterized by seeing things lying on the floor that are not really there. As he spends much of his time in his wheelchair, he often leans forward to brush these imaginary objects away or pick them up, which leads to over balancing and falling forward from his wheelchair. Observations were conducted in the facility on [DATE], and staff were not observed to implement Residents fall interventions, as follows: * On [DATE] at 10:00 AM, Resident #2 was observed self-propelling around the nurse's station. He would randomly stop, lean out of his wheelchair, touch the ground for several seconds, then self-propel his wheelchair for ,d+[DATE] steps, and then reach for the ground again. When introduced to survey staff, he stated, Oh, I guess it's time to get my car insurance up to date. He continued to self-propel the wheelchair around the nurse's station and into the dayroom, touching the floor and the nurse's station when there were no objects to pick up. He leaned to the right side of his wheelchair to touch the ground and the front wheel of his wheelchair multiple times during the observation. During the observation, when Resident #2 leaned down to touch the ground while in his chair, staff did not offer Resident #2 his calculator, phone, or a car part to distract him, and did not assist him to the floor to fix things when he leaned down while in his chair. * On [DATE] at 3:50 PM, Resident #2 was at the nurse's station. A bedside table was in front of him with a carburetor, toothbrush, washcloth, pencil, and calculator sitting on the table. He was rotating the carburetor and touching it with the toothbrush. When asked what he was doing, he stated he was working and fixing this. Resident #2 leaned over the right side of his wheelchair to touch the floor. He was in line of sight of LPN #1 during this observation. When Resident #2 leaned down to touch the ground while in his chair, LPN #1 did not assist him to the floor to fix things when he leaned down while in his chair. On [DATE] at 4:15 PM, LPN #1 stated she was aware of multiple interventions for Resident #2 to prevent falls in his care plan. She stated due to lack of staffing, Resident #2 spent most of his day at the nurse's station where staff could watch him and prevent him from falling. She stated he bent over to touch the ground so often that he was usually on the floor before staff could get to him. When asked if being at the nurse's station prevented Resident #2 from falling, she stated, No, nothing does. b. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and dependence on a wheelchair. On [DATE], an MDS change in status assessment documented Resident #3 was severely cognitively impaired. Resident #3's records contained Fall risk assessments, dated [DATE], [DATE], and [DATE] which documented Resident #3 was at risk for falls. Resident #3 Physician Orders were reviewed and included the following orders: Beginning on [DATE], use gripper socks and wear no shoes. On [DATE], roll-back prevention bars were ordered for her wheelchair. On [DATE], a motion sensor light was ordered for her bathroom due to poor safety awareness. On [DATE], a fall mat was ordered for the right side of her bed due to poor safety awareness. An I&A Report, dated [DATE], documented Resident #3 was found on the floor in her bathroom with her wheelchair under the sink. Resident #3 told staff she was attempting to transfer from the toilet to her wheelchair, but the wheelchair moved and she lost her balance. She was found on her right side and had right shoulder/arm pain. The report documented Resident #3's anti-roll back brakes on her wheelchair were not working and there were no non-skid strips on her bathroom floor as directed her care plan. An I&A Report, dated [DATE], documented Resident #3 was found lying in front of her wheelchair on the floor in front of the nurses' station on [DATE] at 1:55 AM. Resident #3 stated she did not know how she fell . Two aides were at the nursing station but did not witness the fall. Resident #3 had bruising noted to her forehead above her right eye. On [DATE], bruising was noted on her right lower shin down to her ankle. An x-ray showed she had a spiral fracture of the right tibia. Resident #3 was sent to the emergency room , a hard cast was placed on Resident #3's leg, and she returned to the facility. On [DATE] at 11:45 AM, CNA #6 and CNA #11 stated staff attempted to keep the at-risk residents near the nurses' station, so they could be monitored. CNA #6 and CNA #11 stated staff attempted to keep residents safe by toileting often, keeping their beds in low positions with fall mats, and re-educating residents to ask for assistance. At times residents might fall asleep in their wheel chairs or reach to pick things up and become off-balance. The facility failed to ensure Resident #3 received adequate supervision to prevent a fall which resulted injury. 2. The facility's policy entitled Protection of Residents: Reducing the Threat of Abuse and Neglect, reviewed [DATE], stated the facility practiced a hardline, zero-tolerance approach to resident abuse. The policy stated the facility assured residents were free from neglect by having structures and processes to provide needed care and services to all residents. The facility was to identify, assess, care plan for interventions, and monitor residents with verbally or physically aggressive behavior. This policy was not followed. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses, including Alzheimer's disease (a progressive disease that destroys memory and other critical mental functions) and chronic kidney disease. Resident #1's MDS assessment, dated [DATE], documented she was severely cognitively impaired. On [DATE], the physician ordered staff to complete behavior entries for this resident, every shift for monitor [sic] behaviors three times a day for Resident #1. Behaviors monitored included signs and symptoms of anxiety, being resistive or combative to cares, exit-seeking, kicking others, signs and symptoms of depression, and spitting or hitting staff. On [DATE], the physician ordered [MEDICATION(S)], an anti-anxiety medication, for anxiety and agitation. On [DATE] the physician ordered a psychiatric evaluation to be scheduled for the soonest available date. The evaluation did not take place before the resident's death on [DATE]. On [DATE], the physician ordered [MEDICATION(S)], an anti-psychotic, to help with behavioral symptoms. On [DATE], Resident #1's Behavioral Care Plan documented she had the potential to be physically aggressive and kick others. It documented behavioral interventions including anticipating her needs for food, thirst, toileting, comfort, body positioning and pain; frequent checks; providing an automated cat for her to hold; playing with a beach ball; receiving visits from her son; and calmly redirecting her when she became agitated or acted inappropriately. A Care Management Note, dated [DATE], documented a meeting was held, with Resident #1's son and daughter in attendance, to discuss Resident #1's behaviors. The note stated Resident #1 was still kicking and swinging at other residents and staff. The note documented the physician stated Resident #1 could not be sedated for the convenience of staff. Resident #1's son stated he had looked at another facility for Resident #1, however, the facility did not have an opening. The physician told Resident #1's son and daughter Resident #1's behaviors were unpredictable and the current facility did not staff for one-to-one (one staff assigned to one resident only) supervision and different interventions would be tried. An I&A Report, dated [DATE], documented Resident #1 wheeled herself in her wheelchair away from the nurses' station and kicked Resident #4 in his right knee. Resident #4 (who had been asleep) woke up and was startled, but not injured. A review of the facility's investigation of the [DATE] incident documented the incident did occur and Resident #1's physical abuse of Resident #4 was substantiated. An I&A Report, dated [DATE], documented Resident #1 kicked Resident #4 twice in the shins on [DATE]. Resident #4 was startled but uninjured. Resident #1 was removed and Resident #1's son was called to sit with Resident #1. On [DATE] at 10:45 AM, the DON was interviewed and stated she was aware of multiple incidents regarding Resident #1 and abuse. The DON stated she contacted Resident #1's son, who came in often to assist with her care. She stated the facility used many resident-centered efforts to occupy Resident #1's time, including providing coloring, music, [MEDICATION(S)] scents, taking her for walks outside, allowing her to kick a beach ball, and keeping her close to the nursing station. She stated Resident #1 was very difficult to redirect, with the most successful being kicking a beach ball or visits from her son, who would sit with Resident #1 until she fell asleep. She stated the facility had reached out for psychiatric help and 2 practitioners had refused to see Resident #1. She stated the facility had made multiple attempts to place Resident #1 in a facility with a higher level of behavior care. The facility failed to ensure Resident #1 received adequate supervision for aggressive behaviors to prevent abuse. 3. The facility's Unsafe Wandering and Elopement Policy, reviewed [DATE], stated the purpose was to promote resident safety and reduce unsafe wandering and elopements by proactively identifying, care planning and monitoring Resident wandering and elopement indicators. A specific system was to be implemented to notify staff that exit doors were opened in areas accessible to residents, including door alarms and monitoring of exits. The policy was not followed. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses, including a healed hip fracture and mild cognitive impairment. Resident #5's quarterly MDS assessment, dated [DATE], documented she was severely cognitively impaired and walked with a walker. On [DATE], Resident #5's care plan documented she was at risk for elopement with a history of attempts to leave the facility unattended. Resident #5's care plan documented she had impaired safety awareness. Resident #5 was added to the facility's elopement book. Resident #5's care plan listed interventions for elopement risk of frequent monitoring, documentation of wandering and exit-seeking behavior. Staff were to encourage Resident #5 to participate in activities to divert from exit-seeking behavior. On [DATE] at 11:11 AM, Resident #5 was placed on alert charting for exit-seeking behavior. Resident #5 had opened an outside door but was prevented from leaving by nursing staff. On [DATE] at 10:15 PM, a nursing note documented the facility received a telephone call at 8:30 PM , from a nearby assisted living facility stating Resident #5 had walked to assisted living facility and was sitting in their lobby. The nursing note documented Resident #5 was seen in her room at 7:30 PM. Resident #5 was returned to the facility and placed on 15-minute visual checks. On [DATE] at 9:58 AM, nursing notes documented the physician noted, Elopement risk? Wander guard candidate? On [DATE] at 10:45 AM, the DON stated no one saw Resident #5 leave the facility, and they do not know how she got out. The DON stated staff preformed frequent checks on residents who were at risk. The DON stated the facility did not have a Wander guard system in place. On [DATE] at 10:55 AM, the Executive Director stated the facility did not have a Wander guard system installed. The Executive Director stated staff were to keep a close eye on Resident #5 when she became restless or exhibited exit-seeking behaviors. The facility failed to ensure Resident #5 received adequate supervision to prevent an elopement from the facility.