Every finding on record at Millcreek Rehabilitation and Nursing

Based on interview, observation, and record review, for 1 of 5 sampled residents, the facility did not ensure that a resident's environment remained free of accident hazards. Specifically, a resident's wheelchair was not secured during transport. Resident Identifier: 1 and 2. It was determined the provider's non-compliance with the requirements of participation caused potential harm However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented on 3/27/26, educated and retrained all staff members who transport residents. Specifically, the facility provided Driver 1 with additional training, during which he demonstrated his step-by-step knowledge of proper wheelchair securement, and all drivers were given additional education to ensure ongoing compliance. In addition,, the Administrator performed random audits. Findings include: The surveyor reviewed the facility's grievance binder. A resident grievance, dated 3/26/26, stated, Resident reported to SS/RA [social services/resident advocate] that during transportation to their appointment earlier this week, the [sic] observed that the other resident in the transport vehicle was not strapped in appropriately, resident specified that the residents w/c [wheelchair] was not anchored via straps to the van floor. It was documented that the grievance was confirmed. The corrective action to the grievance included: Driver 1 was written up and re-educated regarding the incident; all staff who drove the van were re-educated on the transport evaluation checklist; additional training on wheelchair securement, technique, and safety; and reminder for all staff on the importance of adhering to all safety guidelines. On 4/7/26 at 11:51 AM, an interview was conducted with Driver 1. Driver 1 stated he transported resident 2 and assisted her into the building for her appointment. Driver 1 stated after determining they were at the wrong location, he drove to the correct destination across the parking lot but failed to secure resident 2's wheelchair with straps. Driver 1 provided a text message dated 3/25/26, that he wrote to the Administrator that stated, During the short transfer, I made a mistake and did not secure the wheelchair with straps, as the distance was very close. I understand this was not the correct procedure, and I take responsibility for it. On 4/7/26 at 11:07 AM, an interview was conducted with resident 1. Resident 1 provided a video of resident 2 in a facility van in a wheelchair not secured. Driver 1 was observed in the video driving and holding the base of resident 2's wheelchair with his right hand. Resident 2 was observed to be holding on to the back of the driver's seat. The video was 49 seconds long, and the speed of the vehicle was unable to be determined from the video. On 4/7/26 at 11:00 AM, an interview was conducted with resident 2. Resident 2 stated that staff transported her in the van to appointments. Resident 2 stated that the staff always secured her wheelchair and made sure she was buckled, and that she had never been injured or had an incident in the van. On 4/7/26 at 12:07 PM, an interview was conducted with the Director of Nursing (DON) regarding the incident with resident 2. The DON stated that Driver 1 transported resident 2 around the building and when he put her back in the van, he did not put the wheelchair strap on appropriately because it was just in the same parking lot. The DON stated Driver 1 did not secure resident 2 in the van and he should have done that. The DON stated immediately they did training again with Driver 1 regarding no matter the distance, the resident must be secured. The DON stated Driver 1 also received a write up for not securing resident 2 in the van prior to transporting. On 4/7/26 at 12:54 PM, an interview was conducted with the Administrator (ADM). The ADM stated Driver 1 was at a large campus with lots of medical offices and he had gone to the wrong building 3 times. The ADM stated Driver 1 did not secure resident 2's wheelchair in the van because the office building was in the same parking lot and driver 1 was in a hurry. The ADM stated Driver 1 was written up and step by step directions on how to secure the wheelchair were done immediately. The ADM stated when a resident is not secured, they could sustain an injury. The ADM stated after the incident with resident 2, all van drivers received retraining, and increased monitoring was implemented for Driver 1 when he left the facility to make sure residents were secured The ADM stated the changes were implemented on 3/27/26.

Based on interview, observation, and record review, for 1 of 5 sampled residents, the facility did not ensure that allegations of neglect were reported immediately to the State Survey Agency. Specifically, the facility did not report an incident where a resident was not secured while being transported in a facility van. Resident Identifier: 2 Findings include: The surveyor reviewed the facility's grievance binder. A resident grievance, dated 3/26/26, stated, Resident reported to SS/RA [social services/resident advocate] that during transportation to their appointment earlier this week, the [sic] observed that the other resident in the transport vehicle was not strapped in appropriately, resident specified that the residents w/c [wheelchair] was not anchored via straps to the van floor. It was documented that the grievance was confirmed. The corrective action to the grievance included: Driver 1 was written up and re-educated regarding the incident; all staff who drove the van were re-educated on the transport evaluation checklist; additional training on wheelchair securement, technique, and safety; and reminder for all staff on the importance of adhering to all safety guidelines. On 4/7/26 at 12:54 PM, an interview was conducted with the Administrator (ADM). The ADM stated when there was an abuse or neglect allegation, there was a trigger call made with the company [NAME] President, Corporate representative, and Director of Nursing (DON) to discuss if they felt like it was at the level of abuse to report. The ADM stated if anyone on the call felt it was abuse, then he reported the incident immediately, called the police and contacted Adult Protective Services. The ADM stated neglect was defined as residents not receiving goods and services. The ADM stated the incident was not reported to the State Survey Agency because they felt it didn't meet the criteria. The ADM stated resident 2 was not injured and Driver 1 went through retraining and a write up. The ADM was provided the definition of neglect and the ADM stated with the definition of neglect, the incident should have been reported.

Based on interview and record review, for 1 of 43 sampled residents, the facility, in response to an allegations of abuse, neglect, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, a resident sustained a fall in a wheelchair while being transported in the facility van and the facility did not investigate the incident or report the incident to the SSA. This was determined to have occurred at an Immediate Jeopardy level. Resident identifier: 47 and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to thoroughly investigate alleged violations, prevent further potential abuse, neglect exploitation or mistreatment while the investigation was in progress, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violations was verified appropriate corrective action must be taken. Specifically the facility failed to report and investigate a resident's fall during transportation in a facility vehicle. The facility had no documentation that an investigation had been conducted, no actions were taken to re-educate transportation staff on how to properly secure residents and their equipment safely to prevent falls or injury during transportation. There was no evidence that monitoring had taken place to ensure that policies were being followed and that safety practices were being adhered to. Notice of the IJ was given verbally and in writing to the Corporate President (CP) and the Regional Nurse Consultant (RNC) 1 who were present by phone, the Regional [NAME] President of Operations (RVPO), RNC 2, the Administrator (ADM), the Director of Nursing (DON), the Minimum Data Set (MDS) Coordinator, and they were informed of the findings of IJ pertaining to F 610 for resident 50. On 3/20/25 at 4:09 PM, the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective 3/20/25 at 10:00 PM. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the identified issue and prevent any additional residents from suffering an adverse outcome (Completion Date: 3/20/25 Completion Time: 10:00 PM) * Resident #50 was evaluated on 3/20/25 at 1440 (2:40 PM) by the Director of Nursing (DON) for pain and offered to be transferred to the hospital to address concerns and to be evaluated for latent injury from the fall on 2/14/25. The resident declined to go to the hospital. The resident was reminded of the treatment modalities available to him including pain medication, muscle relaxation and non-pharmacological interventions. * Resident #50's w/c [wheelchair] was evaluated for safety and to ensure proper functioning by the DON and Nursing Home Administrator (NHA) on 3/19/25. There were no concerns identified. * The NHA inititiated an initial report to the State for the van incident that occurred on 2/14/25 on 3/19/25. * The incident report for resident #50 was reviewed and updated for the event that occurred on 2/14/25 on 3/20/25 to address inaccuracies identified during the investigation initiated on 3/19/25. * The Transpiration Driver (TD) was suspended on 3/19/25 pending the outcome of the investigation. * On 3/20/25 the DON and designee(s) assessed all residents that have been transported by the facility since 2/14/25 to ensure they did not sustain any injury or falls while being transported on the facility van. No additional residents were identified. * On 3/20/25 the Regional Nurse Consultant (RNC) completed a 100% audit of risk management reports and progress notes from 2/14/25 to present to ensure all incidents to have been appropriately reviewed and investigated for potential abuse or neglect. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring (Completion Date: 3/20/25 Completion Time 10:00 PM) * On 3/20/25 the RNC conducted a Root Cause Analysis (RCA) on all transport incidents from the previous 90 days. Current residents impacted by the findings of the RCA had safety measures and resident specific interventions added to their care plans. * On 3/20/25 the RVPO educated the NHA and DON on the facility Trigger Call process, driver safety including proper securement technique of w/c dependent residents such as seatbelt placement through the arm rest and secured against post assuring seat belt is against the resident and does not have any slack as well as securing the wheelchair to the wheelchair van through the appropriate placement of the wheelchair restraints onto a fixed part of the frame of the wheelchair, how to conduct a RCA, review of incidents to ensure allegations of abuse and neglect are investigated timely, and how to ensure incident investigations are timely and complete including the Event Note Template. The Trigger Event process includes the NHA and DON notifying the RNC and RVPO of high risk events to ensure they are handled appropriately with targeted interventions and actions to investigate and prevent recurrence. Trigger Events include areas such as allegations or suspicions of abuse and neglect, fall with major injury and any incidents that occur on an outing or transport. The incident investigation process includes IDT (Interdisciplinary Team) review of an incident report daily at stand up meeting and the use of an investigation checklist to assure the investigation process is thorough and complete. The Event Note Template includes a list of the IDT members involved in the incident RCA and investigation the event date and time, a description of the event, risk factors and root cause identification, preventative measures in place prior to the event and new interventions implemented post incident. * On 3/20/25 the RVPO educated the NHA and IDT Leadership on identifying, reporting and investigating neglect. The education included the definition of neglect and how to identify when a situation needs to be reported and investigated as neglect. * The NHA educated all staff involved in using the facility van for transportation on safety including proper securement technique for wheelchair dependent residents, placement of the seatbelt and what to do if an accident occurs. A documented return demonstration checklist was completed on 3/20/25 with transportation staff including the RA [Resident Advocate], DON, BOM [Business Office Manager], and AD [Activities Director] prior to their next transport. Instructions for what to do if an incident/accident occurs while performing a transport was placed in the facility van for staff to refer back to in the event of an incident/accident. * The NHA or designee will visually inspect residents being transported in the facility van prior to transport to ensure w/c is properly secured for the next 30 days. * The Corporate Nurse or RVPO will review all incident reports within one working day for three months to ensure an RCA has been conducted and the resident specific interventions are reflected in the care plan. * The NHA or designee will initiate a Trigger Call with the RVPO and RNC for all incidents that occur on the facility van to ensure appropriate action has been taken and a comprehensive plan for investigation and RCA has been developed. * The DON or designee will review all falls and transport related incidents at the daily stand-up meeting with the IDT for three months to ensure appropriate safety interventions are implemented, the resident's care plan has been reviewed and revised, and staff education has been completed as needed. * A QAPI [Quality Assessment Performance Improvement] PIP [Performance Improvement Plan] has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA [Quality Assessment and Assurance] meeting. Monitoring/auditing and reporting will continue for a minimum of three months. On 3/21/25, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 3/20/25. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. On 3/17/25 at 10: 07 AM, an interview was conducted with resident 50 who stated the Transportation Driver (TD) was taking him to a cardiology appointment when he fell backward in his wheelchair, hit his head and neck on the floor. Resident 50 stated his wheelchair was strapped into the van and he was not sure about the placement of a seatbelt. Resident 50 stated he reported the accident when he returned to the facility and was provided an x-ray the day after the incident. Resident 50 stated the incident happened on 2/14/25 at approximately 9:30 AM. Resident 50 also stated that his roommate was also riding in the van and was a witness to the accident. Resident 50 stated he requested a copy of the incident report and was provided one. Resident 50 also stated the incident report was not accurate. Resident 50 stated he requested to have a second opinion regarding his injuries and was provided an appointment 2-3 weeks later. Resident 50 stated he spoke with the Director of Nursing (DON) about the incident the day after it occurred and was told he knew nothing about it. Resident 50's medical records were reviewed between 3/17/25 and 3/31/25. A progress note dated 2/15/25 at 8:34 PM revealed, Note text: During cares today, resident reported that he had a witnessed fall yesterday during transportation to his appointment. Resident states that he fell backwards and hit his head and neck. Fall was reported to management and MD [Medical Doctor], neuros initiated, no visible injuries but due to pain MD ordered cervical spine xrays. VS [vital signs] WNL [within normal limits]. Awaiting results on xrays. On 2/15/25 an incident report revealed, Witnessed fall: Resident: [Resident 50] .Incident location: out of facility/during transport .Incident Description: Nursing Description: Resident reported to the nurse today (2/15/25), that yesterday (2/14/25) he had a witnessed fall during transportation to his appointment. States that he fell and hit his head. Was heading to appointment, and when getting inside of the van he fell backwards and hit his head. states that heck[sic] has been hurting .Immediate action taken: Description: The resident was assessed for injuries and no injuries found. He reports tenderness to the neck on palpation. Reported to management and MD, initiated neuros and MD ordered cervical spine xrays- xrays ordered. X-ray results were negative for a fracture. Resident requested a second opinion, was referred to ortho. Alert charting initiated. IDT intervention: DON and NHA retrained the transportation driver on proper and safe transportation techniques. Also, resident's appointments to be rescheduled if the resident is not medically stable .Resident taken to Hospital? N .Injuries Observed at Time of Incident .No injuries observed at time of incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with assistance Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Injuries Report Post Incident: No injuries observed post incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with Assistance . Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Predisposing Environmental Factors: None .Predisposing Physiological Factors: None .Predisposing Situational Factors: Using Assistive Device .Other Info: Resident had loose bowels and was in his w/c at the time it happened. The back of his wheelchair opens backward. When the driver was at the light, the resident had another episode of loose BM [bowel movement], he got agitated and started to scream and thrash around while in wheelchair. His erratic movements caused the back of his wheelchair to reclined backward, which caused him to lean backward. According to driver, resident didn't land on the floor and did not hit his head on the floor or anything .Statements: Staff on 2/17/25 On Friday the 14th of March, [Resident 50] was having a cardiology appointment at [facility]. [Resident 50] was secured appropriately in the van according to our regular safety standards. When I went to get him, he was having diarrhea and a bad day as well, as he was so sad. Before we left the building, I changed his brief twice, so while we are driving he kept on yelling in the van because he also had diarrhea twice on our way. While this is happening, I always encourage him, and promise him that I will help him do a brief change when we get to the [facility]. So we got to the light close to the [facility], the moment it was green, I moved the car, all I heard was shit I just had diarrhea again. The he said I'm falling down, so I quickly park the van by the side of the road, he was still strapped with the seat belt, but he was down with his wheelchair. I asked him if hit his head and he said no, so I helped him up, and we continued our trip . Agencies/People notified: DON on 2/15/25 at 8:34 PM, Physician 2/15/25 at 8:34 PM. On 3/19/25 at 9:33 AM, an interview was conducted with resident 47 who stated he was sitting in the back seat of the van when the accident occurred on 2/14/25. Resident 47 stated he was wearing a seat belt. Resident 47 stated the TD placed the hooks of the straps to the frame of the wheelchair. Resident 47 stated, something in the front came undone. [TD] pushed on the gas and the wheelchair fell backward. Resident 47 stated the TD had to put the hooks back on the front of the wheelchair and re-tighten it down again. Resident 47 stated he did not remember if resident 50 hit his head, but he fell backward really fast. Resident 47 stated the TD stopped the van and opened the door to check on resident 50. Resident 47 stated he did not remember if resident 50 was wearing a seatbelt. Resident 47 stated resident 50 told him when he turned his head he could hear his bones popping and his neck hurt. Resident 47 stated resident 50 told everyone about the accident and asked for an x-ray right away but did not get on until the next day. On 3/19/25 at 9:40 AM, a follow-up interview was conducted with resident 50. Resident 50 stated he was not assessed after he returned to the facility. Resident 50 stated he was seen at [facility] on 3/7/25 and obtained a note stating that he had whiplash. Resident 50 stated he had a follow-up appointment on 3/28/25 for an MRI (Magnetic Resonance Imaging). Review of the facility abuse investigations revealed no documentation or investigation of resident 50's fall in the transportation van on 2/14/25. On 3/19/25 at 2:26 PM, an interview was conducted with the DON. The DON stated the TD was transporting resident 50 to an appointment. The DON stated that while riding in the van, resident 50 had a bowel movement and was yelling at the TD. The DON stated the TD told him the light turned green and he started to move and resident 50 fell down in the van. The DON stated they did a risk management on the incident and did not report it to the State Survey Agency (SSA). The DON stated he did not know why. The DON stated it did not seem like it was abuse or neglect. On 3/19/25 at 3:18 PM, an interview was conducted with ADM who stated resident 50 was having diarrhea really bad on the day of the incident. The ADM stated the TD was taking resident 50 to an appointment and he had 2 bowel movements in the van. The ADM stated that the TD reported that resident 50 freaked out for lack of a better term. The ADM stated that he did not think that the TD was accelerating when resident 50 fell back, but that he was already in motion. The ADM stated that he did not go and investigate because the TD told him the chair opened up and the resident did not have any injuries. The ADM stated if there was an accident in the van the process that should have been followed was that 911 should have been called and the resident should have been assessed. The ADM stated the TD should have reported to incident to him immediately. The ADM stated the TD notified him of the incident after returning to the facility but does not remember what time it was. The ADM stated he did not have any documentation. The ADM stated if a resident had an accident in the van he should be notified immediately. The ADM stated once notified, he should conduct an investigation. The ADM stated he did not investigate this incident because the TD reported the resident did not hit his head or receive any harm and that the wheelchair was secured. The ADM did not ask about how the chair was secured. The ADM stated it could have made a difference. The ADM stated he did not think to do an investigation. The ADM stated he did talk to the resident about the incident that day or the day after, he did not remember which. The ADM stated resident 50 was apologetic to the TD about the diarrhea. The ADM stated he was not aware that the resident was having ongoing pain. The ADM stated he was told the following day that the resident hit his head by either the DON or the nurse over his section. The ADM stated he did not think it would be considered neglect. The ADM stated they probably should have reported it. [Cross-refer F689]

Based on observation, interview and record review it was determined, for 2 of 43 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident fell backwards while being transported in a facility van due to not being secured properly and the resident sustained an injury to the head/neck. This was determined to have occurred at an Immediate Jeopardy level. Also, a resident with multiple falls did not have interventions in place to prevent additional falls. Resident identifiers: 1, 47, and 50. On 3/20/25 at 1:30 PM, an Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that staff transporting residents and their equipment were trained on how to secure residents properly to prevent falls or injury. Notice of the IJ was given verbally and in writing to the Corporate President (CP) and the Regional Nurse Consultant (RNC) 1 who were present by phone, the Regional [NAME] President of Operations (RVPO), RNC 2, the Administrator (ADM), the Director of Nursing (DON), the Minimum Data Set (MDS) Coordinator, and they were informed of the findings of IJ pertaining to F 689 for resident 50. On 3/20/25 at 4:09 PM, the Administrator provided the following revised abatement plan for the removal of the Immediate Jeopardy effective 3/20/25 at 10:00 PM. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the identified issue and prevent any additional residents from suffering an adverse outcome (Completion Date: 3/20/25 Completion Time: 10:00 PM) * Resident #50 was evaluated on 3/20/25 at 1440 (2:40 PM) by the Director of Nursing (DON) for pain and offered to be transferred to the hospital to address concerns and to be evaluated for latent injury from the fall on 2/14/25. The resident declined to go to the hospital. The resident was reminded of the treatment modalities available to him including pain medication, muscle relaxation and non-pharmacological interventions. * Resident #50's w/c [wheelchair] was evaluated for safety and to ensure proper functioning by the DON and Nursing Home Administrator (NHA) on 3/19/25. There were no concerns identified. * The NHA inititiated an initial report to the State for the van incident that occurred on 2/14/25 on 3/19/25. * The incident report for resident #50 was reviewed and updated for the event that occurred on 2/14/25 on 3/20/25 to address inaccuracies identified during the investigation initiated on 3/19/25. * The Transpiration Driver (TD) was suspended on 3/19/25 pending the outcome of the investigation. * On 3/20/25 the DON and designee(s) assessed all residents that have been transported by the facility since 2/14/25 to ensure they did not sustain any injury or falls while being transported on the facility van. No additional residents were identified. * On 3/20/25 the Regional Nurse Consultant (RNC) completed a 100% audit of risk management reports and progress notes from 2/14/25 to present to ensure all incidents to have been appropriately reviewed and investigated for potential abuse or neglect. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring (Completion Date: 3/20/25 Completion Time 10:00 PM) * On 3/20/25 the RNC conducted a Root Cause Analysis (RCA) on all transport incidents from the previous 90 days. Current residents impacted by the findings of the RCA had safety measures and resident specific interventions added to their care plans. * On 3/20/25 the RVPO educated the NHA and DON on the facility Trigger Call process, driver safety including proper securement technique of w/c dependent residents such as seatbelt placement through the arm rest and secured against post assuring seat belt is against the resident and does not have any slack as well as securing the wheelchair to the wheelchair van through the appropriate placement of the wheelchair restraints onto a fixed part of the frame of the wheelchair, how to conduct a RCA, review of incidents to ensure allegations of abuse and neglect are investigated timely, and how to ensure incident investigations are timely and complete including the Event Note Template. The Trigger Event process includes the NHA and DON notifying the RNC and RVPO of high risk events to ensure they are handled appropriately with targeted interventions and actions to investigate and prevent recurrence. Trigger Events include areas such as allegations or suspicions of abuse and neglect, fall with major injury and any incidents that occur on an outing or transport. The incident investigation process includes IDT (Interdisciplinary Team) review of an incident report daily at stand up meeting and the use of an investigation checklist to assure the investigation process is thorough and complete. The Event Note Template includes a list of the IDT members involved in the incident RCA and investigation the event date and time, a description of the event, risk factors and root cause identification, preventative measures in place prior to the event and new interventions implemented post incident. * On 3/20/25 the RVPO educated the NHA and IDT Leadership on identifying, reporting and investigating neglect. The education included the definition of neglect and how to identify when a situation needs to be reported and investigated as neglect. * The NHA educated all staff involved in using the facility van for transportation on safety including proper securement technique for wheelchair dependent residents, placement of the seatbelt and what to do if an accident occurs. A documented return demonstration checklist was completed on 3/20/25 with transportation staff including the RA [Resident Advocate], DON, BOM [Business Office Manager], and AD [Activities Director] prior to their next transport. Instructions for what to do if an incident/accident occurs while performing a transport was placed in the facility van for staff to refer back to in the event of an incident/accident. * The NHA or designee will visually inspect residents being transported in the facility van prior to transport to ensure w/c is properly secured for the next 30 days. * The Corporate Nurse or RVPO will review all incident reports within one working day for three months to ensure an RCA has been conducted and the resident specific interventions are reflected in the care plan. * The NHA or designee will initiate a Trigger Call with the RVPO and RNC for all incidents that occur on the facility van to ensure appropriate action has been taken and a comprehensive plan for investigation and RCA has been developed. * The DON or designee will review all falls and transport related incidents at the daily stand-up meeting with the IDT for three months to ensure appropriate safety interventions are implemented, the resident's care plan has been reviewed and revised, and staff education has been completed as needed. * A QAPI [Quality Assessment Performance Improvement] PIP [Performance Improvement Plan] has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA [Quality Assessment and Assurance] meeting. Monitoring/auditing and reporting will continue for a minimum of three months. On 3/21/25, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 3/20/25. Findings included: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. On 3/17/25 at 10:07 AM, an interview was conducted with resident 50, who stated while being transported to a medical appointment on 2/14/25 at about 9:30 AM, in the facility van, he had fallen backward and hit his head. Resident 50 stated he was unhappy because the incident report he received from the administration was not accurate in the details of the accident. Resident 50 stated his wheelchair was strapped to the floor of the vehicle but he could not recall if he had a seatbelt on. Resident 50 stated he fell backward while the van was in motion and hit his head and neck on the floor of the van. Resident 50 stated his roommate, Resident 47, was also in the van and witnessed the accident. Resident 50 stated the incident report said the Transportation Driver (TD) had to sit the wheelchair back up but the resident did not fall. Resident 50 stated that after the fall he had pain to the base of his skull and when turning his neck he heard a cracking sound. Resident 50 stated he told staff about it upon returning from his appointment, but was not assessed. Resident 50 stated he received an x-ray the following day. Resident 50 also stated when he spoke with the Director of Nursing (DON), he was told he had not heard anything about it. Resident 50 stated that 2-3 weeks after his fall he went for a second opinion. Resident 50's medical record was reviewed between 3/17/25 and 3/31/25. An admission Minimum Data Set, dated [DATE] revealed resident 50 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Resident 50's physician orders included: a. Referral for Orthopedic for Neck Pain Revision date; 2/26/25. b. Acetaminophen Oral tablet; Give 650 mg [milligram] every 4 hours as needed for pain. NOTE: 3 GM [grams] daily from all sources. Order date: 1/28/25. Resident 50's care plan included: a. The resident has limited physical mobility r/t [related to] Bilateral BKA [below knee amputation] and multiple wounds on BLE [bilateral lower extremities] and on coccyx. Date initiated: 1/29/25, Revision on 3/14/25. The goal was, The resident will remain free of complications related to immobility, including contracture's, thrombus formation, skin-breakdown, fall related injury through the next review date. Date initiated:1/29/25, Target date: 5/12/25. Interventions included, Monitor/document/report PRN [as needed] any s/sx [signs/symptoms] of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date initiated: 1/29/25. b. The resident is at risk for falls r/t Hx [history] of BKA, bilateral multiple wounds and needs for assistance with ADL [activities of daily living] at times. Date initiated: 1/29/25, Revision on: 3/14/25. Interventions included, 2/15/25 FALL-IDT intervention: DON [Director of Nursing] and NHA [Nursing Home Administrator] retrained the transportation driver on proper and safe transportation techniques. Also, resident's appointments to be rescheduled if the resident is not medically stable. Date initiated: 2/17/25 .; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date initiated: 1/29/25; Follow facility fall protocol if a fall occurs. Date initiated: 1/29/25. Resident 50's progress notes documented: a. On 2/15/25 at 8:34 PM, a Health Status Note revealed, Note Text: During Cares today, resident reported that he had a witnessed fall yesterday during transportation to his appointment. Resident states that he fell backwards and hit his head and neck. Fall was reported to management and MD [Medical Doctor], neuros initiated, no visible injuries but due to pain, MD ordered cervical spine X-rays. VS [vital signs] WNL [within normal limits]. Awaiting results on X-rays. b. On 2/15/25 at 10:48 PM, a Health Status Note revealed, Note Text: Resident continues on neuro checks, no delayed injuries noted, no c/o [complaints of] pain or discomfort r/t the incident expressed during this shift. bed in the lowest position, call light within reach. c. On 2/17/25 at 5:40 AM, an Alert Note revealed, Note Text: Resident being monitored due to recent unwitnessed fall. residents neuros have been wnl. No changes to LOC [level of consciousness]. d. On 2/17/25 at 9:56 AM, a Health Status Note revealed, Note Text: MD was notified of and reviewed the cervical Spine x-ray results, NNO [no new orders]. e. On 2/26/25 at 11:03 AM, a Health Status Note revealed Resident requested a second opinion regarding the pain he has in his neck following the fall in the van. A referral for Orthopedic for Neck Pain was made. f. On 3/7/25 at 2:07 PM, a Health Status Note revealed, Resident had an appointment today at [name omitted] Orthopedic Center. [Facility] transported to and from the appointment. Reason for Appointment: Neck Pain. Facility Comments/Questions: None. Findings at Appointment: Base of Skull pain; Cervical x-rays showing degenerative changes. New orders/Recommendation: External PT; Cervical MRI [magnetic resonance imaging]; Can try Tizanidine 2mg at night as needed; Tylenol, topical medications (Icy hot, lidocaine patches, etc). Next Appointment: PRN [as needed]. Transport coordinator was notified. MD notified. On 2/15/25 an incident report revealed, Witnessed fall: Resident: [Resident 50] .Incident location: out of facility/during transport .Incident Description: Nursing Description: Resident reported to the nurse today (2/15/25), that yesterday (2/14/25) he had a witnessed fall during transportation to his appointment. States that he fell and hit his head. Was heading to appointment, and when getting inside of the van he fell backwards and hit his head. states that heck[sic] has been hurting .Immediate action taken: Description: The resident was assessed for injuries and no injuries found. He reports tenderness to the neck on palpation. Reported to management and MD, initiated neuros and MD ordered cervical spine X-rays- X-rays ordered. X-ray results were negative for a fracture. Resident requested a second opinion, was referred to ortho. Alert charting initiated. IDT intervention: DON and NHA [Nursing Home Administrator] retrained the transportation driver on proper and safe transportation techniques. Also, resident's appointments to be rescheduled if the resident is not medically stable .Resident taken to Hospital? N[no] .Injuries Observed at Time of Incident .No injuries observed at time of incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with assistance Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Injuries Report Post Incident: No injuries observed post incident .Level of Pain: 0 .Level of Consciousness: Alert, Mobility: Ambulatory with Assistance . Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time .Predisposing Environmental Factors: None .Predisposing Physiological Factors: None .Predisposing Situational Factors: Using Assistive Device .Other Info: Resident had loose bowels and was in his w/c at the time it happened. The back of his wheelchair opens backward. When the driver was at the light, the resident had another episode of loose BM [bowel movement], he got agitated and started to scream and thrash around while in wheelchair. His erratic movements caused the back of his wheelchair to reclined backward, which caused him to lean backward. According to driver, resident didn't land on the floor and did not hit his head on the floor or anything .Statements: Staff on 2/17/25 On Friday the 14th of March, [Resident 50] was having a cardiology appointment at [facility]. [Resident 50] was secured appropriately in the van according to our regular safety standards. When I went to get him, he was having diarrhea and a bad day as well, as he was so sad. Before we left the building, I changed his brief twice, so while we are driving he kept on yelling in the van because he also had diarrhea twice on our way. While this is happening, I always encourage him, and promise him that I will help him do a brief change when we get to the [facility]. So we got to the light close to the [facility], the moment it was green, I moved the car, all I heard was shit I just had diarrhea again. Then he said I'm falling down, so I quickly park the van by the side of the road, he was still strapped with the seat belt, but he was down with his wheelchair. I asked him if hit his head and he said no, so I helped him up, and we continued our trip . Agencies/People notified: DON on 2/15/25 at 8:34 PM, Physician 2/15/25 at 8:34 PM. On 2/15/25, a cervical spine x-ray was obtained for resident 50. The findings of the x-ray documented that the lower cervical spine and cervicothoracic junction was incompletely imaged given shoulder positioning. Patient in pain and could not reposition. The report documented no acute fracture was evident. The impression documented that the Patient may ultimately benefit from CT [computed tomography] or MRI [magnetic resonance imaging] if symptoms persist. On 3/7/25, a referral note to the Orthopedic clinic documented the reason for the referral was neck pain. The findings at the appointment documented Base of skull pain. The New Orders/Recommendations documented physical therapy, cervical MRI, Tizanidine at night as needed and Tylenol and topical medications for pain. The Orthopedic provider documented an associated diagnoses of cervical spondylosis and whiplash injury to the neck. On 3/19/25 at 8:22 AM, an interview was conducted with the Transportation Driver (TD), who stated that he made the medical appointments for residents and transported them to most of the appointments. The TD stated if a resident was in a wheelchair he would take the big van. The TD stated on the day of resident 50's appointment, resident 50 had diarrhea during the ride to his appointment and got upset. The TD stated that resident 50 said he was falling down. The TD stated that he did not know how the wheelchair fell, but it was while the van was in motion. The TD demonstrated that the back of the w/c was flat on the floor of the van. The TD stated that he pulled over and stopped immediately. The TD stated resident 50 was holding onto the seatbelt strap. The TD stated the wheelchair floor straps were tensioned on the floor. The TD also stated that he placed the seatbelt on resident 50. The TD stated the seatbelt went on top of the arms of the wheelchair, then the TD stated he could not remember if the seat belt went over or under the arm rests. The TD stated he sent a text to contact the facility about what happened and was told to make a progress note, which the TD said he did. The TD stated it might have been the next day. On 3/19/25 at 9:19 AM, an observation was made of the TD demonstrating how a wheelchair would be secured in the large facility van. The TD raised the wheelchair with the van lift and pulled the wheelchair into the van. The TD locked the brakes on the wheelchair. From the back, the TD placed the two hooks on the left and right sides of the frame of the wheelchair. Going to the front of the wheelchair, the TD showed that the front straps would not reach the wheelchair so he released the tension on the straps so he could apply the hooks. The TD applied the hooks to the outside of each of the wheels of the wheelchair. The TD then checked to ensure the wheelchair was secure. The TD demonstrated that he put the seatbelt over the arm of the wheelchair, but under the arm of the resident and across the resident's body, and secured it into the buckle on the floor. The State Surveyor [SS] asked how resident 50 fell back and the TD stated, honestly, I do not know. The SS asked what the TD saw when he looked in the rear view mirror and the TD stated that initially he did not look in the rear view mirror as he was trying to find a place to pull over. The TD stated after pulling over, he went to the back of the van and asked resident 50 if he was ok, and resident 50 stated that he was. The TD stated that he did not assess resident 50 but sat the chair up and continued to the appointment at the hospital. The TD stated after getting resident 50 cleaned up and to his appointment, he contacted the facility about what had happened. The TD stated he spoke with the Director of Nursing (DON). After returning to the facility the TD stated he spoke with the Administrator (ADM), and was asked several questions about what had happened. The TD stated resident 50's roommate, resident 47, was also in the van and was a witness to the incident. On 3/19/25 at 9:33 AM, an interview was conducted with resident 47 who stated he was present in the van when resident 50 fell backward in his wheelchair. Resident 47 stated he was sitting in the back seat of the van. Resident 47 stated the strap hooks were on the frame of resident 50's wheelchair. Resident 47 stated, something in the front came undone. Resident 47 stated that the TD pushed on the gas and the wheelchair fell backward. Resident 47 stated he did not remember if resident 50 hit his head, but stated he fell backwards really fast. Resident 47 stated that the TD stopped the van and opened the van door to see if resident 50 was ok. Resident 47 stated that the TD took the residents' to their appointments and then back to the facility. Resident 47 stated resident 50 told him after returning that his neck hurt and he could hear his bones popping. Resident 47 stated resident 50 told everyone about falling in the van. Resident 47 stated resident 50 asked to have an x-ray done right away, but did not get one until the next day. Resident 47 stated that after the chair fell, the TD had to put the hooks back on the chair and re-tighten the chair down again. On 3/19/25 at 9:40 AM, a follow-up interview was conducted with resident 50. Resident 50 stated his wheelchair was specialized for him. A crossbar was observed under the seat of the wheelchair near the back of the frame. The front of the wheelchair had small wheels attached to the frame by bars on either side of the chair and the bars were angled downward where the wheel was attached. Resident 50 stated that was where the front straps were attached. Resident 50 stated, again, that he was not assessed when he returned to the facility. Resident 50 stated he was seen at [facility] on 3/7/25 and obtained a note stating that he had whiplash. Resident 50 stated he had a follow-up appointment scheduled on 3/28/25 for an MRI (Magnetic Resonance Imaging). It should be noted that upon inspection of resident 50's wheelchair it was observed by the State Surveyor that the chair back did not recline backwards as previously reported in the facility incident report. On 3/19/25 at 1:28 PM, a follow-up interview was conducted with the TD who provided transportation schedules for the months of February and March of 2025. The TD stated 99.9% of the time, he was the staff member who transported residents to their appointments. The SS and the TD reviewed the schedules day by day and marked off residents day by day who ended up not going to their appointments. On 3/19/25 at 1:36 PM, an interview was conducted with the AD who stated she was approved to drive the facility vans. The AD stated the last time she drove the facility van was last week. The AD stated she took a resident to get a hot dog. The AD stated she took residents shopping every other Tuesday as well. The AD stated the TD had shown her how to secure resident wheelchairs into the big van. The AD stated the TD showed her to secure the floor strap hooks onto the back and front of the wheelchair frame. The AD stated that the seatbelt should go across the resident and over the armrests of the wheelchair. The AD stated she did not have anyone verify the resident's wheelchair was secured before leaving the facility grounds. The AD stated she had completed the computer based training for the company but none of the training was specific to transportation in the facility vehicle. The AD stated she had not been provided any guidance about what she should do should she have an accident, and she had not seen any transportation policies. The AD stated she had not had any accidents while driving residents in the van. The AD stated she was told about the accident the TD had while transporting resident 50 and resident 47. The AD stated that she overheard the TD talking about the accident and the TD stated that the wheelchair had tipped back. The AD stated that she had not been provided any additional training or instructions for driving residents in the facility van after the accident with resident 50. On 3/19/25 at 1: 54 PM, an interview was conducted with the BOM who stated she provided transportation occasionally for residents. The BOM stated the last time she provided transportation was about 2 months ago when she took a resident to the bank. The BOM stated when she first started working at the facility, the DON and the TD had trained her on how to secure a wheelchair in the facility van. The BOM stated that she was taught to lower the ramp, put the wheelchair on, lock the wheels, raise the ramp, and hook the belt on the bottom of the chair. The BOM stated she never had to do a return demonstration, she just had to repeat back what she saw them do. The BOM stated she thought there was a clip on the floor that the wheelchair was attached to. The BOM stated the seatbelt should be placed over the wheelchair armrest and secured. The BOM stated if a resident needed to be transported she would have the TD or the AD drive the van. The BOM stated she thought the DON did a demonstration and training recently. The BOM stated she had not heard of any resident related falls while being transported. On 3/19/25 at 2:03 PM, an interview was conducted with the RA who stated she had been authorized to transport residents in the van but had not done so since October 2024. The RA stated she had been trained how to secure a wheelchair into the van. The RA stated the ADM and the TD did the training. The training included using the lift, making sure the wheelchair brakes were on, and placing the floor straps on the front and the back of the wheelchair by the hooks. The RA stated the hooks were supposed to be put on the frame of the wheelchair. The RA stated the seatbelt should be brought across the resident and hooked into the buckle down near the floor. The RA stated the seatbelt would go over the arm rests, but as close to the body as possible. The RA stated she had a brief discussion at an all staff meeting about 3 months ago and about a year ago about safe transporting of residents. The RA stated they were all verbal trainings. The RA stated the training held one month ago was just for transportation about safety. The RA stated it was written documentation read to them about why safety was important, what to watch for, examples were reviewed, staff looked at pictures of buckles, and there was a wheelchair demonstration. The RA stated the ADM and the TD showed how to secure the buckles across the wheelchair. The RA stated one staff member did a return demonstration, but she did not do a return demonstration. The RA stated she had not had any residents fall while she transported them. The RA stated during the training they also talked about what supplies and tools should be in the van. The RA stated she had been instructed what to do if a resident fell during a transport, which would be pull over, assess for wounds, clear the surrounding areas, and report immediately to the facility. The RA stated staff who should be notified would be nurse management. The RA stated if there was no visible injury, the resident should be assisted. The RA stated there could be an injury even if it was not visible. The RA stated if the resident was in pain or there was a suspected injury, she would contact the facility administrator and take direction from him. The RA stated she was aware of the incident with resident 50. The RA stated resident 50 came to her after the incident and wanted to discuss the incident report as he felt it was inaccurate. The RA stated she did not know about the incident before resident 50 came to speak with her. The RA stated resident 50 was upset that the TD had stated that he had not fallen to the ground during the transport and that he was thrashing around, and that he did not hit his head. The RA stated resident 50 told her that resident 47 was a witness. The RA stated after resident 50 spoke to her he appeared to be more calm about the situation. The RA stated she was not the first person resident 50 had reported this to and it was several days after the event. The RA stated resident 50 told her he fell and hit his head and did not give any more details. The RA stated she did not have reason not to believe resident 50's account of what happened. On 3/19/25 at 2:26 PM, an interview was conducted with the DON who stated he did not recall the last time he transported a resident in the facility van. The DON stated that the corporation had a computer based training for transportation drivers on safe driving practices. The DON stated staff who were eligible to drive the van, did a background check, provided a copy of their driver's license, completed a driver's safety training, and the DON was unsure if a driving history was checked on the staff member. The DON stated he and the ADM trained the staff on how to transport a resident in the facility van. The DON stated demonstration was used on how to safely buckle up residents, how to strap the wheelchair in the van, and how to use the van lift. The DON stated he told staff to ensure the locks were engaged on the wheels of the wheelchair and the floor straps were secured to each corner of the wheelchair. The DON stated that he preferred the floor straps to be connected to the frame of the wheelchair, but if there was no other area the strap could be placed on the wheel. The DON stated the seatbelt should be placed over the hips of the resident and under the armrests if there was space. The DON stated a training was done after the most recent incident with resident 50. The DON stated prior to that incident staff were doing computer based training. The DON stated that they also provided verbal education along with a demonstration on how to secure a wheelchair in the facility van. The DON stated that demonstration was provided by himself and the ADM. The DON stated there was no documentation of the training. The DON stated that nobody used the big van except the TD, the ADON, and himself. The DON stated he did not know if the computer based

Based on interview and record review it was determined, for 3 out of 43 sampled residents, that the facility did not ensure resident's were free from abuse. Specifically, a resident reported that another resident groped his genitals and attempted to penetrate his anus without his consent to the sexual activity. This deficient practice was found to have occurred at a Harm level. Additionally, a resident's capacity to consent to sexual activity assessment was not completed prior to the resident engaging in sexual activity. Resident identifiers 23, 49, and 112. Findings included: HARM 1. Resident 23 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, type 2 diabetes mellitus, right below the knee amputation, phantom limb syndrome, congestive heart failure, hypertension, viral hepatitis C, schizoaffective disorder, insomnia, anxiety disorder, and post-traumatic stress disorder (PTSD). On 3/17/25 at 10:38 AM, an interview was conducted with resident 23. Resident 23 stated that he had an incident with resident 112 and the other resident tried to touch him improperly. Resident 23 said that was all he wanted to say about it. Resident 23 stated that he informed the Resident Advocate (RA) about the incident and the facility called the police. Resident 23 stated that resident 112 was not arrested. Resident 23 stated that after that incident the facility did nothing. Resident 23 stated that resident 112 was still in the facility for another 2 months after the incident. Resident 23 stated that it made him really angry that resident 112 was still there at the facility. Resident 23 stated he felt he was angry a lot because of the incident. Resident 23 stated that he spoke to the RA afterwards but felt as if nothing happened. Resident 23 stated that after the incident staff did not do anything to try and keep the residents separated. On 9/28/24 at 11:15 AM, the facility reported to the State Survey Agency (SSA) that on 9/28/24 at 3:00 AM, resident 23 reported that he woke up to resident 112 touching his private area and trying to put a finger in his rear end. Resident 23 yelled saying, don't touch me, I'm not a faggot!. Resident 23 stated that resident 112 did not respond back to him when he yelled this. Resident 23 reported he went to his girlfriends room and stayed with her until 6:00 AM. The facility's final investigation report documented on Form 359 that on 9/27/24 at 10:00 AM, the RA interviewed resident 23. The victim stated 'I was wearing sweatpants while sleeping. I woke up to his hands down my pants, fondling my manhood and trying to put a finger in my anus. I turned over and said 'get away from me, I know that's you [resident 112]'. He then crawled backwards on all fours and back into his bed. I took a minute to collect myself and then decided to go outside to have a cigarette.' RA asked why it took several hours to report to staff and the resident stated 'I was in shock'. The summary of interviews documented, On 9/27/24 at 10:45 AM the RA spoke with the alleged perpetrator. He seemed disinterested but agreed. The RA started the conversation by asking, 'How are things? Did something happen to upset you this morning?' He then explained that he felt like others were talking about him, a frequent behavior with his diagnosis. I explained to him that an allegation was made against him and he responded with, 'I didn't do anything. That girl is making up rumors.' I let him know that it wasn't a female but it was a male that reported it. He was very taken aback and promptly stated 'That's crazy. I'm not attached to dudes'. He continued to tell me that he was in bed all night and slept like a rock. He became very upset and denying all claims. He asked to speak with his therapist, and we worked on his coping skills while waiting for his therapist to return our call. He stated multiple times, 'I'll stay away from other [sic] but I will not isolate myself because I did nothing wrong.' The conclusion of the facility investigation was documented as inconclusive. The allegation could not be verified based on evidence collected. After interviewing resident and staff, no conclusive evidence was found to implicate the alleged perpetrator. Resident 23's medical records were reviewed. On 9/13/24, the Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 12/15, which would indicate a moderate cognitive impairment. Resident 23's Treatment Administration Record (TAR) documented verbalizations of anxiety with one episode documented on 9/28/24 and 9/29/24 during the morning shift and one episode documented on 9/28/24 and 9/29/24 during the evening shift. It should be noted that no other episodes of anxiety were documented for the month of September. Resident 23's progress notes documented the following: a. On 9/28/24 at 10:08 AM, the Health Status Note documented, Alert charting r/t [related to] resident to resident altercation. [Resident 23] told this nurse that early Saturday morning at 3 am his roommate [resident 112] came up to [resident 23] and touched him inappropriately a few times. As [resident 112] continued to touch [resident 23's] private parts, [resident 23] started yelling at [resident 112] and [resident 112] didn't say anything back to him but went back to his bed and pretended to be asleep. [Resident 23] left his room after the incident and stayed in his girlfriend's room until about 6 am and only then decided to tell staff about what happened at 3 am. The two residents were separated and DON [Director of Nursing], Administrator were contacted. [Resident 112] was moved to a different room and is being monitored. b. On 9/28/24 at 5:30 PM, the Health Status Note documented, Alert charting r/t resident to resident (R:R) altercation. This resident reported an incident to the NOC [night] shift nurse at 0551 [5:51 AM] and NOC shift nurse informed this nurse (oncoming RN [registered nurse]) at 0600 [6:00 AM] shift report. Facility administrator/abuse coordinator was notified immediately. The alleged perpetrator was moved to the front of the facility away from this resident (alleged victim.) The residents remained separated for this shift. No verbal or physical contact between the two residents was witnessed by this RN during this shift. This resident reported anxiety about the altercation at morning med pass and received emotional support from this RN. He did not report any physical changes r/t to the altercation to this RN. His safety and mental and physical health was continuously assessed during this shift and he received all medical care as usual. c. On 9/30/24 at 6:00 AM, the behavioral health Nurse Practitioner Psych Follow Up note documented, Staff report that the pt. [patient] experiences moments of increased agitations. Will continue to monitor this pt Psychiatric Exam: General Appearance: alert and dishevelled [sic]. Behavior: eye contact is good and guarded. Mood: depressed. Affect: appropriate and flat. Thought Processes: concentration intact. Thought Content: no delusions, hallucinations, suicidal ideation, or homicidal ideation and normal thought content. Judgment: is intact. Insight: limited. Neurological System: Orientation: oriented to person, place, and time. Memory: immediate recall is intact and remote memory is intact. Fund of Knowledge: shows at least average vocabulary. Speech: volume is normal; fluent. d. On 9/30/24 at 12:44 PM, the Alert Note documented, Resident had a visit with social worker, regarding an incident with another resident. He was visibly upset and asked to speak with someone. She was called in they visited for about an hour. He seems to be coping better after their session. e. On 10/1/24 at 12:48 PM, the Alert Note documented, [Resident 23] is still trying to effectively cope with the incident with another resident. He is doing better today. I have had to remind [Resident 23] and friends that the Administrator is handling it accordingly. This seems to elevate some stress about the situation. f. On 10/3/24 at 9:49 AM, the Health Status Note documented, Resident has been verbalising [sic] increased anxiety and acute insomnia d/t [due to] recent trauma. Per [behavioral health services Nurse Practitioner]: start resident on Hydroxyzine 25mg [milligrams] po [by mouth] q [every] 6hrs [hours] PRN [as needed] x [times] 14 days for anxiety. MD [Medical Doctor] notified. g. On 10/9/24 at 2:21 PM, the Health Status Note documented, Per [behavioral health services Nurse Practitioner]: [Resident 23] reports that his depression is getting better, but residual anxiety is still there, so he agreed; 1). Increase Escitalopram to 20 mg daily. 2). Reduce Abilify to 10 mg in AM. MD approved. Resident 23's care plans revealed the following: a. On 9/17/24, resident 23 had a care plan initiated for TRAUMA INFORMED CARE: Has a history of trauma that affects him negatively. The care plan did not identify any interventions that were specific to the sexual abuse incident that occurred on 9/28/24. b. On 11/8/24, resident 23 had a care plan initiated for Resident has expressed/demonstrated a desire to participate in sexual activity with others. The interventions identified for the care plan were If sexual abuse or other sex-related crimes are suspected, staff shall immediately intervene to protect the resident and notify the administrator and law enforcement.; If the resident does not demonstrate capacity for consent or loses the capacity to consent to sexual activity, staff shall intervene as indicated to protect the resident from the risk for sexual abuse.; Staff shall educate resident that sexual activity should occur in a private setting to honor the rights of other residents and provide a private setting for sexual activity as needed.; Staff shall notify the attending physician if a resident desires to participate in sexual activity to obtain orders for contraceptive products, prophylactic or active antibiotics/antivirals, labs, etc. as indicated.; and The sexual capacity for consent assessment will be performed upon initiation of sexual activity, and then quarterly thereafter or with significant changes. On 3/18/25, a Sexual Activity Capacity for Consent assessment was conducted. The assessment documented Residents providers endorse that he is mentally at his baseline and is stable. When he is in a heightened state of emotion he tends to spend long amounts of time sleeping. He states his relationship with [resident 112] helps to get him out of his 'funks'. The resident's stated choice documented, Interview regarding residents choice to engage in sexual activity reflects consistency. He endorses that him and resident [resident 112] have been in a mutual and voluntary relationship for a long time. He spoke about how they met through mutual friends and bonded over their history. He states he enjoys having someone to confide in. Understands STI's [sexually transmitted infections] can be transmitted through sex. Understands pregnancy can be a risk. Patient understands how to prevent these risks. Resident also expressed an understanding of emotional risks associated with a sexual relationship and how to cope with these feelings. c. On 1/28/25, resident 23 had a care plan initiated for MOOD AND BEHAVIOR: History for an alteration in mood or exhibition of behavioral symptoms r/t: Schizoaffective disorder depressive type, Anxiety disorder, PTSD. The care plan identified an actual resident to resident altercation on 9/27/24. The interventions identified for the altercation were to move the alleged perpetrator to the farthest room away, as possible, from resident 23, in-person meeting with therapist, and weekly phone calls with therapist. The interventions were initiated on 1/28/25. It should be noted that the interventions were initiated 4 months after the incident occurred. On 3/25/25 at 9:02 AM, an interview was conducted with the RA. The RA stated that resident 23 reported that he woke up to his roommate [resident 112] having his finger near his butt. Resident 23 reported that resident 112 was on the floor on his knees and resident 23 yelled at him to get away from him. The RA stated that resident 23 reported that he went to his girlfriends room and they went to have a cigarette before reporting it to the nurse. The RA stated that she had no other documentation of the interview with resident 23 that was not already contained in the Form 359. The RA stated that resident 23 was agitated throughout the interview. The RA stated that they moved resident 112 to another room on 9/28/24. The RA stated that resident 23 had never made any allegations of sexual abuse prior to this incident. The RA stated that resident 112 had a history of sexual assault where he was the perpetrator and this information was contained within his Pre-admission Screening Resident Review (PASRR) Level II. The RA stated that resident 112 was not a registered sex offender. The RA stated that they asked the residents to stay apart and to have staff present during smoking breaks. The RA stated that she could not recall any new interventions that were implemented for resident 23 after the incident. The RA stated that she encouraged resident 23 to attend Mental Health Mondays where they reviewed coping skills, words of affirmations, wrote in a notebook for feelings, and identified 5 good things that happened that week. The RA stated she did not observe any prolonged change in resident 23's behavior. The RA stated that monitoring of resident 23 was alert charting for the nurses and she would meet with the resident several times a week. The RA stated she was not sure if those meetings were documented. The RA stated that during those short visits with resident 23 she would ask how his day was going. The RA stated that there was no reason for her not to believe resident 23's account of the incident and he had no history of making false allegations. The RA stated that she interviewed resident 112 and he was confused and shocked about the allegation and then he denied all claims. The RA stated that she asked him what happened this morning, and resident 112 replied he did not know. The RA stated that resident 112 was confused about the incident with his roommate. The RA stated she told resident 112 of the allegation and he denied all claims. The RA stated that resident 112 got loud and raised his voice. The RA stated that resident 112 stated no I would never. The RA stated that she informed resident 112 of a room change and the resident agreed. The RA stated that resident 112 remained in the facility for several more months after the incident. The RA stated that after the initial incident she was not aware of any additional conflicts between resident 23 and resident 112. On 3/25/25 at 10:33 AM, an interview was conducted with the contracted Certified Social Worker (CSW). The CSW stated she had been resident 23's therapist since October 2024. The CSW stated that she was not aware of any sexual abuse allegation that may have occurred in September 2024. The CSW stated that resident 23 was exhibiting signs and symptoms (s/sx) of depression and that was when she started seeing him. The CSW stated that when she took over she did not receive a report or hand off from resident 23's previous therapist. The CSW stated that she was able to see resident 23's notes by other behavioral health providers, but she did not review the resident's past therapy notes. The CSW was observed to review resident 23's history and notes. The CSW stated that resident 23 started individual therapy in November 2024. The CSW stated that she did a care plan in November and February for resident 23 and there were no mentions of sexual abuse allegations in resident 23's chart. The CSW stated that she started actual individual therapy with resident 23 on February 17, 2025. The CSW stated that the November visit was for the development of the care plan and annual assessment. The CSW stated at that time she conducted a PHQ-9 (Patient Health Questionnaire) depression test and the score was a 2 on 11/4/24, which would indicate a very low depression score. The CSW stated that she looked back in resident 23's notes from the previous provider and did not see any mention of a sexual abuse allegation. The CSW stated that if she had been informed she would have come in once a week to see resident 23. The CSW stated that she did see where a previous Nurse Practitioner had ordered Hydroxyzine for resident 23, but she was no longer his provider. The CSW stated that she viewed the note and recommendation to increase the Hydroxyzine medication but the note did not state why the medication increase was needed. The CSW stated that her experience with resident 23 focused on his depression related to feeling stuck and his adjustment with his amputation. The CSW stated that resident 23 did not have a history of delusions or hallucinations. The CSW stated that resident 23 had no grandiosity with making up stories. The CSW stated that resident 23 was pretty accurate with what his life was like in the drug world. The CSW stated that resident 23 had a tendency to perseverant on the same idea. Sometimes he did not think ahead, and he exhibited a lack of judgement and planning. The CSW stated an example of this was with resident 23's discharge planning and wanting to leave the facility, but through discussions he was able to identify his own limitations. The CSW stated that resident 23 exhibited good cognitive thinking. The CSW stated that resident 23 had never mentioned any female relationships in the facility, and she was not aware of any girlfriends. On 3/25/25 at 11:19 AM, an interview was conducted with the Administrator (ADM). The ADM stated that he was informed of the sexual abuse allegation by the staff nurses. The ADM stated that it was reported that resident 23 woke up to someone touching him and he went to his girlfriends room and she told him to report it and that was what he did. The ADM stated that he spoke with resident 23 and he reported what was documented in the facility investigation on Form 358 and Form 359. The ADM stated that he did not have any other documentation of the investigation. The ADM stated that he asked resident 23 why he waited so long to tell the staff and resident 23 replied that he was just freaked out by the whole thing. The ADM stated that resident 49 was resident 23's girlfriend. The ADM stated that resident 23 went into resident 49's room often. The ADM stated that resident 23 reported the incident to RN 2 and RN 3 during shift change and RN 3 informed him of the incident by email. The ADM stated that resident 112's room change was completed by the time he arrived at the facility and was done at the DON's direction. The ADM stated that RN 3 texted the DON immediately about the allegation. The ADM stated that resident 23 initially reported that resident 112 had come into his section of the room and attacked him. The ADM stated that resident 23 was upset when talking about the incident. The ADM stated that he reviewed the video footage and he did not see anything out of the ordinary, but that the cameras did not have resident room access. The ADM stated that the video footage showed resident 23 exit his room and go into his girlfriends room. The ADM stated that he was unable to recall the time that occurred and he did not have documentation of it. The ADM stated that after he spoke to resident 23 he went and spoke to resident 112. The ADM stated that resident 112 denied the allegation, and replied he was not into dudes. The ADM stated that resident 23 had not made any other allegations prior to or since this incident. The ADM stated that they informed resident 112 that if he went past the nurse's station or wanted to go on smoke break he had to have someone with him. The ADM stated that the conclusion of the investigation was inconclusive due to a he said/he said situation. The ADM stated that the allegation could not be verified based on the lack of evidence collected, and it was essentially one resident's word against another. The ADM stated that resident 23 had not made any prior allegations, and he did not have any reason to doubt his account of the situation. The ADM stated that resident 112 continued to reside at the facility after the incident for approximately another 5 months. The ADM stated that during that time resident 112 was agreeable to stay on the east side of the nurses's station, but there may have been times that they passed each other. 2. Resident 112 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, atrial fibrillation, schizoaffective disorder, insomnia, anxiety disorder, post-traumatic stress disorder, borderline personality disorder, and borderline intellectual functioning. Resident 112 was discharged from the facility on 2/5/25. Resident 112's medical records were reviewed. On 9/17/24 resident 112's MDS assessment documented a BIMS score of 10, which would indicate a moderate cognitive impairment. Resident 112's September 2024 TAR documented the following: a. Monitoring for EPISODES OF AGITATION Q SHIFT documented 8 episodes on 9/24/24, 2 episodes on 9/29/24, and 4 episodes on 9/30/34. b. Monitoring for VERBALIZATIONS OF ANXIETY Q SHIFT documented 10 episodes on 9/24/24, 1 episode on 9/26/24, 1 episode on 9/28/24, 4 episodes on 9/29/24, and 4 episodes on 9/30/24. c. Monitoring for : # OF MANIC EPISODES (PRESSURED SPEECH, FLIGHT OF IDEAS) documented 4 episodes on 9/24/24. On 9/23/24 at 9:04 AM, resident 112's Resident Trauma Interview documented a history of physical, emotional, and sexual trauma. The resident reported experiencing nightmares, flashbacks, sleep disturbances, difficulty concentrating, irritation, anger, and anxiety. The resident reported episodes 1-2 times a month. The resident reported triggers of violent tv shows and conversations about past trauma. The resident identified coping mechanisms as medication, quiet environment, and talk therapy. Resident 112's progress notes documented the following: a. On 9/28/24 at 10:24 AM, the Health Status Note documented, Alert charting r/t resident to resident altercation. [Resident 112] roommate [resident 23] accused him of touching him inappropriately early Saturday morning at 3 am but shared this information with staff only at around 6 am. This nurse was unable to take a statement from [resident 112] because [resident 112] either pretended to be asleep or was asleep. Refused to talk. Residents were separated. DON, Administrator were called and [resident 112] was moved to a different room. He is being monitored. WCTM [will continue to monitor]. b. On 9/29/24 at 10:19 PM, the Health Status Note documented, Resident has been up in his wheelchair this shift. He was heard saying 'something is not right or not fair'. He would not express details, though repeated the same thing two to three times. Resident made no reference to others or any situation. Resident took his night-time medications and tolerated them well. No new negative behaviors have been observed or reported at this time. WCTM. c. On 10/1/24 at 6:26 PM, the Alert Note documented, Resident is on Alert charting r/t R:R altercation. Resident remained separated from two other residents that he has had R:R altercations with. Resident was sitting WC [wheelchair] in doorway of his room this afternoon with his pants down past buttox [sic]. Asked resident if would go back into his room and asked if he needed assistance fixing his pants. Resident was compliant with going back into his room to fix his pants. No other behaviors observed this shift. On 1/28/25, resident 112 had a care plan initiated for MOOD & BEHAVIOR: History for an alteration in mood or exhibition of behavioral symptoms r/t: Schizoaffective disorder bipolar type, GAD [generalized anxiety disorder], PTSD, BPD [borderline personality disorder], Borderline Intellectual functioning. The care plan identified an actual resident to resident altercation on 9/27/24. The interventions identified on the care plan included resident was moved to the farthest possible room away from alleged victim; resident met in person with therapist; administer medications as ordered; allow resident time to calm down and reapproach [sic] at a later time; evaluate for need and refer to psychological couseling [sic] as recommended by the physician; interact in an empathetic and supportive manner; monitor and document each behavioral event; 1:1 interaction as needed; offer psychosocial support as needed; and Psychotropic Review Committee to review medications. The interventions were initiated on 1/28/25. It should be noted that the interventions were inititiated 4 months after the incident occurred. On 1/13/25, resident 112 had a Montreal Cognitive Assessment (MOCA) conducted and the resident scored 11/30, which would indicate a moderate cognitive impairment. The resident had deficits in visuospatial/executive function, naming, memory, attention, language, abstraction, delayed recall, and orientation. On 6/27/24, resident 112's PASRR Level II documented, Bipolar Disorder: A review of the record shows he has had the following symptoms of mania: grandiosity, pressured speech, racing thoughts, flight of ideas, distractibility, increased risk taking, including hypersexuality and general impulsivity. He has had auditory hallucinations during periods of mania. As best can be determined, symptoms of mania were not solely related to substance abuse. Posttraumatic Stress Disorder: [Resident 112] has a history of physical and emotional abuse by his father, as well as a history of rape as an adult, leading to a response of fear and helplessness. He has had flashbacks as often as once or twice a week, and experiences psychological distress as a result. Flashbacks are triggered by violent television shows, such as Law and Order: Special Victims Unit, and conversations about past trauma by others. These triggers are avoided. Hypervigilance, exaggerated startle response, and concentration problems are present, causing clinically significant distress and impairment, and have been problematic for years. He also reports having nightmares once or twice a month, and takes prazosin to help with this. Antisocial Personality Disorder: He has a history of 22 arrests in Florida, often for sexual assault, and was extremely aggressive, requiring frequent restraints and seclusion during the first three or more years of his [state hospital] stay. Failure to comply with social norms, impulsivity, irritability and aggressiveness, disregard for the safety of others, consistent irresponsibility, and lack of remorse. Many of these symptoms are not in evidence at this time, as he has greatly improved in his ability to manage his aggression. During the Level 2 evaluation in April 2024, Patient was significantly manic and hyperverbal with grandiose thought content, pressured speech and flight of ideas. Patient spoke with a very loud voice and was animated throughout the conversation. Patient showed his arms to evaluator that were covered in scars from cutting himself with a razor. Patient stated he has tried to kill himself 100-200 times. Patient stated he 'sometimes falls into the anger trap' and talked about what he does when he gets frustrated but using coping skills he has learned. Patient endorsed hearing ongoing almost constant voices. 'I always hear voices. I consider it telepathy. I consider the good voices guardian angels and the bad voices Satan's dominions.' He also stated, 'I've had visions in my head of Satan, but it doesn't scare me.' 3. Resident 49 was admitted to the facility on [DATE] with diagnoses which consisted of schizoaffective disorder bipolar type, fetal alcohol syndrome, post-traumatic stress disorder, opioid dependence, anxiety disorder, attention-deficit hyperactivity disorder (ADHD), and insomnia. On 3/17/25 at 9:14 AM, an interview was attempted with resident 49. Resident 49 made eye contact but did not respond to greeting. Resident 49 turned away from surveyor and closed her eyes. On 3/18/25 at approximately 1:30 PM, an observation was made of resident 49 and resident 23 in the hallway. Resident 49 was heard inviting resident 23 to watch a movie. Resident 23 replied that he was not allowed to go into her room to watch the movie. Resident 49's medical records were reviewed. Resident 49's physician orders revealed the following for behavior monitoring: a. On 7/18/22, an order was initiated for BEHAVIOR MONITORING: # OF VERBALIZATIONS OF ANXIETY Q [every] SHIFT. The TAR documented 3 episodes in November 2024, 4 episodes in December 2024, 5 episodes in January 2025, 2 episodes in February 2025, and 6 episodes in March 2025. b. On 7/19/22, an order was initiated for BEHAVIOR MONITORING:# OF DELUSIONS Q SHIFT. The TAR documented 1 episode in November 2024, 2 episodes in January 2025, 8 episodes in February 2025, and 2 episodes in March 2025. c. On 7/19/22, an order was initiated for BEHAVIOR TRACKING:# HALLUCINATIONS Q SHIFT. The TAR documented 1 episode in December 2024. d. On 8/8/22, an order was initiated for BEHAVIOR MONITORING:# EPISODES OF CRYING/TEARFULNESS Q SHIFT. The TAR documented 1 episode in November 2024, 14 episodes in December 2024, 11 episodes of January 2025, and 1 episode in March 2025. e. On 6/7/23, an order was initiated for BEHAVIOR MONITORING: # EPISODES OF FLASHBACKS Q SHIFT. f. On 3/21/25, an order was initiated for BEHAVIOR MONITORING: # OF PSYCHOSIS Q SHIFT. Resident 49's progress notes revealed the following: a. On 7/19/24 at 6:45 AM, the Psych Evaluation note documented, Psychiatric Exam: General Appearance: body odor and appears fatigued. Behavior: uncooperative, disruptive, guarded, does not make eye contact, attitude is disinterested, and shows impulsivity. Mood:dysphoric, depressed, anxious, and irritable. Affect: agitated, hostile, and labile. Thought Processes: shows loosening of associations and poverty of thought and attention wandered throughout interview, concentration impaired, and is tangential. Thought Content: delusions, obsessions, and hallucinations: both. Judgment: is impaired. Insight: is impaired. Neurological System: Orientation: o[TRUNCATED]

Based on observation and interview, the facility failed to ensure that all corridors were equipped with firmly secured handrails. Specifically, 3 handrails throughout the facility were found to be loose which created a resident safety hazard. Findings included: On 3/17/25 at 2:09 PM, an observation was made in the resident corridor of a handrail outside of room [ROOM NUMBER]. The handrail was not secured to the wall. On 3/20/25 at 4:09 PM, an observation was made in the resident corridor of the handrail between rooms [ROOM NUMBERS]. The handrail was not secured to the wall. On 3/20/25 at 4:10 PM, an observation was made in the resident corridor of the handrail between rooms [ROOM NUMBERS]. The handrail was not secured to the wall. On 3/31/25 at 10:13 AM, an interview was conducted with the Maintenance and Housekeeping Supervisor (MHS) who stated audits were conducted with housekeeping staff everyday. The MHS stated audits included inspecting handrails at least everyday. The handrail between rooms [ROOM NUMBERS] was inspected with the State Surveyor (SS). The MHS stated, Maybe this one could be a little more tight. The handrail between rooms [ROOM NUMBERS] was inspected with the SS. The MHS stated it was loose and needed to be more tight. The handrail between rooms [ROOM NUMBERS] was inspected with the SS. The MHS stated it needed to be tightened maybe a little bit. The MHS stated if he was unable to tighten the handrails he would have to replace them. The MHS stated he had not noticed the loose handrails on his daily audits.

3. On 3/17/25 02:57 PM, an observation was made of Certified Nurse Assistant (CNA) 5 passing afternoon snack to residents in the hallway. CNA 5 was observed to hand residents cookies bare handed. On 3/31/25 at 8:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should use tongs to plate the cookies and should hand sanitize between each resident. 2. Resident 58 was admitted to the facility on [DATE] with diagnoses that included sepsis, need for assistance with personal care, moderate protein-calorie malnutrition, personal history of traumatic brain injury, major depressive disorder, acute respiratory failure with hypoxia, tachycardia, cellulitis, and olecranon bursitis of the right elbow. On 3/17/25 at 10:42 AM, an interview was conducted with resident 58 who stated he had been on IV antibiotics for an extended period of time but was not taking oral antibiotics for his wound. Resident 58's medical record was reviewed between 3/17/25 and 3/31/26. A physician order, dated 3/17/25, indicated, Right elbow wound: WOUND VAC: Cleanse wound NS [normal saline] /wound cleanser, Apply skin prep to peri wound area, Apply 1 piece of wound vac sponge to wound bed. Apply wound vac drape to seal and secure dressing. Change dressing once weekly between visits and PRN [as needed] for accidental removal, saturation and/or soiling. Resident 58's Care Plan Focus, Potential for complications related to SEPSIS, CELLULITIS OF RIGHT UPPER LIMB. Interventions included, Administer antibiotics in accordance with physician orders. Monitor for and report any adverse side effects to MD. Date initiated: 10/18/24; Administer antipyretic medication as needed for fever > [Greater than]100.4 or per MD [Medical Doctor] orders. Date initiated: 10/18/24; Monitor for and report to MD s/s [signs and symptoms] of infection that are not resolving with current plan of care. In collaboration with MD, revise plan of care as indicated. Date initiated: 10/1/24; Monitor vital signs as indicated. Report abnormal vital signs to MD as needed. Date initiated: 10/1/24; Obtain labs as indicated. Report results to MD. Date initiated: 10/18/24; Offer and encourage fluids to maintain proper hydration status. Date initiated: 10/18/24; Staff shall utilize universal precautions before and after providing care. Date initiated: 10/18/24. On 3/25/25 at 1:30 PM, an observation was made of the doorway to resident 58's room. There was no posting for Enhanced Barrier Precautions related to resident 58's use of a wound vac. Based on observation, interview, and record review it was determined, for 2 of 43 sampled residents, that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, there was direct food contact with bare hands and 2 residents who had indwelling medical devices or wounds and did not have Enhanced Barrier Precautions (EBP) in place. Resident identifiers: 22 and 58. Findings included: 1. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure with hypoxia, hypertension, pneumonia, paroxysmal atrial fibrillation, chronic viral hepatitis C, chronic kidney disease, bladder-neck obstruction, and retention of urine. On 3/17/25 at 9:45 AM, resident 22 was observed in his room in bed with a foley catheter drainage bag hanging from his bed. Resident 22 stated he had had a foley catheter in place. There was no signage outside of his room which indicated he was on EBP. Resident 22's medical record was reviewed 3/17/25 through 3/31/25. A physician's order, dated 2/11/25 at 3:43 PM, indicated, (18F [French]/10cc [cubic centimeters])(Foley) catheter to down drain for dx [diagnosis] of (obstructive uropathy) r/t [related to] (Urine retention and bladder neck obstruction). May change PRN [as needed] if dislodged or clogged. The Care Plan Report had a Focus, The resident has an ADL [Activities of Daily Living] self-care performance and mobility deficit r/t recent infections, debility, cognitive deficits r/t metabolic encephalopathy, multiple chronic health conditions, use of multiple medical devices/lines including indwelling catheter r/t bladder outlet obstruction, incontinence of bowel . Date Initiated: 06/23/2021Revision on: 11/14/2023. It included the Intervention, CATHETER CARE: Nursing staff should provide catheter care per physician order and standards of best practice, including ensuring drainage bag is below level of bladder and tubing is not touching floor, cleaning tubing, emptying catheter drainage bag as needed, ensuring privacy cover is in place over catheter drainage bag, flushing/changing catheter or catheter bag per physician order and as needed. Date Initiated: 06/23/2021 Revision on: 06/23/2021. On 3/27/25 at 1:48 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 22 had a foley catheter since they started working at the facility. CNA 1 stated when they emptied the foley catheter bag or provided cleaning they would wear gloves and did not need to wear a gown. CNA 1 stated resident 22 was on precautions a month ago but not anymore. On 3/27/25 at 2:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 22 was not on contact or enhanced barrier precautions and that when they emptied the catheter bag they would wear gloves and no gown. RN 1 stated they had not heard of enhanced barrier precautions. On 3/31/25 at 11:17 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP should be implemented for anyone with an invasive device like a foley catheter.

Based on interview and record review it was determined, for 5 of 43 sampled residents, that the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, the State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. Specifically, an allegation of sexual abuse was not reported to the SSA, APS, or local law enforcement within 2 hours after the facility became aware of the allegation, an allegation of sexual abuse was not reported to the APS within 2 hours after the facility became aware of the allegation, and an injury sustained in the transportation van was not reported to the SSA and APS within 2 hours of the incident. Resident identifiers 23, 50, 112, 113, and 114. Findings included: 1. a. Resident 23 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, type 2 diabetes mellitus, right below the knee amputation, phantom limb syndrome, congestive heart failure, hypertension, viral hepatitis C, schizoaffective disorder, insomnia, anxiety disorder, and post-traumatic stress disorder (PTSD). 1. b. Resident 112 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, atrial fibrillation, schizoaffective disorder, insomnia, anxiety disorder, post-traumatic stress disorder, borderline personality disorder, and borderline intellectual functioning. Resident 112 was discharged from the facility on 2/5/25. On 9/28/24 at 11:15 AM, the facility reported to the State Survey Agency (SSA) that on 9/28/24 at 3:00 am, resident 23 reported that he woke up to resident 112 touching his private area and trying to put a finger in his rear end. The facility investigation, Form 358, documented that staff became aware of the incident on 9/28/24 at 5:51 AM and the Administrator (ADM) was notified on 9/28/24 at 9:18 AM. It should be noted that this was approximately 3.5 hrs after the staff first became aware of the incident. The facility investigation, Form 358, documented that the SSA was notified on 9/28/24 at 11:16 AM. It should be noted that this was over 5 hours after staff first became aware of the incident. The facility investigation, Form 358, documented that the local law enforcement was notified on 9/28/24 at 10:13 AM. It should be noted that this was over 4 hours after staff first became aware of the incident. The facility investigation, Form 358, documented that APS was notified on 9/28/24 at 11:15 AM. It should be noted that this was over 5 hours after staff first became aware of the incident. On 3/25/25 at 11:19 AM, an interview was conducted with the ADM. The ADM stated that he informed APS on 9/28/25 at 11:04 AM and the SSA on 9/28/24 at 11:16 AM. The ADM confirmed that staff were informed of the incident on 9/28/24 at 5:51 AM. The ADM stated that the timeframe for reporting to the SSA was 2 hours and it was not reported to him until after 9:00 AM. The ADM stated that staff should have reported it to him immediately and staff had been educated that allegations of abuse should be reported to him immediately. 2. a. Resident 113 was admitted to the facility on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, overactive bladder, hypertension, insomnia, repeated falls, and congestive heart failure. 2. b. Resident 114 was admitted to the facility on [DATE] with diagnoses which consisted of cerebral palsy, schizoaffective disorder bipolar type, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, catatonic disorder, suicidal ideations, and insomnia. The facility investigation, Form 358, documented on 07/14/23 at 7:33 PM, the facility reported to the SSA that on 07/14/23 at 6:30 pm, resident 113 and resident 114 had engaged in a sexual act in the bathroom with the door open. The facility investigation, Form 359, documented that APS was notified on 7/18/23, no time was documented. It should be noted that the notification was made 4 days after the facility staff became aware of the incident. The facility investigation, Form 359, documented that local law enforcement was notified on 7/18/23, no time was documented. It should be noted that the notification was made 4 days after the facility staff became aware of the incident. 3. Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. (38480) On 3/17/25 at 10:07 AM, an interview was conducted with resident 50 who stated that on 2/14/25 at approximately 9:30 AM, he was in his wheelchair in the facility van being transported to a medical appointment when he fell over backward and hit his head and neck on the floor of the van. Resident 50 stated he was upset because the incident report did not reflect the facts of what happened, he was not properly assessed until the day after the incident and did not receive an x-ray until the day after the incident. On 3/19/25, the State Survey Agency (SSA) received an entity 358 report for the incident that occurred on 2/14/25. On 3/20/25, an email confirmation correspondence was sent to the facility to confirm the date of the incident. On 3/19/25 at 2:26 PM, an interview was conducted with the Director of Nursing (DON) who stated they did not report the incident to the State Survey Agency (SSA). The DON stated he did not know why. The DON stated it did not seem like abuse or neglect. On 3/19/25 at 3:18 PM, an interview was conducted with the ADM who stated he did not think this would have been considered neglect. The ADM stated the state should be made aware so they know what was done to correct the situation, and how it could be prevented. The ADM stated they probably should have reported it. On 3/26/25 an exhibit 359 follow-up investigation report was received from the facility. The report stated other agencies were not notified at the time of the incident.

2. Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of end stage renal disease, arteriovenous fistula, hypertension, encephalopathy, and ascities. On 3/18/25 at 10:00 AM, an interview was conducted with resident 33. Resident 33 stated that he had a fistula in his left arm for dialysis access. Resident 33 stated that he went to dialysis 3 times a week on Monday, Wednesday and Friday. Resident 33 stated that staff did not use the arm with the fistula for blood pressure readings. Resident 33 stated that the nurse assessed the site. Resident 33 stated that he had no complications with the fistula, just bruising at the access site. Resident 33's medical records were reviewed. Resident 33's care plan revealed no focus areas specific to dialysis or interventions in the care, treatment, and monitoring of the arteriovenous fistula. On 3/25/25 at 8:36 AM, an interview was conducted with RN 4. RN 4 stated that she assessed resident 33's fistula every morning for a thrill. RN 4 stated that she obtained resident 33's vital signs in the morning and she documented them on the dialysis communication form that went with the resident to dialysis. RN 4 stated that the dialysis center filled out the form with the resident's weights and vital signs at the appointment. RN 4 stated that when resident 33 returned from dialysis she obtained another set of vital signs, assessed the fistula bandage for drainage, assessed the fistula for a bruit or thrill, reviewed the communication form and documented the assessment in a progress note and on the communication form. RN 4 stated that she would expect resident 33 to have a care plan for dialysis that had interventions specific to the care and monitoring of the fistula and monitoring of vital signs pre and post dialysis for any fluid overload or signs of too much fluid pulled off. On 3/25/25 at 8:47 AM, an interview was conducted with the DON and the MDS Coordinator. The DON stated that nursing managers were responsible for care plan development. The DON stated that resident 33 should have a care plan for dialysis. The MDS Coordinator confirmed that resident 33 did not have a care plan for dialysis. The MDS Coordinator stated that the care plan should have interventions for monitoring for signs and symptoms of complications with dialysis, monitoring lab work, assessing and monitoring of the fistula, and notification to the Medical Doctor of any abnormal assessments or lab values. The MDS Coordinator stated that the purpose of the care plan was for the licensed nursing staff to find the proper care and interventions for resident specific care. 3. Resident 58 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, muscle weakness protein-calorie malnutrition, major depressive disorder, respiratory failure with hypoxia, olecranon bursitis, right elbow and cellulitis of right upper limb. Resident 58's records were reviewed between 3/17/25 and 3/31/25. A review of resident 58's progress notes revealed: a. On 2/24/25 at 11:26 AM, Health Status Note: Note Text: MD notified of urine tox [toxicology] screen. Now new orders. b. On 2/25/25 at 12:01 PM, Health Status Note: Note Text: MD was notified of and reviewed the final drug screen. No new orders. c. 2/25/25 at 4:25 PM, Health Status Note: Note Text: [NAME] and BOM asked the resident to search his room as there were complaints about him having a TSH [sic] vape in his room. Resident was ok with DON and BOM to search his room. DON found a brand new TSH [sic] vape in his room and confiscated it. No other TSH [sic] or other illicit drugs found in his room. DON and BOM went over the drug and alcohol policy with resident again. The resident signed a new policy and consented to follow it. d. 2/27/25 at 6:03 PM, Health Status Note: Note Text: Resident had an unknown visitor drop by for under a minute they went out front on the patio and resident came back alone. e. 3/2/25 at 4:40 AM, Health Status Note: Note Text: CNA reported to the DON that they smell marijuana coming from the resident's room. Resident was OK with DON to search his room. DON found a brand new TSH [sic] vape hidden in his socks and confiscated it. No other TSH [sic] or other illicit drugs found in his room. f. 3/3/25 at 8:42 AM, Social Service/Resident Advocate Note: Note Text: RA [Resident Advocate] offered resident supportive services for his marijuana dependency-such as MA {Marijuana Anonymous] meetings and/or addiction Treatment centers. Resident has continually refused. RA will continue to offer supportive services. Resident 58's care plan revealed there were no care focus area addressing use of a THC vape device or use of other illicit drugs. There were no goals or interventions related to the use of a THC vape device or other use of illicit drugs. On 3/31/25 at 8:59 AM, an interview was conducted with the ADON who stated he thought there was something in resident 58's care plan but he did not know for sure. The ADON stated the staff were aware of the resident's history of substance abuse and go talk with him frequently. The ADON stated the resident usually handed over whatever he had. The ADON stated the resident was on probation and had gone to court. The ADON stated the administrative staff had talked about putting something in the resident's care plan about his use of drugs. The ADON stated they also talked about having the resident show a staff member everything he brought back when he went to the store. On 3/31/25 at 11:03 AM, an interview was conducted with the DON who stated he had confiscated THC (Tetrahydrocannabinol) vapes from the resident 2 times. The DON stated the resident signed a Drug and Alcohol policy care plan agreement and immediately broke it. The DON stated the resident was drug tested and the test came back positive. The DON stated the resident's use of drugs had the possibility to have an effect on other residents. The DON stated they had spoken to the resident about discharging. The DON stated they were planning on discharging the resident if they could find a safe place to discharge him to. The DON stated he had told the nurses to let him know if they suspected anything in the resident's possession. The DON stated the medical director was aware of what was going on with resident 58. The DON stated it made sense for there to be something in his care plan about it. Based on observation, interview, and record review it was determined, for 3 of 43 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident that received dialysis did not have a care plan, a resident that vaped THC (Tetrahydrocannabinol) did not have a care plan, and a resident with frequent falls did not have care plan interventions implemented. Resident identifiers: 1, 33, and 58. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, mild intellectual disabilities, traumatic brain injury, subdural hemorrhage, dementia with agitation, presbyopia, and sensorineural hearing loss. On 3/19/25 at 1:14 PM, an observation was made of resident 1 laying in his bed with the pressure alarm mat under the resident's bed, in a location that it would not be activated if resident 1 were to get out of bed. On 3/24/25 at 3:28 PM, an observation was made of resident 1 sitting in his wheelchair, self-propelling down the hallway wearing socks on his feet. On 3/27/25 at 2:21 PM, an observation was made of resident 1 sitting in his wheelchair in the hallway wearing socks on his feet. At 2:25 PM, resident 1 was observed standing up, approximately 4 feet from his wheelchair, and trying to open the front doors. Resident 1's wander guard was alarming. Staff was observed to be with the resident and asked him to sit down and that they would take him outside and resident 1 stated, Let me alone. Resident 1's medical record was reviewed from 3/17/25 through 3/31/25. An admission Minimum Data Set (MDS) Assessment, dated 1/25/25, indicated a Brief Interview for Mental Status (BIMS) score of 1. A BIMS score between a 0-7 indicated a severe cognitive impairment. It further indicated resident 1 was dependent on staff to: a. Put on socks and shoes or other footwear that was appropriate for safe mobility; b. Come to a standing position from sitting in a chair, wheelchair, or on the side of the bed; and c. To walk 10 feet. A Health Status Note, dated 2/1/25 at 5:50 PM, indicated, Alert charting r/t [related to] unwitnessed fall. Resident has been passing all neuro checks, vitals WNL [within normal limits]. ROM [range of motion] WNL in upper extremities. ROM weak in both legs. No c/o [complaints of] of pain or discomfort since resident got back in bed after fall. Resident transferred to toilet with SBA [stand-by assist] appropriately and is back resting in bed with call light in reach, WCTM [will continue to monitor]. An Alert Note, dated 2/1/25 at 7:29 PM, indicated, Resident is on alert charting due to unwitnessed fall. Resident has difficulty making needs known, and is non-compliant with bearing weight, and walking to use the bathroom. Staff is checking on patient frequently, changing briefs and offering to be toileted, which appears to be effective with keeping resident safe. MD [Medical Doctor] ordered bilateral x-rays of hips to ensure no fractures occurred from fall. Neuro checks have been wnl to baseline. An Alert Note, dated 2/2/25 at 7:16 PM, indicated, Alert charting r/t an unwitnessed fall. Resident has pain, and a hip Xray was completed. Results state 'no evidence of acute fx [fracture]' Resident took pain pill to help with pain. Resident is currently resting in bed. An Event Note Template, dated 2/7/25 at 11:42 AM, indicated, IDT [Interdisciplinary Team] Members: DON [Director of Nursing], NHA [Nursing Home Administrator], ADON [Assistant Director of Nursing], MDS coordinator, RA [Resident Advocate], BOM [Business Office Manager], CNA [Certified Nursing Assistant] coordinator,. Event Date/Time: 2/1/2025 @ 12:45. Event Description: The nurse heard a door slam in room [ROOM NUMBER]. When the nurse arrived to the room, the nurse found the resident on the floor between his bed and bathroom door. The resident was barefoot and did not use the call light for help. The resident is s/p [status post] Left hip fracture from a previous fall at his previous facility with Left hip surgery. He is WBAT [weight bearing as tolerated]. Risk Factors and Root Cause Identification: Resident has a diagnosis of dementia He lacks insight into his own limits and tries to do things independently without asking for help. The resident is S/P hip fracture and surgery. He is unsteady on his feet. The resident was bare foot and did not call for help. Preventative Measures in Place Prior to Incident: Resident has a working and reachable call light. He has been educated on using his call light and performed a return demonstration indicating he is able to use the call light. Facility staff anticipate resident's needs. Staff have been educated and encouraged to keep frequently used items within resident's reach. He has been working with PT/OT [physical therapy/occupational therapy] for strength and ROM improvement. New Interventions: Resident was assessed for injuries and none were found. The CNA and nursing helped resident back into chair then back into bed. VSs [vital signs stable] and neuro checks initiated and WNL. BP [blood pressure] 125/62, HR [heart rate] 93, RR [respiratory rate] 18 and Temp [temperature] 99.8. The resident is being monitored closely. Alert charting initiated. MD, DON and the administrator were notified. IDT Intervention: Ensure resident is wearing a Gerihip hip protector. Ensure resident is wearing proper footwear. Educated the resident to call for assistance for any transfer, Printed a sign and posted it in the resident room to remind him to call for assistance. In a Skilled Charting note, dated 2/7/25 at 9:16 PM, indicated, .Resident is weight bearing as tolerated, can walk to the bathroom independently but fell last night d/t wet floor. No injuries. Staff will make sure that floors are dry. WCTM. A Health Status Note, dated 2/10/25 at 10:15 AM, indicated, Alert charting for unwitnessed fall at 730A [sic] .Resident has not been compliant with assistance with transferring this shift . A Skilled Charting note, dated 2/10/25 at 1:37 AM, indicated, .Resident is weight bearing as tolerated and requires assistance to transfer to the bathroom safely. An Event Note Template, dated 2/17/25 at 2:15 PM, indicated, IDT Members: DON, NHA, ADON, and MDS coordinator. Event Date/Time: 2/7/25 @ around 05:39. Event Description: The Resident was trying to use the restroom with CNA present in the room but then he slipped and fell landing on his knees. There was urine spilled on the floor from one of his roommates. The CNA tried to intervene but [resident 1] fell down too fast that the CNA couldn't intervene. Resident had proper footwear on. Risk Factors and Root Cause Identification: Resident has a diagnosis of dementia He lacks insight into his own limits and tries to do things independently without asking for help. The resident is S/P hip fracture and surgery. He is unsteady on his feet. Wet floor and resident slipped and fell landing on his knees. Preventative Measures in Place Prior to Incident: Resident has a working and reachable call light. He has been educated on using his call light and performed a return demonstration indicating he is able to use the call light. Facility staff anticipate resident's needs. Staff have been educated and encouraged to keep frequently used items within resident's reach. He has been working with PT/OT for strength and ROM improvement. Ensure resident is wearing a Gerihip hip protector. Ensure resident is wearing proper footwear. Educated the resident to call for assistance for any transfer, Printed a sign and posted it in the resident room to remind him to call for assistance. New Interventions: Resident was assessed for injuries and no injuries found, then placed on the toilet so he could use the bathroom. Resident has no injuries, didn't hit his head, and no marks on the knees. ROM is at resident's baseline. MD was notified. Alert charting initiated, v/s are WNL: B/P 115/64, P [pulse] 83, RR 18, T [temperature] 98.0, O2 [oxygen] 95% on RA [room air]. 2/7/25 FALL - IDT intervention: Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: Floors free from spills and/or clutter; adequate, glare-free light. A Skilled Charting note, dated 2/21/25 at 8:44 PM, indicated, Resident is doing well. Walks to the bathroom on his own. Resident is resting in bed with eyes closed . An Event Note Template, dated 3/4/25 at 1:49 PM, indicated, IDT Members: DON, NHA, ADON, MDS coordinator, RA, BOM, CNA coordinator,. Event Date/Time: 2/23/2025 @ around 09:36. Event Description: Nurse found resident lying on his back on the bathroom floor between sink and toilet with no brief on and WC [wheelchair] to his left side. Floor was not wet. Resident did not have his non-skid socks on. Resident said he was trying to get to the toilet, lost his balance and fell hitting his head on the sink counter. Risk Factors and Root Cause Identification: Resident has a diagnosis of dementia He lacks insight into his own limits and tries to do things independently without asking for help. The resident is S/P hip fracture and surgery. He is unsteady on his feet. Resident mattress was flat on the edges and resident wasn't wearing proper footwear. Preventative Measures in Place Prior to Incident: Resident has a working and reachable call light. He has been educated on using his call light and performed a return demonstration indicating he is able to use the call light. Facility staff anticipate resident's needs. Staff have been educated and encouraged to keep frequently used items within resident's reach. He has been working with PT/OT for strength and ROM improvement. Ensure resident is wearing a Gerihip hip protector. Ensure resident is wearing proper footwear. Educated the resident to call for assistance for any transfer, Printed a sign and posted it in the resident room to remind him to call for assistance. New Interventions: Assessed resident for injuries. Small laceration to right top side of head. Abrasion to spine and right side of back. Resident is Responding at his baseline. No changes with ROMx4 [person, place, situation, and time] extremities. Initiated Neuro checks. PERRL [pupils equal, round, reactive to light], Vitals 98 T, 117/54 BP, 73 P, 18 R, O2 Sats 99% RA. Assisted resident onto the toilet, brief changed and assisted back to his bed. Alert charting initiated. MD, DON and NHA notified. Education provided verbally and in writing d/t [due to] HOH [hard of hearing] about using call light and keeping non-skid socks on. IDT intervention: Placed pressure alarm mat by his bedside. A care plan Focus indicated, The resident is at risk for falls r/t General weakness, Impaired mobility, left hip fracture. Date Initiated: 01/24/2025. The Goal indicated, The resident will be free of falls with injury through the review date. Date Initiated: 01/24/2025 Target Date: 05/14/2025. Interventions included: a. 2/1/2025 FALL - IDT Intervention: Ensure resident is wearing a Gerihip hip protector. Ensure resident is wearing proper footwear. Educated the resident to call for assistance for any transfer, Printed a sign and posted it in the resident room to remind him to call for assistance. Date Initiated: 02/03/2025 Revision on: 02/07/2025; b. 2/10/25: IDT Intervention: Ensure resident is wearing anti-skidding socks at all times and maintenance team will ensure mattress is functioning well. Date Initiated: 02/10/2025; c. 2/23/25 FALL - IDT intervention: Placed pressure alarm mat by his bedside. Date Initiated: 02/24/2025; d. 2/7/25 FALL - IDT intervention: Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: Floors free from spills and/or clutter; adequate, glare-free light. Date Initiated: 02/07/2025; and e. Educate and encourage the resident to wear appropriate footwear, such as nonskid socks or shoes, when ambulating/mobilizing. Date Initiated: 01/24/2025. On 3/27/25 at 1:48 PM, an interview was conducted with CNA 1. CNA 1 stated the pressure alarm pad was there in case resident 1 got up by himself and it would alert staff so they could immediately help him because he had an injury. CNA 1 stated resident 1 could walk with therapy and that he needed a 1-person assist to transfer. CNA 1 stated that he used his call light, but sometimes he forgot. CNA 1 stated resident 1 did not wear any protector on his hip. On 3/27/25 at 2:00 PM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated they had been working with resident 1 due to safety because of a fall and that he could not walk on his own and needed a contact guard, someone there just in case he fell. The DOR stated they communicated with him by using a whiteboard because he was so hard of hearing. The DOR stated resident 1 could understand instructions with routine. On 3/27/25 at 2:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated they were not sure if resident 1 wore a Gerihip hip protector, but he had a hip fracture. RN 1 stated they did not know what a Gerihip hip protector was or why one would be used. On 3/27/25 at 2:30 PM, an interview was conducted with CNA 2. CNA 2 stated that they helped resident 1 in the bathroom today and he was not wearing a hip protector. CNA 2 stated he was at a risk for falls and knew that he had a pad next to his bed that alarms when he tried to stand up but was not sure of any other interventions in place to prevent falls. On 3/27/25 at 2:30 PM, an interview was conducted with CNA 3. CNA 3 stated resident 1 had to wear nonskid socks and have his bed low to help prevent falls. CNA 3 stated they had to assist resident 1 with putting on nonskid socks or his cowboy boots. On 3/31/25 at 11:10 AM, an interview was conducted with the DON. The DON stated resident 1 was admitted to the facility because he got a hip fracture from a fall that happened at a different facility. The DON stated he implemented a Gerihip hip protector as an intervention after one of his recent falls. The DON stated that because resident 1 was noncompliant, the hip protector would provide extra support if he had another fall. The DON stated resident 1 sustained falls at the facility because he would not use the call light and get up on his own. The DON stated the resident could not remember to use the call light. The DON stated resident 1 was not wearing a Gerihip hip protector on 3/27/25 because it was in the laundry, so he ordered more and gave them to the staff to use. The DON stated the resident would also take the hip protector off and throw it on the floor and scratch and swear at staff.

3. Resident 49 was admitted to the facility on [DATE] with diagnoses which consisted of schizoaffective disorder bipolar type, fetal alcohol syndrome, post-traumatic stress disorder, opioid dependence, anxiety disorder, attention-deficit hyperactivity disorder (ADHD), and insomnia. Resident 49's medical records were reviewed. Resident 49's progress notes contained the following: a. On 3/9/25 at 5:18 AM, the Health Status Note documented, Incomplete Documentation - Note Text: [Resident 9's name omitted] went into room [ROOM NUMBER] last night to ask [resident 59's name omitted] for a cigarette but [resident 49] wheeled [resident 9's name omitted] out of the room [ROOM NUMBER]. [Resident 9's name omitted] got upset and started calling [resident 49] names. Despite this, [resident 49] continued to be nice to [resident 9's name omitted] and gave [resident 9's name omitted] a can of soda. [Resident 9's name omitted] accepted soda but didn't stop insulting [resident 49]. Then [resident 9's name omitted] decided to go to her room and [resident 49] followed her because now she felt like [resident 9's name omitted] doesn't deserve a can of soda and [resident 49] wanted it back. They started arguing, [resident 49] took her soda back and as she was leaving [resident 9's name omitted] room, [resident 9's name omitted] threw a mug full of ice and water at [resident 49]. It hit [resident 49] in the lower back. On assessment, [resident 49] had no visible injuries to any areas of her body r/t [related to] this incident. CNA [Certified Nurse Assistant] was in the room and witnessed everything. [Resident 9's name omitted] called 911 and police came and handled this situation. b. On 3/9/25 at 4:48 AM, the Health Status Note documented, Note Text: Alert charting r/t [related to] R:R [resident to resident] altercation. Resident had an argument with [Resident 9's name omitted] last night and [Resident 9's name omitted] threw her water mug at [resident 49] hitting her in the lower back. Tylenol was given for pain. On assessment no visible injuries to the back or any other areas of the body. Residents were separated and had no further contact with each other. WCTM [will continue to monitor]. On 3/31/25 at 9:35 AM, an interview was conducted with the DON. The DON stated that staff should not document another resident name in a different resident record or chart. The DON stated that staff should be using a room number or resident identifier but not the resident name in other resident's medical records. The DON stated that staff had been provided education on the documentation policy. 4. Resident 164 was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy, cirrhosis of the liver, nonalcoholic steatohepatitis, acute kidney failure, hepatorenal syndrome, and ascites. Resident 164's medical records were reviewed between 3/17/25 and 3/31/25. Upon reviewing resident 164's discharge documentation for 3/18/25, documentation was found for another resident who had discharged to another facility on that day. Based on observation, interview, and record review it was determined that, for 4 of 43 sampled residents, the facility failed to maintain medical records on each resident that were complete, accurately documented, and readily accessible and failed to protect resident-identifiable information from being released to the public. Specifically, one resident did not have a physician's rationale for an on-going use of a PRN (as needed) psychotropic medication located in the medical record and 3 residents had another resident's name or documents located in their medical records. Resident identifiers: 49, 59, 164, and 214. Findings included: 1. Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included post-traumatic stress disorder (PTSD), schizoaffective disorder bipolar type, generalized anxiety disorder (GAD), cognitive communication deficit, and frontal lobe and executive function deficit. Resident 59's medical record was reviewed 3/17/25 through 3/31/25. A physician's order, dated 2/24/25, indicated, clonazepam Oral Tablet 1 MG [milligram] (Clonazepam) *Controlled Drug* Give 1 mg by mouth every 24 hours as needed for GAD until 04/19/2025 23:59 [11:59 PM]. On 3/25/25 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated a PRN order of clonazepam should be ordered for 14 days initially and then could be extended to 90 days and that resident 59's PRN clonazepam order had been extended to 90 days. The DON stated that a rationale for the extension should be documented under documents in the medical record. No rationale for the extension was located in the medical record. On 3/25/25 at 3:38 PM, a follow-up interview was conducted with the DON. The DON provided the document, Physician Rationale for Clinically Contraindicated Gradual Dose Reduction, Duplicative Medication, or On-going use of PRN Psychotropic Medication, dated 1/9/25, and stated that it was not in the chart and that he had to dig through the shredder bin to find it. 2. Resident 214 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paranoid schizophrenia and psychoactive substance abuse. Resident 214's medical record was reviewed 3/17/25 through 3/31/25. Health Status Notes included resident 34's first and last name on 8/25/23 at 2:00 PM, 8/26/23 at 4:01 AM, and 8/27/23 at 4:19 AM. An Event Note Template, dated 9/6/23 at 4:43 PM, included resident 34's first name.

2. Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of type II diabetes mellitus, end stage renal disease, arteriovenous fistula, hypertension, encephalopathy, hidradenitis suppurativa, borderline personality disorder, major depressive disorder, anxiety disorder, and ascities. Resident 33's medical records were reviewed. On 8/15/23, resident 33's physician ordered routine labs for a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a hemoglobin A1c (HbA1c) every 6 months in February and August. The order was updated on 1/10/25. On 1/7/25, resident 33's physician ordered a respiratory panel due to exposure and signs and symptoms of influenza A. No documentation could be found in resident 33's medical records for the results of the respiratory panel that was ordered on 1/7/25 or the routine labs for the CBC, CMP, and HbA1c that was ordered for August 2024. On 3/25/25 at 7:43 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the lab results would be located with the dialysis communication form because resident 33 would not allow the facility to draw blood, and only allowed the dialysis center to obtain labs. On 3/25/25 at 9:35 AM, the ADON stated that he called the laboratory and they said they performed the respiratory panel on 1/7/25, but there was an error on the results. The ADON stated that he just received the respiratory panel today from the laboratory. On 3/25/25 at 2:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that he just obtained the laboratory results from the dialysis center for the August 2024 ordered CBC and CMP. 3. Resident 49 was admitted to the facility on [DATE] with diagnoses which consisted of schizoaffective disorder bipolar type, fetal alcohol syndrome, post-traumatic stress disorder, opioid dependence, anxiety disorder, attention-deficit hyperactivity disorder (ADHD), and insomnia. Resident 49's medical records were reviewed. On 1/7/25, resident 49's physician ordered a respiratory panel due to exposure and signs and symptoms of influenza A. No documentation could be found in resident 49's medical records for the results of the respiratory panel that was ordered on 1/7/25. On 3/18/25 at 2:46 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that laboratory staff obtained the samples for the routine lab orders on Tuesday and Thursday. RN 4 stated that the nurse would enter the lab into the requisition book under the ordered date. RN 4 stated that the results came back within 12 to 24 hours. RN 4 stated that the results would be uploaded into the resident's medical records and would be viewable under the results review tab. RN 4 stated that the results were also sent to the physician by the ADON and were viewable to the nurses on the communication app. On 3/18/25 at 3:05 PM, an interview was conducted with the ADON. The ADON stated the the physician ordered routine labs every 6 months for most residents. The ADON stated that the lab would draw the routine specimens on Tuesdays and Thursdays. The ADON stated that for any stat lab order the staff would draw and call the laboratory for a pickup. The ADON stated that results were back within a couple of hours for stat orders and for routine orders usually by the end of the day. The ADON stated that the results were faxed to the facility, but that the lab sometimes needed a call to remind them to fax the results. The ADON stated that he then forwarded the results to the physician or Nurse Practitioner. The ADON stated that he sent the results to the providers on the Whatsapp, and then he would upload the results into the resident's medical records. The ADON stated that resident 49's respiratory panel that was ordered on 1/7/25 was still in the fax cue and had not been uploaded to the resident's medical records. The ADON stated that he tried to have the records uploaded into the resident's medical records within a week. Based on interview and record review it was determined, for 3 of 43 sampled residents, that the facility did not file, in the resident's clinical record, laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, 3 residents did not have laboratory reports filed in their medical record. Resident identifiers: 33, 37, and 49. Findings included: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, congestive heart failure, thrombocytopenia, disorder of bilirubin metabolism, chronic kidney disease, hypertension, bipolar disorder, and generalized anxiety disorder. Resident 37's medical record was reviewed 3/17/25 through 3/31/25. A physician's order, dated 10/4/24 at 12:32 PM, indicated, Collect one time BMP [Basic Metabolic Panel] on 10/29/24 one time only . There were no laboratory results in resident 37's medical record. On 3/31/25 at 11:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 37's lab results from 10/29/24 were not in his medical chart and were accidentally uploaded to another resident's chart.

Based on interview and record review it was determined for 1 of 43 sampled residents that the facility did not promote and facilitate the resident right to self-determination through support of the resident choice. Specifically, a resident who was assessed as not requiring supervision with smoking was not allowed access to the secured outside smoking patio after 9:00 PM unless it was at the supervised smoking times of 11:00 PM or 3:00 AM. Resident identifier 33. Findings included: Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type II diabetes mellitus, end stage renal disease, arteriovenous fistula, hypertension, encephalopathy, hidradenitis suppurativa, borderline personality disorder, major depressive disorder, anxiety disorder, and ascities. On 3/18/25 at 10:43 AM, an interview was conducted with resident 33. Resident 33 stated that he would like to sit outside on the smoking patio at night but he was told by staff that he had to be inside the facility by 9:00 PM. Resident 33 stated that he was treated like a child and could not leave when he wanted. On 1/10/25 and 3/24/25, resident 33's smoking evaluation documented that the resident was safe to smoke without supervision. On 3/27/25 at 11:01 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the back interior door locked automatically at 9:00 PM and opened again at 6:00 AM daily. The ADON stated that the policy was that residents were supposed to go outside at the supervised smoking times at night even if they were independent with smoking. The ADON stated that was the policy at night because otherwise it would be too much for the staff to let residents in and out when they wanted. The ADON stated that the supervised smoking times at night were 11:00 PM and 3:00 AM. The ADON stated that resident 33 was a supervised smoker due to breaking the smoking policy. It should be noted that the resident assessment for smoking documented that the resident was safe to smoke without supervision. The ADON stated that the policy was after 9:00 PM residents needed to wait for the designated supervised smoking times to exit to the back smoking patio. The ADON stated that during the daytime residents were free to come and go as they wanted. The ADON stated that once the door locked at night if residents were outside alone the staff would not know when they wanted to be let back inside the building. On 3/27/25 at 11:34 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the smoking patio doors locked at night after a certain time and then smoking times were at designated supervised times. The ADM stated that those residents who were assessed as safe to smoke independently could go out when they pleased. The ADM stated that his expectation was that staff unlock the door for those residents that were able to smoke independently. The ADM stated that there was no way for residents to alert staff other than knocking on the back door, and the back patio door did not have a doorbell.

Based on observation and interview, it was determined that, for 1 of 43 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, a resident had a brown substance on the wall next to the toilet for the entire length of the survey. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes, osteomyelitis, and diarrhea. On 3/17/25 at 10:07 AM, resident 50 stated there was fecal matter on the wall next to the toilet that had been there since he was admitted . The State Surveyor (SS) observed the area in the resident's bathroom and found there was a brown substance on the wall near the toilet next to the toilet paper dispenser and below the dispenser. On 3/27/25 at 11:15 AM, an observation was made in resident 50's bathroom. The brown substance that was observed on the wall previously was seen on the wall in the same place. On 3/31/25 at 10:10 AM, an observation was made in resident 50's bathroom. The brown substance that was observed on the wall previously was seen on the wall in the same place. On 3/31/25 at 10:12 AM, an interview was conducted with Housekeeper (HK) 1 who stated she cleaned the bathrooms every day which included the sink, the toilet, the toilet lid, the mirror, the floor, and the wall. On 3/31/25 at 10:19 AM, an interview was conducted with HK 2 who stated she cleaned the toilets, sinks, mirrors and floors. HK 2 stated if needed she would clean the walls. HK 2 was shown the area on resident 50's bathroom wall. HK 2 stated she did not notice it and would clean it right away. On 3/31/25 at 10:23 AM, an interview was conducted with the Maintenance and Housekeeping Supervisor (MHS) who stated he monitored the housekeeping staff every day. The MHS stated he did not receive consistent complaints and if he received a complaint he would get it addressed quickly. The MHS stated he had a maintenance log where staff or residents could let him know of a maintenance issue so he could have it repaired or addressed quickly. The MHS stated residents or staff were also able to catch him in the a hallway and let him know if they had a problem that needed to be fixed and he would make sure it was fixed. The MHS was taken in to resident 50's bathroom to show him where the brown substance had been on the wall. The brown substance had been partially cleaned off of the wall, but there was still some brown particles on the wall. The MHS stated he would have it cleaned right away.

Based on interview and record review it was determined, for 1 of 43 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically, resident had routine orders for a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a hemoglobin A1c (HbA1c) every 6 months in February and August that were not completed. Resident identifier: 33. Findings included: Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of type II diabetes mellitus, end stage renal disease, arteriovenous fistula, hypertension, encephalopathy, hidradenitis suppurativa, borderline personality disorder, major depressive disorder, anxiety disorder, and ascities. Resident 33's medical records were reviewed. On 8/15/23, resident 33's physician ordered routine labs for a CBC, a CMP, and a HbA1c every 6 months in February and August. The order was updated on 1/10/25. No documentation could be found in resident 33's medical records for the results of the routine labs for the CBC, CMP, and HbA1c that was ordered for August 2024 and February 2025. On 3/25/25 at 2:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that he just obtained the laboratory results from the dialysis center for the August 2024 ordered CBC and CMP. The DON stated that the order did not contain a HbA1c result. On 3/26/25 at 1:32 PM, a follow-up interview was conducted with the DON. The DON stated that resident 33 had a HbA1c test completed by the dialysis center every 3 months in January 2025, October 2024, July 2024 and April 2024. The DON stated that the dialysis center was obtaining lab orders from their Nurse Practitioner and were not following the facility's physician orders. The DON stated that he was not sure if the facility's physician was able to view the labs from the dialysis center and confirmed that the lab results were not located in resident 33's medical records.

Based on observation, interview, and record review it was determined that, for 1 of 43 sampled residents, the facility failed to provide each resident with food prepared in a form designed to meet individual needs. Specifically, 1 resident received a modified diet that was not approved by the physician. Resident identifier: 5. Findings included: On 3/18/25 at 12:08 PM, an observation was made of resident 5 sitting in his wheelchair eating in the dining room. Resident 5's plate contained Lo Mein, chicken, and vegetables that were chopped into very small pieces. Resident 5 was observed to have no teeth and he stated that he could not remember the last time that he had teeth. Resident 5 was observed to finish his lunch and self-propel himself out of the dining room with a full fortune cookie in his lap. Resident 5 stated he would be fine eating the fortune cookie. On 3/18/25 at 1:44 PM, an observation was made of resident 5 in the dining room doing an activity that included French fries. Resident 5 was observed to eat whole French fries. Resident 5's medical record was reviewed 3/17/25 through 3/31/25. A Quarterly Minimum Data Set (MDS) Assessment, dated 1/3/25, indicated a Brief Interview for Mental Status (BIMS) score of 8. A BIMS score of 8-12 indicated moderate cognitive impairment. It further indicated resident 5 had a loss of liquids/solids from mouth when he ate or drank, held food in his mouth/cheeks or had residual food in his mouth after meals, and had complaints of difficulty or pain when he swallowed. A physician's order, dated 12/18/24 at 2:21 PM, indicated, Large portions diet Soft & Bite Sized SB6 texture, Regular consistency. A Nutrition/Dietary Note, dated 2/28/25 at 12:43 PM, indicated, Resident informed DM [Dietary Manager] he is having trouble chewing his food because the chunks are too large. SLP [Speech-Language Pathologist] notified. I will downgrade him on Nutrition Management to MM5 [Minced and Moist] until SLP can evaluate him. A meal ticket, dated 3/17/25, indicated, Diet Order: Minced & Moist MM5, Large Portions, Thin liquids Notes: Resident may have chips, crackers, and breads at regular texture, sandwich fillings minced and moist. On 3/18/25 at 2:33 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 5's diet was chopped but she did not know why. CNA 1 stated resident 5 had no teeth or dentures. On 3/18/25 at 2:36 PM, an interview was conducted with CNA 4. CNA 4 stated he did not know what diet resident 5 was on but he could know by looking at the meal ticket or the care plan. On 3/18/25 at 2:47 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that resident 5 was on a soft and bite-sized diet and he was saying that he was having trouble chewing these big chunks of food. The DM stated they had been serving resident 5 a minced and moist diet since 2/28/25 and that she also messaged the clinical team and the SLP that day. The DM stated she did not know if the SLP had seen resident 5 yet. The DM stated the Director of Nursing (DON) can change the diet order on the medical chart and she could update the tray card. In a follow-up interview at 3:14 PM, the DM stated a minced and moist diet was a lot more specific from the size and softening requirements than the soft and bite-sized diet. The DM pointed to an IDDSI (International Dysphagia Diet Standardization Initiative) document that was posted on the inside of the kitchen door and stated the minced and moist was smaller than the soft and bite-sized diet and had to be moistened. On 3/18/25 at 3:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated he was notified by the DM on 2/28/25 on the messaging application and that he should have followed up on it and that the SLP had not evaluated the resident yet. The text message was shown to said surveyor and it indicated, [Resident 5] just told me he's having trouble eating because he 'doesn't have no teeth' I'm going to downgrade him to MM5 [minced and moist] from SBS [soft and bite-sized] until Speech therapy can evaluate him. The DON stated that any downgrade had to be approved by the provider and the SLP would have to evaluate the resident. The DON stated the DM could change the meal card to match what the physician order was.

Based on observation, interview, and record review, it was determined for 1 of 26 sampled residents that the facility did not provide the necessary assistance to ensure each resident maintained or improved their ability to perform activities of daily living, including eating. Specifically, a resident with swallowing issues was not provided one-to-one assistance while eating as ordered by the physician. Resident identifier: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included non-displaced fracture of head of left radius, dysphagia, epilepsy, schizoaffective disorder, and diabetes mellitus type 2. On 6/13/23 at 12:26 PM, an observation was made of resident 10. Resident 10 was observed to be taking multiple spoonful's of his mechanical soft meal and eating it without one-on-one staff assistance. Resident 10 was observed to be using a spoon to feed himself. The Director of Nursing (DON) was observed to be in the dining room assisting other residents with various needs. At 12:33 PM, an observation of the DON approaching resident 10 and asked if resident 10 was finished with his meal. It was observed resident 10 did not answer but proceeded to take another bite of food. The DON sat with resident 10 and was assisting resident 10 with his meal. At 12:36 PM an observation was made when the DON left the table of resident 10. The DON went into the kitchen and left the dining room area. Resident 10 was observed to take a spoonful of his meal and place it in his mouth. At 12:38 PM the DON was observed to return to the dining room and sat next to resident 10 and was observed to provide one-on-one assistance. Resident 10's medical record was reviewed 6/12/23 through 6/15/23. A quarterly Minimum Data Set, dated dated dated [DATE] indicated resident 10 required one-person extensive assistance with eating. Resident 10's Care Plan initiated on 6/2/23 and revised on 6/13/23 indicated resident was at risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages related to oropharyngeal dysphagia. It further indicated resident 10's interventions included aspiration precautions compensatory strategies with small bites or sips at a slow rate, one-to-one feeding assistance to monitor for alertness at meals and to ensure residue was cleared from mouth between bites, and to monitor for overt and clinical signs and symptoms of aspiration. A Speech Therapy Pathology (SLP) Evaluation and Plan of Treatment document dated 5/31/23 indicated that additional intake recommendations included functional maintenance one-to-one assist with all feedings. A review of resident 10's physician's orders dated 6/11/23 indicated SLP recommendations one-to-one assistance and check resident's oral cavity for oral residue prior to initiating another bite. On 6/13/23 at 12:47 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 10 was unable to eat without staff supervision because resident 10 stuffed his mouth with food and he could choke. On 6/14/23 at 12:45 PM, a telephone interview was conducted with the Speech-Language Pathologist (SLP). The SLP stated resident 10 had a Modified Barium Swallow Study (MBSS) completed when he was in the hospital a few weeks ago. The SLP stated the MBSS revealed that resident 10's swallow was very weak and resident 10 was at risk for aspiration. The SLP stated resident 10 readmitted with orders for pureed with thickened liquids. The SLP stated she evaluated resident 10 two days ago and he was pocketing a lot of food in his mouth while eating. The SLP stated resident 10 was not eating so she upgraded his diet and ordered for staff to supervise resident one-to-one when eating. The SLP stated staff needed to cue resident 10 to take small bites and clear his mouth when eating. The SLP stated if resident 10 was not supervised there was a concern he would aspirate. The SLP stated resident 10 needed to be supervised one-on-one at all times when he was eating. On 6/14/23 at 2:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 10 needed one-to-one assistance to eat because he pocketed food in his mouth and staff needed to be with resident 10 to check their mouth between bites.

Based on observation and interview it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, food was not covered when transported through the hallways. Findings include: On 6/12/23 at 12:40 PM, an observation was made of the meal trays. The meal trays were delivered to the hallway from the kitchen. The meal cart was observed to be covered. At 12:48 PM, an observation was made of the Certified Nursing Assistant (CNA) Coordinator. The CNA Coordinator was observed to remove a meal tray from the meal cart outside room [ROOM NUMBER] and the tray was transported through the hallway to 118 with the dessert uncovered. There were residents observed in the hallway. The CNA Coordinator was observed to remove a meal tray from the meal cart outside room [ROOM NUMBER] to room [ROOM NUMBER] with dessert uncovered. The CNA Coordinator was observed to remove a tray from the meal cart outside room [ROOM NUMBER] and was transported through the hallway to room [ROOM NUMBER] with the dessert uncovered. On 6/12/23 at 12:54 PM, an observation was made of CNA 1. CNA 1 was observed to be transported uncovered dessert from the kitchen to room [ROOM NUMBER] through the hallway past residents. 43212 On 6/15/23 at 10:32 AM, an interview was conducted with the Dietary Manager (DM). The DM stated anytime food left the kitchen it should be covered. The DM stated plates and drinks should be covered. The DM stated silverware should be wrapped in plastic. The DM stated when the cart went out to the hallway, it had a plastic covering over the whole cart. The DM stated the tickets on the cart were in order of how they should be taken off of the cart as the cart moved down the hallway. The DM stated CNA's were educated about how to pass trays by herself and the Director of Nursing (DON). The DM stated that the CNA coordinator helped to deliver training to the CNA's so everything is done to standard and the CNA's are held accountable.

Based on interview and observation, the facility did not provide a safe, clean, comfortable and homelike environment to residents. Specifically, resident wheelchairs and walkers were dirty and furniture was in disrepair. The facility shower room was not clean. Findings include: On 9/29/21 at 3:26 PM an interview was conducted with the facility Maintenance Manager (MM). The MM stated a maintenance log was kept at the nurse's station for staff to report items in need of repair. The MM stated that he performed an environmental audit and a housekeeping audit daily both inside and outside. The MM stated Certified Nursing Assistants (CNA's) were responsible for cleaning wheelchairs. The MM stated the wheelchair cleaning schedule was located at the nurse's station. The MM stated the CNA's alerted him when they became aware of repairs that needed to be fixed throughout the facility. The MM stated he checked every room every day and if he missed something the CNA's should have reported broken furniture so it could be fixed. On 9/29/21 at 3:41 PM an observation was made of the facility shower room. Multiple paint patches were observed on the walls. The grouting in the shower area had brown spots in multiple areas. An interview was conducted with the MM. He stated the shower is sprayed with disinfectant between each shower. The MM also stated the shower room would be getting a remodel soon. On 9/30/21 at 8:37 AM an observation was made of a resident wheelchair in room 121. The arm rests of the chair were unclean with crumbs and dried liquid. On 9/30/21 at 8:43 an observation was made in room 116. A bedside chair had a rip down the middle that was several inches long. On 9/30/21 at 8:50 AM an observation was made of resident 28 walking with her walker in the hallway. The seat of the walker was covered with grayish debris. On 9/30/21 at 9:05 AM an interview was conducted with CNA 3. CNA 3 stated a wheelchair cleaning schedule was kept at the nurse's station. CNA 3 stated the night shift had a rotation they used to clean wheelchairs, or they would clean them as needed if they became dirty between cleanings. CNA 3 stated a maintenance log was kept at the nurse's station. CNA 3 stated if a CNA noticed something was in disrepair they would write it on the maintenance log for the maintenance manager to fix. CNA 3 stated bed sheets were changed on the resident's shower day, or more frequently if needed. On 9/30/21 at 9:10 AM an observation was made of the wheelchair cleaning schedule at the nurse's station. 1-2 rooms were listed for each of the night CNA's for each day of the week. All resident rooms in the facility were listed. On 9/30/21 at 9:10 AM, an observation was made of the maintenance log at the nurse's station. There was one item on the list dated 9/30/21. Two old sheets were in the binder from April 2021 and June 2021. An interview with the MM was conducted regarding where he kept the completed maintenance sheets. The MM stated he sent them to the corporate office when the items were completed and kept them in a folder in his office. The MM provided copies of his September 2021 maintenance logs. On 9/30/21 the facility maintenance logs were reviewed. There was no documentation found that the chair in room 116 had been reported as being in need of repair or replacement. On 9/27/21 at 10:00 AM, an observation was made of resident 15's room. Resident 15 had a large brown spot with splatter around it on his bed. Resident 15 stated that he had changed his [CONDITION(S)] bag and it spilled on his bed. Resident 15 was observed to have brown splatter substance on his shirt. Resident 15 stated the brown substance had been there since early that morning. An additional observation was made at 10:31 AM, staff were observed to enter residents room with linens. On 9/30/21 at 10:12 AM, an observation was made of resident 39. Resident 39 was outside in an electric wheelchair. Resident 39's wheelchair was observed to be soiled on the part above the engine and around the seat. On 9/27/21 at 10:36 AM, an observation was made of the bathroom between rooms 118 and 119. The bathroom floor was sticky and dirty.

Based on interview and record review it was determined, for 2 of 42 sample residents, that the facility did not conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, not less than once every 12 months. Specifically, resident Annual Minimum Data Set (MDS) assessments were not completed. Resident identifiers: 23, 30 Findings include: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 23's medical record was reviewed on 9/29/21. Resident 23's MDS assessments were reviewed and revealed a 2021 Annual MDS was completed 9/28/21. Further review revealed the 2021 Annual MDS had a required completion date of 8/17/21 2. Resident 30 was admitted to the facility on [DATE] which diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's medical record was reviewed on 9/29/21. Resident 30's MDS assessments were reviewed and revealed a 2021 Annual MDS was completed 9/28/21. Further review revealed the 2021 Annual MDS had a required completion date of 7/16/21. On 9/29/21 at 3:29 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that he had been the coordinator since July 2021. The MDS coordinator stated that shortly after starting he went on vacation and then go COVID-19. The MDS coordinator stated he was out for about 3 weeks. The MDS coordinator stated the facility was behind when he started. The MDS coordinator stated he was planning to catch up in the next 2 to 3 weeks.

Based on observation, interview, and record review it was determined, for 10 of 42 sampled residents, that the facility did not assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. Specifically, 11 residents did not receive timely Quarterly Review Assessments. Resident identifiers: 4, 12, 15, 18, 19, 20, 22, 24 31, and 44. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4's medical record was reviewed on 9/29/21. Resident 4's Minimum Data Set (MDS) quarterly assessment was due on 8/1/21. The medical record showed the quarterly assessment was in progress and 44 days overdue 2. Resident 12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 12's medical record was reviewed on 9/29/21. Resident 12's MDS quarterly assessment was due on 8/13/21. The medical record showed the quarterly assessment was in progress and 32 days overdue 3. Resident 18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 18's medical record was reviewed on 9/29/21. Resident 18's MDS quarterly assessment was due on 8/17/21. The medical record showed the quarterly assessment was in progress and 28 days overdue 4. Resident 19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 19's medical record was reviewed on 9/29/21. Resident 19's MDS quarterly assessment was due on 8/19/21. The medical record showed the quarterly assessment was in progress and 26 days overdue 5. Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 20's medical record was reviewed on 9/29/21. Resident 20's MDS quarterly assessment was due on 8/19/21. The medical record showed the quarterly assessment was in progress and 26 days overdue 6. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22's medical record was reviewed on 9/29/21. Resident 22's MDS quarterly assessment was due on 8/20/21. The medical record showed the quarterly assessment was in progress and 25 days overdue 7. Resident 31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31's medical record was reviewed on 9/29/21. Resident 31's MDS quarterly assessment was due on 7/23/21. The medical record showed the quarterly assessment was in progress and 53 days overdue. 8. Resident 15 was admitted to the facility 3/28/19 and readmitted to the facility on [DATE] [CONDITION(S)], abnormalities of gait and mobility, [CONDITION(S)] disorder, chronic pain syndrome, [CONDITION(S)] [CONDITION(S)], sympathetic uveitis, muscle weakness. Resident 15's medical record was reviewed on 9/29/21. Resident 15 had a quarterly MDS completed on 5/25/21. A quarterly MDS dated [DATE] was in progress and not completed. 9. Resident 44 was admitted to the facility 12/26/19 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 44's medical record was reviewed on 9/29/21. Resident 44 had a quarterly MDS completed on 6/9/21. A quarterly MDS dated [DATE] was in progress and not completed. 10. Resident 24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 24's medical record was reviewed on 9/29/21. Resident 24 had a quarterly MDS completed on 5/22/21. A quarterly MDS dated [DATE] was in progress but not completed. On 9/29/21 at 3:29 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that he had been the coordinator since July 2021. The MDS coordinator stated that shortly after starting he went on vacation and then go COVID-19. The MDS coordinator stated he was out for about 3 weeks. The MDS coordinator stated the facility was behind when he started. The MDS coordinator stated he was planning to catch up in the next 2 to 3 weeks.

Based on interview and record review, it was determined for 1 of 6 sampled residents, the facility did not provide sufficient preparation and orientation prior to a facility initiated discharge. Specifically, Resident 1 expressed she was not assisted with discharge planning and was not prepared when, on 10/17/19 the facility provided her a notice of discharge and then carried out the facility initiated discharge within a seven hour time to an extended stay hotel. Resident 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/17/19, at approximately 11:30 AM, the facility provided Resident 1 a Notice of Discharge with the expressed reason, The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Per documentation on the Notice of Discharge, the effective date of the discharge was 10/17/19 and the resident was being discharged to a hotel. On 10/17/19 at approximately 6:00 PM, the facility carried out Resident 1's discharge and the resident was transported by facility staff to a hotel. Resident 1 was discharged despite the evaluation and determination of the State Mental Health Authority. On 9/21/19, and based upon a comprehensive evaluation, Resident 1 was provided a Letter of Determination from the State Mental Health Authority. The Letter of Determination included, The purpose of this letter is to inform you of the results of your Preadmission Screening Resident Review (PASRR) evaluation. You have been approved for Nursing Facility Services. The State PASRR Office has determined that as long as your medical condition requires services you are approved for Long Term Care. Cross-Refer F622. On 10/30/19 at 2:00 PM and again on 11/7/19 at 9:21 AM, telephone interviews were held with Resident 1. Resident 1 was asked to describe the discharge process she experienced at the nursing facility. Resident 1 replied, It was not good. This information was out of the blue. Resident 1 stated she was not prepared for the discharge, stating she did not have a home or anywhere else to go. Resident 1stated she called the ombudsman and the ombudsman called the facility and told them not to discharge me. Resident 1 stated that at the time of her discharge, the facility was going to pay for 30 days at the extended stay hotel. However, on 11/1/19 at 9:30 PM, the hotel main office called and told her they had her personal belongings and told her she was supposed to be out by 10/31/19 and that she owed money for staying 11/1/19. Resident 1 stated the hotel staff told her she would have to pay for her stay on 11/1/19 in order to get her belongings back. Resident 1 stated that because of the ombudsman's help the facility did finally provide her a $50 dollar gift card, some food, and bus pass the day prior to the interview on 10/30/19. However, Resident 1 stated, the bus pass would not work until 11/1/19. At the time of the interview on 11/7/19, Resident 1 stated she was couch surfing. She stated she was trying to avoid going to the shelter because she did not want a relapse of her prior drug addiction. Resident 1 stated, The shelters aren't a good place for people with a history like mine. Resident 1 was asked how she was getting food. She stated, I reached out to the church, the relief society lady helped. I just walked into a church Sunday and asked for help. Resident 1 stated they set up a time to take me to the food warehouse the next day, Monday. Resident 1 stated she went to a state agency and completed an application for food stamps and hoped to be receiving food stamps soon. Resident 1 was asked about the training or education she received prior to her discharge from the nursing facility. Resident 1 stated there was no preparation or a discharge plan. Resident 1 stated she was a mess. She stated, I was given pain meds for five days; [MEDICATION NAME] and oxy ([MEDICATION NAME]). Resident 1 stated she did not get any of the over-the-counter medications she had been using; [MEDICATION NAME]es and Tylenol. Resident 1 stated that after her discharge, I called (name of attending physician at nursing facility) but she told me I'm no longer her patient so she can't help me. Resident 1 stated she had an appointment the next week at (name of medical clinic associated with the homeless shelter). Resident 1 stated the facility discharged her on a Thursday night, which meant she needed to line up all her appointments on Friday because no place would be open on the weekends. Resident 1 stated the medical clinic was booked out three weeks so she was not able to get her pain medications refilled. She stated she went without pain medications for approximately three weeks, stating she went through withdrawals, she was hurting and that she missed her physical therapy because her pain was so bad. During the interview on 11/7/19, Resident 1 expressed that her pain level at the time of the interview was 7 on a scale of 1 to 10. She stated a level of 3 or 4 was acceptable to her. She stated she had constant pain in her back and a collapsed spine that put pressure on her nerve causing pain to go down to her hip and leg. Note: On a pain scale of 1 through 10, the higher the number reflects a higher level of pain. Resident 1 was asked to describe how she had been getting along since her discharge from the nursing facility. She stated, I'm constantly bawling and worrying about what I'm going to do. I just want to bury my head and say to hell with it. The anxiety is awful. Depression is awful. The fact that I've been able to keep doing what I've been doing is an 'Atta-boy' to me. I'm proud of myself, but this should have never happened. On 11/7/19 at 11:14 AM, an interview was held with the facility Administrator. When asked how the facility determined Resident 1 was prepared for her discharge, the administrator responded, Everything is in the paperwork we provided you. Everything is there that we did. I don't have any additional info (information) besides what's in the paperwork we gave you. As far as why she was discharged so urgently, you'd have to talk to (name of Corporate Resource Nurse (CRN)). (Name of CRN) was the one who mandated that decision, to discharge that night. I didn't really have a choice. At the time, we felt like she was safe and she had enough resources. When asked how the facility prepared her for discharge, the Administrator stated, (CRN) took care of most of that part. We gave her the 55 plus book (55+ Senior Resource Directory), we got her groceries, we got her a $50 gift card, we offered to take her grocery shopping and get a bus pass but she declined both. Initially we paid for 3 days but then upped it to the end of the month, or the 31st (October). On 10/30/19 at 11:02 AM the CRN was interviewed. When asked about resident 1's discharge, the CRN stated, Her health improved, there was no reason to do the whole 30 day notice. She was fully functional and capable; she didn't need to be here any longer. When asked why resident 1 discharged so quickly she stated, It's a case by case basis. With (resident 1) she didn't need to be here any longer so she could leave the same day. She specifically said she did not want appeal. She signed the discharge form and we gave you a copy. On 11/7/19 at 11:02 AM the Resident Advocate was interviewed. The RA stated that after informing Resident 1 she was being discharged , the resident was very upset. The RA stated the Administrator, Director of Nursing and CRN, took over Resident 1's discharge because the RA had to leave early that day. A review of Resident 1's Discharge Summary, dated 10/17/19 was completed. The Discharge Summary included the following: a. Discharge arrangements for follow-up care: She (Resident 1) has been provided the community resource guide, has a reservation at an extended stay hotel, been provided a supply of groceries and a UTA bus pass. b. Describe any post-discharge medical or non-medical services that are needed: (Name of Resident 1) demonstrated the ability to manager her medications. Previous PCP (primary care physician) was physician at (name of medical clinic associated with the homeless shelter). Educated (Name of Resident 1) to re-establish services at (name of medical clinic associated with the homeless shelter). Provided resources to establish housing, food stamps, general assistance etc in community. c. Provide information, including date, time, location and provider for any follow-up appointments that are scheduled post-discharge: 11/20/19 (at) 9 AM: (Name and phone number of clinic). d. Resident 1's medications included the following for pain management: i. [MEDICATION NAME] tablet, 975 miligram (mg) every eight hours as needed; ii. Ibuprophen 800 mg every eight hours as needed; iii. [MEDICATION NAME] 4% every morning; iv. [MEDICATION NAME] 200 mg three times a day; v. [MEDICATION NAME] 5 mg every four hours as need; A review of Resident 1's Medication Administration Record [REDACTED]. Per the MAR, Resident 1 received the following medications on an, As Needed, basis for pain control. a. [MEDICATION NAME] 5mg: Received 63 times. Resident 1 rated her pain equal to or greater than 6 on 31 occasions. b. [MEDICATION NAME] 975mg: Received 5 times. Resident 1 rated her pain equal to or greater than 6 on 3 occasions. c. Ibuprophen 800 mg: Received 19 times. Resident 1 rated her pain equal to or greater than 6 on 12 occasions. On 10/17/2019 at 6:29 PM, the CRN documented the following Discharge Progress Note for Resident 1: . Discharge teaching/instructions completed during discharge/transfer process: Resident was educated about the reason for discharge by administrator, DON (Director of Nursing) and RNC (Resource Nurse Consultant, also referred to as CRN). She expressed understanding and signed the discharge/transfer notice. She declined to have a copy and declined to appeal the notice. She was educated on her medication regimen by ADON (Assistant Director of Nursing) and was able to return demonstrate the ability to manage her medications. Medication instructions were written in layman's terms. The information on the discharge summary was reviewed with her by ADON and she expressed understanding. She expressed understanding on how to use the public transportation system, expressed understanding on how to restart her community Medicaid services such as food stamps and general assistance, and expressed understanding that she needs to see a PCP (primary care provider) within 10-14 days of discharge from the facility. She indicated she planned to be seen by a doctor at the (name of medical clinic associated with the homeless shelter). She was encouraged to bring a copy of the discharge summary and medication list to that appointment and to have the clinic PCP contact the facility with any questions about her stay. Resident was discharged with a community resource guide, discharge summary and medication list. She expressed understanding about the information provided to her .The facility is unable to send the discharge summary to a PCP at this time as resident indicates she plans to establish PCP services at the (name of medical clinic associated with the homeless shelter) after discharge. However, resident was sent with the discharge summary and was encouraged to bring the discharge summary with her to the appointment with her PCP. On 10/17/19 at 5:17 PM, the following Health Status Note was documented in Resident 1's medical record: Dr. (Name of the facility's Medical Director and Resident 1's attending physician) was notified of resident's discharge and approves sending resident with all medications.

Based on interviews and record review, it was determined the facility did not ensure 1 of 6 sample residents was permitted to remain in the facility. Specifically, the facility provided a notice of discharge to resident 1 and carried out the facility initiated discharge within a seven hour time frame despite a Preadmission Screening and Resident Review level II recommendation for continued nursing care facility placement and after receiving verbal notice from the ombudsman that the decision to discharge would be appealed. Resident 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/17/19, prior to 12:00 PM, the facility provided resident 1 a notice of discharge and by 6:00 PM the facility initiated discharge was carried out. On 10/30/19 at 2:00 PM and again on 11/7/19 at 9:21 AM, telephone interviews were held with Resident 1. Resident 1 was asked to describe her discharge experience. Resident 1 stated that at about 11:45 AM, (Name of the Resident Advocate (RA)) came to my room and said, 'We need to talk. I've got bad news. I need to discharge you. You need to leave today.' Per Resident 1, the RA had been told by the Corporate Resource Nurse (CRN) that Resident 1 was functioning too well to be in a skilled nursing facility and had to leave. Resident 1 stated the RA had been informed by the CRN that Medicaid was not going to pay for the resident's stay any longer. Resident 1 stated that upon receiving the news she was being discharged that day, she was a mess! She stated she contacted the State's employment and public assistance agency as well as the local mental health agency, Just trying to figure out what I was going to do. Resident 1 stated she also called the local Ombudsman to inform her she was being discharged . Resident 1 stated she expressed her concerns and was informed the facility was going to put her in a hotel. Resident 1 stated at around 6:00 PM, the Central Supply Manager came to her and told her she would give her a ride to the hotel. Resident 1 stated that on the day of her discharge, the CRN handed her some papers and told her, This isn't a discharge form, just a med (medication) review. Resident 1 stated the CRN tried to get her to sign some papers. Resident 1 stated she became upset and said she did not want to sign the papers and told her that she could not make her sign them. Resident 1 stated the CRN replied, Well, actually we can. Resident 1 stated the CRN continued by asking her what the resident would do differently if the facility had provided more notice. Resident 1 was asked to describe her current status. Resident 1 stated, I'm constantly bawling and worrying about what I'm going to do. I just want to bury my head and say to hell with it. The anxiety is awful. Depression is awful. Resident 1 stated she was, currently couch surfing. She stated she was trying to avoid going to the shelter because she did not want to have a relapse with drug addiction. Resident 1 stated, The shelters aren't a good place for people with a history like mine. On 11/7/19 at 11:02 AM, the RA was interviewed. The RA was asked about her involvement with resident discharges. The RA replied, I take care of the entire discharge process, but I don't handle care plans. That's more of a nursing function. When asked to describe Resident 1's discharge the RA stated, I told (name of Resident 1) that morning (day of discharge) that Medicaid was not going to pay any longer. The RA further stated Resident 1 was very upset when she was informed she was being discharged . The RA stated Resident 1 was typically super happy. The RA stated she had to leave work after she informed Resident 1 about the discharge and that the Administrator, Director of Nursing (DON) and CRN took over with the discharge. On 11/7/19 at 12:05 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated, I was her (Resident 1's) nurse that day, I was notified by (name of CRN) that (name of resident 1) was being discharged . The ADON stated the CRN told him to start the discharge process, which would include calling the doctor, reviewing her medications, and getting her medications ready. The ADON stated he went over Resident 1's medication schedule with the resident and how long she needed to keep taking the medications. The ADON state he went over this two or three times. The ADON stated Resident 1 verbalized an understanding of what her medications were, including how and when to take them. When asked how Resident 1 was planning to refill her pain medication, the ADON replied resident 1 was informed of the facility's recommendation that she get and see a primary care physician within seven to fourteen days to get her pain medications refilled. The ADON was asked what further role he played in Resident 1's discharge. The ADON replied that he only did the vital signs and explained that was the reason his name was on the discharge summary form. The ADON stated that except for the resident's vital signs and his signature, the CRN filled out the discharge summary. On 11/7/19 at 12:44 PM, the Director of Nursing (DON) was interviewed. The DON was asked to describe Resident 1's discharge from the facility. The DON stated she received an email informing her Resident 1 was being discharged . The DON stated the CRN was at the facility that day and that the CRN ended up taking the lead on Resident 1's discharge. The DON stated her involvement was very minimal. The DON stated she was in the room when Resident 1 was informed she was being discharged . The DON stated Resident 1 was informed about her need to follow up with her primary care physician and how she needed to make appointments. The DON stated Resident 1 was informed about a free transport company that could take her to her appointments. The DON explained that she thought the company offered free transportation, but that they ask for a donation. The DON stated Resident 1 was informed about the appeal process and offered the resident a chance to appeal her discharge, but Resident 1 refused. The DON explained Resident 1 was offered the opportunity to remain in the facility while she appealed the discharge but that Resident 1 refused. The DON stated Resident 1 completely understood her right to appeal and that she could remain in the facility until an appeal decision was made. The DON was asked for details regarding Resident 1's discharge planning. The DON stated that prior to the resident's discharge on 10/17/19, Resident 1 was hoping for approval for a Medicaid waiver that would allow her to live in the community. The DON stated, the facility had discussed an option of talking to family about staying with them temporarily. However, the DON stated Resident 1 said she could not stay with any of them. The DON explained the plan was to get her on the Medicaid waiver program, but the facility knew that without any income, Resident 1 would not be approved. The DON stated there had been talk of other plans, but stated the RA would have more information regarding any other discharge plans for Resident 1. The DON stated the RA completes the discharge care planning. Note: During an interview with the RA, the RA stated the DON completes the care planning. When asked why Resident 1 was discharged so quickly, the DON replied, Like I said, I wasn't involved in all that but what I was told was she had improvement and she didn't need to stay here any longer. The DON added, Plus she declined to stay while we discharged her. The DON stated Resident 1was doing very well and did not need to be at the facility any longer. The DON stated she felt like Resident 1's discharge was safe and orderly and that before she left, we asked Resident 1if she had any concerns. The DON stated Resident 1 said she felt like she had everything she needed and that Resident 1 felt comfortable with the discharge. The DON stated she did not know why Resident 1 was discharged so fast, but reiterated that she did not lead the discharge, explaining the CRN lead the discharge. On 10/30/19 at 11:02 AM, the Corporate Resource Nurse (CRN) was interviewed. When asked about resident 1's discharge, the CRN stated, Her health improved, there was no reason to do the whole 30 day notice. The CRN stated Resident 1was fully functional and capable and that she did not need to be at the facility any longer. When asked why Resident 1 was discharged so quickly, the CRN responded, It's a case by case basis. With (name of Resident 1) she didn't need to be here any longer so she could leave the same day. The CRN added, She (Resident 1) specifically said she did not want appeal. She signed the discharge form. On 11/7/19 at 11:14 AM the facility Administrator was interviewed. The Administrator stated, (Name of Resident 1) had gotten a LTC (long term care) determination from PASRR (Pre-Admission Screening/Resident Review); however, a representative of the State Medicaid Agency informed the facility that (resident 1) no longer qualified for long term care and Medicaid was not going to pay. The Administrator stated Resident 1 was informed she could stay and appeal at three different times but that the resident declined each time. The Administrator stated Resident 1 said the appeal would take too much time and effort. The Administrator acknowledged he had received a telephone call from the local ombudsman who had informed him that the ombudsman was going to work with Resident 1 to appeal the discharge, but continued to proceed with the discharge. On 10/31/19 at 2:00 PM, a telephone interview was conducted with a manager within the State Medicaid Agency. This manager oversees the preadmission and continued admissions of Medicaid eligible residents residing in Medicaid certified nursing homes. The manager stated Resident 1 was approved for nursing care facility placement on 9/6/19 and that the resident was not due for review until (MONTH) of 2019. The manager stated that had the State Medicaid Agency determined the resident no longer met eligibility requirements for Medicaid to pay for Resident 1's nursing facility placement, the facility and resident would have received a notice of denial and that payment would continue for 30 days from the date of the denial notice. The manager stated no notice of denial was issued for Resident 1. On 10/30/19 at 9:21 AM, a telephone interview was conducted with the local ombudsman providing advocacy for residents residing in the facility. The ombudsman stated on Thursday, 10/31/19, she received a call from Resident 1 and that Resident 1 told her Medicaid would no longer cover her stay at the nursing facility so the facility was kicking her out. The ombudsman stated the facility informed Resident 1 and carried out the discharge on the same day. The ombudsman stated she instructed Resident 1 not to sign anything. The ombudsman stated she contacted the facility Administrator by telephone on 10/17/19 at 5:00 PM and told the Administrator not to kick Resident 1 out and that on Resident 1's behalf, she was going to appeal the discharge. The ombudsman stated she received a telephone call the next day from Resident 1 saying the facility made her sign a form, which Resident 1 thought was a discharge notice. The ombudsman stated the form was allegedly to waive the resident's right to appeal. The ombudsman stated she called the Administrator and he informed her the resident had signed a form indicating she did not wish to appeal the discharge. The ombudsman stated she did not believe the resident understand what she was signing and that the Administrator, DON and CRN misrepresented the document that Resident 1 signed. A review of Resident 1's medical record was completed and included the following: a. Health Status Note, dated,10/17/2019 at 7:16 PM: The CRN documented, Corporate BOM (business office manager) notified facility staff that (name of State Medicaid Agency representative) at (name of State Medicaid Agency) declined to reopen resident's 10A (Preadmission/Continued Stay Inpatient Care Transmittal) based on the re-assessment by PASRR (Pre-Admission Screening/Resident Review) evaluator with a long term care determination. Resident did not demonstrate a medical need to justify ongoing services in a skilled nursing facility. RA will notify resident of this determination by (Name of State Medicaid Agency) and initiate discharge planning if resident does not want to remain in the facility under private pay. b. Social Service/Resident Advocate Note, dated, 10/17/2019 at 1:32 PM: The RA documented, RA went and spoke w/pt (with patient) in regards to discharging facility today. Pt (patient) was informed she will be going to (name of local hotel). The facility has covered 3 days. RA has given a copy of the 55 plus booklet for other resources. Pt has been given a copy of all of her upcoming appointments. c. Preadmission Screening Resident Review (PASRR) Level II, assessment start date 9/20/19: The PASRR evaluator, a Licensed Clinical Social Worker (LCSW) documented the following assessment of Resident 1: Section 2: Medical Justification & Intensity of Services Needed In Nursing Facility .(Resident 1) was referred for an end of stay PASRR evaluation as pt continues to need SNF (skilled nursing facility) level of nursing care. Pt reported that SNF staff has been taking her to her appointments at (name of acute care hospital), and without their help she does not feel she would be able to make it to these appointments. Pt reported that, when she was homeless, follow up with these types of appointments was basically impossible for her. She reports that she has been applying for and seeking out other housing options, but as this process can take time, she has not heard anything back yet. Pt reported she is grateful for the medical supervision and care she has been given from all the SNF staff. Pt could benefit from continued SNF level of nursing care, medical management, and support in ensuring ongoing compliance with her medical needs and compliance with follow up with her providers at (name of acute care hospital) to avoid rehospitalization and decompensation in regards to pt's chronic and severe back problems. Section 3: Mental Health Symptoms/Substance Abuse Summary; Current Pyschiatric Functioning: . Pt endorses significant anxiety and depression, and reports she is doing all she can to avoid relapse on heroin. She feels that the rehabilitation and structure of the SNF setting will help to stabilize her medical condition and will help her cope with her excessive anxiety/worry and poor mood. Pt is homeless but is trying to find housing, and is working with case managers to help her in this process. Section 15: PASRR Level II Nursing Facility Levels of Care: Due to diagnosed medical conditions, the Applicant/Resident requires at least substantial physical assistance with activities of daily living about the level of verbal promptings, supervising, or setting up; . The medical condition and intensity of services indicate that the care needs of the Applicant/Resident cannot be safely met in a less structured setting or without the services and support of an alternative Medicaid health care delivery program (Justification is provided that less structured alternatives have been explored and why alternatives are not feasible). d. PASSR Letter of Determination, dated 9/21/19: The purpose of this letter is to inform you of the results of your Preadmission Screening Resident Review (PASRR) evaluation. You have been approved for Nursing Facility Services. The State PASRR Office has determined that as long as your medical condition requires services you are approved for Long Term Care. e. physician progress notes [REDACTED]. at Millcreek Care Center. Her condition has improved. Staff report that she no longer requires assistance with ADLs (activities of daily living). She no longer has any medical conditions that would preclude her living independently. She was admitted following treatment for [REDACTED]. This has resolved. She does not have impairment of cognition that would preclude her living independently. (Name of Resident 1) no longer requires skilled nursing care. Note: This note was entered one day after Resident 1 had been discharged . f. Notice of Discharge/Transfer, dated 10/17/19: The Administrator, DON, and social worker each signed the notice. The reason identified for the facility initiated discharge was, The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. The effective date of the discharge was identified as 10/17/19. The notice further documents, .30 day notice is not being given because: The resident's health is improved sufficiently to allow a more immediate transfer or discharge. You are being discharged to the following location: (name of hotel). g. Discharge Progress Note, dated 10/17/19 at 6:29 PM: . Resident had reported that her brother would come to transport her and her belongings at time of discharge. This plan fell through, so the facility provided transportation to the resident to the (name of hotel). Resident was educated about the reason for discharge by administrator, DON, and RNC (Resource Nurse Consultant, also identified as CRN). She expressed understanding and signed the discharge/transfer notice. She declined to have a copy and declined to appeal the notice. h. Health Status Note, dated 10/17/19 at 7:17 PM, (Name of attending physician) was notified of resident's discharge and approves sending resident with all medications. i. Health Status Note, dated 10/17/19 at 7:48 PM, Medical Records director transported resident to the (name of hotel). Resident declined to have assistance in securing groceries or a UTA (Utah Transit Authority) transportation pass.

Based on observation, interview and record review, it was determined for 14 of 45 sample residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, residents who were cognitively impaired were allowed to leave the facility Against Medical Advice with multiple residents who had eloped from the facility without staff knowing they were missing. One resident who had multiple falls with a resulting subarachnoid hematoma and a pelvic fracture within 6 days of each other and multiple observations of her bed not found in a low position nor to have the fall mat consistently in place. Multiple residents were observed smoking without staff supervision with [MEDICAL CONDITION] clothing, residents were smoking in rooms and with oxygen in place and insulin needles were found in resident rooms. Resident identifiers: 5, 9, 17, 21, 24, 25, 29, 37, 40, 41, 51, 102, 103 and 104. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 5/8/19 at 12:46 PM. On 5/10/19, the facility Administrator provided the following written allegation of removal of the immediate jeopardy: Please find attached our Plan of Correction for the immediate jeopardy of F689 given on (MONTH) 8, 2019 to Millcreek Rehab and Nursing. Please consider this plan of correction our credible allegation of abatement and removal of the immediate jeopardy status for F689 bringing us into compliance as of 3:00 PM on (MONTH) 10, 2019. IJ Abatement Plan For Millcreek May 9, 2019 Identified Resident #1 no longer resides in the community; therefore, an individualized plan of correction is not indicated. Identified Resident #2 was reassessed for Elopement/Wander Risk. The plan of care has been updated to reflect Resident #2 current status. Implemented a Resident Identification Form. Identified Resident #3 no longer residents in the community; therefore, an individualized plan of correction is not indicated. The community implemented a new Wander/Elopement Risk Evaluation. All other residents were immediately re-assessed to determine their elopement / wander risk. Any Resident determined to be at risk will have a person centered plan of care developed to determine how to minimize the risk of elopements to occur. If the IDT team determines a Wanderguard is necessary, the community will complete an assessment, obtain consent and order, and implement a plan of care to include the wanderguard as an intervention. The community will implement an At Risk for Elopement Binder which will include a photograph of the Resident as well as other identifiers. This binder will be kept at the nursing station for quick reference for staff to use in the event of an Elopement. The community reassessed all residents who expressed desire to have Residents Pass Privileges to determine who would be safe in the community on Independent Passes (IP) or who would require Supervised Pass (SP) Privileges. If a Resident is determined to have IP privileges, a physician order [REDACTED]. informed of this. If a Resident is determined to require SP privileges, a physician order [REDACTED].>obtained an (sic) a plan of care will be initiated and the Resident will be informed of this. The community implemented a Resident Sign In and Out Book that will be utilized for when Residents leave the community out on pass. If a Resident verbalizes a desire to leave the community Against Medical Device (AMA), prior to Resident leaving the community AMA the community will initiate the following procedures: 1. The Resident Advocate and/or licensed nursing staff will discuss alternatives to leaving the facility against medical advice, including but not limited to less-restrictive environments, other nursing facilities, home health care, board and care homes, living with family or friends, hospitalization , etc. 2. If a resident is adamant about leaving the facility, his/her primary physician will be notified. Whenever possible, the physician should participate in communicating the medical risks the resident will assume if he/she leaves the facility. 3. If the resident leaves the facility against medical advice, the licensed nurse will obtain an order from the resident's physician for the resident to be discharged against medical advice. 4. If the resident leaves the facility against medical advice, he/she cannot take instructions or medications with them, as they are not leaving with the consent of either the facility or the primary physician. a. The physician may override this policy by ordering AMA with medications. This must be a written order by the physician or a telephone order received by a licensed nurse. 5. If the resident leaves the facility against medical advice, the Resident Advocate, or a charge nurse if Resident Advocate is not in the building, will contact Adult Protective Services and inform them that the resident left AMA. They will be informed of any pertinent information related to the resident's medical or mental health care needs and potential risks for leaving the facility AMA. 6. If the resident is involved with any mental health services, the appropriate agency should be notified of the resident's discharge from the facility against medical advice. 7. The Resident Advocate or licensed nurse will ensure the resident receives community resource information e.g. food bank, community mental health center if appropriate, Senior Center, etc. in addition to The State Ombudsman name and telephone number prior to the resident leaving the facility. 8. All of the above information will be documented in the medical record by the Resident Advocate and/or licensed nurse as appropriate. If a Resident requests to leave the community Against Medical Advice (AMA), the community will complete an AMA Discharge Checklist and follow the procedures in the AMA Policy and Procedure. This will include minimally the following steps: ¿ - Notification to the Ombudsman, APS, Police, Physician and Resident Representative if applicable ¿ - Arrange for Home Health Services, if physician gives order ¿ - Assist with Home and Community Based Medicaid Application ¿ - Food Resources - Meal on Wheels or Food Bank ¿ - Motel Resources ¿ - 55+ Senior Resource Directory The DON or designee completed new smoking assessments for all residents who wish to smoke to determine the level of supervision required for smoking as well as any safety concerns. The community will revise the plan of care to reflect their current status. Administrator has scheduled a staff member to supervise the front entrance of the facility to ensure that all residents who go through the door are permitted to be entering an unsupervised area while staff and residents are educated regarding facility smoking, elopement and LOA policies. Administrator has designated separate smoking areas for residents who require supervision (back patio) with smoking and residents who may smoke independently. The community has cameras in the front lobby and front/back of the community for additional monitoring of Residents whereabouts. The Consultants will provide training and education with the Medical Director, IDT Team and community staff on the following areas: ¿ - Expectations for community rounds - minimally every two hours to know whereabouts of Residents residing in the community. ¿ - Elopement Policy and Procedure ¿ - Pass (LOA) Policy and Procedure ¿ - AMA Policy and Procedure / AMA Discharge Checklist ¿ - Discharge Policy and Procedure - specifically related to steps to take if discharge is an unsafe discharge from the community. ¿ - Smoking Policy and Procedure On 5/13/19, The State Agency reviewed the immediate plan of correction for removal of the immediate jeopardy for accident hazards/elopements and confirmed the abatement of the Immediate Jeopardy situation as of 5/10/19 at 3:00 PM Findings include: 1. Resident 102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/19 resident 102's medical record was reviewed. Nursing progress notes revealed the following entries: a. 4/25/2019 at 07:45 AM, Nurse Practioner (sic) Note Text: Recertification visit. Progressive dementia and [MEDICAL CONDITION]. Had been consistently refusing meds (medications) so after numerous attempts and explanations of risks of not taking medication, all his meds have been stopped. Blood pressures reviewed, stable. Wt (weight) up a few pounds during recert (recertification) period. Smokes, no cessation desired. Male resident at bedside, friendly now, smiles, engages easily. Conjunctiva clear neg (negative) injection neck supple rrr (regular rate and rhythm) s1s2 (normal heart tones) lungs clear unlabored ab (abdomen) snt (soft, non tender) calves sNT uses all 4 extremities. A/p (assessment/plan) Intermittent explosive behavior: track behaviors dementia in diseases specified elsewhere with behavior disturbance: track [MEDICAL CONDITION](hypertension): not taking meds screened for tobacco use: no cessation desired. b. 4/26/2019 at 11:00 AM, Social Service/Resident Advocate Note Late Entry: Note Text: Pt (patient) came and spoke with SS (social services) in regards to wanting to d/c (discharge). SS offered to help pt start applying for NCW (Waiver Program). Pt refused. Stated he wanted to d/c now. SS offered to set up home health or send pt to a hotel and pt continued to refuse. SS went over AMA (against medical advice) form w (with)/ pt. SS explained the risks of going AMA and how the facility, house MD (Medical Doctor) and his family did not approve of him leaving. Pt was adamant on leaving. SS offered to give him the 55 select book w/ all resources on how to get food, home health, etc. Patient still refused. Administrator and DON (Director of Nursing) tried speaking w/ pt but he grew angry. Pt became verbal w/ staff and was refusing to speak w/ his family on the phone. Business office manager cut him his check. CNA's (Certified Nursing Assistants) attempted to help pt pack up his room, but refused for anyone to touch his belongings. SS attempted one more time w/ activities and transportation present to stay. Pt continued to refused and stated he just wanted his Damn Money Pt received all of his belongings, refused to take his medications w/ him and was sent w/ his check. SS explained to family how pt is his own guardian and he has a right to leave. Pt left on a bus around 1530-1600 (3:30 PM-4:00 PM). c. 4/26/2019 at 15:20 (3:20 PM), Health Status Note Note Text: (Resident 102) has chosen to discharge to the community AMA. He had already packed his belongings and was ready to leave the facility. He refused to allow an assessment by a nurse, refused to allow any education, refused the 55+ reference guide. Prior to (Resident 102) leaving the facility, DON, Administrator and RA (Resident Advocate) spoke with his niece and nephew. They called and attempted to talk him into staying at the facility without success. They expressed understanding that resident has the right to self-determination, even when his choices aren't safe and requested that facility contact them with any changes. Resident stated he had all of his belongings and that he was going to the bus stop. Staff assisted him safely to the bus stop. MD notified of AMA discharge. The Annual Minimum Data Set (MDS) assessment dated [DATE] Section C (Cognitive Patterns) revealed that resident 102 was coded as 4 on his BIMS (Brief Interview for Mental Status). (NOTE: A BIMS score for mental status is coded between 0, meaning severely cognitively impaired to 15 meaning no cognitive impairment.) According to the coding of 4 for resident 102, resident 102 had severely impaired cognition. The Quarterly MDS assessment dated [DATE] Section C revealed that resident 102 was coded as 3 or severely impaired cognition. Thee Quarterly MDS assessment dated [DATE] Section C Question C0100 Should brief interview for mental status be conducted? The answer was coded No, (resident is rarely/never understood). A psychiatric hospital history and physical for resident 102 dated 9/9/17 revealed got angry at female staff and another CNA who reported that he was swinging a broom handle and swinging his fists at staff, mental issues more concerning than criminal issues with assault, otherwise has had aggressive (sic) behaviors according to SNF (skilled nursing facility) staff as a baseline, poor cognition, h/o (history of) paranoid delusional thoughts when asked a sreies (sic) of questions about why he is in a SNF, he could only say that 'I couldn't make it on my own - apartment, finances' smells of urine and feces, yet denies incontinence. physician's orders [REDACTED]. A Care Conference Summary Form dated 4/5/19 revealed (Resident 102's) niece is looking for a discharge at the end of the year. She would like him to discharge to her home. SS will follow up with a discharge plan. The Care Conference Summary Form further revealed that resident 102 does not have a desire to attend activities, his niece wants activities to purchase some things for him to do. She is emailing (Activity Director) a list. A care plan dated 10/21/17 and revised 8/24/18 revealed that resident 102 had a problem area of Verbally aggressive or abusive at times. The goal for resident 102 was will express self without becoming aggressive or abusive. One intervention for resident 102 was take resident for a walk, do something active to use up energy and decrease resident's anxiety. No documentation could be located in resident 102's medical record to show that a discharge care plan for resident 102 was in the works nor how the discharge was to be carried out, that the facility tried to arrange for resident 102 to get to the niece's home in Philadelphia as discussed in the care conference dated 4/5/19, that the facility Ombudsman had been notified of resident 102's AMA, that the Adult Protective Services office had been notified of resident 102's AMA nor that the police had been notified by facility staff. On 4/30/19 at approximately 3:30 PM, a telephone interview was conducted with resident 102's sister who lived in Philadelphia. Resident 102's sister stated that she had called in a complaint because she had been notified by resident 102's niece this morning that resident 102 was missing. Resident 102's sister stated that resident 102 had Alzheimer's or dementia and could not care for himself. Resident 102's sister stated that she was extremely worried about resident 102. On 5/1/19 at approximately 11:30 AM, an telephone interview was conducted with resident 102's niece. Resident 102's niece stated that she had been informed of resident 102 going AMA on 4/26/19 and that she did not call police until 4/27/19 because she thought that was protocol and that resident 102 had to be missing for 24 hours before calling police. Resident 102's niece stated that she was extremely worried about resident 102 because he was unable to care for himself. On 5/1/19 at 12:04 PM, an interview was conducted with the facility Business Office Manager (BOM). The facility BOM stated that he had talked with the facility Administrator and told him that since resident 102 was so upset that they should just cut him his check and let him leave the facility. The facility BOM stated that the facility Administrator agreed with him and they cut resident 102 a check for $1, 456.45 and closed his trust account. On 5/1/19 at 3:00 PM an interview was conducted with the facility RA. The facility RA stated that she had talked with resident 102 on the day he left AMA. The facility RA stated that resident 102 had told her I want to leave, I want to leave now. The facility RA stated that she told him that they could apply for the new choices waiver and called his niece. The facility RA stated that she told resident 102, your niece is on the phone and he said an expletive and I want my crap and I want to leave. The facility RA stated that she told resident 102 You are your own POA (Power of Attorney). You can make that decision. The facility RA stated that they went over the AMA forms and that resident 102 understood the choice he was making, we filled out the form and he packed his stuff from his room. The facility RA stated that about an hour later he said he wanted his money so I referred him to the (business office manager). We gave him his check because it's more secure than cash. The facility RA stated that after they had called resident 102's niece, resident 102's uncle had called back. The facility RA stated that she had resident 102 come to her office to talk with them and he started screaming. The facility RA stated that he was very verbal and looked like he was going to hit (Name of Administrator). The facility RA stated that she told resident 102's family that they could not hold him against his will. The facility RA stated that she tried to get him some resources (Waiver Program) and that he refused the 55 select book. The facility RA stated that the Business Office Manager (BOM) tried to get him to come back in the facility but resident 102 would not. The facility RA stated that they have a high psych population and the residents get combative, aggressive and go off but they can make their own decisions. The facility RA was asked if there was a protocol to look at the resident's [DIAGNOSES REDACTED]. The facility RA stated that there were no recommendations made by resident 102's physician to her, but she was unaware if there were any recommendations made by resident 102's physician to any of the nursing staff. The facility RA stated that police were notified the day after resident 102 left by resident 102's niece and that the police had found resident 102 and brought him back to the facility. The facility RA stated that the police were informed that resident 102 did not want to be here and that he had left AMA and was no longer a resident at the facility. The facility RA stated that she was not aware whether or not the police had been informed of resident 102's severe and progressive dementia. The facility RA stated that they had heard from resident 102's sister and that she was upset because he was allowed to leave the facility. The facility RA stated that she had not heard from anyone else regarding resident 102's whereabouts and did not know where resident 102 was. The facility RA refused to answer whether or not she was worried about resident 102 and declined to answer further questions. On 5/1/19 at 3:30 PM, an interview was conducted with the facility Director of Nursing (DON) and the facility Administrator. The facility DON stated that on the day that resident 102 left, he decided he was leaving the facility AMA. The facility DON stated that for hours people tried to distract him and then called family and he did not want to talk with them. The facility DON stated that she asked resident 102 where he was going and he said downtown, across from the temple. When asked if he was going to a hotel, the facility Administrator stated he said Third South, then across the street from the temple. The facility Administrator stated that he didn't have an address he didn't know the name of the place. The facility Administrator stated that they did not have a contact for where he was going. The facility Administrator stated that they let him leave because he was threatening. It looked like he was going to hit me. The facility Administrator stated that resident 102 had an aggressive stance and was close to my face. The facility Administrator stated that he kept saying give me my money and get me out of here and let me go. When asked if the police were notified, the facility DON stated we don't notify the police when residents are leaving AMA. The facility DON stated that they had notified the family and that the facility staff had walked with him to make sure he was getting to the bus stop safely. When asked when a resident discharges AMA from the facility, if there was a protocol in place that would be taken into account based on a resident's cognitive status and BIMS, the facility DON stated that she was aware that resident 102 had dementia but that he had a history of [REDACTED]. When asked if he was paranoid, yelling and getting aggressive or combative, why they did not call the police, the facility DON stated, I get what you're saying. The facility DON and facility Administrator stated that they were aware that there had been inclement weather after resident 102 left the facility but stated that they had done everything we could to ensure resident 102's safety. The facility DON and facility Administrator stated that they were not notified immediately when resident 102 came back to the facility via the police on 4/27/19. The facility DON and facility Administrator stated that of course resident 102 would have been welcomed back and that they were not aware that other facility staff had told the police that resident 102 had left the facility AMA and that he was no longer a resident at the facility nor that the police had been told that resident 102 could not stay. On 5/7/19 at 1:57 PM, an interview was conducted with the facility CNA Coordinator. The facility CNA Coordinator stated that she was not working the day that resident 102 left the facility. The CNA Coordinator stated that resident 102 required assistance with his ADL's (Activities of Daily Living). The CNA Coordinator stated that resident 102 was incontinent at night only, and that he would tell the aides that he made a mistake after wetting the bed. The facility CNA Coordinator stated that resident 102's niece who lived in Philadelphia called and notified the police that resident 102 was missing on 4/27/19. The facility CNA Coordinator stated that the police had located resident 102 on 4/27/19 and brought him back to the facility. The facility CNA Coordinator stated that she had met with the police and resident 102 briefly at the door, and that she had informed the police that resident 102 had gone AMA and was no longer a resident of the facility and could not return. The facility CNA Coordinator stated that Registered Nurse (RN) 5 also told the police that resident 102 was out of the system (online medical record) and was therefore no longer a resident of the facility. The facility CNA Coordinator stated that resident 102 requested and was given a drink of water. The facility CNA Coordinator stated that she did not ask resident 102 if he was hungry nor offered him any food. The facility CNA Coordinator stated that after resident 102 had his drink of water, he stated that he did not want to stay at the facility. The facility CNA Coordinator stated that the police asked her if resident 102 was a good resident to which resident 102 answered, tell them I was good. The facility CNA Coordinator stated that the encounter with the police lasted about 5 minutes and that they left with resident 102 to drop him off at a friend's home and that it was her understanding that the friend was not home and he was dropped off at Temple Square. The facility CNA Coordinator further stated that she did not notify the facility administrative staff that resident 102 had come back to the facility on [DATE] for several hours after the resident had returned and left again. The CNA Coordinator stated that I would never let him leave by himself to go to a bank because he would not be able to get there. The CNA Coordinator stated that I would not feel safe with him walking anywhere. The CNA Coordinator stated that I would be concerned that (resident 102) would get lost and I would not put him on a bus because he could get into trouble. On 5/7/19 at 12:54 PM, a telephone interview was conducted with resident 102's niece. Resident 102's niece stated that resident 102 had been found down and dehydrated and had been taken to the hospital but did not know of the circumstances Resident 102's niece stated that resident 102 was currently in another nursing facility. Resident 102's niece stated that she did not know if resident 102's check had been cashed. On 5/7/19 at 2:32 PM, an interview was conducted with the facility Nurse Practitioner (NP). The facility NP stated that she did not see resident 102 often but did notice that he was more happy and engaging on her visit on 4/25/19. The facility NP stated that she did not know that resident 102 had left the facility AMA. The facility NP stated that she had never seen him angry or explosive but more dismissive or ignoring. The facility NP stated that it was concerning that resident 102 had left AMA and that she would be worried about him leaving the facility and living in the community as he had progressive dementia, would not understand the AMA form and that she would worry about his safety. On 5/7/19 at 2.44 PM, an interview was conducted with the facility BOM. The facility BOM stated that resident 102 had not cashed his check. A hospital History and Physical dated 4/30/19 revealed the following: Chief complaint: Patient has come into the ER (emergency room ) complaining of pain in his legs that has been going on 'for all my life.' Patient cannot state why he has decided to come into the ER specifically today except that he couldn't walk. History of Present Illness: PCP (Primary Care Physician): Patient states he does see a doctor in this hospital, not sure of his name. (Resident 102) is a [AGE] year old gentleman with a history of HFrEF (heart failure related to ejection fraction) (EF (ejection fraction ~ (around) 30%) likely 2/2 ischemic [DIAGNOSES REDACTED], history of cocaine use, alcohol use disorder, homelessness,[MEDICAL CONDITION](hypertension), medication non-compliance, poor health literacy, intermittent explosive personality disorder and anxiety. When asking the patient what brings him to the hospital today, he says it was the cops. He was at the train station when what sounds like the police approached him and he was told, he can go to jail or go to the hospital. Patient states they stopped him for nothing. Patient states he couldn't walk. States that he couldn't walk because of his legs. When asked why he couldn't walk he had trouble telling me and said 'they are messing with me' referring to his legs. Patient states he has had leg problems all his life. Unable to tell me if they are worse than usual. The patient himself denies having any medical problems except for his legs. In the patient's chart, he at one point was on a BB (beta blocker), ACE (angiotensin converting enzyme), aspirin, [MEDICATION NAME]. He doesn't recall taking medications regularly. Overall he is a poor historian with very little insight into his medical problems previous diagnosed . ED (emergency department) Course: Vitals: Hypertensive, afebrile, normal HR (heart rate), satting normally on room air. Labs drawn, imaging obtained, NS (normal saline) 2L (liters) given Assessment/Plan: (Resident 102) is a [AGE] year old gentleman with a history of HFrEF (EF ~ 30%) likely 2/2 ischemic [DIAGNOSES REDACTED], history of cocaine use, alcohol use disorder, homelessness,[MEDICAL CONDITION] non-compliance, poor health literacy, intermittent explosive personality disorder and anxiety who presented to the ER with complaints about his legs. Ultimately though the patient was admitted for acute kidney injury. #. Acute kidney injury: On admission, Cr (creatinine) 2.2 (high), most recent on file is from (YEAR) and was 1.7. Appears pre-renal based on his labs. No evidence of infection. Drug screen negative. ER states that the patient was thirsty possibly suggesting dehydration. The patient has known heart failure, does not appear decompensated, but low EF could be chronically affecting his kidneys. Hypertensive [MEDICAL CONDITION] another consideration. It may be progression of [MEDICAL CONDITION]. -s/p (status [REDACTED]. -Maintenance IV (intravenous fluids) overnight (patient does not appear fluid overloaded at this time). -Repeat CMP (comprehensive metabolic panel) in AM -Check A1c now for possible diabetes. #. Rhabdomyolysis: CK ([MEDICATION NAME] Kinase) on admission was ~ 2.000 (high). Possible etiologies include dehydration, excessive walking or being sedentary, drug use. -Fluids as above. -Recheck CK in AM #. Direct [DIAGNOSES REDACTED]: #. Elevated Liver Enzymes: On admission: bili (bilirubin) 1.9 (high), AST ([MEDICATION NAME] Aminotransferase) 215 (high), LFT (Liver Function Test) 140 (high). [MEDICATION NAME] level negative. Denies any history of [MEDICAL CONDITIONS]. Etiologies are many but include [MEDICAL CONDITIONS], alcohol and non-alcohol [MEDICAL CONDITION]. low flow states or liver congestion also considerations. -Add on acute [MEDICAL CONDITIONS] panel -Trend with daily CMPs -Consider liver ultrasound if they do not improve On 5/7/19 at 2:47 PM, an interview was conducted with the Assistant Director of Nursing (ADON) for the new facility where resident 102 was admitted to. The ADON stated that resident 102 was admitted to their facility from the hospital on [DATE]. The ADON stated that resident 102's clothing and wallet went missing when he was at the park. The ADON stated that she would get with resident 102 and find out if he still had his check with him. On 5/7/19 at 2:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that resident 102 was his own responsible party and wanted to discharge from the facility. The facility MDS Coordinator stated that the facility RA, the facility BOM and the facility DON had explained to resident 102 that he needed to stay at the facility. The facility MDS Coordinator stated that the facility Administrator was not in the facility and had not talked with resident 102. The facility MDS Coordinator stated that after a few people had talked with resident 102, he continued insisting that he was going and told facility staff that he could cash a check at his bank. The facility MDS Coordinator stated that normally resident 102's niece could talk him down but was unable to do that this time. The facility MDS Coordinator stated that resident 102 was usually quiet and cooperative. The facility MDS Coordination stated that she did not know of any place where resident 102 could have been discharged to be taken care of, short of the homeless shelter or the 4th Street Clinic. The facility MDS Coordinator stated that she was unaware whether or not the homeless shelter or the clinic had been contacted for resident 102. The facility MDS Coordinator stated that resident 102's reasoning was adequate in a structured setting, but, that there were too many variables for resident 102 to be safe in the community. The facility MDS Coordinator stated that it was very easy to have resident 102 put back into the system when he returned. Th (TRUNCATED)

Based on interview, observation and record review it was determined, for 3 of 45 sample residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, one resident experienced pain without intervention by facility staff, another resident was not given her ordered pain patch, and a final resident was not given pain medication prior to a painful procedure. Resident identifiers: 10, 14 and 51. Findings include: 1. Resident 14 was admitted the facility on 11/10/17, he was admitted to the hospital on [DATE] for wound treatment, and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/6/19 at 1:26 PM an interview was conducted with resident 14. Resident 14 reported that the facility was not controlling his pain well, he rated his pain at an 8 on average (on a scale from 1-10, with 10 being the worst). Resident 14 stated that he received [MEDICATION NAME] and [MEDICATION NAME] for pain. Resident 14's medical record was reviewed on 5/7/19. Review of resident 14's physician orders [REDACTED]. a. On 10/19/18, an order was entered into the electronic medication order system for MS ([MEDICATION NAME])[MEDICATION NAME] Extended Release 30 mg(milligrams) by mouth two times a day for pain. This order was discontinued on 2/6/19. b. On 2/6/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 30 mg by mouth three times a day for pain. This order was discontinued on 2/16/19. c. On 2/16/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 30 mg by mouth two times a day for pain. d. On 10/19/18, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL ([MEDICATION NAME]) Tablet 15 mg by mouth every 4 hours as needed for pain. e. On 2/15/19, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL Tablet 15 mg by mouth one time only for unresolved pain. Resident 14's Care Plan had a care area for pain initiated 2/18/19 which stated Potential for altered comfort related to: chronic pain. One of the goals listed was The resident's risk for inadequate pain relief will be minimized through next review date. Several interventions were initiated 2/18/19 as follows: Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Implement other measures to decrease pain eg: a) re-positioning b) hot/cold packs. Medications as ordered and assess possible need for change or increase needs. Monitor for s/s eg: a) verbal c/o pain b) guarding c) facial grimacing d) refusal to participate in ADL's or therapies e) agitation f) restlessness. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Offer non-pharmacological interventions for pain prior to administering medication and PRN: (SPECIFY: Offer snack, redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with resident as needed, offer shower or bath, active listening and validation, offer ROM, massage, Relaxation and Breathing Techniques, Imagery and Distraction Techniques, Re-positioning, Therapeutic touch and Message.). Resident 14 had a care plan intervention initiated for pain on 3/6/19, this intervention was also entered into the MAR indicated [REDACTED]. Acceptable pain level: 3. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t no pain 1) Scheduled pain medication 2) PRN pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions. On 5/7/19 at 3:57 PM a follow up interview was conducted with resident 14. Resident 14 reported that the majority of his pain was in his left foot and right stump. Resident 14 described his pain as an achy [MEDICAL CONDITION] pain, and reported that it was constant. Resident 14 stated that he had a pain goal of 5/10, which was a level he felt he could function at. Resident 14 stated that he told staff almost daily about how much pain he was in, resident 14 stated that nothing new had been attempted to reduce his pain in the last several months. Resident 14 stated that staff had never offered him heat or cold packs for pain relief, or any other non-pharmacological interventions. Resident 14 stated that he had requested to go to the pain clinic but was informed that he could not go. Resident 14 stated that every time he asked why he was unable to go to the pain clinic, staff gave him a different answer. Resident 14 stated that the Medical Director (MD) 1 would not give him anymore pain medication because of risk for decreased respirations. Resident 14 stated that he wanted to go to the pain clinic because he believed the pain clinic would be able to find a better option to control his pain other than narcotic pain medications so his respirations would not be suppressed. Resident 14 stated that he wished he had more options for pain control that did not consist of a pill, as long as it reduced his pain. Resident 14 stated that his pain prevented him from doing activities he enjoyed, such as building models or drawing, because he was unable to focus through the pain. Resident 14 stated that the pain was mentally and emotionally exhausting, and most days he would just sit in agony. Resident 14 stated that he dreamed of being able to wake up in the morning and participate in life without planning his days around pain. Resident 14 stated that he took his as needed [MEDICATION NAME] every 4 hours, but that it usually only lasted for 2 hours, if it worked at all. Resident 14's pain scores during the previous month that were above resident 14's pain goal of 5/10, charted by the facility nurses in the electronic charting system: 5/7/19 at 3:31 PM: 6 5/7/19 at 10:49 AM: 6 5/7/19 at 12:01 AM: 6 5/6/19 at 9:03 PM: 7 5/6/19 at 3:06 PM: 6 5/6/19 at 8:22 AM: 8 5/6/19 at 6:25 AM: 7 5/5/19 at 5:31 PM: 7 5/4/19 at 10:06 AM: 8 5/3/19 at 3:54 PM: 8 5/3/19 at 11:43 AM: 6 5/3/19 at 7:49 AM: 7 5/2/19 at 11:28 AM: 7 5/2/19 at 7:36 AM: 6 5/1/19 at 3:50 PM: 7 5/1/19 at 11:44 AM: 7 5/1/19 at 7:51 AM: 9 4/30/19 at 3:38 AM: 7 4/29/19 at 5:13 PM: 8 4/29/19 at 6:59 AM: 7 4/28/19 at 10:43 PM: 7 4/28/19 at 1:55 AM: 8 4/27/19 at 11:01 PM: 7 4/27/19 at 8:25 PM: 7 4/27/19 at 8:50 AM: 5 4/27/19 at 1:29 AM: 8 4/26/19 at 17:35 PM: 8 4/26/19 at 11:16 AM: 6 4/25/19 at 6:38 PM: 8 4/24/19 at 3:55 PM: 7 4/24/19 at 10:27 AM: 6 4/23/19 at 2:20 AM: 6 4/22/19 at 7:23 AM: 7 4/21/19 at 11:12 AM: 7 4/21/19 at 10:24 AM: 9 4/21/19 at 5:36 AM: 8 4/20/19 at 8:20 PM: 8 4/20/19 at 10:20 AM: 8 4/19/19 at 6:03 PM: 7 4/19/19 at 4:56 PM: 8 4/19/19 at 12:18 PM: 8 4/19/19 at 7:31 AM: 8 4/18/19 at 10:59 PM: 9 4/18/19 at 5:39 PM: 8 4/18/19 at 4:18 PM: 9 4/17/19 at 2:00 PM: 7 4/16/19 at 10:00 AM: 6 4/15/19 at 8:55 PM: 7 4/14/19 at 10:49 AM: 8 4/13/19 at 6:41 AM: 7 4/12/19 at 4:30 PM: 8 4/12/19 at 2:30 PM: 7 4/12/19 at 9:54 AM: 7 4/11/19 at 10:15 AM: 9 4/10/19 at 11:17 PM: 8 4/9/19 at 4:13 AM: 6 4/8/19 at 11:39 PM: 6 4/8/19 at 7:36 PM: 7 4/7/19 at 9:13 AM: 7 (Note: resident 14's pain level was charted as greater than 5/10 fifty-nine times in the previous month.) An MDS dated [DATE] documented that resident 14 felt that it was very important that he was able to participate in his favorite activities and do things with groups of people. An ACTIVITIES - QUARTERLY/ANNUAL PARTICPATION (sic) REVIEW dated 3/12/19 documented that resident 14 attends most group activities, refuses when hes (sic) in to (sic) much pain On 11/5/18 at 6:31 PM a Health Status Note was documented in the facilities electronic charting system by a facility nurse (MD 1) clarifies. (Resident 14) is to have a one time visit to the pain clinic arranged by the facility. (Resident 14) today has had intermittent s/s of leg and phantom pain related to medical diagnosis. No noted s/s of over sedation on this shift noted related pain control medications . On 11/6/18 a physician's orders [REDACTED]. On 3/21/19 at 8:47 AM a progress note was documented by the facility Nurse Practitioner (NP) REcertification visit. Resident is awaiting an appt. with the pain clinic. On 5/9/19 at 10:33 AM a phone interview was conducted with the Pain Clinic Receptionist (PCR) at (Name of Hospital) pain clinic. The PCR stated resident 14 did not have an appointment with their office; the PCR reported that their office had no record that a referral was sent over for resident 14. The PCR stated that when they receive a referral for a new patient that the pain clinic doctors reviewed the patient's medical record before an appointment was made. The PCR stated that they very rarely refused a patient, and usually only refused to accept a patient if they had an acute pain injury, since their office only saw chronic pain patients. On 5/13/19 at 10:29 AM an interview was conducted with the Dietary Manager (DM). The DM stated that she acquired the role of making appointments for residents at the beginning of the year, when the previous employee left. The DM stated that she turned over the role to the current Van Driver in April. The DM stated that she sent resident 14's referral paperwork for a pain clinic consult to several offices including the (Name of Hospital) Pain Clinic, and that all of the pain clinics refused to treat resident 14. The DM was unable to find any documentation showing who she sent the referrals to, and when they were sent. On 5/7/19 at 3:34 PM an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 14 almost always rated his pain at an 8 or higher, RN 2 stated that he did not think that resident 14's pain was controlled. RN 2 stated that resident 14 rarely went longer than the 4 hour interval during the day, but at night resident 14 would sometimes stretch it out to 6 hours between PRN pain medications. RN 2 was unsure how often resident 14's pain regimen was reviewed by nurse management or the MD 1. RN 2 stated that the nurses would call or text the MD 1 with pain concerns for resident 14. A progress note by RN 4 dated 2/6/19 at 4:35 PM revealed (Resident 14) asked me to call (MD 1) to get an extra pain dose. I called and she said no. and another note charted at 4:42 PM by RN 4 (Resident 14) constantly refuses wound changes due to pain. On 5/9/19 at 8:20 AM an interview was conducted with RN 8. RN 8 reported that he did not usually use the FLACC scale to assess resident 14's pain level. RN 8 stated that he believed resident 14 was able to accurately rate his own pain level. RN 8 stated that resident 14's pain level was usually pretty high, and would easily get up to an 8/10 if resident 14's as needed [MEDICATION NAME] was given closer to the 5 hour interval mark instead of at the 4 hour interval. RN 8 stated that in his opinion resident 14's pain was not controlled; RN 8 also stated that resident 14 never refused pain medication. RN 8 stated that resident 14's pain sometimes prevented resident 14 from completing ADL's such as showering. RN 8 stated that he had not heard that resident 14 had orders for a pain clinic consult, or that resident 14 had been refused. A review of resident 14's narcotic record log showed that resident 14 was closely maximizing his PRN pain medications. (Note: there was a notable discrepancy between the narcotic log and the MAR. Cross refer to F755.) On 5/9/19 at 8:29 AM an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 14 had pain throughout the day but was unsure what kind of pain or where. CNA 1 stated that resident 14 frequently asked the nurses for more pain medication, even before the next dose was due. CNA 1 stated that the CNA's did not implement any interventions for resident 14's pain. On 5/9/19 at 2:15 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the DM was the person trying to make an appointment for resident 14 at the pain clinic. The MDS Coordinator did not know if that appointment had been made or if there were any updates. The MDS Coordinator would not state if she believed a pain level consistently greater than 6/10 would indicate controlled or uncontrolled pain. On 5/9/19 at 2:52 PM an interview was conducted with the DON. The DON stated that she had heard resident 14 was denied at the pain clinic, but she did not know why he was denied or which pain clinic denied him. The DON stated that resident pain regimens and pain scores should be reviewed every week, but that she had not been doing that. The DON would not answer whether she thought a pain level greater than 6/10, when the documented pain goal was 3/10, indicated controlled or uncontrolled pain in a resident. On 5/9/19 at 1:56 PM an interview was conducted with MD 1. MD 1 stated that the facility DON was supposed to do pain regimen and pain score reviews every week. MD 1 stated that resident 14 was a high risk for respiratory suppression with use of narcotics, and did not believe that resident 14's pain was uncontrolled. MD 1 stated that she had written an order for [REDACTED]. On 5/9/19 at 9:33 AM an observation was made of resident 14. Resident 14 complained to RN 8 that he was in a lot of pain, resident 14 displayed nonverbal signs of pain with facial grimacing and groaning. On 5/10/19 at 8:08 PM an observation was made of resident 14 in the dining room. Resident 14 was rocking back and forth, groaning and rubbing his legs, and appeared very restless related to pain. During this time resident 14 rated his pain at an 8-9/10 and stated that his pain was unbearable. Resident 14 stated that on average he spent five out of seven days in agonizing pain. Resident 14 stated that he had gone to the wound care clinic earlier in the day and the clinic had debrided his wounds to help with healing. Resident 14 then asked RN 6 for pain medication, which she administered and charted. (NOTE: Resident 14 had three areas on his person that had been debrided at the wound clinic.) When the corresponding documented pain scores were reviewed it was noted that RN 6 charted resident 14's pain level on 5/10/19 at 8:30 PM at a 3/10, however the resident had just reported that his pain was an 8-9/10, and had multiple nonverbal signs of pain. RN 6 later charted that the pain medication administered around 8:30 PM was effective, but a pain score of 9/10 that was charted at 9:56 PM indicated that the pain medication was ineffective. 2. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/6/19 at 1:40 PM, an interview was conducted with resident 10. Resident 10 stated that he had a pressure ulcer but was not allowed to talk about it. Resident 10 was observed in his geri chair with his ankles crossed and socks on both feet. On 5/14/19 at 9:03 AM, an observation was made of resident 10's pressure ulcer with Registered Nurse (RN) 2. Resident 10 was observed to be in bed with his ankle resting on the air mattress. RN 2 was observed to remove a foam dressing on resident 10's outer left ankle. Resident 10 was observed to have facial wincing and stated, No please, Please no more. The pressure ulcer was observed to be located on the lateral malleolus. There was partial thickness loss, the wound bed was red with granulation and minimal drainage to dressing. The pressure ulcer edges were intact with no tunneling and no odor noted. The pressure ulcer peri-wound area was red and inflamed but not hot. RN 2 stated that resident 10 recently developed the pressure ulcer. RN 2 stated that resident's pressure ulcer was 1 centimeter (cm) by .5 cm by .1 cm. RN 2 stated that he was cleaning the wound with normal saline (NS), applying medi-honey to the wound and covering with an allevyn foam dressing. Resident 10 was observed to pull his foot away from RN 2 when applied medi-honey. Resident 10 was observed to move around and have facial grimacing. Resident 10 was observed to state repeatedly, Please no more. RN 2 stated that resident 10 crosses his ankles and there is pressure on the left outer ankle onto the right ankle. RN 2 stated that there were no devices used to reduce pressure between his crossed ankles because resident 10 kicked them off in the past. RN 2 stated that staff uncrossed resident 10's ankles but resident 10 moved them back to the crossed position. RN 2 stated that the wound was unavoidable because of weight loss and his terminal illness. On 5/14/19 at 12:00 PM, an observation was made of resident 10 in the hallway. Resident 10 was observed in his geri chair. Resident 10 was observed to have his ankles crossed with the foam dressing on the left ankle resting against the other ankle. Resident 10's medical record was reviewed on 5/14/19. A quarterly Minimum (MDS) data set [DATE] revealed that resident 10 did not have a pressure ulcer but was at risk for developing a pressure ulcer. A care plan dated 3/28/19 revealed, Skin Integrity Impaired stage 2 left lateral ankle. The goal developed was Resident will show s/s of healing wound. The interventions were, Administer wound care per MD (medical doctor) order. Notify MD of any wound worsening, s/s complications or if a change in treatment orders is felt to be indicated. Air Mattress to bed; check each shift to ensure it is functioning properly two times a day. Daily assessment and documentation by residents nurse a)fever b) area of body c) odor present d)drainage color and amount e) pain. Monitor for s/s (signs and symptoms) of infection e.g. a) redness b) swelling c) warmth d) drainage/odor e) increase in pain f)increase in temp. Notify MD as needed . Turn and reposition every 2 hours and as needed for prevention of further breakdown. A nursing progress note dated 3/28/19 at 3:03 PM revealed, Hospice Nurse reported a stage 2 to left lateral ankle. New orders to change dressing to L (left) ankle twice a week and PRN (as needed). Cleanse with wound cleaner or NS (normal saline). Apply foam boarder or plain boarder gauze, Also ok to apply [MEDICATION NAME] to wound bed as needed. A form titled, Physician order [REDACTED]. The interventions were, measures 1.5 x 1.5cm. SN (skill nursing) to (change) dressing to L ankle 2 x a week and prn. Cleanse with wound cleanser or NS apply foam bordered or border gauze ok to apply [MEDICATION NAME] to wound bed. A physicians order dated 4/1/19 revealed, Air Mattress to bed; check each shift to ensure it is functioning properly. Two times a day. (Note: A progress note dated 3/28/19 revealed that hospice notified staff of the pressure ulcer and the air mattress was not initiated until 4/1/19.) Resident 10's Treatment Administration Record (TAR) for (MONTH) 2019. There were no treatment orders or treatments completed in the TAR for (MONTH) 2019. The (MONTH) 2019 TAR revealed on 4/1/19 the treatment to cleanse with wound cleaner or NS apply foam border or plain border gauze and apply [MEDICATION NAME] as needed in the afternoon every Monday and Friday was completed. (Note: The order was written by the physician on 3/28/19 and was not entered into the TAR until 3/30/19.) Resident 10's TAR for (MONTH) 2019 further revealed treatments were completed on 4/5/19 and 4/8/19. The treatment was Clean left lateral ankle wound with wound cleanser and apply [MEDICATION NAME] and foam border dressing, change twice a week and prn (as needed). A form titled Physician order [REDACTED]. D/c (discontinue) previous wound care order. 2. Using aseptic technique, clean wound to L lateral ankle (with) wound cleanser, apply boarder (sic) gauze. (Change) 2x wk (week) and prn. The goal documented, Wound healed. According to resident 10's (MONTH) 2019 TAR nurse staff provided treatment on 4/12/19, 4/16/19 and 4/19/19. The treatment was .Cleanse wound using aseptic technique to Left Lateral Ankle with wound cleanser, apply border gauze, Change 2 x a week and PRN. The treatment was discontinued on 4/21/19. A form titled Physician order [REDACTED]. The documented goal was wound healed. (Note: According to the (MONTH) 2019 TAR resident 10 did not receive the new ordered treatment until 4/16/19 and received the same treatment on 4/19/19. The treatment order dated 4/9/19 was not discontinued until 4/21/19 and resident 10 had received a new physicians order on 4/16/19.) According to the (MONTH) 2019 TAR nurse staff provided treatment to Cleanse wound using aseptic technique to Left Lateral ankle with wound cleanser, place calcium alginate in wound bed cover with foam and then bordered gauze, change 2 x a week and prn. The treatments were documented as completed on 4/23/19, 4/26/19 and 4/30/19. The (MONTH) 2019 TAR revealed the same treatments were completed on 5/3/19 and 5/7/19. A nursing progress note dated 5/6/19 at 4:48 PM revealed, Stage 2 ulcer to left lateral malleolus measuring 1x1. Slight serous drainage. Peri wound pink. No s/s of infection. Wound care as ordered. Will continue to monitor. (Note: There were no other nursing progress notes with measurements or assessments of resident 10's pressure ulcer located in resident 10's medical record since the 3/28/19 when the hospice nurse reported it to the nursing staff.) A physicians order dated 5/7/19 revealed, PT (patient) has a stage 2 pressure wound on lateral left ankle. SN to cleanse with wound cleanser, pat dry with gauze. Apply small amount of [MEDICATION NAME] to wound base. Cover with foam dressing 2x/week and prn. Measurements to be done 1x/week. Hospice nurse to provide wound care 2x/week. Unavoidable weight loss, skin breakdown, and [MEDICAL CONDITION] due to terminal illness of senile degeneration of the brain. (Note: The goal was to heal resident 10's pressure ulcer until 5/7/19 when the physician documented the pressure ulcer was unavoidable.) There were no treatment orders documented in the (MONTH) 2019 TAR after 5/7/19. A nursing progress note dated 5/13/19 at 4:38 PM, Stage 2 pressure injury to left lateral malleolus measures 1x0.5x0.1 cm with red wound base, new [MEDICATION NAME], blanchable [DIAGNOSES REDACTED] to peri wound, no slough, no s/s infection. Will continue to monitor. On 5/4/19 at approximately 12:15 PM, a follow up interview was conducted with RN 2. RN 2 stated that earlier that day was the first time he had changed resident 10's pressure ulcer dressing. RN 2 stated that resident was showing signs and symptoms of pain. RN 2 stated that resident 10 had an order for [REDACTED]. On 5/14/19 at 1:38 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after reviews resident 10's medical record the wound orders were not implemented when the physician ordered them. The DON stated that she did not know why there was a delay in implementing resident 10's wound orders. On 5/14/19 at 2:05 PM, an interview was conducted with the DON. The DON stated that there were no orders in the TAR for a dressing change because the order was for prn and hospice did the regularly dressing changes. The DON stated that the nurses were to document all dressing changes in the TAR or with a nursing progress note. The DON stated that there was no area to document dressing changes on the TAR because the order was prn. On 5/14/19 at 8:03 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that wound measurements should be done weekly. The CRN stated that hospice should communicating with the facility nurse that dressing changes were completed so they could be documented on the TAR. 3. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/19 at 10:10 AM, an observation was made during medication pass of resident 51 as she requested a pain medication twice from Registered Nurse (RN) 4. Resident 51 was observed rubbing her right shoulder. RN 4 was observed to tell resident 51 that her pain medication had been administered about 7:30 and was not time yet for another pain medication. RN 4 was observed to tell resident 51 that he would place the [MEDICATION NAME] Patch on her. RN 4 was observed to administer resident 51's medications and was observed to go to the bathroom twice to get more water for resident 51. RN 4 was observed to pull off a [MEDICATION NAME] Patch from her right shoulder. RN 4 was observed to tell resident 51 since the [MEDICATION NAME] Patch had been placed after her shower the night before, and had not been off for 12 hours, that he was unable to apply the [MEDICATION NAME] Patch. On 5/11/19 at approximately 10:13 AM, an interview was conducted with resident 51 as RN 4 went to retrieve more water for her. Resident 51 stated that her pain level was 9 and that the location of her pain was in her right shoulder. No observation was made of RN 4 asking what resident 51's pain level was, where her pain was located, offering a Tylenol which had been ordered for resident 51 as needed nor of calling the physician to report that resident 51 had a pain level of 9. On 5/11/19 at approximately 10:18 AM, an observation was made of RN 4 as he documented that resident 51's pain level was 7 in the online medical record. RN 4 stated that I asked her earlier what her pain level was. On 5/13/19 resident 51's Medical Record was reviewed. Resident 51's [MEDICATION NAME] 5 mg (milligrams) was administered at 11:48 AM, approximately 1 hour and 38 minutes after resident 51 had requested a pain medication and had told this surveyor that her pain level was 9. On 5/13/19 at 9:32 AM, an interview was conducted with RN 3. RN 3 stated that he would have notified resident 51's physician that the [MEDICATION NAME] Patch could not have been administered. RN 3 stated that with the verbalization of a pain level of 9, he would have called resident 51's physician and requested a one time order for [MEDICATION NAME] 5 mg. RN 3 stated that he would have asked resident 51 if she wanted to try a prn Tylenol. On 5/13/19 at 10:57 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that RN 4 should have called resident 51's physician or taken some kind of action for resident 51's pain.

Based on interview and record review it was determined, for 4 of 45 sample residents, that the facility did not ensure that resident's received treatment and care in accordance with professional standards of practice based on the resident's person-centered care plans. Specifically, there was no monitoring or nursing assessments completed after a resident tested positive for influenza A. The same resident experienced a change in condition and the nurse did not assess the resident prior to her passing away. In addition, another resident was not provided her anti-psychotic medications and anti-depressants for 5 days after admission. Another resident did not receive treatment after having symptoms of a urinary tract infection. Resident identifiers: 21, 37, 52 and 54. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 52's medical record was reviewed on 5/8/19. Nursing progress notes revealed the following entries: a. On 3/26/19 at 4:51 AM, Res (resident) febrile 105.5, flushed. PRN (as needed) Tylenol given. TSB (tepid sponge bath) done. Enc (encourage) fluids w (with) intake tolerated. (positive) cough. Rechecked 102. TSB continued. Latest Temp: 100.9. Res appears comfortable in her room sleeping. wctm (will continue to monitor) b. On 3/26/19 at 4:59 AM, MD (Medical Doctor) Notified of above. No new orders at this time. wctm. c. On 3/26/19 at 5:30 AM, MD ordered STAT Influenza swab and CXR (chest x-ray) on Res. d. On 3/27/19 at 3:00 PM, Late Entry: Flu results received, Positive for Influenza A, MD notified, orders to place resident et (and) room mates on isolation, start [MEDICATION NAME] 75mg (milligrams) BID (twice daily) (times) 5 days. Chest Xray results as follows, Mild Bibasilary patchy opacity which may be atelectasis or pneumonia, MD notified no new orders. e. On 4/4/19 at 12:07 PM, CNA (Certified Nursing Assistant) notified nurse that res was unresponsive and not acting as she usually does. Nurse was administering med (medications). Nurse immediately went to res room and noticed her condition. Nurse left to obtain VS (vital signs) equipment and when returned res was not breathing and had no pulse. DON (Director of Nursing), ADON (Assistant Director of Nursing) and M.D. notified. The last documented vital signs for resident 52 were on 4/3/10 at 3:40 AM. Resident 52's blood pressure was 112 / 58 millimeters of mercury , pulse was 70 beat per minute, respirations were 20 Breaths/minute, 92.0 (percent) oxygen saturations on room air, and her temperature was 98.4 degrees Fahrenheit. The vital signs prior to 4/3/19 were documented on 3/26/19. (Note: Resident 52 was diagnosed with [REDACTED].) An Antibiotic Stewardship assessment dated [DATE] revealed that resident 52 had influenza A and was prescribed Tami-flu twice daily for 5 days. A care plan dated 3/27/19 revealed, The resident has Influenza A. The goal was The resident will be free from s/sx (signs and symptoms) of dehydration as evidenced by good skin turgor, normal mucous membranes, vital signs within normal limits electrolytes within normal limits, adequate urinary output through the review date (and) The resident will verbalize an acceptable level of comfort through the review date. The interventions developed were, Resident On Isolation r/t (related to) Influenza A- Room to be on contact precaution. Please educate staff and visitors to wear PPE (personal protective equipment) when entering room two times. Encourage good fluid intake and offer residents favorite beverages. Give antipyretics and [MEDICATION NAME] as ordered for fever and pain. Monitor/document side effects and effectiveness. Give good oral care. Give good peri care and use lotions or barrier creams to comfort and protect skin. Keep room cool and cover lightly, avoid overheating. Measure intake and output. Monitor labs (laboratory values) and report abnormal findings to physician. Monitor/document/report PRN for signs of dehydration: poor skin turgor, dry mucous membranes, slowed capillary refill, increased heart rate ([MEDICAL CONDITION], cool dry skin, sunken eyeballs, decreased urinary output, difficulty breathing (Dyspnea), [MEDICAL CONDITION]. [MEDICATION NAME] X. On 5/9/19 at 2:16 PM, an interview was conducted with Registered Nurse (RN) 8. RN 8 stated that there was a form regarding when and what to complete for alert charting. A form titled Alert Charting Criteria revealed for residents with Respiratory Infection Every shift during (the) duration of ABX (antibiotics) (plus) 72 hours (If no abx until stable). The Charting to include (but not limited to) revealed, Vital signs, Lung sounds, cough, endurance, appetite, level of awareness, reaction to ABX, incentive spirometry, X Ray results. In addition, Change of Condition should have been charted Until resolvement. The Charting to include (but not limited to) revealed Acute changes, head-to-toe assessment findings, lab/diagnostic ordered (per MD) New interventions, effectiveness. On 5/9/19 at 8:07 AM, an interview was conducted with Certified Nurses Aide (CNA) 1. CNA 1 stated that resident 52 had been at the facility for several years. CNA 1 stated that resident 52 was non-verbal but was able to express pain with facial gestures like grimacing. CNA 1 stated that resident 52's roommate tested positive for the flu and then resident 52 tested positive. CNA 1 stated that resident 52 was on isolation in her room and he fed her breakfast and lunch on 4/3/19. CNA 1 stated that when resident 52 was eating breakfast he noticed Something different with resident 52 and reported it to the nurse. CNA 1 stated that resident 52's breathing was a little faster than usual and she had a flat affect. CNA 1 stated that he reported the change of condition to the nurse and then received further instructions regarding monitoring from the nurse. CNA 1 stated that he did not know if resident 52 was assessed by the nurse that he reported resident 52's change of condition to the nurse on 4/3/19. CNA 1 stated that Registered Nurse (RN) 4 worked the next day on 4/4/19 when resident 52 passed away. CNA 1 stated that he tried to feed resident 52 breakfast between 8:45 AM to 9:00 AM. CNA 1 stated that resident 52 usually had a lot of tone in her arms and looked stiff but that morning she did not look stiff. CNA 1 stated that when he tried to feed resident 52 her full liquid diet, she was not swallowing and the liquid was coming out of her mouth. CNA 1 stated that resident 52 body felt a little warm when he put her back in bed. CNA 1 stated that he reported the symptoms to RN 4. CNA 1 stated that he went back into resident 52's room to assist her roommate around 11:00 AM and resident 52 was staring at the ceiling and looked worse so he notified RN 4 again. CNA 1 stated that he started working with the roommate and was not notified to obtain vital signs. CNA 1 stated that RN 4 went in around 11:00 AM and RN 4 stated that depending on the resident's vital signs then the nurse called the physician about sending resident 52 to the hospital. CNA 1 stated that the next thing CNA 1 said that RN 4 told him was that resident 52 had passed away. On 5/9/19 at 12:41 PM, a phone interview was conducted with RN 4. RN 4 stated that he could not remember resident 52. RN 4 stated that after a resident was diagnosed with [REDACTED]. RN 4 stated that he could not remember if he checked resident 52's vitals, listened to her lungs or checked her temperature. RN 4 stated that if he had assessed resident 52, then he would have documented it in the progress notes. The surveyor read RN 4's nursing progress note to him and RN 4 denied writing the note about resident passing away on 4/4/19. RN 4 stated that he was unable to remember resident 52 passing away and what happened that morning. No documentation could be located in the medical record to show that resident 52's vital signs were monitored every two hours nor that there had been any assessment for her change of condition, nor that the physician had been notified of the change in condition. On 5/13/19 at 9:15 AM, an interview was conducted with the Cooperate Resource Nurse (CRN). The CRN stated that the DON told her that she talked to RN 4 and told her that he assessed resident 52 early in the morning on 4/4/19 and she was fine. The CRN stated that there was no documentation to support RN 4's statement because there were no assessments or vitals signs in the medical record. On 5/9/19 at 8:57 AM, an interview was conducted with RN 3. RN 3 stated that after a resident was diagnosed with [REDACTED]. RN 3 stated that nurses should be documenting all vital signs obtained as well as any complaints from the resident. RN 3 stated if there was a change in a resident's condition he would perform an assessment which involved vital signs, listening to heart, listening to lungs and listen to what the resident was telling them. RN 3 stated if a resident was non-verbal he would perform the same assessment. RN 3 stated that he did not work with resident 52 very often but knows that when resident 52 was diagnosed with [REDACTED]. RN 3 stated that with influenza he would also evaluate the resident's swallowing and evaluate for aspiration by checking lungs every shift. On 5/9/19 at 1:46 PM, an interview was conducted with the Medical Doctor (MD) 1. MD 1 stated that resident 52 was diagnosed with [REDACTED]. MD 1 stated that she ordered Tami-flu and encouraged fluids. MD 1 stated that resident 52 passed away while she was out of town. MD 1 stated that she would expect the facility to follow their policy and procedures for monitoring when a resident was diagnosed with [REDACTED]. On 5/9/19 at 2:18 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated resident 52 was able to verbalize her need a little. The MDS Coordinator stated that resident 52 was able to express pain by being restless, facial grimacing and crying. The MDS Coordinator stated that resident 52 had upper respiratory congestion and the physician ordered an influenza test and it was positive. The MDS Coordinator stated that nurses were to monitor lung sounds, oxygen saturations, vital signs, and temperature every shift. The MDS Coordinator stated that resident 52 finished the Tami-flu and her respirations improved. The MDS Coordinator stated that, All of the sudden there was a decline for a couple of days. The MDS Coordinator stated that resident 52's vital signs should have been monitored when she declined. The MDS Coordinator stated that when a CNA noticed a change in condition it needed to be reported to the nurse. The MDS Coordinator stated that the nurse was to document all assessments in the medical record. On 5/9/19 at 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after a resident was diagnosed with [REDACTED]. The DON stated all vitals and assessments would be documented in the progress notes or assessments. The DON stated that she did not know what happened with resident 52 because she passed away before she became the DON. The DON stated she did not have additional information. 2. Resident 54 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 54's medical record was reviewed on 5/9/19. An admission MDS dated [DATE] revealed that resident 54 had antipsychotic, antianxiety, and antidepressant medications. A care plan dated 1/30/19 revealed, (Resident 54) is at risk for violence, directed at self/others related to [MEDICAL CONDITION]. The goal revealed, Signs of physical agitation are abating and no physical injury occurs daily through stay. The interventions revealed, .Medication as ordered Aripirazole solution, Memantadine HCL tablet, [MEDICATION NAME] tablet, Ziprasidone HCL capsule and [MEDICATION NAME] solution. Resident 54's physicians orders dated 1/25/19 revealed the following entries: a. Ziprasidone HCl (hydrogen chloride) Capsule 40 MG. Give 1 capsule by mouth two times a day related to [MEDICAL CONDITION]. b. [MEDICATION NAME] HCl Tablet 50 MG. Give 1 tablet by mouth at bedtime for Depression. c. [MEDICATION NAME] Tablet. Give 5 mg by mouth one time a day for Hypertension. d. [MEDICATION NAME] Tablet 5 MG. Give 1 tablet by mouth at bedtime related to [MEDICAL CONDITION]. e. [MEDICATION NAME] Patch 5 % ([MEDICATION NAME]). Apply to shoulder topically two times a day for Pain On for 12 hours Off for 12 hours. f. Atorvastatin Calcium Tablet 10 MG. Give 10 mg by mouth at bedtime for [MEDICAL CONDITION]. g. Carvedilol Tablet 6.25 MG. Give 4 tablet by mouth two times a day for Hypertension. h. [MEDICATION NAME] HCl Tablet 75 MG. Give 1 tablet by mouth one time a day for Depression. i. Fiber Tablet 625 MG (Calcium Polycarbophil). Give 1 tablet by mouth two times a day for Constipation. j. [MEDICATION NAME] Tablet 9000 UNIT. Give 1 tablet by mouth before meals for Digestive Aide. Resident 54's progress notes revealed the following entries: a. On 1/25/19 at 5:21 PM, Late Entry: Resident arrived at about 1725 (5:25 PM). Medications faxed to pharmacy. b. On 1/25/19 at 8:00 PM, Late Entry: Pharmacy states that cream is on back order. (MD 1) notified- hold med until received from pharmacy. c. On 1/25/19 at 9:00 PM, Late Entry: Fiber tablet held. MD held, OK to hold medication until medication received in facility. d. On 1/25/19 at 9:00 PM, Late Entry: Pharmacy reported that it is too soon to refill carvedilol, Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. e. On 1/25/19 at 9:00 PM, Late Entry: Pharmacy reported that it is too soon to refill Ziprasidone HCL, Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. f. On 1/25/19 at 10:00 PM, Late Entry: Note Text: Pharmacy reported that it is too soon to refill [MEDICATION NAME], Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. g. On 1/25/19 at 10:00 PM, Late Entry: Note Text: Pharmacy reported that it is too soon to refill [MEDICATION NAME], Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. h. On 1/25/19 at 10:00 PM, Late Entry: Pharmacy reported that it is too soon to refill atorvastatin calcium, Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. i. On 1/25/19 at 10:00 PM, Late Entry: Pharmacy reported that it is too soon to refill olanzepine, Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. j. On 1/26/19 at 11:00 AM, Late Entry: [MEDICATION NAME] tablet held. MD notified. Ok to hold medication until received from pharmacy. k. On 1/26/19 at 4:00 PM, Late Entry: [MEDICATION NAME] held. MD notified, OK to hold medication until meds received from pharmacy. l. On 1/26/19 at 9:00 PM, Late Entry: Pharmacy reported that it is too soon to refill Ziprasidone HCL, Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. m. On 1/26/19 at 9:39 PM, [MEDICATION NAME] Cream 0.625 MG(milligram)/GM (gram).Held till AM. n. On 1/26/19 at 10:59 PM, Ziprasidone HCl Capsule 40 MG.related to [MEDICAL CONDITION].Waiting on pharmacy to deliver. o. On 1/26/19 at 10:59 PM, [MEDICATION NAME] Tablet 5 MG.related to [MEDICAL CONDITION].Waiting on pharmacy to deliver. p. On 1/27/19 at 7:30 AM, Late Entry: Note Text: [MEDICATION NAME] held. MD notified, OK to hold med until medication received. q. On 1/27/19 at 8:54 AM, [MEDICATION NAME] Tablet 9000 UNIT. waiting on pharm (pharmacy). r. On 1/27/19 at 1:50 PM, Ziprasidone HCl Capsule 40 MG.related to [MEDICAL CONDITION].witing (sic) on pharm. s. On 1/27/19 at 1:50 PM, Fiber Tablet 625 MG. pharm delivering. t. On 1/27/19 at 1:50 PM, [MEDICATION NAME] HCl Tablet 75 MG. Give 1 tablet by mouth one time a day for Depression. pharm waiting on. u. On 1/27/19 at 4:34 PM, [MEDICATION NAME] Tablet 9000 UNIT.waiting on pharm. v. On 1/27/19 at 7:25 PM, [MEDICATION NAME] Cream 0.625 MG/GM. waiting on pharm. w. On 1/27/19 at 8:17 PM, Fiber Tablet 625 MG. pharm. x. On 1/27/19 at 8:18 PM, Ziprasidone HCl Capsule 40 MG.related to [MEDICAL CONDITION].waiting on pharm. y. On 1/27/19 at 10:47 PM, [MEDICATION NAME] Solution 0.12 %.pharmacy waiting. z. On 1/27/19 at 10:47 PM, Atorvastatin Calcium Tablet 10 MG.waiting on pharm. aa. On 1/27/19 at 10:47 PM, [MEDICATION NAME] HCl Tablet 50 MG. waiting on pharm. bb. On 1/27/19 at 10:48 PM, [MEDICATION NAME] Tablet 5 MG.related to [MEDICAL CONDITION]. waiting on pharm. cc. On 1/28/19 at 1:21 PM, MD Progress Note: (resident 54) is a [AGE] year old female with [MEDICAL CONDITION]. 4. [MEDICAL CONDITION] - will continue usual meds. dd. On 1/28/19 at 3:11 PM, Spoke with resident about concerns, she stated 'I am just sad et depressed that I am sick et have to be here, I know I can leave if I wanted to but I don't think that I will be happy anywhere, its just not home.' I then asked the resident if she would like me to try et (and) find her a different room which she declined stating its not the room just that it's not home. Asked resident if there was anything that i could do to make her more comfortable she stated she is just fine in her corner. Educated resident on letting the nurses or administration know if there are any issues in the future. ee. On 1/29/19 at 9:31 AM, [MEDICATION NAME] HCl Tablet 75 MG.for Depression. pharm. ff. On 1/29/19 at 9:33 AM, [MEDICATION NAME] Capsule 100 MG. waiting on pharm. gg. On 1/29/19 at 11:46 AM, [MEDICATION NAME] Tablet 9000 UNIT .waiting opn (sic) pharm. hh. On 1/29/19 at 2:51 PM, (Resident 52) is looking for a new facility to move to. She spends most of her time in room. ii. On 1/29/19 at 3:52 PM, [MEDICATION NAME] Tablet 9000 UNIT.waiting on pharm. jj. On 1/30/19 at 12:11 PM, Memantine HCl Tablet 10 MG.related to [MEDICAL CONDITION]. Pharmacy has not delivered medications to the facility. MD is aware and med can be placed on hold or given late until meds are available in the facility. kk. On 1/30/19 at 12:14 PM, Ziprasidone HCl Capsule 40 MG.related to [MEDICAL CONDITION], .Medication not delivered from pharmacy. MD notified and is ok to hold med or give late when medication arrives to the facility. ll. On 1/30/19 at 12:17 PM, [MEDICATION NAME] HCl Tablet 50 MG.for Depression. Medication not delivered for new admit from pharmacy. MD notified and is aware of situation. New order to hold med or give late when medication is available in the building. mm. On 1/30/19 at 12:18 PM, Atorvastatin Calcium Tablet 10 MG.for [MEDICAL CONDITION]. Medication not delivered from pharmacy. MD notified. MD order to hold meds or give late when medication is available to give to pt (patient). nn. On 1/30/19 at 12:20 PM, [MEDICATION NAME] Tablet 5 MG.related to [MEDICAL CONDITION], .Medication not delivered by pharmacy for new admit. MD notified and aware of situation. New order to hold or give med late as soon as medication is available. oo. On 1/30/19 at 12:25 PM, [MEDICATION NAME] Tablet 9000 UNIT.for Digestive Aide. Medication held. Not delivered to facility by pharmacy. MD notified and is ok to hold med or give late as soon as medication is available. pp. On 1/30/19 at 12:26 PM, [MEDICATION NAME] Tablet 9000 UNIT.for Digestive Aide. Medication not delivered from pharmacy. MD was notified and order to hold med or give late when medication is available. qq. On 1/30/19 at 12:29 PM, [MEDICATION NAME] Cream 0.625 MG/GM.Medication was not delivered due to being on back order from pharmacy. MD is notified and order to hold med or give late as soon as medication is available in the building. rr. On 1/30/19 at 12:34 PM, Ziprasidone HCl Capsule 40 MG.related to [MEDICAL CONDITION]. Medication was not deliveries into the facility. MD notified and ok to hold med or give late when medication is available in the building. ss. On 1/30/19 at 1:05 PM, Pharmacy reported that it is too soon to refill [MEDICATION NAME] Patch, Was refilled 1/16/2019 at previous facility. We will need to pick up meds from prior facility. MD notified, is aware of situation, ok for meds to be held until meds are available. tt. On 1/30/19 at 3:32 PM, Pts meds picked up from previous facility. MD notified that meds were delivered. uu. On 2/4/19 at 5:24 AM, @0350 Res lying in bed eyes open, pupils nonreactive to light, unresponsive, VS (vital signs) BP (blood pressure): 74/42, PR (resting pulse):89, RR (resident respirations):14, T (temperature):96.9, O2 (oxygen) sat: 93% RA (room air). Skin cold to touch, CBG (Capillary blood glucose): 35. Res unable to tolerate oral intake, does not respond to verbal command. Called paramedics, CBG:27mg/dl when they arrived. Res treated. Res alert and oriented. CBG:125, VSS BP:148/100, PR:77, T:97.5, O2:97%, RR:18. Oral intake tolerated. To [MEDICAL TREATMENT] today. MD aware of above. vv. On 2/4/19 at 6:11 AM, As per paramedics send res to [MEDICAL TREATMENT]. Called ([MEDICAL TREATMENT] center) [MEDICAL TREATMENT], .As per [MEDICAL TREATMENT] nurse, res is doing fine, on ongoing [MEDICAL TREATMENT] as of this time. ww. On 2/9/19 at 4:05 PM, (Resident 54) has been coughing with lung sounds congested and O2 sats stable on room air. Afebrile 97.4 (temperature), 148/80 (blood pressure), 80 (pulse), 20 (respirations). Sent above information to (name of physician) with new orders, '[MEDICATION NAME] 1200 mg po BID prn resp. congestion.' allergies [REDACTED]. Resident informed. xx. On 2/10/19 at 1:02 PM, Checked resident blood sugar 48 cont (continue) w (with) med pass and OJ (orange juice) Noted labored breathing auscultated lung sounds noted wheezes in all bases 02 at 90% 02 applied to assist in breathing (physician's name) notified. FNP (Family Nurse Practitioner) .into see residents she assessed resident order Chest X-ray 2 views .[MEDICATION NAME] Neb (Nebulizer) Tx (treatment) 2.5 TID (three times a day) for 3 days Then PRN 1 week. yy. On 2/10/19 at 1:03 PM, Nurse Reactionary: Seen emergently at request of staff. Resident with acute complaints of shortness of breath. SATS 90% but placed on 1 L 02 due to complaints. Feeling cold, afebrile. Blood sugars this morning 48 at 1230, given juice and medpass, is alert. Sugar now 94. No chart can be located at this time to check labs. Blood sugar trends reviewed. Smokes. Female resident up in chair, alert, good eye contact and engagement. expiratory wheezes heard in all fields, no increased respiratory effort.Cough: cxr (chest x-ray) 2 view [DIAGNOSES REDACTED]: follow a1c, monitor sugars. Wheezing: [MEDICATION NAME] nebs tid x 3 days, then prn x 1 wk. zz. On 2/10/19 at 1:56 PM, Called to resident room found on floor lying on right side and stomach. reported that she fell walking to bed from bathroom. Logged rolled resident onto back VS taken superficial pinpoint area to chin applied pressure and applied steri strip 3 person transfer to bed. Xray department in for CXR requested X-ray of right rib cage. aaa. On 2/10/19 at 3:11 PM, (Resident 54) fell going from bathroom to bed in her room. She was instructed to call CNA when she was done on toilet to help transfer her to her bed. She did not do this. She fell on her right side and hit her chin. She was quite shaken up by the fall. She also had been given an order for [REDACTED]. I called (local ambulance transport) and she was transported at 1515 (3:15 PM) to (local hospital). bbb. On 2/10/19 at 3:44 PM, Resident was in the restroom and was educated to pull the call light when done using the rest room so a CNA could help her back to bed. Resident can walk alone but is unsteady and is educated to not walk alone or use her walker. The walker was not with her. She finished using the restroom and tried to walk to her bed without using her call light which she had done many times before. Resident states that she tripped over the small strip that separates the flooring in the bathroom from the bedroom. Pt started to cry and a CNA ran into the room and immediately got the nurse. An assessment was started and the resident states that she fell on her right wrist and her ribs. Vitals were taken and a full head to toe assessment was completed. Resident was not moved until after she was assessed and nurse felt she was stable. Resident had on proper foot wear. Room was assessed for clutter and room was free of clutter. Resident was helped onto her bed where She states she did not hit her head but will start neuro checks at this time due to it being un-witnessed. Pt states that she is in pain. Family notified and family friend in the facility stating that he wants her shipped to the hospital for further evaluation. MD notified and ordered her to be shipped out to (local hospital). Family upset about her fall and states that we should be sitting with her at all times. Alert charting started.Vital signs B/P 146/96, P 83,RR 20,T 98.9 and head to toe assessment immediately done before helping resident up from the floor. Resident fell on her left side and is complaining of increased pain on her right side. Resident was walking out of bathroom and not using her call light because she thought she could make it to her bed and tried to walk alone tripping over the flooring separating the bathroom from the bedroom. Resident had on proper foot ware. Pt is educated to use call light and is very non compliant when using her call light. Resident is alert and oriented x4. Family called and immediately came to the facility. Very upset stating we should have someone sitting with her at all times. Resident was getting a lung xray due to congestion and so they did an xray on her ribs. Results were negative for broken ribs. Family wanted her shipped out for further evaluation to (local hospital). MD notified and gave new order to have her shipped to be further evaluated. EMS (emergency medical services) called to transport resident to (local hospital). Administrator, DON, MD and family notified. ccc. On 2/10/19 at 4:53 PM, At 1130 (11:30 AM), I went in to check resident's blood sugar. She was asllep (sic) so I woke her up. Her BS was 45 but she was alert. I got her to drink 8 oz of o.j. with 2 sugar packets and 8 oz med pass. Resident was more alert and decided to go to lunch. I requested CNA help her down to lunch and they did. She was alert and ate lunch with no problem. Aafter (sic) lunch her BS was 78. ddd. On 2/10/19 at 5:46 PM, Event Note.Administrator, DON, ADON, MDS Event Description: Resident was in the restroom and was educated to pull the call light when done using the rest room so a CNA could help her back to bed. Resident can walk alone but is unsteady and is educated to not walk alone or use her walker. The walker was not with her. She finished using the restroom and tried to walk to her bed without using her call light which she had done many times before. Resident states that she tripped over the small strip that separates the flooring in the bathroom from the bedroom. Pt started to cry and a CNA ran into the room and immediately got the nurse. An assessment was started and the resident states that she fell on her right wrist and her ribs. Vitals were taken and a full head to toe assessment was completed. Resident was not moved until after she was assessed and nurse felt she was stable. Resident had on proper foot wear. Room was assessed for clutter and room was free of clutter. Resident was helped onto her bed where She states she did not hit her head but will start neuro checks at this time due to it being un-witnessed. Pt states that she is in pain. Family notified and family friend in the facility stating that he wants her shipped to the hospital for further evaluation. MD notified and ordered her to be shipped out to (local hospital). Family upset about her fall and states that we should be sitting with her at all times. Alert charting started. Administrator, DON and MD notified. Family all notified. Risk Factors and Root Cause Identification: Resident has a [DIAGNOSES REDACTED]. Residents blood sugar has been running low which has caused some Cognitive Decline et Awareness Preventative Measures: Ensure call light is within reach at all times, Educate resident on the importance of using call light, ensure call light is answered timely et promptly. Provide proper foot wear when resident is out of bed. New Interventions: Vital signs .head to toe assessment immediately done before helping resident up from the floor. Resident fell on her left side and is complaining of increased pain on her right side.Family called and immediately came to the facility. Very upset stating we should have someone sitting with her at all times. Resident was getting a lung xray due to congestion and so they did an xray on her ribs. Results were negative for broken ribs. Family wanted her shipped out for further evaluation to (local hospital). MD notified and gave new order to have her shipped to be further evaluated. EMS called to transport resident to (local hospital). Administrator, DON, MD and family notified. eee. On 2/10/19 at 7:14 PM, Xray report back Basilar pneumonia and pleural effusions suggested, correlate clinically. No definite rib abnormality. MD notified of results. No new orders. Resident was sent to (local hospital). (Local hospital) nurse called with same results. On 5/9/19 at 12:41 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that he remembered resident 54. RN 4 stated that on 2/10/19 resident 54 was sent to the hospital because her blood sugar was low and resident 54 sustained a fall. RN 4 stated that resident 54 was bleeding a lot from her chin after the fall and that resident 54 stated to RN 4 she would be better in the hospital. RN 4 stated that resident 54 had a chest x-ray and the results were that everything was fine. RN 4 stated that he did not do any monitoring because the chest x-ray was fine. RN 4 stated that resident 54 was sent to the hospital by non-emergent ambulance and did not know why progress notes revealed there was contradicting documentation about how resident 54 was sent out. RN 4 stated that he had, the worst memory. RN 4 stated that he did not remember what happened when resident 54 fell but did know that resident 54 insisted that she be sent to the hospital. RN 4 stated he did not remember if he offered to send her to the hospital. RN 4 stated he did not remember anything about resident 54's medicatio (TRUNCATED)