Every finding on record at Monument Healthcare Bountiful

Based on observation, interview, and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that each resident received supervision and assistance devices to prevent accidents. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and it was determined that the lift was missing safety latches on the cradle hooks. Resident identifier: 2.NOTICEOn [DATE] at 10:38 AM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Notice of IJ was given verbally and in writing to the facility Administrator (ADM), Director of Nursing (DON), and the Regional Compliance Nurse (RCN). On [DATE] at 2:46 PM, the Administrator provided the following abatement plan for the removal of the IJ effective on [DATE] at 2:30 PM. Immediate Action Taken1. 2 Hoyer lifts in question were removed from the facility on [DATE] at 1040 [10:40 AM]. 2. 2 new Hoyer lifts were rented the evening of [DATE] from [Durable Medical Equipment (DME) name omitted] to replace the Hoyer lifts in question.3. On [DATE] all Hoyer Lifts were inspected and staff on shift were trained and performed a return demonstration to show competency.4. Manufacturer guide was obtained for new Hoyer lifts5. Education to facility maintenance team that if there is ever a concern with equipment that it is pulled out of use immediately.6. Hoyer lift policy updated for clarityIdentification of others:1. On [DATE], the nursing administration performed a skin check on all 13 residents that use the Hoyer Lifts and have potential to be affected.2. All residents that are able to be interviewed were questioned in regard to their experience with mechanical lifts. No additional concerns have been identified.Ongoing Compliance Plan:1. Before clinical staff work their next shift, they will be required to pass off and return demonstrate the correct way to use the Hoyer Lifts per manufacturer guides and assess for safe function.2. Rental of Hoyer Lifts will continue until the original Hoyer Lifts can be replaced/repaired.3. Hoyer use training will be passed off before a new clinical employee operates them as part of general orientation and annually and as needed.Monitoring:1. The manufacturer's guide was obtained for new Hoyer Lifts and a weekly audit/inspection will be completed by Maintenance manager/designee to ensure functionality and efficacy per manufacturer's guidelines. Any defective equipment will be removed and replaced.2. Clinical staff will be randomly interviewed and/or observed at an interval of 5 times per week regarding appropriate Hoyer lift use and safety x 4 weeks for one month, then 2 per week for one month and 1 per week for one month.3. All monitoring results will be presented to facility QAPI [Quality Assurance and Performance Inprovement] and plan of correction will be adjusted as needed by QAPI team.On [DATE] at 2:36 PM, while completing the abbreviated complaint 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 [DATE] at 2:30 PM. Findings included:Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, fracture of the right femur, abrasion of lower back, asthma, insomnia, major depressive disorder, obstructive sleep apnea, hemiplegia and hemiparesis, respiratory failure, hypertension, dysphagia, cognitive communication deficit, anxiety disorder, presence of urogenital implants, and bilateral cataracts.Resident 2's medical record was reviewed.On [DATE], resident 2's annual Minimum Data Set (MDS) assessment documented that resident 2 had a Brief Interview for Mental Status score of 13, which indicated that the resident was cognitively intact. The assessment documented that the resident had a functional limitation in Range of Motion to the bilateral lower extremities and that a wheelchair was utilized as a mobility device.On [DATE], the Restorative Program review documented that the resident was unable to complete functional tasks of bed mobility, and upper extremity strength due to history of a stroke.On [DATE], the Interdisciplinary Team (IDT) fall review documented that resident 2 sustained a fall from a Hoyer lift on [DATE] at 8:00 AM. The injuries documented were bruising to the buttocks and pain in the left shoulder. RNA [Restorative Nurse Aide] alerted nurse that resident had fallen from the Hoyer lift during transfer from bed to wheelchair. Nurse rushed into room to assess resident. Resident was found on her back slightly on R [right] side. Nurse evaluated resident for step off or fx [fractured] limbs and extremities and spine felt intact with no step off felt or unusual movement and pain to joints or extremities. Resident did c/o [complaints of] pain to L [left] knee and R hip. Goose egg to back of L side head found approximately 30 mins [minutes] after fall. The new intervention identified was coaching for the staff member that set up the Hoyer. On [DATE] at 1:20 PM, the Discharge-Transfer report documented that the resident was transferred to the hospital with Almost Constantly c/o pain with a score of 9/10.On [DATE], the IDT for functional status section GG of the MDS documented the reason for the evaluation was discharge. The resident was documented as dependent for toileting, showers, lower body dressing, and transfers.Review of the progress notes revealed the following:a. On [DATE] at 12:13 AM, the provider note documented, Mobility: Wheelchair dependent, requires assistance for all transfers and ADLs [activities of daily living]. Power chair driving privileges removed for safety; retains repositioning features.b. On [DATE] at 7:36 AM, the nursing note documented, RNA alerted nurse that resident had fallen from the Hoyer lift during transfer from bed to wheelchair. Nurse rushed into room to assess resident. Resident was found on her back slightly on R side. Nurse evaluated resident for step off or fx limbs and extremities and spine felt intact with no step off felt or unusual movement and pain to joints or extremities. Resident did c/o pain to L knee and R hip. Goose egg to back of L side head found approximately 30mins after fall.Nurse evaluated resident for injuries, broken bones, bruising and pain. No new injuries noted but resident did c/o pain to R shoulder, R hip, and L knee. Bruising to R buttock was already present and being monitored before fall. Nurse notified On-call [provider company name omitted] provider [name omitted]. Neworders [sic] received from provider for x-rays to R shoulder, R hip, and bilateral knee 2 views, and to start neuro's [neurological assessment] and to apply ice PRN [as needed] and PRN pain medications as applicable. Neuros started.c. On [DATE] at 6:39 PM, the nursing note documented, Alert note: res [resident] had fall at shift change on day shift. On-call notified new orders received for x-ray to R shoulder, R hip, and bilat [bilateral] knees. Also to start neuros and hold RNA therapy until x-ray results received and reviewed by provider. X-ray done and results were reviewed by provider, new order to continue RNA received by this nurse.d. On [DATE] at 8:53 AM, the IDT Fall Review note documented, IDT Review of Fall: Resident sustained a fall on [DATE] 8:00 AM with minor injury: MINOR Bruising to buttock and pain in LT [left] shoulder Fall (1) details: RNA alerted nurse that resident had fallen from the Hoyer lift during transfer from bed to wheelchair. Nurse rushed into room to assess resident. Resident was found on her back slightly on R side. Nurse evaluated resident for step off or fx limbs and extremities and spine felt intact with no step off felt or unusual movement and pain to joints or extremities. Resident did c/o pain to L knee and R hip. Goose egg to back of L side head found approximately 30mins after fall.FALL RESPONSEThis information was reviewed by the Interdisciplinary Team (IDT) and the following new intervention(s) placed: Coaching and discipline for the staff member that set up the hoyer.Fall Report: MD [Medical Doctor]/Provider notified. Responsible party notified.e. On [DATE] at 1:20 PM, the Discharge summary documented, Type: Hospital Transfer [name omitted] hospital Critical Access Hospital[DATE] 1:20 PMTransported via Non-Emergent TransportDetails:A&O 3 [alert and oriented person, time, and place] and able to make needs known.f. On [DATE] at 4:57 PM, the progress note documented, Note Text: Patient complained of extreme pain on the right side of the groin and anterior hip area. She rated the pain as 9/10. Percocet was administered but provided only minimal relief for approximately one hour, according to the patient. She screamed during care due to the severity of the pain. Movement significantly exacerbated the pain. No discoloration or swelling was noted at the site.Patient requested to be sent to ER [emergency room] due to increasing and persistent pain. The provider was notified, and an order was received to send the patient to the ER, despite negative X-ray results for fracture.patient described the pain as sharp and throbbing, occurring intermittently at rest but becoming very severe with movement.Patient was transferred to [name omitted] ER at 1:20 PM. notified POA (Power of Attorney) [name omitted].On [DATE], resident 2's X-ray findings revealed the following:Right shoulder impression within normal right shoulder, no change indicating fx., dislocation, or lesion. Right hip impression was minor right hip arthritic change, no fracture or dislocation.Left knee impression was in excellent position, there has been a total knee replacement and the patellar, femoral, and tibial parts all in excellent position.On [DATE], resident 2's hospital history and physical documented that a pelvis computed tomography showed a right humeral neck fracture. The resident had significant pain. The orthopedic surgeon was consulted and recommended hospital admission to evaluate if the resident was a surgical candidate. The surgical consult ultimately recommended no surgical intervention at this time.The facility investigation summary documented that the witnesses to the incident were Certified Nursing Assistant (CNA) 1 and CNA 2. The incident review documented that on [DATE], the resident had an assisted fall during a Hoyer lift transfer. No signs and symptoms of injury were noted when x-rays were reviewed by the provider. The resident had increased pain and was sent to the hospital on [DATE], for further evaluation. The resident was diagnosed with a hip fracture at the hospital. The summary documented that the facility had implemented mechanical lift checks, sling checks, and in-service to assure all staff that use mechanical lifts were aware of the procedures.On [DATE] at 11:24 AM, an interview was conducted with resident 2. Resident 2 was in her motorized wheelchair and was assisted back to her room by CNA 1. The resident was observed seated on a Hoyer sling in her wheelchair. Resident 2 sated that she was dropped from the Hoyer lift. Resident 2 stated that she could not recall any of the details of the incident. Resident 2's roommate, resident 6, stated that she was present when the resident was dropped from the Hoyer. Resident 6 stated that the staff who was assisting during the transfer was not trained, and the strap to the Hoyer was not secured. The strap came off and she went down. Resident 2 stated that she had pain in the right hip, that she had broken her hip, but did not recall any of the details of the injury. Resident 2 stated she recalled the pain though.On [DATE] at 1:31 PM, an interview with the DON. The DON stated that CNA 2 hooked resident 2 to the Hoyer, lifted her up, and then CNA 1 came to assist her. The DON stated that they determined that one of the sling straps was not attached. The DON stated that upon investigation they determined that CNA 2 knew that she should have had two staff present for the Hoyer transfer and she did not. The DON stated that CNA 2 showed low remorse for not following the facility policy, and they determined that it was too big a risk to keep her employed at the facility. The DON stated that they inspected the sling and the Hoyer Lifts and they all checked out and were in good working condition. The DON stated that when the nurse helped the CNA afterwards one of the straps was not hooked to the Hoyer. The DON stated that this Hoyer sling had three straps on each side and it was the left side that had only two straps attached to the lift hooks. The DON stated that during the investigation they conducted staff interviews, inspected the sling and Hoyer, and then conducted training with every CNA on the Hoyer use which emphasized inspecting the sling each time for damage and proper placement.On [DATE] at 3:31 PM, an interview was conducted with CNA 1. CNA 1 stated that when he arrived to resident 2's room the other CNA had the Hoyer sling on resident 2 and it was hooked up to the lift. CNA 1 stated the sling had six hooks total and the middle hook on the right side was not secured. CNA 1 stated at the time he arrived the resident was already suspended in the Hoyer lift. CNA 1 stated that CNA 2 did not ask for assistance with the Hoyer lift transfer and that he had just entered the room to do checks as the RNA. CNA 1 stated that he assumed that CNA 2 had checked everything with the Hoyer. CNA 1 stated that he did not inspect the sling for proper placement because he assumed that the other CNA 2 had already done that. CNA 1 stated that when transferring using a Hoyer you should make sure that the lift was functioning and then inspect the sling to make sure it was not damaged or expired. CNA 1 stated that two trained staff were required for a Hoyer transfer. CNA 1 stated that one staff was controlling the machine and the other person would move the resident and position them over to the transferred device, i.e. chair or stretcher. The second staff would direct the resident as they were lowered and verify position or placement. CNA 1 stated that when they had the resident positioned almost over the wheelchair he heard a pop and that was when the resident slid out from the sling. The resident was approximately 4-5 feet off the ground. CNA 1 stated that resident 2 hit her hip on the wheelchair leg. CNA 1 stated that CNA 2 asked him about the sling and told him she was not familiar with it. CNA 1 stated that if the sling been inspected for proper placement he believed the fall could have been prevented. CNA 1 stated that CNA 2 was moving pretty fast because she had a lot of showers that she had to do.On [DATE] at 3:58 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 2 was being transferred with a Hoyer lift and had a fall. CNA 2 stated that she placed the Hoyer sling under resident 2 and attached it to the Hoyer lift and then CNA 2 walked into the resident's room. She started to lift her off the bed and one of the straps came undone and she fell out of the sling and hit the ground. CNA 2 stated that the resident was approximately 4 feet suspended when she fell out of the sling. CNA 2 stated that she assumed that CNA 1 had inspected the straps for placement, but it was my bad that she did not verify placement. CNA 2 stated that the Hoyer sling had three straps on each side instead of two straps and it tended to push the third strap off the hook. CNA 2 stated that usually the cradle had clips (safety latches) that closed the hook so that the strap did not slide off and this lift did not have that.On [DATE] at 4:20 PM, an observation was made of two Viking XL Hoyer Lifts with CNA 1. CNA 1 stated that the Hoyer Lift with the scale was utilized during the incident with resident 2's fall. The lift with the scale was observed with a one safety latch on the bottom left hook and the other three hooks did not have safety latches. CNA 1 stated that was the only clip/latch present at the time of resident 2's fall. CNA 1 stated that the clips keep the strap in place. CNA 1 stated that after resident 2's fall he inspected the Hoyer lifts and noted that both lifts were missing safety clips. CNA 1 stated that they ordered new clips but they were too thick and did not fit the lifts. The second lift without the scale was observed with two clips present on both bottom hooks, but the top hooks were missing the safety clips. CNA 1 stated that since the incident they have not fixed the missing clips on the Hoyer Lifts because they were not been able to find replacements from the DME company or the local hardware store.On [DATE] at 4:31 PM, a follow-up interview was conducted with the DON. The DON stated that after the incident the CNA Coordinator and CNA 1 had inspected all the Hoyer slings, and and the Regional Operations Facilities Manager calibrated and inspected the Hoyer lifts. The DON stated that one of the weights was off and that was corrected. The DON stated that the lifts had safety latches on each hook to secure the straps on the hooks. The DON stated that no issues were identified with the latches. The DON stated that if the latches were missing that would be concerning because it was open, and it posed a risk of malfunction and harm. The DON stated that without the safety latches the lifts were not in good working condition and the slings could potentially slip off.Review of the Viking XL Mobile Lift Instruction Guide documented under safety to ensure the latches are intact; missing or damaged latches must always be replaced; . The guide further documented under Installation of Latches, After installation, ensure that the spring loaded latches is taut against the sling bar and moves freely in the sling bar hook.Review of the facility policy and procedure for Positioning/Moving: Lifting Machine, Using a Mechanical documented under general guidelines that at least two nursing assistants were needed to safely move a resident with a mechanical lift. The policy documented under procedure steps to Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition. The policy further documented, Attach sling straps to sling bar, according to manufacturer's instructions. a. Make sure the sling is securely attached to the clips and that it is properly balanced. b. Check to make sure the resident's head, neck and back are supported. c. Before resident is lifted, double check the security of the sling attachment. d. Examine all hooks, clips or fasteners. e. Check the stability of the straps. f. Ensure that the sling bar is securely attached and sound. The policy was last revised on February 1, 2024.

Based on interview and record review it was determined, for 1 out of 6 sampled residents, the facility did not ensure that all alleged violations involving neglect were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and the State Survey Agency (SSA) and Adult Protective Services (APS) were not notified within 24 hours of the incident. Resident identifier: 2.Findings included:Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, fracture of the right femur, abrasion of lower back, asthma, insomnia, major depressive disorder, obstructive sleep apnea, hemiplegia and hemiparesis, respiratory failure, hypertension, dysphagia, cognitive communication deficit, anxiety disorder, presence of urogenital implants, and bilateral cataracts.Resident 2's medical record was reviewed. On 9/25/25, the Interdisciplinary Team fall review documented that resident 2 sustained a fall from a Hoyer lift on 9/22/25 at 8:00 AM.The facility abuse investigation documented that the facility reported to the SSA that on 9/29/25 at 1:45 PM, Certified Nurse Assistant (CNA) 1 and CNA 2 were assisting resident 2 with a Hoyer lift transfer, and resident 2 fell out of sling upon lifting. It should be noted that the SSA was notified of the incident approximately seven days after the injury occurred. Additionally, no documentation could be found to demonstrate that APS was notified of the incident. On 11/5/25 at 1:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were mandated to report to the SSA to identify problems such as harm, neglect, and policy failures. The DON stated that the regulatory requirement for reporting to the state for suspected abuse or neglect was two hours. The DON confirmed that from the investigation it was not evident that they investigated the incident for possible neglect. The DON stated that they did not report to APS and she did not know why.

Based on interview and record review it was determined, for 1 out of 6 sampled residents, that in response to allegations of neglect the facility must have evidence that all alleged violations were thoroughly investigated. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and the facility abuse investigation did not contain documentation of all staff and resident interviews that were conducted to rule out neglect. Additionally, the abuse investigation incorrectly documented the date of the incident.Findings included:Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, fracture of the right femur, abrasion of lower back, asthma, insomnia, major depressive disorder, obstructive sleep apnea, hemiplegia and hemiparesis, respiratory failure, hypertension, dysphagia, cognitive communication deficit, anxiety disorder, presence of urogenital implants, and bilateral cataracts.Resident 2's medical record was reviewed. On 9/22/25 at 7:36 AM, the nursing note documented, RNA [Restorative Nurse Aide] alerted nurse that resident had fallen from the Hoyer lift during transfer from bed to wheelchair. Nurse rushed into room to assess resident. Resident was found on her back slightly on R [right] side. Nurse evaluated resident for step off or fx [fracture] limbs and extremities and spine felt intact with no step off felt or unusual movement and pain to joints or extremities. Resident did c/o [complaint of] pain to L [left] knee and R hip. Goose egg to back of L side head found approximately 30mins [minutes] [sic] after fall.Nurse evaluated resident for injuries, broken bones, bruising and pain. No new injuries noted but resident did c/o pain to R shoulder, R hip, and L knee. Bruising to R buttock was already present and being monitored before fall. Nurse notified On-call [provider company name omitted] provider [name omitted]. Neworders [sic] received from provider for x-rays to R shoulder, R hip, and bilateral knee 2 views, and to start neuro's [neurological assessment] and to apply ice PRN [as needed] and PRN pain medications as applicable. Neuros started.On 9/25/25, the Interdisciplinary Team fall review documented that resident 2 sustained a fall from a Hoyer lift on 9/22/25 at 8:00 AM.The facility abuse investigation documented that the facility reported to the State Survey Agency (SSA) that on 9/29/25 at 1:45 PM, Certified Nurse Assistant (CNA) 1 and CNA 2 were assisting resident 2 with a Hoyer lift transfer, and resident 2 fell out of sling upon lifting. The investigation documentation did not contain interviews with CNA 1 or CNA 2 regarding the incident. Additionally, the Investigation Summary documented that an interview was conducted with resident 2, but no documentation could be found of the interview. On 11/5/25 at 1:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were mandated to report to the SSA to identify problems such as harm, neglect, and policy failures. The DON stated that during the investigation they conducted staff interviews, inspected the sling and Hoyer, and then conducted training with every CNA on the Hoyer use which emphasized inspecting the sling each time for damage and proper placement. The DON stated she would have to ask the previous Administrator where the interviews for the staff and resident were located. The DON confirmed that from the investigation it was not evident that they investigated the incident for possible neglect and that the investigation documentation did not contain copies of the interviews that were completed.

Based on observation, interview, and record review, the provider failed to ensure that all residents had appropriate supervision to prevent accidents. Specifically, one resident was being pushed in a wheelchair without footrests by facility staff, and the resident fell out of the wheelchair, hitting her face, causing scrapes and a lip laceration. Resident identifier: 2. In response to the incident involving Resident 2, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined that the facility had implemented corrective measures and met the requirements of F689. Due to the facility's corrective measures, the noncompliance was determined to be past noncompliance. The facility's corrective action plan, which was developed and implemented by May 10, 2025, included the following measures: a. Therapy and nursing inspected the wheelchair used by Resident 2 during the incident and removed it from service pending the evaluation. b. The facility's Fall Prevention policy was updated to clarify that footrests must be used at all times during resident transport unless medically contraindicated. On April 29, 2025 a staffing inservice was conducted on the policy. c. The Director of Nursing (DON) conducted weekly wheelchair safety rounds to verify the proper positioning of footrests. d. Facility staff completed daily visual wheelchair safety checks for all high-risk residents. e. Therapy evaluated all wheelchair- dependent residents by May 10, 2025. The evaluations conducted were to ensure each wheelchair met safety standards and was equipped with all necessary components. f. On April 28, 2025, Resident 2's care plan was updated with the intervention of the use of bilateral footrests when staff transported the resident. While allowing Resident 2 to use a single footrest when self-propelling. Findings include: The surveyor reviewed Resident 2's medical records, and the following entries were observed: a. Resident 2's care plan at the time of the incident indicated that due to diagnoses of Cerebral Palsy, pain, functional quadriplegia, contractures to the right and left hands and fingers, and balance deficits, she had difficulty completing activities of daily living independently. It was also documented that Resident 2 was able to self-propel in her wheelchair, as she was able to use one foot. b. A nurse documented in a nursing note on April 28, 2025 that Resident 2 was being propelled in a wheelchair by a Certified Nursing Assistant (CNA) to her bedroom, and Resident 2 fell out of her wheelchair and was unable to brace her fall due to her cerebral palsy and quadriplegia; she landed on her face. Resident 2 was bleeding from her mouth and was coughing and crying. Resident 2 was able to inform the nurse what hurt on her body, but was unable to say full sentences due to shallow breathing. Resident 2 stated that her back, mouth, face, and chest hurt. The nurse documented that Resident 2 had abrasions noted under her right eye, and on the right side of her nose, and had blood running down her mouth with clots forming. Resident 2 also had a skin tear to her right wrist and redness noted on her back. Resident 2 had an abnormal breathing rhythm with shallow breathing noted. Resident 2 stated she wanted to go to the hospital when asked. Emergency Medical Services (EMS) arrived and transferred Resident 2 to a local hospital. c. A review of Resident 2's emergency room (ER) visit notes revealed there were no Fractures. There was superficial abrasion to the facial area and wrist. d. A dental appointment note dated April 29, 2025, completed by the dentist, included documentation that an oral evaluation was conducted on Resident 2 at the request of a nurse practitioner, as Resident 2 had fallen and there was concern that some of her teeth might be broken. The Dentist documented that Resident 2 had no broken teeth from the fall, and that two teeth that were broken had already been broken before the fall. The Dentist documented that it appeared Resident 2 had bitten through her lip when she fell, which could be causing the pain. A surveyor reviewed the investigation summary, which revealed that the staff involved in the incident were pushing Resident 2 in her wheelchair. Resident 2's foot caught the ground, and she then fell forward onto the ground. On June 9, 2025, at approximately 10:30 am, a surveyor conducted an interview with Resident 2. Resident 2 stated that she had not experienced any falls and that the staff had taken care of her needs. The surveyor observed that Resident 2 had bilateral footrests on her wheelchair. On June 9, 2025, a surveyor conducted an interview with two CNAs. Both CNAs stated that when transferring a resident in a wheelchair they will make sure the footrests are down and the residents feet are on the wheelchair and to make sure the residents back and butt are all the way back on the wheelchair. On June 9, 2025, a surveyor conducted an interview with the DON. The DON stated that after Resident 2 fell, the facility educated the staff member involved 1 on 1, as well as group education with staff. The DON stated that she performed visual checks on each resident who used a wheelchair to ensure they were sitting properly in the chair with their feet in the correct position. Additionally, when being transferred by staff, the leg rests were lowered. DON stated that the therapy team reviewed all wheelchair-dependent residents to ensure their wheelchairs were safe. The DON stated that the hospital's recommendation for a dental appointment pertained to teeth that were broken prior to the fall.

Based on observation, interview, and record review, the provider failed to ensure that each resident was free from significant medication errors. Specifically, a nurse administered the incorrect medications to a resident. Resident identifiers: 1 In response to the incident involving Resident 1, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined that the facility had implemented corrective measures and met the requirements of F760. Due to the facility's corrective measures, the noncompliance was determined to be past noncompliance. The facility's corrective action plan, which was developed and implemented by May 17, 2025, included the following measures: a. The nurse involved in the incident was removed from the facility staff. b. Medication training was implemented for both current and new staff. c. The quality assurance nurse initiated a monthly medication pass audit to ensure physician orders were followed and medication administration was accurately documented. d. Medication error and risk management reviews were added to the facility's (monthly/quarterly) Quality Assurance and Performance Improvement agenda. Findings Include: The surveyor reviewed resident 1's medical records and incident reports. The following entries were observed. a. A nurse documented in an Incident Note on May 17, 2025 at 11:21 PM that Resident 1 was accidentally given her roommate's medications. The physician was notified and ordered the nurse to hold Resident 1's scheduled Tylenol (for pain), Senna (for constipation), and Trazodone (for insomnia). The nurse was ordered to monitor resident 1 and contact their emergency contact. b. After the incident, nursing staff initiated additional assessments each shift for Resident 1 to promptly identify any changes in status resulting from the medication error. Throughout May 18, 2025, Resident 1's condition remained at its baseline, with no noted changes. The surveyor reviewed the facility's investigation that was completed on May, 21, 2025. On May 21, 2025, the DON interviewed RN 1, the nurse who administered the incorrect medications to Resident 2. RN 1 reported that she administered Resident 1 her roommate's medications by accident. The medications were acetaminophen tablet 325 milligrams (mg), senna tablet 8.6mg, trazodone oral tablet 50mg, and extended release morphine 15mg. RN 1 called the nurse manager on call for further directions, contacted the on-call provider for recommendations, checked the resident for allergies, and initiated neurological checks. The on-call provider told RN 1 to hold Resident 1's Tylenol 1000mg, senna 8.6mg, and trazodone 50mg. RN 1 called Resident 1's emergency contact and continued to check on Resident 1 throughout her shift, which ended at 12:00 PM. RN 1 passed the report on to the oncoming nurse and confirmed that Resident 1 did not experience any side effects from the incorrect medications. The surveyor interviewed the DON on June 9, 2025. The DON stated that she had received a phone call on May 17th, 2025 from RN 1, who reported that she had accidentally given Resident 1 her roommate's medications. The DON directed RN 1 to call the on-call provider, start neurological checks, and report any adverse reactions.The DON stated that this had been the only medication error in the past 60 days, and multiple measures were in place to prevent the incident. The DON stated that the agency nurse was not permitted to work at the facility after the incident.

Based on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required services consistent with professional standards of practice and the comprehensive person-centered care plan and the resident's goals and preferences. Specifically, for 1 out of 18 sampled residents, a resident was not provided pain medications prior to wound care treatments nor afterwards and the resident had complaints of pain throughout the treatment. Resident identifier: 42. Findings included: Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, orthostatic hypotension, anemia, chronic kidney disease, dementia, pain, abrasion right foot, anxiety disorder, pressure ulcer right and left heel unstageable, restless leg syndrome, presence right knee joint, peptic ulcer, depression, and anorexia. On 12/16/24 at 9:06 AM, an interview was conducted with resident 42. Resident 42 stated that he had pain in the right knee and right toes. A healed surgical scar was observed on resident 42's right knee. Resident 42 stated that his current pain was an 8 out of 10 on a pain scale with 10 being the worse pain possible. Resident 42 stated that the staff had not given him anything for his pain and he had not requested anything for it yet. Resident 42's medical record was reviewed on 12/16/24 through 12/18/24. On 11/19/24, resident 42's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 8 out of 15 which would indicate a moderate cognitive impairment. The MDS assessment documented that resident 42 was dependent on staff for toileting hygiene, lower body dressing, and putting on and taking off footwear; and was a substantial/maximal staff assist for showers, rolling left to right, sitting to lying, sit to stand, and transfers. Resident 42's physician's orders revealed the following: a. On 10/13/24, an order was initiated for Acetaminophen Oral Tablet 500 milligram (mg), give two tablets by mouth every eight hours as needed for pain. b. On 10/13/24, an order was initiated for a pain evaluation to be conducted every shift. c. On 12/6/24, an order was initiated for Morphine Sulfate (Concentrate) Oral Solution 20 mg/milliliter (ml), give 0.25 ml by mouth every hour as needed for pain. Resident 42's December 2024 Medication Administration Record (MAR) documented pain scores of 1 to 4 with the majority of scores being a 0. The MAR documented on 12/6/24, a pain score of 8 out of 10. The MAR documented that Tylenol was administered 10 times for pain scores of 1 to 8 and all administrations were documented as effective. On 12/6/24, Morphine was ordered and no documentation of administration was noted. On 12/16/24, the MAR documented that the resident was last given Tylenol at 4:19 PM, and the medication was documented as effective. On 12/17/24 for the morning shift the licensed nurse documented a pain score of 0 out of 10. On 12/11/24, the Pressure Injury and Wound evaluation documented a right and left heel pressure ulcer. The right heel measured 3.7 centimeter (cm) length x (by) 6.8 cm width x 0.3 cm depth. The wound was documented as unstageable with obscured full-thickness skin and tissue loss. The left heel measured 3.5 cm x 3.5 cm x 0.3 cm. The wound was documented as unstageable with obscured full-thickness skin and tissue loss. On 8/28/24, resident 42 had a care plan initiated for at risk for pain related to inflammation of prosthetic devices, restless leg syndrome, pressure ulcers and Peptic ulcer. Interventions identified on the care plan included: Administer analgesia medication as per orders; Anticipate need for pain relief and respond as soon as possible to any complaint of pain; Monitor/document for side effects of pain medication; Monitor/record/report to nurse resident complaints of pain or requests for pain treatment; and Notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. On 12/17/24 at 8:40 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 42 was dependent on staff for cares and mostly stayed in bed. CNA 1 stated that resident 42 had pain in his right knee from a previous surgery and he did not like to straighten that leg. CNA 1 stated that the knee stayed bent and they propped a pillow underneath it for comfort and support. CNA 1 stated that resident 42 complained of pain with any movement of that knee and leg and would become agitated with cares. CNA 1 stated that resident 42 had wounds on both feet and the podus boots were to be worn while the resident was in bed. On 12/17/24 at 10:46 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 42 was alert and oriented to self only. RN 3 stated that resident 42 had dementia with occasional confusion, and had both short and long term memory deficits. RN 3 stated that resident 42 complained of pain in the bilateral heels and the right knee. RN 3 stated that resident 42 had pressure ulcers on both heels and his right knee was contracted due to a previous surgery. RN 3 stated that she evaluated resident 42's pain using the Pain Assessment in Advanced Dementia scale. RN 3 stated that resident 42 would vocalize pain with any wound care and dressing changes and would start to yell. RN 3 stated that resident 42 had both Tylenol and Morphine ordered for pain management. RN 3 stated that the Morphine was a new order and had not been administered yet. RN 3 stated that she evaluated resident 42's pain during the scheduled medication administration times and with any wound care. RN 3 stated that the Tylenol was effective if it was given in the morning and evening and she thought it controlled resident 42's pain. RN 3 stated that she liked to administer Tylenol before or after wound care because the wound care was uncomfortable for him. On 12/17/24 at 11:58 AM, an observation was made of RN 3 performing wound care on resident 42's bilateral heel pressure ulcers. RN 3 gathered her wound care supplies and donned a gown and gloves for wound care. RN 3 asked resident 42 prior to wound care what his level of pain was and the resident stated it was a 2 out of 10 and the right foot was worse than the left. RN 3 attempted to reposition resident 42 and attempted to straighten the right leg. Resident 42 was observed moaning during the repositioning of the legs. RN 3 removed the podus boot and sock from resident 42's right foot. Resident 42 stated Owe, watch that heel. RN 3 removed the podus boot and sock from left foot and resident 42 moaned in pain. RN 3 removed the old dressing from the right heel and resident 42 moaned. RN 3 placed a 2 x 2 gauze that was soaked in wound cleanser on the wound bed. Resident 42 moaned and stated owe. RN 3 wiped the wound bed in a circular motion with the gauze and resident 42 moaned in pain throughout the wound care that was provided to the right heel. RN 3 asked resident 42 if he wanted some Tylenol and resident 42 replied no. RN 3 again asked if she could bring him some Tylenol and resident 42 replied okay. RN 3 doffed her Personal Protective Equipment and exited the room to obtain more wound care supplies. RN 3 returned with more wound care supplies and donned a gown and gloves. RN 3 did not administer any Tylenol to resident 42. RN 3 removed the old dressing from the left heel and stated that slough came off with the dressing. The dressing was observed to stick to the wound bed during removal. RN 3 stated that the left heel wound was open to the bone. RN 3 applied a 2 x 2 gauze dressing soaked in wound cleanser to the wound bed and the wound was cleaned using a circular motion. Resident 42 was observed to moan throughout the dressing change to the left foot. Upon completion of the wound care RN 3 told resident 42 that she would bring him some Tylenol along with a protein drink. RN 3 exited the resident room. On 12/17/24 at 3:17 PM, a follow-up interview was conducted with RN 3 RN 3 stated that she did not attempt to premedicate resident 42 with pain medication prior to wound care today. RN 3 stated that premedicating with pain medication helped resident 42 and she should have done that. RN 3 stated that she still had not administered any pain medication to resident 42. On 12/18/24 at 8:08 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that for any pain associated with wound care the licensed nurse should administer pain medication 30 to 40 minutes prior to wound care. The DON was informed of the wound care observation with resident 42 and the observations of pain. The DON stated, he has a morphine order too. The DON was informed that the resident had not been administered pain medication prior to wound care nor afterwards up until 3:17 PM, no further comment was provided.

Based on interview and record review, the facility did not ensure that residents received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident slid out of her wheelchair during a transport and sustained a femur fracture. Resident identifier: 20 Finding included: Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease, type 2 diabetes mellitus, unspecified asthma, fatty liver, anxiety disorder, major depressive disorder, essential hypertension, muscle weakness, and cognitive communication deficit. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 20 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 8 to 12 would suggest moderate cognitive impairment. In addition, section GG functional range of motion revealed that resident 20 had impairment on both sides in the lower extremities. A review of resident 20's progress notes revealed the following: a. On 11/18/24 at 12:00 AM, a speech therapy note documented, . SLP [speech language pathologist] instructed pt [patient] to recall appointment 3 days prior. Pt unable to recall appointment three days prior indicating decrease short term recall skills. With max [maximum] verbal cues, Patient able to recall going to appointment and falling out of wheelchair. SLP reviewed strategies to prevent falls from wheelchair and from bed in which patient verbalized understanding. SLP and patient discussed possible electric wheelchair for patient in which SLP provided wheelchair company with patient's information. SLP reviewed strategies to prevent falls and prevent cognitive communication decline. b. On 11/19/24 at 3:19 PM, a health status note documented, Note Text: ADON [Assistant Director of Nursing] noted an abrasion that has scabbed over her right knee and asked what happened and patient said 'Oh I fell when I went to the eye doctor.' ADON asked how she fell and she said the wheelchair tipped over and the driver asked strangers for help. She doesn't recall any other information. No other injuries noted. NP [Nurse Practitioner] [name redacted] in the building and informed him. [Name redacted] also assessed the patient and said that she is fine. DON [Director of Nursing] made aware. c. On 11/20/24 at 12:00 AM, a speech therapy note documented, . To increase short term recall skills, SLP instructed pt to recall appointment 3 days prior. Pt unable to recall appointment three days prior indicating decrease short term recall skills. With max verbal cues, Patient able to recall going to appointment and falling out of [sic] wheelchair. d. On 11/26/24 at 1:32 PM, a note documented, Note Text: pt complaining of Bilateral knee and hip pain. pt was assessed by [facility contracted name redacted] provider who ordered bilateral knee and bilateral hip x rays. e. On 11/27/24 at 12:45 AM, a radiology results note documented, Note Text: Requested and received XR [x-ray] results for L [left] knee, pelvis and bilat [bilateral] hips, all findings normal, results to MD [Medical Doctor]. f. On 11/27/24 at 9:33 AM, a progress note documented the following, Note Text: Resident complaining of severe pain to Rt. [right] knee. Bruising present, site warm to touch, abrasion noted to shin. Ice packs applied. recent xrays [sic] performed to Lt. [left] knee with no abnormal findings. Resident requesting xrays [sic] to be done on Rt. knee. g. On 11/27/24 at 10:11 AM, an alert charting note documented, Change of Condition Summary: Message left for provider to return call regarding Rt knee and if we need to x ray. [sic] Nurse manager printed xray [sic] report for this nurse, this nurse messaged Provider. Awaiting orders. h. On 11/27/24 at 12:26 PM, an alert charting note documented, Change of Condition Summary: Radiology called this nurse with critical FX [fracture] to Rt Leg/knee. [medical provider name redacted] aware here at facility. i. On 11/27/24 at 12:46 PM, a communication with physician note documented, Note Text: [Medical provider name redacted] here. N.O. [new order]to send pt to ER [emergency room ] for TX [treatment] and Eval.[evaluation] Non-ER ambulance called/report given. Copy of Face Sheet and meds [medications] ready for pick up. Message left for stepdaughter, [name redacted] about N.O. results. j. On 11/27/24 at 5:30 PM, a progress note documented, Note Text: [Resident 20] returned from the hospital r/t [related to] pain and fx. She has a knee immobilizer in place. The hospital reports a complicated slightly displaced metaphysis fx of the distal right femur. This is an extensive surgery to repair, d/t [due to] comorbid conditions, there is significant risk to doing a surgery like this. Use the immobilizer, continue Non weightbearing [sic] in wheelchair as needed. Please see pt visit notes. A review of resident 20's physician's orders revealed: a. On 11/26/24 at 1:14 PM, obtain 3 View x ray [sic] of R [right] knee and R hip one time only for r hip and r knee pain for 1 Day. b. On 11/26/24 at 1:20 PM, obtain 3 view L knee and L hip x ray one time only for L hip and L knee pain for 1 Day. A review of resident 20's hospital emergency room history and physical dated 11/27/24, documented . Patient is complaining of significant pain primarily in the right hip she does report having a fall where she slid out of her wheelchair 1 week ago, she has had ongoing pain with pain in the right knee, pain primarily in the right hip. A review of resident 20's November 2024 Medication Administration Record revealed: a. On 11/20/24, an as needed (PRN) Percocet Tablet 5-325 milligram (mg) was administered for a pain score of 6. b. On 11/25/24, a PRN Percocet Tablet 5-325 mg was administered for a pain score of 9. c. On 11/26/24, a PRN Percocet Tablet 5-325 mg was administered for a pain score of 6. It should be noted that resident 20 did not receive PRN Percocet for pain on any other days in November 2024. On 12/17/24 at 10:55 AM, an interview was conducted with the DON. The DON stated that the van driver from the contracted company did not inform the facility that resident 20 had fallen out of her wheelchair during transport to an appointment. The DON stated that resident 20 started complaining of pain on 11/26/24. The DON stated that orders for x-rays were obtained and x-rays were completed. On 12/18/24 at 9:17 AM, an interview was conducted with the ADON. The ADON stated that she noticed an abrasion on resident 20's right knee and asked resident 20 what happened. The ADON stated that resident 20 informed her that she fell during transportation and the driver had to get help from strangers. The ADON stated the NP went in and assessed resident 20 the same day. The ADON stated that resident 20 denied any other injuries and there was no swelling to her right knee. On 12/18/24 at 10:11 AM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that he was not the Administrator at the time the incident occurred. The ADMIN stated that the only information he had about the fall with resident 20 was a statement given by the van driver from the contracted transport company. The ADMIN stated that he reviewed the contract the facility had with transport company and the company had been used by the facility since February 2024. The ADMIN stated that his expectations were that if an incident occurred with a resident during transport the facility should be notified. On 12/18/24 at 10:36 AM, an interview was conducted with the ADMIN and the DON. The ADMIN stated that the transport driver did notify the Admissions Coordinator that resident 20 slid out of her wheelchair and he had to stop to get help to boost her up. The ADMIN stated that the Admissions Coordinator asked the transport driver to notify resident 20's nurse. The DON stated that her expectations of staff were to assess the resident and document in the progress notes the findings. The DON stated that she became aware of the incident on 11/19/24, when the ADON noticed that resident 20 had a scabbed over abrasion on her knee. The DON stated that was when resident 20 informed the ADON that she fell out of her wheelchair during transport. The DON stated that she requested a written statement by the transport driver about what occurred with resident 20. On 12/18/24 at 10:45 AM, an interview was conducted with the SLP. The SLP stated that resident 20 had informed her on 11/18/24, that resident 20 had slid out of the wheelchair during transport. The SLP stated that resident 20 informed her that her knee was painful. The SLP stated that she informed the DON on 11/18/24. The SLP stated that she did not make a progress note that she alerted staff and she should have. On 12/18/24 at 10: 58 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the van driver did report to her that resident 20 slid out of her wheelchair and hit her knee. RN 2 stated that it was close to shift change and she put resident 20 back into bed. RN 2 stated that she did not ask resident 20 anything about what happened, if she was injured, or in any pain. RN 2 stated she did not assess resident 20. RN 2 stated that she did not chart anything in resident 20's medical record about what had occurred. On 12/18/24 at 11:12 AM, a phone interview was conducted with the contracted transportation company van driver. The van driver stated that on 11/15/24, he was taking resident 20 to a doctors appointment. The van driver stated that as he was driving resident 20, she informed him that she was sliding out of her wheelchair. The van driver stated that he stopped in the parking lot of a local school. The van driver stated that resident 20 had slid down in her wheel chair and the seatbelt was wrapped around resident 20's chest and resident 20's lower half was dangling in the air. The van driver stated that he was unable to pull resident 20 back up in her chair. The van driver stated he flagged down a mail man to call for help from security inside the school. The van driver stated that after a bit of time, someone from the school came out to assist him. The van driver stated that he instructed the security personnel to lift resident 20 under the arms and he would pick resident 20 up from her legs and lift her back up into the wheelchair. The van driver stated that it was company policy that if they were transporting someone and they fell on to the floor then he would have to call 911. The van driver stated that resident 20 was held in her chair by the seatbelt and was not fully onto the ground and that was why he continued taking her to the appointment. The van driver stated that resident 20 stated she was okay and wanted the van driver to put her fluffy socks back onto her feet because they fell off while she slid down. The van driver stated that he contacted his boss and requested the mini van to transport resident 20 back to the facility because the resident's wheelchair would be facing a different direction and she would be more secure. The van driver stated that he followed the mini van back to the facility and did not transport resident 20 back to the facility. The van driver stated that he took resident 20 back inside the facility and informed the Admissions Coordinator about what happened. The van driver stated that he spoke with the nurse who was caring for resident 20 and informed her of what happened because he was worried that resident 20 was injured. The van driver stated that he spoke with the nurse in charge about what happened, but could not recall her name. The van driver stated that resident 20 told him that she slid down in her wheelchair often. On 12/18/24 at 1:12 PM, a phone interview was conducted with the Admissions Coordinator (AC). The AC stated that resident 20 had gone to an appointment and upon return, the van driver informed her that resident 20 had slipped out of her wheelchair. The AC stated the van driver informed her that he was able to pull resident 20 back up and into her wheel chair. The AC stated that she informed the van driver to report it to the charge nurse. The AC stated that she could not recall who the charge nurse was that day. The AC stated that she did not think that slipping out of a wheel chair was a problem and she did not report it to anyone.

Based on interview and record review, the facility assessment did not accurately reflect the resident's status. Specifically, for 2 out of 18 sampled residents, a resident who was receiving hospice services was not coded on two quarterly Minimum Data Set (MDS) assessments and an annual MDS assessment as receiving hospice services. In addition, a resident that had a Preadmission Screening and Resident Review (PASRR) Level II was not coded on the MDS as having one. Resident identifiers: 22 and 27. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, acute kidney disease, hypertensive heart disease with heart failure, atrial fibrillation, protein-calorie malnutrition, dementia, anxiety disorder, urticaria, and pain. On 12/16/24 at 9:41 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 22 was receiving hospice services. Resident 22's medical record was reviewed on 12/16/24 through 12/18/24. A hospice Clinical Summary note documented a hospice start of care date of 10/13/23. The quarterly MDS assessment dated [DATE], documented that resident 22 was not on hospice while a resident. The annual MDS assessment dated [DATE], documented that resident 22 was not on hospice while a resident. The quarterly MDS assessment dated [DATE], documented that resident 22 was not on hospice while a resident. On 12/17/24 at 1:41 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she made a schedule and the whole building ran on that schedule for completing the MDS assessments. The MDS Coordinator stated that she would give the schedule to the department heads. The MDS Coordinator stated that she did not want the nurses over loaded with to many assessments so she would spread the assessments out. The MDS Coordinator stated that Social Services would do the Brief Interview for Mental Status score and the Patient Health Questionnaire-9. The MDS Coordinator stated that she would go over all the other questions with the residents that no one else asked. The MDS Coordinator stated that Social Services, Activities, and the Director of Nursing would do their annual MDS assessment off of the schedule she provided them. The MDS Coordinator stated that Social Services completed sections C, D, E, and Q on the MDS assessment. The MDS Coordinator stated that Activities completed section F on the admission MDS assessment and the annual MDS assessment for Skilled Nursing Facility residents. The MDS Coordinator stated that she completed all other sections on the MDS assessment. The MDS Coordinator stated an Interdisciplinary Team meeting would be held to discuss section GG and they would use the nursing assessments. The MDS Coordinator stated that section O on the MDS assessment was gathered from the many assessments. The MDS Coordinator stated the first place she would look to see if a resident was on hospice services would be the printed daily census but resident 22 was listed as private. The MDS Coordinator stated that she would also look in the census section of the residents medical record but resident 22 was listed as private pay there also. The MDS Coordinator further stated that on the Special Instructions section of resident 22's medical record the hospice company was listed. 38031 2. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of, but were not limited to, arthrogryposis multiplex, functional quadriplegia, chronic kidney disease, schizotypal disorder, major depressive disorder, and generalized anxiety disorder. Resident 27's medical record was reviewed on 12/16/24 through 12/18/24. On 6/17/22, the PASRR Level II was completed for resident 27. The assessment documented resident 27's diagnoses under Section 7 were schizotypal personality disorder, generalized anxiety disorder, and major depressive disorder. On 6/23/22, the PASRR Letter of Determination documented that resident 27 had been approved for Nursing Facility Services and Recommendations for specialized services were available on the PASRR evaluation. On 11/1/24, resident 27's significant change MDS assessment documented under section A1500 PASRR a No response to the question was the resident currently considered by the state level II PASRR process to have a serious mental illness. On 12/18/24 at 11:30 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that Section A on the admission or annual MDS Assessment was where the question on PASRR was located. The MDS Coordinator confirmed that the 11/1/24, significant change assessment documented a No response to the question was the resident currently considered by the state Level II PASRR process to have a serious mental illness. The MDS Coordinator stated that she would look for the information to that question in the resident electronic medical record under documents for a Level II PASRR. The MDS Coordinator stated that the PASRR Letter of Determination said that resident 27 was approved for medical services but it did not say that resident 27 had a Serious Mental Illness (SMI) or an Intellectual Disability. The MDS Coordinator stated that she only reviewed the letter of determination when answering the PASRR question in section A of the MDS assessment because the letter of determination summarized the PASRR Level II evaluation. The MDS Coordinator reviewed the PASRR Level II assessment from 6/17/22, and stated that section 4 of the assessment documented that resident 27 had a SMI. The MDS Coordinator stated that she did not verify with the PASRR level II evaluation before she made the determination to answer question A1500 to the negative. The MDS Coordinator stated that she made the determination to answer No to the question based on the information contained within the letter of determination. The MDS Coordinator stated that it was her responsibility to read the entire PASRR Level II evaluation and based on the evaluation question A1500 should have been marked Yes.

Based on observation, interview, and record review, the facility did not 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, for 1 out of 18 sampled residents, hand hygiene and donning and doffing of Personal Protective Equipment (PPE) was not performed appropriately during a wound care treatment observation. Resident identifier: 42. Findings included: Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, orthostatic hypotension, anemia, chronic kidney disease, dementia, pain, abrasion right foot, anxiety disorder, pressure ulcer right and left heel unstageable, restless leg syndrome, presence right knee joint, peptic ulcer, depression, and anorexia. On 12/16/24 at 9:06 AM, an interview was conducted with resident 42. Resident 42 stated that he had pain in the right knee and right toes. A healed surgical scar was observed on resident 42's right knee. Resident 42 was observed wearing bilateral podus boots on his feet. Resident 42 stated that he had wounds on the heels of both feet and he stated that the dressings were changed every three days. Resident 42 was observed lying on an air mattress with a pillow positioned under his right knee. Resident 42's medical record was reviewed on 12/16/24 through 12/18/24. On 11/19/24, resident 42's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 8 out of 15 which would indicate a moderate cognitive impairment. The MDS assessment documented that resident 42 was dependent on staff for toileting hygiene, lower body dressing, and putting on and taking off footwear; and was a substantial/maximal staff assist for showers, rolling left to right, sitting to lying, sit to stand, and transfers. Resident 42's physician's orders revealed the following: a. On 11/1/24, an order was initiated for Enhanced Barrier Precautions for wound every shift. b. On 12/16/24, an order was initiated for Wound care left heel: Cleanse with wound cleanser, apply skin prep to surrounding wound and then apply Medi-Honey and cover with border foam dressing. Change daily and PRN [as needed] one time a day for wound management AND as needed. c. On 12/16/24, an order was initiated for Right heel wound: Clean with wound cleanser, apply Medi-Honey, skin prep to surrounding skin then cover with foam dressing. Change daily and PRN. every day shift AND as needed. On 12/11/24, the Pressure Injury and Wound evaluation documented a right and left heel pressure ulcer. The right heel measured 3.7 centimeter (cm) length x (by) 6.8 cm width x 0.3 cm depth. The wound was documented as unstageable with obscured full-thickness skin and tissue loss. The left heel measured 3.5 cm x 3.5 cm x 0.3 cm. The wound was documented as unstageable with obscured full-thickness skin and tissue loss. On 8/28/24, resident 42 had a care plan initiated for Enhanced Barrier Precautions. Interventions identified on the care plan included: [NAME] and Doff gown and glove as per facility protocol for high contact care activities; patient identifier placed on door frame; and perform hand hygiene per facility policy. On 10/17/24, resident 42 had a care plan initiated for impairment to skin integrity related to unstageable pressure injuries. Interventions identified on the care plan included: avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short; encourage good nutrition and hydration in order to promote healthier skin; follow facility protocols for treatment of injury; monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to provider; and skin maintenance to prevent and treat bruises, injuries, pressure sores, and infection. On 12/17/24 at 8:40 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 42 was dependent on staff for cares and mostly stayed in bed. CNA 1 stated that resident 42 had pain in his right knee form a previous surgery and he did not like to straighten that leg. CNA 1 stated that the knee stayed bent and they propped a pillow underneath it for comfort and support. CNA 1 stated that resident 42 complained of pain with any movement of that knee and leg and would become agitated with cares. CNA 1 stated that resident 42 had wounds on both feet and the podus boots were to be worn while the resident was in bed. On 12/17/24 at 10:46 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 42 was alert and oriented to self only. RN 3 stated that resident 42 had dementia with occasional confusion, and had both short and long term memory deficits. RN 3 stated that resident 42 complained of pain in the bilateral heels and the right knee. RN 3 stated that resident 42 had pressure ulcers on both heels and his right knee was contracted due to a previous surgery. On 12/17/24 at 11:58 AM, an observation was made of RN 3 performing wound care on resident 42's bilateral heel pressure ulcers. RN 3 stated that the wound orders for the right and left heel were to cleanse the wound bed with wound cleaner, apply Medihoney to the wound bed, apply skin prep to the surrounding wound skin and to cover the wound with a foam dressing. RN 3 was observed to gather the wound care supplies. RN 3 squeezed approximately a tablespoon amount of Medihoney into a medication cup. RN 3 performed hand hygiene with Alcohol-based Hand Rub (ABHR). RN 3 was observed to open the wound cart drawer and take out multiple packages of 2 x 2 sterile gauze dressings. RN 3 tore open the package and pulled the sterile gauze out with her bare hands and placed them into a water cup and sprayed them with wound cleanser. RN 3 obtained two foam dressings and a package of sterile cotton tipped applicators. RN 3 sated that she had to donn a gown and gloves for wound care because resident 42 had an infection but she was not sure what the organism was. RN 3 donned a gown, performed hand hygiene with ABHR, and donned gloves just inside resident 42's room. RN 3 adjusted resident 42's bed height using the bed remote. RN 3 asked resident 42 prior to wound care what his level of pain was and the resident stated it was a 2 out of 10 and the right foot was worse than the left. RN 3 attempted to reposition resident 42 and attempted to straighten the right leg. Resident 42 was observed moaning during the repositioning of the legs. RN 3 removed the podus boot and sock from resident 42's right foot. Resident 42 stated Owe, watch that heel. RN 3 removed the podus boot and sock from left foot and resident 42 moaned in pain. RN 3 removed the old dressing from the right heel and resident 42 moaned. RN 3 stated that the wound had purulent drainage on the old dressing that was yellow and green in color. RN 3 placed a 2 x 2 gauze that was soaked in wound cleanser on the wound bed. Resident 42 moaned and stated owe. RN 3 wiped the wound bed in a circular motion with the gauze and resident 42 moaned in pain. RN 3 then removed her gloves and donned new gloves. RN 3 did not perform hand hygiene. RN 3 applied Medihoney to the wound bed with a sterile cotton tipped applicator. No measurements were obtained. RN 3 stated that the wound was improving, that it no longer bled with dressing changes, and the skin was starting to look more even. RN 3 then applied a foam dressing to cover the wound. RN 3 placed the sock and podus boot back on resident 42's right foot. RN 3 asked resident 42 if he wanted some Tylenol and resident 42 replied no. RN 3 again asked if she could bring him some Tylenol and resident 42 replied okay. RN 3 doffed her PPE and exited the room to obtain more wound care supplies. RN 3 was observed to place more 2 x 2 sterile gauze into the water cup with her bare hands and then sprayed them with wound cleanser. RN 3 returned to the resident room with the wound care supplies and donned a gown. RN 3 performed hand hygiene with ABHR and then donned a new pair of gloves. RN 3 removed the old dressing from the left heel and stated that slough came off with the dressing. RN 3 stated that the purulent drainage was less and there was a mild odor noted today. The dressing was observed to stick to the wound bed during removal. RN 3 stated that the left heel wound was open to the bone. RN 3 applied a 2 x 2 gauze dressing soaked in wound cleanser to the wound bed and the wound was cleaned using a circular motion. RN 3 then doffed her dirty gloves and donned new gloves. RN 3 did not perform hand hygiene. RN 3 applied Medihoney to the wound bed using a sterile cotton tipped applicator and then a bordered adhesive dressing was applied to the wound. RN 3 applied resident 42's left sock and podus boot. Resident 42 was observed to moan throughout the dressing change to the left foot. Upon completion of the wound care RN 3 told resident 42 that she would bring him some Tylenol along with a protein drink. RN 3 doffed her gown and gloves, performed hand hygiene with ABHR, and exited the resident room. On 12/17/24 at 3:17 PM, a follow-up interview was conducted with RN 3. RN 3 stated that gloves should be changed after going from a dirty area to a clean area. RN 3 stated that she removed the old dirty dressing, cleaned the wound bed, and then changed her gloves. RN 3 stated that she performed hand hygiene upon entrance to the room and prior to donning gloves. RN 3 stated that hand hygiene should be performed between glove changes as well. RN 3 stated she should have changed her gloves and performed hand hygiene prior to cleaning the wound bed and applying the new treatment. On 12/18/24 at 8:08 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that her expectation for staff during wound care was that hand hygiene should be performed prior to donning any gloves. The DON stated that gloves needed to be changed when moving between a dirty to clean area. The DON stated that staff should doff dirty gloves, perform hand hygiene, and then donn clean gloves for each wound that was provided treatment and after removing an old bandage and before the new treatment was applied. The DON was informed of the wound care observation with resident 42 and no further comment was provided. Review of the facility policy and procedure for Handwashing/Hand Hygiene documented, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV [intravenous] access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin' j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g. medical equipments) in the immediate vicinity of the resident; m. After removing gloves; The policy was last revised on February 1, 2024.

Based on interview and record review, the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, for 1 out of 18 sampled residents, a resident's x-ray report was not located in the medical record. Resident identifier: 20 Findings included: Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease, type 2 diabetes mellitus, unspecified asthma, fatty liver, anxiety disorder, major depressive disorder, essential hypertension, muscle weakness, and cognitive communication deficit. Resident 20's medical record was reviewed on 12/16/24 through 12/18/24. A review of resident 20's progress notes revealed the following: a. On 11/26/24 at 1:32 PM, a progress note documented, Note Text: pt [patient] complaining of Bilateral knee and hip pain. pt was assessed by [facility contracted name redacted] provider who ordered bilateral knee and bilateral hip x rays [sic]. b. On 11/27/24 at 12:45 AM, a radiology results note documented, Note Text: Requested and received XR [x-ray] results for L [left] knee, pelvis and bilat [bilateral] hips, all findings normal, results to MD [Medical Doctor]. c. On 11/27/24 at 9:33 AM, a progress note documented the following, Note Text: Resident complaining of severe pain to Rt. [right] knee. Bruising present, site warm to touch, abrasion noted to shin. Ice packs applied. recent xrays [sic] performed to Lt. [left] knee with no abnormal findings. Resident requesting xrays [sic] to be done on Rt. knee. d. On 11/27/24 at 10:11 AM, an alert charting note documented, Change of Condition Summary: Message left for provider to return call regarding Rt knee and if we need to x ray [sic]. Nurse manager printed xray [sic] report for this nurse, this nurse messaged Provider. Awaiting orders. e. On 11/27/24 at 12:26 PM, an alert charting note documented, Change of Condition Summary: Radiology called this nurse with critical FX [fracture] to Rt Leg/knee. [medical provider name redacted] aware here at facility. An x-ray report for resident 20's right knee was not found in the medical record. On 12/17/24 at 10:55 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 20 had x-rays performed on her bilateral knees and hips. The DON stated that the facility had received printed reports for resident 20's left knee and bilateral hips, but did not receive a printed report for the right knee. The DON stated that she would provide me a copy of the report once she obtained it. On 12/18/24 at 9:25 AM, the Regional Clinical Operations Director provided a copy of the x-ray report of resident 20's right knee.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency (SSA). Specifically, for 1 out of 18 sampled residents, the facility did not report to the SSA when a resident sustained a fracture during a transportation. Resident identifier: 20 Finding included: Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease, type 2 diabetes mellitus, unspecified asthma, fatty liver, anxiety disorder, major depressive disorder, essential hypertension, muscle weakness, and cognitive communication deficit. A review of resident 20's progress notes revealed the following: a. On 11/18/24 at 12:00 AM, a speech therapy note documented, . SLP [speech language pathologist] instructed pt [patient] to recall appointment 3 days prior. Pt unable to recall appointment three days prior indicating decrease short term recall skills. With max [maximum] verbal cues, Patient able to recall going to appointment and falling out of wheelchair. SLP reviewed strategies to prevent falls from wheelchair and from bed in which patient verbalized understanding. b. On 11/19/24 at 3:19 PM, a health states note documented, Note Text: ADON [Assistant Director of Nursing] noted an abrasion that has scabbed over her right knee and asked what happened and patient said 'Oh I fell when I went to the eye doctor.' ADON asked how she fell and she said the wheelchair tipped over and the driver asked strangers for help. She doesn't recall any other information. No other injuries noted. NP [Nurse Practitioner] [name redacted] in the building and informed him. [Name redacted] also assessed the patient and said that she is fine. DON [Director of Nursing] made aware. c. On 11/20/24 at 12:00 AM, a speech therapy note documented, . To increase short term recall skills, SLP instructed pt to recall appointment 3 days prior. Pt unable to recall appointment three days prior indicating decrease short term recall skills. With max verbal cues, Patient able to recall going to appointment and falling out of [sic] wheelchair. d. On 11/26/24 at 1:32 PM, a note documented, Note Text: pt complaining of Bilateral knee and hip pain. pt was assessed by [facility contracted name redacted] provider who ordered bilateral knee and bilateral hip x rays. e. On 11/27/24 at 12:45 AM, a radiology results note documented, Note Text: Requested and received XR [x-ray] results for L [left] knee, pelvis and bilat [bilateral] hips, all findings normal, results to MD [Medical Doctor]. f. On 11/27/24 at 9:33 AM, a progress note documented the following, Note Text: Resident complaining of severe pain to Rt. [right] knee. Bruising present, site warm to touch, abrasion noted to shin. Ice packs applied. recent xrays performed to Lt. [left] knee with no abnormal findings. Resident requesting xrays to be done on Rt. knee. g. On 11/27/24 at 10:11 AM, an alert charting note documented, Change of Condition Summary: Message left for provider to return call regarding Rt knee and if we need to x ray. Nurse manager printed xray report for this nurse, this nurse messaged Provider. Awaiting orders. h. On 11/27/24 at 12:26 PM, an alert charting note documented, Change of Condition Summary: Radiology called this nurse with critical FX [fracture] to Rt Leg/knee. [medical provider name redacted] aware here at facility. i. On 11/27/24 at 12:46 PM, a communication with physician note documented, Note Text: [Medical provider name redacted] here. N.O. [new order] to send pt to ER [emergency room ] for TX [treatment] and Eval.[evaluation] Non-ER ambulance called/report given. Copy of Face Sheet and meds [medications] ready for pick up. Message left for stepdaughter, [name redacted] about N.O. results. j. On 11/27/24 at 5:30 PM, a progress note documented, Note Text: [Resident 20] returned from the hospital r/t [related to] pain and fx. She has a knee immobilizer in place. The hospital reports a complicated slightly displaced metaphysis fx of the distal right femur. This is an extensive surgery to repair, d/t [due to] comorbid conditions, there is significant risk to doing a surgery like this. Use the immobilizer, continue Non weightbearing in wheelchair as needed. Please see pt visit notes. On 12/18/24 at 1:03 PM, an interview was conducted with the DON. The DON stated that when she first heard about the allegation with resident 20 falling with the transport company, she notified the previous administrator on 11/19/24. The DON stated on 11/19/24, she did not believe that this was a reportable incident. The DON stated that when the x-ray results came back on 11/26/24, for resident 20 and resident 20 was found to have sustained a fracture due to the fall she notified the previous administrator again and left that up to him to report it. The DON stated that the fracture would be a reportable incident. On 12/18/24 at 1:40 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that there were no reports filed with the SSA in regards to the fall with a fracture for resident 20. The ADMIN stated when the patient had complained of pain and it was identified through x-rays that there was a fracture he would have reported it. The ADMIN stated that something like this should be reported to the SSA within 24 hours. The ADMIN stated that in this situation he would not have any concerns of neglect or harm for resident 20. The ADMIN stated that he would have reported it to the SSA as a fracture.

Based on observation, interview, and record review it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Specifically, staff members were observed to touch resident medications with bare hands and staff did not clean the top of an insulin vial prior to drawing up the insulin for administration. Resident identifiers: 25 and 31 Findings include: On 3/15/23 at 8:30 AM, an observation was made of Registered Nurse (RN) 3 during the morning medication administration. RN 3 was observed to scoop out a diary aid capsule with an ungloved hand from resident 31's medication cup. RN 3 proceeded to return the capsule back into it's original container. RN 3 was observed to dispense resident 25's aspirin tablets onto the aspirin container lid and then proceeded to touch the extra aspirin tablet with their bare fingers while they turned the lid over into the medication cup to drop the one aspirin tablet. The extra tablet was then returned to the original bottle. RN 3 was not observed to clean the top of resident 25's insulin vial with an alcohol swab before drawing up the insulin. The insulin was administered to resident 25 in the left upper arm. On 3/16/23 at 1:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they expected the nurse to use proper hand hygiene throughout medication pass. The DON stated an insulin vial needed to be cleaned with an alcohol wipe before the nurse drew up and administer the insulin.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a staff member was observed to not perform hand hygiene after touching dirty dishes and was observed to hold clean dishes against a plastic apron that was dirty. In addition, there was dust on the vents above the food preparation area and there were items not dated in the refrigerators. Findings include: 1. On 3/13/23 at 9:43 AM, an initial tour of the kitchen was conducted. The following observations were made: a. An observation was made of Dietary Aide (DA) 1. DA 1 was observed to be washing dishes. DA 1 was observed to touch dirty dishes and then observed to pick up meal trays and hold them against her body. DA 1 was observed to be wearing a plastic apron. DA 1 was observed to touch dirty dishes and load them into the dishwasher. DA 1 was observed to pick up 2 trays, bowls, 2 handled cups with lids without performing hand hygiene. DA 1 was observed to pick up a load a large black container from the floor and load it into the dish machine. DA 1 was observed to pick up clean cups without performing hand hygiene and replace the cups onto the clean dish shelf. b. There was a opened container labeled Thickened Orange Juice in the reach in refrigerator. There was an open date of 2/28. The container revealed May be kept in refrigeration for up to 7 days. c. There was an opened bag of whipped topping with no open date in the walk in refrigerator. The label revealed Self life is up to 14 days refrigerated. d. There were bags of brown lettuce in the walk in refrigerator. e. There was peeling paint on the ceiling around the lights above the food preparation area. f. There was dust on the vents on the ceiling above the food preparation areas. 2. On 3/16/23 at 10:38 AM, a follow-up kitchen tour was conducted. The following was observed: a. There was peeling paint on the ceiling around the lights above the food preparation area. b. There was dust on the vents on the ceiling above the food preparation areas. An interview was conducted with the Dietary Manager (DM). The DM stated the maintenance staff cleaned the vents but he was not sure what the schedule was and how often the vents were cleaned. The DM stated if the staff noticed dust on the vents, maintenance staff were notified between the routine cleaning. The DM stated there was a hand washing sink in the bathroom in the dish machine room. The DM stated that DA's were to wash their hands between touching the dirty dishes and touching the clean dishes.

Based on observations and interviews it was determined, for 5 of 18 sample residents, that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, there were opened multi-dose vials of medication available for use without a documented open date. Resident Identifiers: 8, 21, 24, 34, and 96. Finding include: 1. On [DATE] at 9:02 AM, the medication carts on the 200 hall were observed. The following observations were made: a. Resident 24's multi dose vial of Novolin ,d+[DATE] (70% NPH, Human Insulin Isophane Suspension and 30% Regular, Human Insulin Injection) was not labeled with an opened date. [Note: RN 3 was observed to draw up the unlabeled insulin and administered it to resident 24.] b. Resident 21's multi dose vial of Tresiba (Insulin deglucdec) was not labeled with an opened date. c. Resident 8's multi dose vial of Insulin Aspart had an open date of [DATE]. On [DATE] at 9:07 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated there were signs to notify staff to put an open date on insulin once it had been opened. RN 3 stated insulin was only good for 28 days once it was opened. RN 3 looked for an open date on resident 24's vial but was unable to find one. RN 3 stated he thought it was opened yesterday. RN 3 stated they would ask the unit manager if they could put yesterday's date on the unlabeled vial. A follow-up interview was conducted with RN 3. RN 3 stated they gave resident 24's insulin vial to the Director of Nursing (DON) and that pharmacy was going to send another vial of resident 24's Novolin ,d+[DATE]. RN 3 stated once a medication was expired, it needed to be disposed of. RN 3 stated he disposed of resident 8's expired insulin. 2. On [DATE] at 9:11 AM, the medication cart on the 100 hall was observed. The following multi dose vials were available for use without an open date: a. Resident 96's multi dose vial of Insulin Aspart was not labeled with an open date. b. Resident 34's multi dose vial of Victoza (liraglutide) was not labeled with an open date. The medication was dispensed from the pharmacy on [DATE]. An interview was immediately conducted with Unit Manger (UM) 1. UM 1 stated that insulin was good for 30 days once it was taken out of the fridge. UM 1 stated the protocol for an unlabeled insulin pen/vial was to discard of it and replace it with a new one. UM 1 stated that the insulin pen/vial needed to be labeled as soon as it was opened. UM 1 proceeded to discard resident 96's and 34's unlabeled medication. On [DATE] at 1:03 PM, an interview was conducted with the DON. The DON stated the procedure for labeling multi dose vials such as insulin was to write the date on them right when they were opened. The DON stated if staff found an unlabeled open vial, the staff member was to order a new one from pharmacy since there was no date to indicate how long the medication had been opened for.

Based on observation, interview, and record review it was determined, for 1 out of 18 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident sustained a left foot injury while being transported in the shower chair. Resident identifier: 23 Findings Included: Resident 23 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, type 2 diabetes mellitus, generalized anxiety disorder, muscle weakness, and major depressive disorder. On 3/13/23 at 10:15 AM, an interview was conducted with resident 23. Resident 23 stated that he did not feel safe on the shower chair and described them as rickety. Resident 23 stated his left foot had gotten injured because of the shower chair. Resident 23 stated he had missing toenails on his left foot after his toes were ran over by the shower chair. Resident 23 stated he was still using the shower chair after his foot injury. Resident 23's medical record was reviewed on 3/14/23. Resident 23's care plan was reviewed and revealed a care area with a focus area stating [Resident 23] has actual impairment to skin integrity r/t [related to] psoriasis and abrasion of left foot. Interventions were identified and included as follows: Use caution during transfer and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan was initiated on 7/19/22 and was updated on 12/30/22. Resident 23's progress notes documented as followed: a. An alert noted dated 12/29/22 stated, Tonight around 22:20 (10:20 PM), the CNA [certified nursing assistant] came to the nurse and mentioned that the pt's [patient's] toes were bleeding. The nurse went into the pt's room to assess the pts toes. Upon assessment the nurse noticed that the pt's left toes were all bleeding. The pt was sleeping and didn't wake up during the assessment and couldn't answer questions. The nurse went and got some clean gauze and dermal wound cleaner to clean up some of the blood so the nurse could get a better look at the pt's skin. After the cleaning the nurse noticed that all of the pts left toes had wounds on them and that his 4th and 5th toenails had been ripped off. the nurse asked the CNA's if they knew what happened and no one knew. The nurse cleaned the wounds and applied some triple anti-biotic ointment and then covered with a dressing. The nurse then contacted the DON [Director of Nursing] and the Dr's [Doctor's] office and informed them about the pt. b. A Health status note dated 12/30/22 stated, Late entry: Left foot anterior toe avulsion x 5. Assessed by NP [Nurse Practitioner] [name removed] and dressed by West hall nurse manager. WCTM [will continue to monitor]. c. An event note dated 12/30/22 stated, Resident has abrasions on the toes of the left foot, also missing toe nails on the fourth and little toe. Resident stated that the shower chair ran over his foot. Injury was assessed by West Unit manager, and [name removed] NP. Sister/POA [Power of Attorney] was notified, [name removed] NP was notified, Unit managers, and DON were notified. Assessment completed; wound orders put in place. d. A health status noted dated 12/31/22 stated, Nurse cleansed left toe avulsions with wound cleanser and gauze. Applied medihoney, adaptic, and soft kerlix. Pt tolerated well. A nursing skin integrity assessment dated [DATE], described resident 23's left foot wounds as followed, linear abrasion across the top of the toes, going from the middle of the little toe to the very top of the big toes. The toe nails on the little toe and the forth toe are completely missing. The physician orders were reviewed and documented the following wound care orders: a. Wound care: Left foot (toes) Clean with wound cleanser and gauze. Ensure toes and in between toes was completely dry. Apply Hydrogel to all open areas on the toes, wrap loosely with gauze and cover with tubular elastic net to hold in place. Directions stated every evening shift Notify NP of any issues or worsening of site. This order had a start date of 12/30/22 and a stop date of 1/12/23. b. Wound care: Left foot (toes). Apply skin prep and leave open to air. Directions included every evening shift to notify NP of any issues or worsening of site. This order had a start date of 1/12/23 and a stop date of 2/16/23. An incident report dated 12/30/22 documented a skin injury was identified on resident 23's left foot and determined to be caused by his left leg falling out of place while being wheeled in shower chair. It stated, [Resident 23] has diminished sensation in left leg and unable to move leg on his own. After investigation, it was determined that for increased safety, resident should be showered in shower bed instead of shower [sic] to protect resident's limbs during transport. On 3/16/23 at 10:15 AM, an interview was conducted with CNA 1. CNA 1 stated resident 23 was a two-person transfer. CNA 1 stated resident 23 was weaker on one side than the other but was unsure which was his weaker side. CNA 1 stated resident 23 liked to use his electric wheel chair to transfer himself to the shower room. CNA 1 stated if they had to use the shower chair, they needed to use a sit to stand lift to transfer resident 23 out of his wheelchair or bed into the shower chair. CNA 1 stated for resident 23's comfort they should use the shower chair that leaned back and had leg rests. CNA 1 stated residents used the shower bed if they were bed bound or if they were unable to use the sit to stand lift safety. CNA 1 stated he had never used the shower bed with resident 23 when he did resident 23's showers. CNA 1 stated he was not aware of any aids using the shower bed with resident 23. On 3/16/23 at 10:20 AM, an interview was conducted with the Unit Manger (UM) 2. UM 2 stated they were aware resident 23 had injured his foot a couple of months ago from the shower chair. UM 2 stated that resident 23 had received abrasion on the top of his foot and had lost 2 toe nails. UM 2 stated resident 23's left leg was weaker than his right due to his stroke. UM 2 stated resident 23's right leg vibrated his left leg off the chair and his left foot was dragged under the wheels. UM 2 stated resident 23 had received wound care for about 2 weeks once this injury happened and they monitored his injuries until 2/16/23. UM 2 stated they had different height shower chairs. UM 2 stated resident 23 needed to use a shower chair where his foot would not touch the floor and be dragged. UM 2 stated that resident 23 preferred to use the shower chair. On 3/16/23 at 10:39 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 23 had used the shower chair in the past before he cut his left foot. CNA 2 stated she was unsure how resident 23 was transferred to the shower room after his injury. CNA 2 stated resident 23 was able to transfer himself into the shower room with his electric wheelchair but was unsure what he was showered on. On 3/16/23 at 11:14 AM, an interview was conducted with the DON. The DON stated she was unsure what had happened to resident 23's left foot. The DON stated it was not a witnessed incident. The DON stated resident 23 had told them the shower chair had ran over his left foot. The DON stated resident 23 had poor feeling and sensation in his feet. The DON stated after they had conducted an investigation, they determined staff needed to be more careful during transfers. The DON stated they looked into having resident 23 use the shower bed instead of the shower chair for transfer from his room to the shower room. The DON stated that resident 23 liked to be showered in the shower chair. The DON stated when new interventions were implemented, they notified staff by educating them at their frequent meetings.

Based on observation, interview and record review it was determined, for 1 of 18 sample residents, that the facility did not ensure the prompt resolution of grievances. Specifically, a resident expressed a grievance regarding the roommates television being too loud. The grievance was expressed to multiple staff members and social services. There was no grievance filed and there was no resolution to the grievance. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, muscle weakness and cognitive communication deficit. On 3/13/23 at 10:48 AM, an interview was conducted with resident 25. Resident 25 stated that she had issues sleeping because her roommate left lights on and the television on all night with the volume too loud. Resident 25 stated that she was not use to sleeping with lights on and a noisy background. Resident 25 stated that she had informed many staff including nurses and Certified Nursing Assistant's (CNA) about her sleep issues. Resident 25 stated that she had a conversation about her roommate with the Social Services Director (SSD). Resident 25 stated that Nothing has been done about it. Resident 25 stated her brother brought her an eye mask to help her sleep. Resident 25 stated the eye mask helped a little but the mask was lost and she was unable to find it. On 3/13/23 at 1:33 PM, an observation of resident 25 was made. Resident 25 was in her room with the television and lights off, resident 25's roommate had the lights on and television was on, the volume of the television was audible from outside of the room in the hallway. Resident 25's medical record was reviewed on 3/14/23. Resident 25's progress notes revealed the following entries: a. On 1/18/23 at 2:03 PM, Licensed Practical Nurse (LPN) 1 documented in a progress note that resident 25 had been sleeping during the day more than usual. b. On 2/28/23 at 8:43 AM, Registered Nurse (RN) 1 documented in a progress note, Pt. [patient] is A&Ox3[alert and oriented to person, place, and time] and can verbalize needs with staff . Pt. remains in bed throughout day. Pt. has hard time sleeping at night d/t [due to] roommates TV and often sleeps through day . c. On 3/1/23 at 5:11 PM, SSD documented in a progress note resident 25 was having a hard time sleeping because of her roommate having her TV on all night. d. On 3/13/2023 at 3:03 PM, RN 2 documented in a progress note, resident 25's physician's office was contacted about resident's complaints about not being able to sleep at night. There was a new physician's order for Trazodone 50mg (milligrams) to be administered every night at bedtime. The facility Grievance Log was reviewed from December 2022 until March 2023. There we no grievances regarding resident 25's complaint of roommate and inability to sleep. On 3/15/23 at 12:31 PM, an interview was conducted with the SSD. The SSD stated that if a resident had a complaint with the room or their roommate first the SSD had a conversation with the residents. The SSD stated if one roommate was up all night or one was really loud and they were just not a good match for roommates then staff did not keep them in the same room. The SSD stated the facility would move the resident that was less difficult to move or if it was the resident complaining about the issue then that resident was moved. The SSD stated resident 25 had reported that her roommate was loud but it was not her roommates television, it was resident 25's audiobook playing. The SSD stated that the facility was giving resident 25 Trazadone for sleeping because it was a very common sleep medication. The SSD stated Melatonin was not an effective sleeping medication for most people. The SSD stated resident 25 became roommates with current roommate 10/11/22. On 3/15/23 at 2:17 PM, an interview was conducted with CNA 1. CNA 1 stated that he had worked for the facility for about 2 months and that resident 25 had mentioned her roommates lights bothered her. CNA 1 stated that resident 25 told he she was unable to sleep when the roommates lights were on. On 3/15/23 at 2:49 PM, a follow-up interview was conducted with the SSD. The SSD stated that not every roommate dispute would need to have a grievance filled out. The SSD stated she liked to get the roommates together to talk about any issues because the residents were adults. The SSD stated staff verbally informed her of resident problems with their roommates. The SSD stated she was aware of resident 25 and was working on the situation, but did not even think to offer a grievance form to resident 25.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were soiled, ants were observed on the floor, and cracked tiles and missing grout were observed. Finding include: 1. On 8/15/22 at 1:50 PM, an initial tour of the kitchen was conducted. The following was observed: a. There was an odor in the walk in refrigerator. b. There was a pipe on the floor with a bracket in the food preparation area. The bracket was soiled with food and debris. There was a plastic soda lid in the bracket. c. There was a floor drain next to the pipe. There were 2 pieces of food with ants on them. d. There was a floor drain under the fryer with pieces of food and ants on the food. e. There were cracked tiles on the floor by the ovens. f. There were cracked tiles and missing grout in the dish machine room. g. There were bins labeled sugar that had a brown substance on the side of it. h. There were 4 plastic drawers with plastic silverware that was soiled. i. There were different color substances on the wall under the 3 compartment sink by the dish room. 2. On 8/18/22 at 10:20 AM, a follow up kitchen tour was conducted. The following was observed a. There was debris and crumbs on the top and between lids of the plate warmer. b. There was a pipe on the floor with a bracket in the food preparation area. The bracket was soiled with food and debris. There was a plastic soda lid in the bracket. c. There was a floor drain under the fryer with pieces of food and ants on the food. d. There were cracked tiles on the floor by the ovens. e. There were cracked tiles and missing grout in the dish machine room. f. There were bins labeled sugar that had a brown substance on the side of it. g. There were 4 plastic drawers with plastic silverware that was soiled. h. There were different color substances on the wall under the 3 compartment sink by the dish room. i. There was debris and crumbs on the floor behind the steamer. j. There was dried brown splattered substance on the wall in the food preparation area. An interview was immediately conducted with the Dietary Manager (DM). The DM stated the plate warmer was wiped down on the outside after each meal. The DM stated they had a contract with a local pest control company that came out on a routine basis. The DM stated there were ants earlier in the summer and the Maintenance Director called to have the pest control company spray again and there were no other ants since. The DM was shown where the ants were, and stated the staff swept and mopped twice daily but no one had reported ants to him. The DM stated that the bracket under the 3 compartment sink was to be deep cleaned on Monday and Tuesday when a staff member was delegated to deep clean. The DM stated that walls were cleaned monthly. The DM stated there were cracked tiles and the facility had extra tiles, but he was not aware of when the tiles would be replaced. The DM stated the grout needed to be replaced in the dish machine room.

Based on observation and interview, the facility did not 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, appropriate Personal Protective Equipment (PPE) was not worn, and cross contamination occurred during a medication pass. Findings include: PPE 1. On 8/15/22 at 11:30 AM, Certified Nursing Assistant (CNA) 6 was observed to walk down the hall to the nurses station by the 100 hall. CNA 6 was observed to have no eye protection. After arriving at the nurses station, CNA 6 then placed her goggles on top of her head. Several residents were near the nurses station at the time. 2. On 8/15/22 at 8:18 AM, an interview and observation was conducted of the Administrator. The Administrator was observed to enter the conference room with her base below her nose and mouth. The Administrator stated she had COVID-19 for the 3rd time and she was not wearing a mask. 3. On 8/15/22 at 9:16 AM, an observation was made of the Administrator. The Administrator was observed in the conference with no mask or eye protection. 4. On 8/16/22 at 3:45 PM, an observation was made of the Administrator and the DON. The Administrator and DON were in the Administrators office within 6 feet of each other. The Administrator was observed to not be wearing a mask or eye protection. 5. On 8/18/22 at 9:02 AM, an observation was made of the Administrator and resident 89 in the Administrator's office. The Administrator and resident 89 were observed within 6 feet of each other without masks or eye protection. 6. On 8/18/22 at 1:00 PM, an observation was made of the Divisional Business Office Manager and Medical Records Staff member. Both staff were in the Business office without masks or eye protection. On 8/15/22 at 8:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility business office manager tested positive on 8/14/22 for COVID-19. The DON stated that the facility did contact tracing and determine that 3 residents had been in contact with the Business Office Manager so those residents were on contact isolation precautions. The DON stated that all staff that had been in contact with the Business Office Manager were tested for COVID-19. On 8/18/22 at 3:09 PM, a follow up interview was conducted with the DON. The DON stated that the facility policy for masks was based on transmission level and outbreak. The DON stated policy staff were to wear masks in resident care areas. The DON stated that staff could take their masks down in staff only areas if all staff were fully vaccinated. The DON stated in an office with a patient, staff needed to wear masks and eye protection at all time. The DON also confirmed that the county transmission rate was high. According to the Utah Department of Health PPE Requirements chart, last updated on 3/21/22, Long Term Care Facility staff were to wear face masks in resident rooms, resident common areas and employee only areas when the community transmission rate was high or during an outbreak. MEDICATION PASS 7. On 8/16/22 at approximately 8:15 AM, an observation was made of Registered Nurse (RN) 1 as she administered medications to several residents. It was observed that a medication cup filled with a resident's medications tipped over and two tablets spilled out on top of the medication cart. It was observed that RN 1 picked up the two tablets and placed them back in the medication cup. RN 1 did not dispose of and replace the tablets with new ones or perform hand hygiene and don gloves before she touched the tablets. 8. On 8/16/22 at approximately 8:35 AM, RN 1 was observed to cut a tablet in half using a pill cutter. RN 1 used her bare hands to place half of the tablet into the resident's medication cup and half of the tablet into the original pill bottle. RN 1 was observed to not perform hand hygiene or don gloves before touching the tablet.

Based on observation, interview and record review it was determined, for 3 of 19 sampled residents, that the facility did not ensure each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, residents' positioning bars were removed from their beds resulting in residents not being able to reposition themselves. Resident identifiers: 20, 29 and 36. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22 at 1:37 PM, an interview was conducted with resident 29. Resident 29 stated last week her small side rail was removed from her bed. Resident 29 stated staff replaced the side rail with a chair. An observation was made of a chair with the back of the chair next to the bed. Resident 29 stated she had a stroke and it was difficult to roll over in bed. Resident 29 stated when she had her brief changed she held onto the side rail. Resident 29 stated she had not fallen out of bed, but did not feel secure when she was on her side without the side rail. Resident 29's medical record was reviewed on 8/18/22. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 29 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated her cognitive function was intact. The MDS further revealed resident 26 required 2 person extensive assistance with bed mobility. Resident 29 had functional limitation in range of motion to her upper and lower extremities on one side. A care plan dated 7/15/22 revealed [Resident 29] needs ADL (activities of daily living) Assistance needed to maintain highest level of function r/t (related to) weakness, [CONDITION(S)], kidney failure, and decreased mobility. A goal developed was [Resident 29] will maintain ADL level of function through next review. Interventions developed were Bed Mobility Extensive 1 person and Resident has 1/4 rails/grab bars to assist in bed mobility with rolling and supine to sit and be more participatory in ADL's was developed on 8/3/22. A nursing evaluation for use of bed rails dated 7/15/22 revealed Pt (patient) has a hx (history) of a stroke that affects her left side and needs help maneuvering in and out of bed. The evaluation revealed a recommendation of 1/4 partial rails to upper right and lower. There were no physician's orders for side rails located in resident 29's medical record. A progress note dated 8/9/22 at 10:40 PM, . The patient has [CONDITION(S)] and [CONDITION(S)] affecting the left side and a cognitive communication deficit. The patient is a 1-2 person assist for all ADLs. The patient had her upper bed rails removed per the facility policy and is distressed. The patient can no longer use the bed rails to aid in her cares in her bed such as rolling from side to side for a brief change. The patient stated she feels less safe in the bed and is very afraid she might fall out of bed. The patient is her (sic) for recovery and therapies which are very limited for the patient when in the bed. On 8/16/22 at 2:23 PM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated she was an agency staff member. CNA 5 stated she had not worked at the facility for a while but worked last week and all the side rails were gone when she returned last week. CNA 5 stated all residents that had side rails had complained that they felt insecure without the side rails. CNA 5 stated resident 29 helped a lot with repositioning in bed. CNA 5 stated she used a draw sheet to move the resident upward in bed. CNA 5 stated that resident 29 required assistance with being turned and was able to stay on her side. CNA 5 stated resident 29 stated resident 29 needed something to hold onto when she turned in bed. CNA 5 stated it would be helpful for resident 29 to have a side bar to hold onto when she was changed. On 8/16/22 at 2:30 PM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated resident 29 had a stroke 7 years ago which affected one side of her body. The DOR stated resident 29 was functionally able to get herself into a position depending on what side she was going onto. The DOR stated staff were looking into another way of her being able to reposition herself, whether it was a bed rail or not. The DOR stated he was not sure if resident 29 currently had a bed rail. The DOR stated a therapist went into observe if the resident was able to use the assistive devices. The DOR stated the therapists determined what side the rail would be appropriate for. The DOR stated no side rails had been removed, if a resident had one. The DOR stated staff had been looking at the upcoming CMS (Centers for Medicare and Medicaid) regulations regarding whether side rails would be considered restraints. The DOR stated therapy staff were looking at what side resident 29 would need the bed rail on. The DOR observed resident 29's bed and stated the bed did not have a side rail or positioning device. On 8/16/22 at 2:37 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated he worked for an agency nursing company. RN 2 stated he worked at the facility once a week. RN 2 stated residents had requested side rails and I know there's a lot of regulation about it. RN 2 stated typically have to have a signature from the patient and a physician's order. RN 2 stated if a resident asked for a side rail then he told the Director of Nursing (DON) or passed the information to the physician. RN 2 stated resident 29 had requested a side rail and he thought he passed the information on to the DON and Physician. RN 2 stated he was not at the facility full time so he did not have the chance to follow up on requests. RN 2 stated he was not sure if resident 29 had ever had a side rail. On 8/16/22 at 2:47 PM, an interview was conducted with RN 1. RN 1 stated she worked for an agency nursing company and worked at the facility 3 days per week. RN 1 stated resident 29 was using a chair next to her bed for a positioning bar and would prefer a bed cane to hold onto when she was repositioned. RN 1 stated My understanding is bed rails are not allowed. RN 1 stated she told resident 29, she could bring up side rails with management. RN 1 stated she thought she verbally told the Unit Manger that resident 29 wanted a side rail. On 8/16/22 at 2:50 PM, an interview was conducted with the DON. The DON stated the facility staff were in process for the new CMS guidelines, where beds were not to have side rails. The DON stated staff tried to provide other interventions before side rails. The DON stated if staff assessed there was a need, then nursing or therapy evaluated the resident. The DON stated the facility was in transition over the last few weeks and management was assessing for side rails over the last 2 weeks. The DON stated staff were going through everyone and if assessed and determined the resident did not need a side rail then the Maintenance Director (MD) was asked to remove the side rail. The DON stated that resident 29 currently did not have a side rail. The DON stated the MD only removed side rails on empty beds. The DON stated the MD did not remove any side rails from any current resident with side rails. The DON stated the reason the facility decided to go through and review side rails was to make sure that all the pieces were there for proper assessments. The DON reviewed resident 29's bed rail evaluation and care plan. An observation was made of the DON calling the MD and told him to put a small bed rail on resident 29's bed. On 8/16/22 at 3:03 PM, an observation was made of the MD. The MD was observed with a 1/4 rail in his hand. The MD stated that he was placing the side rail on resident 29's bed. The MD stated the DON told him resident 29 was evaluated and needed the side rail. The MD stated he was asked to remove all side rails and positioning bars from all beds last week. The MD stated he could not remember who had instructed him to remove the side rails and bars. The MD was observed to replace the 1/4 side rail on resident 29's bed at 3:05 PM. Resident 29 stated that she injured her rib cage and was very sore from reaching over. Resident 29 stated an x-ray was completed on 8/13/22 because she was in so much pain. On 8/16/22 at 3:15 PM, a follow up interview was conducted with the DOR. The DOR stated that a therapist did an assessment for bed rails to be put back on. On 8/16/22 at 3:23 PM, an interview was conducted with Occupational Therapist (OT) 1. OT 1 stated he had been asked to evaluate resident 29 for a side rail today. OT 1 stated he was not sure why the side rail was taken off. OT 1 stated resident 29 had full side rails on both sides. Another therapist was observed to tell OT 1 resident 29 had a small rail on the left side only. On 8/16/22 at 3:45 PM, an interview was conducted with the Administrator. The Administrator stated that staff were in the process of evaluating all resident side rails. The Administrator stated that corporate had instructed the MD to remove all side rails and positioning bars. On 8/17/22 at 10:39 AM, an interview was conducted with the Regional Nurse Consultant (RNC) and Divisional Rehab Director (DRD). RNC stated residents should be evaluated for side rails upon admission and when a resident experienced the change in condition. RNC stated that a nursing assessment was completed for side rails. RNC stated a physician's order was obtained and the care plan was updated. RNC stated once there was a side rail the nursing side rail assessment was completed quarterly. RNC stated if the side rail was for positioning it was the same process. RNC stated therapy then completed an evaluation and it was discussed in the morning clinical meeting. RNC stated the facility had a side rail policy and the policy was never regarding that there were to be no side rails. RNC stated corporate asked each facility to evaluate the side rails because there were some breaches in the process. RNC stated staff were instructed to obtain consents and assessments. DRD stated she had not heard anything about resident 29 and a side rail. DRD was observed to review therapy notes. DRD stated an Certified Occupational Therapist Assistant (COTA) wrote a note at 1:45 PM on 8/16/22 that resident 29 needed a side rail and OT 1 evaluated resident 29 and recommended bilateral side rails. DRD stated that the nursing evaluation for side rails should have not been completed on 7/15/22 but therapy should have completed an evaluation. DRD stated that a nursing evaluation was actually a screening. DRD stated a screening was observation only and an evaluation was hands on, after obtaining a physician's order for therapy to evaluate. DRD stated after the evaluation, then recommendations were made by therapy staff. DRD and RNC stated they reviewed their emails and had instructed facilities to remove side rails from all vacant beds but not sure why the side rails were removed from all beds. On 8/18/22 at 10:57 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that repositioning in bed was hard for resident 29 and when her side rail was removed, some of her independence was taken away. LPN 1 stated that the State Survey Agency came in and told them they could not have side rails. LPN 1 stated side rails had been removed about a week or so ago. LPN 1 stated resident 29 complained to her that it was easier for her to reposition with the side rail. LPN 1 stated resident 29 was independent at home prior to admission. LPN 1 stated resident 29 wanted her side rail back and asked for it a lot. LPN 1 stated she had informed management resident 29 needed her side rail back. On 8/18/22 At 10:37 AM, an interview was conducted with resident 29. Resident 29 stated that her shoulder was feeling better since they replaced her side rail. Resident 29 stated they said the state had ordered for the side rails to be removed because they were a hazard. Resident 29 stated she was sick and became very dizzy and was afraid she would end up on her head. Resident 29 stated when she rolled onto her left side her right leg pulled her over. Resident 29 stated that she told a lot of staff that she wanted the side rail back and no one was able to help. Resident 29 stated she felt frustrated when they took the side rail off and then It was a danger for me because I'm aware. Resident 29 stated They put a chair there and the chair slid and I went with the chair. Resident 29 stated her rib cage was feeling like she pulled a muscle under her breast and all the way around the back. Resident 29 stated she was still tender but feeling better. On 8/18/22 at 1:20 PM, the RNC and DRD provided additional information of a progress note by LPN 1. The skilled progress note dated 8/13/22 at 10:45 AM, .Improvement is seen with bed mobility with her helping to hold herself over. She has better balance with transferring and is not so scared with the process. On 8/18/22 at 1:39 PM, an interview was conducted with LPN 1. LPN 1 stated resident 29 was a 3 person assist when she was admitted and was improving in strength overall. LPN 1 stated the note on 8/13/22 did not have anything to do with bed mobility and the positioning bar. 2. Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/15/22 at 1:40 PM, an interview was conducted with resident 36. Resident 36 stated he could not use his right leg because it was injured in an accident. Resident 36 stated he was unable to walk and that he had limited range of motion in his right leg. On 8/17/22, resident 36's medical records were reviewed. A progress note revealed the following: 7/11/2022 15:18 [3:18 PM] Note Text: Bed Rail Screening performed by PT (physical therapy) and determined that pt (patient) requires B (bilateral) bed rails to assist in bed mobility with rolling and sit to supine leading to decreased assistance by the aides. Resident 36's care plan had a focus area that stated, resident 36 has an ADL self-care performance deficit r/t (related to) or decreased mobility, Hx (history) of Cervical fracture, refusal of cares, pain, communication and cognitive deficits, [CONDITION(S)] (end stage [CONDITION(S)]) with hemodialysis, Spinal Stenosis, [CONDITION(S)] affecting right dominant side, weakness and difficulty walking. The goal associated with the focus area stated, [resident 36's] needs will be met through the review date. One of the interventions associated with the focus area and goal stated, Has bilateral 1/4 rails to assist with repositioning and participation in ADL's. Date Initiated: 08/17/2022. Resident 36's care plan had another focus area that stated, [Resident 36] is at risk for falls r/t impaired mobility, balance deficits, hx Cervical fracture, pain, communication and cognitive deficits, psychoactive, cardiac and respiratory medication use, impaired gas exchange with use of oxygen, DX (diagnoses) [CONDITION(S)], history of TBI ([CONDITION(S)]), [CONDITION(S)] unspecified affecting right dominant side, poor safety awareness and hx of falls. He demonstrates behavioral symptoms that contribute to falling and also has a history of intentionally self transferring to the floor. The goal associated with the focus area stated, [Resident 36] will not sustain serious injury requiring hospitalization through the review date. One of the interventions associated with the focus area and goal stated, Bariatric bed in lowest position Date Initiated: 02/09/2021. Orders for resident 36 revealed the following: a. Order: Bed rails to be placed on both sides of patient's bed to allow improved bed mobility, ease burden of care for caregivers and increase safety with all cares provided in bed. Directions: No directions specified for order. Revision date: 8/17/22. b. Order: PT (physical therapy) evaluation and treatment as indicated for bed mobility. Directions: one time only for 7 days. Start date: 8/17/22 12:02 PM. End date: 8/24/22. [Note: The above listed orders were written on 8/17/22 during the facility's recertification survey.] On 8/15/22 at 1:51 PM, it was observed that resident 36 appeared to be lying on a bariatric mattress on top of what appeared to be a standard hospital bed frame. It was observed that the mattress was too big for the bed frame. It was observed that no bed rails or bed canes were in place, and a large chair was positioned up against the left side of resident 36's bed. It was observed that several of resident 36's personal items were on the chair. On 8/16/22 at 3:09 PM, it was observed that resident 36 had a standard hospital bed frame and a bariatric mattress with no bed rails or bed canes in place. It was observed that a large chair was positioned up against the left side of resident 36's bed. On 8/17/22 at 7:57 AM, it was observed that resident 36's bariatric mattress was gone, and a standard hospital bed mattress was positioned on top of the standard hospital bed frame. It was observed that bed canes were in place on both sides of the bed. On 8/17/22 at 10:40 AM, an interview was conducted with the RNC and DRD. The RNC and DRD stated that resident 36's progress note dated 7/11/22 showed a screen had been completed. The DRD stated the therapist who did the screen on resident 36 probably watched the resident and determined the bed rails were beneficial. The DRD stated that bed rails were already in place so the therapist did not need to do an evaluation. The DRD stated that after the screen was done, the facility removed all bed rails and bed canes. On 8/18/22 at 2:09 PM, a follow up interview was conducted with the RNC and DRD. The RNC stated upon admission, all residents typically had a standard pressure relieving mattress that was effective in the prevention of pressure ulcers up to a stage 2. The RNC stated if the resident was admitted with orders for a mattress, or if the resident had a fall out of bed, the issues would be discussed with the IDT (interdisciplinary) team to determine what new interventions could be implemented. For resident 36, the intervention was to provide a bariatric bed to help him feel more secure. The RNC stated in IDT the task to implement the new intervention would be assigned to a staff member to complete. On 8/18/22 at 2:20 PM, the interview with the RNC and DRD reconvened in resident 36's room. Resident 36 was observed to be lying in bed. It was observed that he appeared to have a bariatric mattress on what appeared to be a standard hospital bed frame. The RNC and DRD evaluated resident 36's bed. The RNC stated that it appeared the bed frame expanded but was too small for the mattress. The RNC stated the bed needed to be adjusted, and stated she would contact the MD. On 8/18/22 at 2:32 PM, the MD arrived at resident 36's room. The MD was observed to evaluate the bed and make some adjustments. The MD stated the bottom of the frame was not in place, but he fixed it to accommodate the bariatric mattress. The MD stated the mattress was now secured on the bed frame. It was observed that no bed rails or bed canes were in place. 3. Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 20's medical record was reviewed on 8/15/22. On 8/17/22 at 8:10 AM, resident 20 was observed to be in her bed with no side rails. There was a chair on the left. The resident was observed to be leaning out of her bed with her upper body outside of the bed. The resident stated she was trying to reach her phone which was on the chair. On 8/17/22 at 10:30 AM, resident 20 was again observed to be in her bed with no side rails. There was a chair on the left. On 7/11/22, a Physical Therapist indicated in a progress note that resident 20 needed side rails. An evaluation was not completed. On 8/18/22 at 11:30 AM, an interview was conducted with the RNC and DRD. The RNC stated that on 7/11/22, when the entered the note, the resident already had a side rail in place, so no further action was taken besides entering the note. The RNC and DRD stated they did not know when the side rail had been removed.

Based on observations, interviews, and record review, it was determined that the facility did not provide residents with the appropriate treatment and services to maintain or improve their abilities to carry out activities of daily living. Specifically, for 1 out of 19 sample residents, the facility did not ensure the resident received 2-person assistance with bed mobility consistent with the resident's needs and choices. Resident identifier: 32. Findings include: Resident 32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/22 at 8:05 AM, Registered Nurse (RN) 1 was observed to administer medication to resident 32 in the resident's room. Certified Nursing Assistant (CNA) 2 was also present in resident 32's room. Resident 32 pointed at CNA 2 and stated, he should be suspended. Resident 32 then stated that CNA 2 pulled him up in bed without help and it hurt his shoulder. RN 1 was observed to assess resident 32's shoulder. RN 1 stated there was no visible injury to resident 32's shoulder. RN 2 asked resident 32 if he had pain in his left shoulder and he said no. On 8/16/22 at 9:30 AM, an interview was conducted with CNA 2. CNA 2 stated that when he changed resident 32's brief, he rolled him to one side, changed the brief and cleaned him up, then rolled him back. CNA 2 stated that resident 32 could be changed by one CNA but required 2 CNAs when wound care was provided with the brief change. CNA 2 stated he usually changed the resident's briefs by himself. CNA 2 stated that on the previous Saturday after he changed resident 32, resident 32 said his shoulder hurt. CNA 2 stated that he told Licensed Practical Nurse (LPN) 3 what the resident had reported about pain. CNA 2 stated that after he talked to LPN 3, it was decided that resident 32 required 2-person assistance when his brief was changed and when wound care was provided. On 8/17/22 at 8:14 AM, a phone interview was conducted with LPN 3. LPN 3 stated that resident 32 had told her and his hospice nurse that CNA 2 had pulled him up in bed without another CNA to help him. LPN 3 stated resident 32 told her when CNA 2 pulled him up it hurt his left shoulder. LPN 3 stated she assessed resident 32's shoulder and did not find any wounds or injuries. LPN 3 stated resident 32 denied pain during her assessment. LPN 3 stated that later she talked to CNA 2 and resident 32 about the incident together. LPN 3 stated she told CNA 2 when he assisted resident 32 he had to have a second person with him. On 8/17/22 at 1:25 PM, a follow-up interview was conducted with resident 32. Resident stated he was happy that CNA 2 knew he needed a second person to help him provide care. On 8/17/22 a review of resident 32's medical record was completed. Progress notes revealed the following: 8/16/2022 09:20 (9:20 AM) Note Text: As team nurse was entering the room, a CNA was leaving, resident stated that the CNA hurt his left shoulder on Saturday when scooting him up in bed alone. ED (Executive Director), DON (Director of Nursing), and UM (Unit Manager) were notified. Team nurse and Unit manager assessed resident. No new issues or bruising were noted with the skin assessment. When asked if he had pain and where he stated that it he has pain in his left shoulder. When assessing resident's pain, he stated there was no pain upon palpation of the shoulder and surrounding area, and he also stated he felt no pain with movement and ROM (Range of Motion). Resident 32's Change of Condition Minimum Data Set (MDS) dated [DATE] stated in Section G that resident 32's self-performance in bed mobility was extensive assistance, and the ADL (Activities of Daily Living) support to be provided was two plus person physical assist. Resident 32's Care Plan had a focus initiated on 4/22/22 which stated [Resident] requires total assistance from staff with his ADL needs. On hospice care. The focus had a goal which stated, [Resident] will receive assistance from staff to complete his ADL's thru (sic) next review, and an intervention that stated, bed mobility extensive assistance of two. The ADL - Bed Mobility task in resident 32's chart showed that from 7/19/22 to 8/19/22, it was documented that resident 32 received one person physical assist 35 times and 2+ persons physical assist 33 times. On 8/18/22 at 11:05 AM, an interview was conducted with CNA 3. CNA 3 stated before her shift she received a change of shift report on every resident and the level of assistance needed with ADLs. CNA 3 stated resident 32 used the side rails on his bed to roll from side to side. CNA 3 stated to keep him calm two people assisted with resident 32's ADLs. CNA 3 stated most of resident 32's care could be done by one person but to cover our own butts they had 2 people assist. CNA 3 stated it was not always possible to provide care with two CNAs and in reality resident 32 was a one person assist with all cares. CNA 3 stated that a brief change could easily be done by one person and he could be slid up in bed by one person but she preferred to use two. CNA 3 stated it was easier to slide resident 32 up in bed with 2 people and it was the best way to protect herself. On 8/18/22 at 11:11 AM, an interview was conducted with CNA 4. CNA 4 stated if she had not worked with a resident before, she asked the resident what assistance they required with ADLs. CNA 4 stated if she was unsure she would ask another aide who had worked with the resident or she would ask the nurse. CNA 4 stated resident 32 was an extensive 2 person assist and the resident felt better with assistance from two people. CNA 4 stated resident 32 sometimes pushed back because he felt he would fall, so the second aide reassured him he was safe. CNA 4 stated if another aide was not available and resident 32 had a bowel movement, she changed the resident's brief by herself. On 8/18/22 at 11:31 AM, an interview was conducted with RN 4. RN 4 stated resident 32 was a total two person assist with his ADLs. On 8/18/22 at 12:30 PM, a follow-up interview was conducted with CNA 4. CNA 4 stated there was CNA binder located at the nurses station, and that the binder provided information about the residents and CNA responsibilities. CNA 4 was then observed to look through the CNA binder, and then stated that the level of assistance that each resident required was not in the binder. CNA 4 stated information about the level of required assistance was available in change of shift reports, by asking the nurse or other CNAs, or looking in the resident's chart.

Based on observation, interview and record review it was determined, for 1 out of 29 sampled residents, that the facility failed to ensure that a resident was free from abuse. Specifically, a resident reported experiencing repeated incidents of verbal abuse from another resident along with an incident of physical abuse. The deficient practice identified was found to have occurred at a harm level. Resident identifier 13 and 22. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/07/22 at approximately 11:45 AM, an interview was conducted with resident 22. Resident 22 stated no when asked if she had any concerns or problems with any of the other residents in the facility, and if anyone had treated her badly. The resident stated no with notable hesitancy when asked if she had any concerns or problems with any of the staff in the facility, and if anyone had treated her badly. Resident 22 was observed grimacing and rubbing her stomach. Resident 22 was asked if she had pain in her stomach to which she replied yes. The resident was asked if she would like to further discuss staff treatment after she received treatment from the nurse for her current complaints of stomach pain and the resident replied, yes. On 2/7/22 resident 22's medical records were reviewed. The Annual Minimum Data Set (MDS) assessment on 1/8/22 documented a Brief Interview for Mental Status score of 7 which would indicate severely cognitively impaired. The assessment documented that resident 22's speech pattern was unclear and was usually able to make self understood. The Resident Mood Interview or PHQ-9 score was a 7, and had indicated symptoms present for feeling down, depressed or hopeless with a frequency of 2-8 days; trouble falling or staying asleep, or sleeping too much with a frequency of 7-11 days; feeling tired or having little energy with a frequency of 2-8 days; and moving or speaking slowly or being restless or fidgety that others noticed with a frequency of 12-14 days. The assessment did not indicate that resident 22 had any behaviors or exhibited any signs of [CONDITION(S)]. The assessment documented that resident 22's functional status was a one person extensive assistance for bed mobility, transfers, locomotion, dressing, and personal hygiene. Resident 22's Preadmission Screening Resident Review (PASRR) Level II assessment on 11/25/19 documented that resident 22 sustained a severe [CONDITION(S)] [CONDITION(S)] that left her with [CONDITION(S)] at 18 months old. Resident 22 was placed into foster care and had been with the same family her entire life. Resident 22 had severe motor deficits, had always been wheelchair bound and required extensive to total assistance with all Activities of Daily Living (ADLs). Her functional abilities declined 2 years ago when she suffered a hip injury that required fusion of the hip. She had been living with her aging foster mother who now had Alzheimer's dementia and was no longer able to physically care for her. The family would like them placed together in a Skilled Nursing Facility (SNF). At this point in her life, it was not felt that a transition into an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) setting would be in her best interest as she would likely not adjust well. The assessment documented resident 22's developmental strengths as follows; was able to crawl around the house; take herself to the bathroom; get in and out of the bathtub and bed independently, was independent with bathing, except for the hair; was independent with dressing; independent with eating; and independent in keeping up her room. This all had changed two years ago after resident 22 had a hip injury that required fusion of the hip. Prior to the surgery, resident 22 was social with family and church activities. There was no history of any behavioral issues. The assessment documented that resident 22 had always been even tempered and pleasant. The assessment documented resident 22's developmental weaknesses as significant weakness in left leg and could no longer crawl or climb after surgery. Resident 22 had limited range of motion in bilateral upper extremities. Resident 22's speech was severely dysarthric, and she was sensitive about this and would shut-down if she was around people who did not understand her. Review of resident 22's progress notes revealed the following: a. On 1/27/22 at 4:53 PM, the note documented that the family was notified of the incident and transfer of roommate to another room. b. On 1/31/22 at 9:21 AM, the Social Service Worker (SSW) note documented, Spoke with resident to see how she is feeling. She is happy. She is happy that her old roommate has a new room. She seems her normal, cheerful self. c. On 2/8/22 at 7:49 PM, the Registered Nurse (RN) 1 note documented, Earlier this evening RN overheard [resident 22] crying in the dining room. CNA [Certified Nurse Assistant] was attempting to comfort her. The other resident reported that another had come into the dining room area and said some 'mean things' causing [resident 22] to cry. It was difficult to console [resident 22]. d. On 2/9/22 at 3:18 PM, the SSW PHQ-9 note documented, Resident is not always interested in the games and activities. Is feeling a little sad today. States that she had a tummy ache last nightand (sic) also felt sad when another resident said, 'Go home,' to her as it hurt her feelings. She states that she does not always like thefood (sic). She reports that she is not sleeping really well at night and feels tired during the day. Resident is somewhat aware that herspeech (sic) is altered. Review of resident 22's Care Plan revealed the following focus areas with interventions: a. Resident 22 had a cognitive deficit [CONDITION(S)], mild intellectual disabilities, and mood problem. The care plan was initiated on 1/28/2020. Interventions included allow the resident extra time to respond to questions and instructions, ask yes/no questions, use resident's preferred name, identify self, make eye contact, and reduce distractions; the resident understands consistent, simple, directive sentences; cue, reorient and supervise as needed; face the resident and speak clearly; keep routine consistent with routine care givers; observe and report any changes in resident 22's cognitive function; and present one thought, idea or question at a time. b. Resident 22 had a communication problem related to [CONDITION(S)], mild intellectual disabilities, cognitive deficits, and mood problem. The care plan was initiated on 1/22/21. Intervention identified included anticipate and meet needs; allow adequate time to respond; encourage resident; monitor frustration level; monitor ability to communicate; observe for problems with decline in cognitive status, mood, or decline in ADLs; observe for nonverbal indicators of distress or discomfort, provide safe environment; observe ability to comprehend language, memory, reasoning, and problem solving; stop sign on door and door to be closed to discourage unwanted visitors; and validate message by repeating aloud. c. Resident 22 was at risk for change in mood or behavior due to medical condition, resident was noted to have tearful episodes when needs were not met. [CONDITION(S)], cognitive/intellectual disability. Mood changes may be related to her menstrual cycle. The care plan was initiated on 11/4/21. Interventions identified included consult with resident on preferences on routine; medications as ordered; provide 1:1 activities; distraction; and redirection to help with sadness/crying and/or depressed feelings. d. Resident 22 had a mood problem related to [CONDITION(S)], pain, Functional [CONDITION(S)], and mild intellectual disabilities. The care plan was initiated on 1/22/21. Interventions identified included behavioral health consults as needed; observe and report any risk for harm to self; observe and report to Medical Doctor (MD) any acute episodes of feelings or sadness in the form of loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, change in ability to concentrate, or change in psychomotor skills; observe and report to MD any signs or symptoms (s/sx) of depression, anxiety, or sad mood; observe and report to MD any risk for harming others; observe for s/sx of [CONDITION(S)] or hypomania; observe mood to determine if problems seem to be related to external causes; and encourage resident to express feelings. e. Resident 22 had a potential psychosocial wellbeing problem related to presence of little interest or pleasure in doing things secondary to cognitive deficits and decreased mobility related to [CONDITION(S)] and mild intellectual disabilities. She also has expressive/receptive communication disorder and may have an altered perception of reality. The care plan was initiated on 1/28/2020. Interventions identified included all concerns investigated per facility policy with resolution communicated in a manner she understood; consult with pastoral care/social services/psych services; provide opportunities for the resident and family to participate in care; simplify communication to allow resident to understand; and when conflict arises remove residents to a calm safe environment and allow to share feelings. f. Resident 22 was at risk for alteration in psychosocial well-being due to environmental situation. The care plan was initiated on 3/20/2020. Interventions identified included encourage alternative ways of communication with friends and family; observe for changes in mental status caused by situational stressors and report to physician as appropriate; observe for psychosocial changes and report to physician as appropriate; and provide opportunities to express feelings. Review of resident 22's January 2022 Treatment Administration Record (TAR) revealed no documentation for behavior monitoring. Review of resident 22's February 2022 TAR revealed behavior monitoring was initiated on 2/9/2022 at 3: 13 PM for Rapid Mood Changes. It should be noted that monitoring was initiated after an incident occurred between resident 22 and resident 13 on 2/8/22. Review of the facility abuse investigation documentation documented that on 1/27/22 at approximately 12:15 PM the facility Activities Director (AD) overheard resident 13 call resident 22 a name. The AD spoke to resident 13 and told her it was not okay to call resident 22 names. The name was not understood by the AD, but resident 22 knew it was directed at her and said hey when resident 13 said it. Resident 13 was witnessed by the AD to wheel herself around the nursing station returning back to resident 22. The AD then heard resident 22 say to resident 13 don't do that. The AD asked resident 22 what had happened and resident 22 replied that resident 13 had kicked her as she was passing by in the wheelchair. The AD statement documented that she did not witness the kick. The AD reminded resident 13 that it was not ok to hurt someone else and to please not kick resident 22 again. The AD asked resident 13 if she understood and resident 13 nodded yes. Resident 22 was assessed for any marks from the kick and none were noted. The AD statement documented that resident 22 was in tears none the less. The facility summary of resident to resident investigation documented that resident 22's foot pedals were on the wheelchair which may have prevented any physical contact. The summary documented that the facility Administrator (ADM) attempted to interview resident 13 about the incident. Resident 13 refused to speak with the ADM, hitting her and wheeled off down the hall. The summary documented that the ADM asked resident 22 if resident 13 had kicked her and resident 22 replied yes. The ADM discussed moving resident 13 out of resident 22's room as her roommate. The summary documented that resident 13 was monitored the remainder of the day for any negative behavior towards resident 22 and resident 13 was transferred to a different room. The summary documented that the ADM spoke with resident 22 the following day on 1/28/22 regarding the room transfer of resident 13 and resident 22 was happy with the transfer, smiling and shaking her head. The summary documented that the allegation of abuse was not substantiated for verbal abuse or physical abuse because the incident of kicking was not witnessed by any staff member or other residents, and both residents were unable to be interviewed to complete a BIMS assessment. On 2/09/22 at 12:26 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that there was an altercation between resident 22 and resident 13 last night, 2/8/22, in the assisted dining room. RN 1 stated that resident 13 had said something mean to resident 22 and resident 22 had cried for over an hour. RN 1 stated that the residents were separated and resident 22 was taken back to her room. RN 1 stated she documented a progress note of the behavior so that management would see it in the morning meeting, but did not report the incident to anyone. RN 1 stated that she was not aware of any previous altercations between residents 22 and resident 13, but it should be charted if it occurred. RN 1 stated that the residents use to be roommates and one day when she came to work they were not roommates anymore. RN 1 stated she did not know why resident 13 was moved to a different room. On 2/9/22 at approximately 2:00 PM, the facility Administrator (ADM), Director of Nursing (DON), and Unit Manager (UM) were notified of the resident to resident altercation between resident 22 and resident 13 that occurred on 2/8/22 by the State Survey Agency. On 2/09/22 at 2:09 PM, a follow-up interview was conducted with RN 1. RN 1 stated that she did not think that the incident between resident 22 and resident 13 on 2/8/22 was an incident of abuse. RN 1 stated that the incident was that resident 13 had said something mean to resident 22 resulting in resident 22 being upset and crying for 30 to 40 minutes. RN 1 stated that the definition of verbal abuse was putting someone down or making someone feel bad about themselves. RN 1 stated that she received education on abuse a few months ago. RN 1 stated that she never got a clear indication of what had happened and she did not ask what was said, but knew that something mean was said. RN 1 stated that resident 22 did not report anything to her as she talked more to the CNAs than to her. RN 1 stated that CNA 4 had reported that resident 22 had got her feelings hurt. RN 1 stated that incidents of abuse should be reported to the facility Administrator within 15 minutes and reported to the State Survey Agency within 2 hours. On 2/09/22 at 2:25 PM, an interview was conducted with CNA 4. CNA 4 stated that at approximately 4:45 PM she took resident 22 to the assisted dining room. CNA 4 stated that at that time resident 13 was yelling at resident 23, who was resident 22's foster mother. CNA 4 stated that resident 23 asked to eat with resident 22. CNA 4 stated that resident 13 started yelling at resident 23 and resident 22. CNA 4 stated at this time resident 13 was still doing laps around the nurse's station in her wheelchair. CNA 4 stated that she went to room [ROOM NUMBER] for approximately 2-3 minutes and during this time resident 13 and resident 22 were left unattended by staff. CNA 4 stated she heard resident 22 screaming and crying. CNA 4 stated that when resident 22 started screaming resident 13 left to go to the main dining room. CNA 4 stated that when resident 13 knows she has done something wrong she goes and hides up by the main dining room. CNA 4 stated that she was able to get resident 22 to calm down a bit. CNA 4 stated that resident 22 was a bit better and she left to assist resident 9 with dining. CNA 4 stated that resident 22 began to cry again and someone put her in her room. CNA 4 stated that the nurse reported that she did not know why resident 22 was crying. CNA 4 stated that she went to resident 22's room and tried to calm her down. CNA 4 stated that when resident 22 had calmed down she told her that resident 13 had said get out and go home. CNA 4 stated that resident 22 wanted to eat in her room with the door closed because she felt safer. CNA 4 stated that resident 22 had stopped crying but her eyes were swollen. CNA 4 stated that resident 22 had asked to go to bed early that night at 7:30 PM and she usually went to bed later at around 8:30 PM. CNA 4 stated that resident 13 did not say names, but she would look you in the eyes and point when she says things to you. CNA 4 stated that she was saying the things intentionally to resident 22 and they were intentionally to hurt her feelings. CNA 4 stated that resident 13 knows that resident 23 was resident 22's mom and CNA 4 thinks that resident 13 feels jealous. CNA 4 stated that the incident started with resident 13 yelling at resident 23, and she told resident 13 to be nice. CNA 4 stated that resident 22 heard CNA 4 telling resident 13 to be nice so resident 22 repeated be nice to resident 13. CNA 4 stated that was when resident 13 stopped in the doorway to the assisted dining room and said things intentionally to resident 22. CNA 4 stated that resident 13 and resident 22 use to share a room and things like that happened in the past. CNA 4 stated that resident 22 was crying so hard that her chin was trembling. CNA 4 stated that when they decided to move resident 13 to another room it was because resident 13 had struck out at resident 22. CNA 4 stated that the facility had provided education on abuse three weeks ago. CNA 4 stated that if she had witnessed abuse she was supposed to report the incident to the nurse, UM, and DON. CNA 4 stated that last night the nurse knew because she was on shift with her and she did not report it to the UM or DON because she let the nurse report it. On 2/09/22 at 2:39 PM, an interview was conducted with the ADM, UM, and DON. The UM stated that the incident between resident 22 and resident 13 that occurred on 2/8/22 was not a reportable event. The UM stated that this was determined by interviews with CNA 4 and RN 1. The UM stated that the incident was that resident 13 stated, go home and it was a repetitive behavior that she had. The UM stated that CNA 4 stated that she brought resident 22 to the assisted dining room to eat with her mother. The UM stated that resident 13 was in the dining room and was saying go home, go home. The UM stated that the nurse did not witness any of the events and what had been reported to her she did not feel was abuse. The UM stated that both RN 1 and CNA 4 were writing statements of the incident for the facility investigation. It should be noted that the determination by the UM that the incident was not a reportable event was made prior to speaking with resident 22. On 2/09/22 at 3:52 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that resident 13 was mostly aggressive with resident 22. The SSW stated that resident 13 had a mind of a 4 year old and sees resident 22 as a sister. The SSW stated that resident 13 and resident 22 were previously roommates. The SSW stated that resident 13's way of communicating was to state go home. The SSW stated that this could be said with the inflection as a question where the pitch would be higher, or if resident 13 was done with you she would say go home in a deeper tone. The SSW explained that it was the behavior of a child. The SSW stated that she could see that it was hurtful to resident 22. The SSW stated that saying go home to you or I does not have the same effect that it has on resident 22. The SSW stated that she had the suspicion that it might be time to have a discussion about a more appropriate placement for resident 13 at another facility. The SSW stated that this was a discussion that she had been having with the ADM for some time now. The SSW stated that she conducted a PHQ-9 test with resident 22 today and she scored 10. The SSW stated that it was consistent with her previous scores. The SSW stated that resident 22 reported that she did not like doing anything and believed it was from a lack of interest, and resident 22 reported feeling down and then said it was due to a tummy ache. The SSW asked resident 22 if something happened with someone that made her feel sad. The SSW stated that resident 22 replied yah. The SSW stated she asked resident 22 if she had talked to resident 13 and she replied yah. The SSW asked resident 22 if resident 13 had said something that made her feel sad, and resident 22 replied yah. The SSW stated that resident 22 feels all the different feelings, she was sensitive and it hurt her feelings. The SSW stated that resident 22 was only equipped to talk as best as she could. The SSW stated that she just found out about the incident an hour ago. The SSW stated that not everyone had the same response as the administration team and considered it abuse. The SSW stated that the facility had been educating the staff on abuse but had been focusing on staff to resident abuse. The SSW stated that they needed to spend more time on resident to resident abuse and situational abuse cases. The SSW stated that resident 22 did not know how to categorize the incident and did not know how to handle it. The SSW stated that resident 13 use to be a roommate with resident 22 and she sees her as a sibling and resident 13 will single resident 22 out. The SSW stated that the targeting would be like a 4 year old would target another 4 year old, and then you would need to separate them. The SSW stated that since the initial incident between resident 13 and resident 22 in January separation was working. The SSW stated that prior to January resident 13 did not have these behaviors. The SSW stated that she correlated it with the holidays and not seeing her family for over a year. The SSW stated that the recent behaviors by resident 13 were in her opinion those of a neglected child. The SSW stated that resident 13 was very happy and cheerful after talking to her family member. The SSW stated that the situation was such that they were dealing with two residents with intellectual disabilities. The SSW stated that resident 13 sees people have interactions with resident 22 and she had some jealousy. The SSW stated that resident 22 was reporting today that she was not able to sleep at night, and she had some weepiness today. The SSW stated that resident 22 reported that she did not feel bad about herself. The SSW stated that resident 22 does recognize that her speech was not normal. The SSW again stated that resident 22's PHQ-9 score was not far off from her previous scores. The SSW stated that her documentation would be located in progress notes. The SSW stated that the facility protocol was that the department head should be informing her of any resident to resident altercations. On 2/10/22 at 11:37 AM, an interview was conducted with the resident 22. Resident 22 was located in the assisted dining room with resident 23. Resident 22 requested the interview be conducted in her room, no, in my room. Nurse Assistant (NA) 1 wheeled resident 22 to her room. Resident 22 immediately stated that someone in a wheelchair passed by and yelled at her. Resident 22 stated that this individual yelled at her and told her to go home and hurry and everybody die. Resident 22 was asked if there was anything else that was said. Resident 22 hesitated, looked downward and said you really, really want me to say that. I replied yes. Resident 22 then mouthed [OBSCENITY] you. Resident 22 was asked to repeat the word a second time. Resident 22 again mouthed [OBSCENITY] you. Resident 22 was asked to confirm that the word that she was mouthing was [OBSCENITY] you, and the resident stated yes. Resident 22 stated that she [resident 13] did not like anybody. Resident 22 was asked if she knew the other resident's name, and could tell me the other resident's name. Resident 22 said she knew her name and sounded out Ka. Resident 22 was asked if the other resident use to be her roommate and she replied yah, over there. Resident 22 was asked why the other resident was moved and resident 22 stated she was mean to me. Resident 22 was asked if she told anyone else about the F word, and she replied no. Resident 22 was asked why she did not tell anyone and resident 22 said I cant. Resident 22 was asked again why she felt she could not tell anyone and resident 22 repeated a second time, I cant. Resident 22 was asked if she was afraid to report this and she replied yes. Resident 22 stated that she trusted to tell her night aide, and she told the night aide the other night. Resident 22 was asked how it made her feel when this happened. Resident 22 replied that it made her cry. Resident 22 was asked if she felt safe in her bedroom, safe at the facility, and that the staff kept her safe, and resident 22 indicated yes. Resident 22 was asked if she felt safe around resident 13 and resident 22 replied no. Resident 22 was asked, when the staff are around do you feel that they can keep you safe from resident 13, and resident 22 replied not really. Resident 22 was asked what the staff do to stop this from happening with resident 13, and resident 22 replied they don't do anything Resident 22 was asked had this happened before the other night, and resident 22 replied oh yah. Resident 22 was asked does it happen more in the day or at night, and resident 22 replied in the day. Resident 22 was asked does it happen in your room or out by the nurse's station, and resident 22 replied out there, really. Resident 22 was asked if resident 13 only said mean things or if resident 13 also touched her. Resident 22 stated that it was saying and kicking. Resident 22 demonstrated kicking and said [NAME]. Resident 22 was not able to state how often this had occurred. Resident 22 was asked if the kick was in the air or had made contact with her skin, and resident 22 pointed to the right leg below the knee and said right there, really. Resident 22 stated the other night she was upset because resident 13 had said mean things and kicked her. Resident 22 stated none of the staff hurt her, no. 2. Resident 13 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/07/22 at 10:22 AM, resident 13 was observed in her wheelchair circling the nurses station. Resident 13 had a water jug in their hands as they wheeled around the nurses' station area. Resident 13 did not interact with any other residents seated near the nurses' station. On 02/09/22 at 12:12 PM, resident 13 was observed in her wheelchair, circling the nurses' station with headphones on. Resident 13 was observed to gently pat a nurse on their back. Resident 13 did not interact with any other residents seated near the nurses' station. On 02/10/22 a review of resident 13's medical record was completed. The following were noted; A Health Status Note from 1/28/22 read, Note Text: Pt [Patient] made her roommate cry yesterday. Pt is more cooperative today yet becomes easily upset intermittently. Room change to [room number]. A Behavior Note from 1/28/22 read, Note Text: Yesterday, just before lunch, resident was wheeling around the west side nurse's station and her roommate was sitting there. RT [Recreational Therapy] Staff heard resident call her roommate a name so RT Staff promptly told her to be nice. As resident wheeled around the nurse's station, RT Staff went past her to far west hall to pass lunch trays and heard her roommate yell don't do that! When the RT Staff asked roommate what happened her roommate told her that resident had kicked her as she passed and roommate immediately started to cry. Roommate had pedals on so there wasn't any marks to roommates legs noted. RT Staff took resident aside and told her it was not ok to hurt someone else and that she was not to kick anyone anymore. When RT Staff asked if she understood, resident nodded. RT Staff immediately reported incident to ED [Executive Director]. A Health Status Note from 1/29/22 read, Note Text: [Resident 13] took another resident's pitcher with soda in it and when CNA [Certified Nursing Assistant] attempted to get it from her she refused to give it up and got mad when CNA tried. This nurse was able to retrieve the pitcher from resident without incident. She was then gotten her own pitcher with soda and everything was fine. Will continue to monitor. A Behavior Note from 2/4/22 read, Note Text: RT Staff was walking into their office and [resident 13] was beading. [Resident 10] was talking to another staff member and RT Staff overheard [resident 13] telling [resident 10] to shut-up. RT Staff reminded [resident 13] to be nice to which [resident 13] told the RT Staff to go home and proceeded to call whomever an ***hole. RT Staff asked her if she was upset about something but there was no comment from [resident 13]. RT Staff suggested if she was upset with someone she could go to her room to get away from everyone but again, there was no comment. [Resident 13] continued to sit and bead outside of the RT office. An Incident Report from 2/4/22 read, Incident Description: Nursing Description: ED was standing next to resident and resident struck ED in the arm with no provocation. [Resident 13] also reported that she kicked roommate . Description: Asked [resident 13] if she was okay and needed anything, asked why she was upset enough to hit. [Resident 13] stated she missed her family. Safety was assured by ensuring resident [13], roommate [resident 22], and ED were all removed from same space . After incidents of aggression, SSD [Social Services Director/ Worker] interviewed resident [13] and resident [13] expressed she was sad that she had not been visited by her family. SSD assisted resident in calling her family and resident was able to talk to her family. Resident expressed that helped her feel better. Resident was also moved into a new room, to remove her from roommate [resident 22]. A Behavior Note from 2/8/22 read, Note Text: Earlier this evening RN [Registered Nurse] overheard another resident crying in the dining room. CNA was attempting to comfort her. The other resident reported that [resident 13] had come into the dining room area and said some mean things causing the other resident cry. It was difficult to console the other resident. [Note: The residents involved in this incident were found to be resident 13 and resident 22. No Incident Report was developed when the Charge Nurse was informed of the incident between resident 13 and resident 22.] A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? chart to prog [progress] notes every shift: Monitor; A. # of Behavior Episodes B. Intervention Code C. Outcome Code (+/-/0): (+) improved (-) worsened (0) unchanged -Order Date- 01/27/2022. Within the TAR from January 2022, several entries were made. On 01/30/22 the nursing staff documented # of behavior episodes 9, intervention code of 9 for change position, and outcome code 0 for unchanged. In review of resident 13's progress notes, there were no progress notes present from 1/30/22. In review of the TAR from February 2022, nursing staff coded 0 for behaviors on 100% of occurrences. [Note: On 2/4/22 and 2/8/22, when progress notes regarding aggressive behaviors were noted, resident 13 was coded as having had no occurrences of aggressive behaviors within the TAR.] Within resident 13's Activities of Daily Living (ADL) task reporting, CN [TRUNCATED]

Based on observation, interview, and record review it was determined the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 29 sampled residents, there were no pain interventions implemented for complaints of unrelieved pain for almost 24 hours. Resident identifier: 191. Findings included: Resident 191 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/9/22 at 9:55 AM, Physical Therapist (PT) 1 was observed informing Registered Nurse (RN) 2 that Resident 191 was in quite a bit of pain and unable to do therapy and asked RN 2 if he could administer pain medication. RN 2 replied that the resident did not have anything ordered, but I think the provider will be coming in later today so we can assess then. It was observed that RN 2 did not call physician or check discharge orders. RN 2 was observed until 12:00 PM without evaluating Resident 191. On 2/9/22 a record review was conducted for Resident 191. Resident 191's Admission assessment documented that resident 191 was admitted to the facility on [DATE] at 5:18 PM. On 2/8/22 at 8:05 PM, resident 191's Nursing Admission/Readmission Collection Tool documented a pain level of four out of ten. The assessment tool documented that resident 191 had chronic lower back pain, left side hip pain and intermittent sharp pain in the back of his thighs. The assessment documented an acceptable level of pain was a two out of ten. The assessment tool documented that resting, Tylenol and narcotics were effective at alleviating the pain. The assessment documented that resident 191 stated that movement provoked great pain, and resting was helpful than pain medication. Review of resident 191's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Acceptable level of pain: Numeric Scale 2/10 Location of pain: 1. Back 2. Left Hip 3. Bilateral Dorsal Thigh Numeric pain scale every shift. Attempt non-med interventions prior to administering PRN pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Do not exceed 3,000 mg (milligrams) Acetaminophen in a 24 hour period from all sources. The order was initiated on 2/9/22 at 2:00 PM. b. Acetaminophen Tablet, give 650 mg by mouth every 4 hours as needed for pain. Not to exceed 3 gm (gram) of Tylenol in a 24 hr period from all sources. The order was initiated on 2/9/22 at 1:30 PM. c. Numeric pain scale every shift Attempt non-med interventions prior to administering PRN pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on 2/8/22 and discontinued on 2/9/22. It should be noted that at the time this order was initiated resident 191 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] d. PainAD Assessment: Location of pain: Attempt non-med interventions prior to administering PRN pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Do not exceed 3,000 mg Acetaminophen in a 24 hour period from all source. The order was initiated on 2/8/22 and discontinued on 2/8/22. It should be noted that at the time this order was initiated resident 191 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] e. [MEDICATION(S)] Capsule 300 MG Give 1 capsule by mouth two times a day for ? The order was initiated on 2/8/22 and discontinued on 2/9/22. Notes on the order documented discontinue per patient request. Patient stated that he does not take this medication anymore. Review of resident 191's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/8/22 the evening dose of [MEDICATION(S)] 300 mg was not administered. On 2/8/22 at 11:20 PM, the eMAR progress note documented that the medication was not delivered from the pharmacy. b. On 2/9/22 the evening dose of [MEDICATION(S)] 300 mg was not administered. On 2/9/22 at 8:19 PM, the eMAR progress note documented that the patient said he did not want the medication anymore. c. On 2/9/22 at 1:40 PM, the Acetaminophen 650 mg was documented as first administered. The medication was documented as effective. Review of resident 191's Treatment Administration Record (TAR) revealed the following: a. On 2/8/22 on night shift the TAR documented a pain score of 0 out of 10. No time was noted on the TAR. b. On 2/9/22 on day shift the TAR documented a pain score of 0 out of 10. No time was noted on the TAR. c. On 2/9/22 on evening shift the TAR documented a pain score of 9 out of 10. No time was noted on the TAR. It should be noted that resident 191 did not have any pain medication documented as administered on the MAR for the complaints of 9/10 pain, and no documentation could be found to indicate that the pain was addressed. d. On 2/9/22 on the night shift the TAR documented a pain score of 9 out of 10. No time was noted on the TAR. It should be noted that resident 191 did not have any pain medication documented as administered on the MAR for the complaints of 9/10 pain, and no documentation could be found to indicate that the pain was addressed. Review of resident 191's pain level summary revealed the following: a. On 2/8/22 at 8:05 PM, a numerical pain score of 4/10. It should be noted that resident 191 did not have any pain medication ordered and no documentation could be found to indicate that the pain was addressed. b. On 2/9/22 at 12:49 AM, a numerical pain score of 0/10. c. On 2/9/22 at 1:40 PM, a numerical pain score of 3/10. d. On 2/9/22 at 1:55 PM, a numerical pain score of 3/10. On 2/9/22 at 12:22 PM, an interview with resident 191 was conducted. Resident 191 stated that he was there because his pain was causing difficulty with walking. He stated that earlier today they tried to do some physical therapy, which he could not do because of the pain. Resident 191 stated they put some cream on his back, and that gave enough relief to get part of his physical therapy completed. Resident 191 stated that they have not given him anything for pain, which he requested at about 9:00 AM today. On 2/9/22 at 12:58 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she expected staff to immediately assess a resident's pain location and how bad the pain was. The DON stated that the nursing staff should start implementing non-pharmacological interventions. The DON stated that new admits all received pain assessments. The DON stated that the licensed nurses should look at the orders and if there were no orders for pain medication, the nurse should contact the physician. On 2/10/22 at 10:00 AM, an interview was conducted with the facility Medical Director (MD). The MD stated that he had not yet evaluated resident 191. The MD stated that he attempted to evaluate resident 191 last night, but that the resident was asleep. The MD stated that he was unaware that resident 191 was in pain. The MD stated that if a resident was recently admitted and in pain, he would expect the facility staff to contact him for a medication the resident needed. The MD further stated, we rely on the nurses because they are going through the medications and seeing the resident in real time. The MD stated that facility staff could call him directly, or the physician company he worked for. The MD also stated the facility had a procedure in place to prevent residents from being in pain for extended periods of time. On 2/10/22 at 11:20 AM, a interview was conducted with PT 1. PT 1 stated he evaluated Resident 191 on 2/9/22. PT 1 stated that at about 10:00 AM on 2/9/22, Resident 191 was in pain at a level of 8/10 following physical therapy. PT 1 stated that he immediately informed the RN that the resident was in pain and was in need of something for that pain. It should be noted that resident 191 waited 3 hours and 45 minutes from the time that he complained of a pain score of 8/10 to PT 1 until he received the first dose of Tylenol at 1:40 PM. On 2/14/22 at 12:45 PM, the facility provided the following additional information. On 2/09/2022 at 9:30 AM, PT was performing a new admit PT evaluation with [resident 191]. Resident stated he had pain with movement and rated it at 8/10. PT then informed resident's nurse of the pain level of 8/10 and would be utilizing diathermy therapy to treat pain. On 2/09/2022 at 9:40 AM, PT implemented non-pharmacological treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It should be noted that PT 1 was interviewed on 2/10/22 at 11:20 AM by the State Survey Agency and made no mention of the non-pharmacological treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, it was determined for 2 of 6 sampled residents that the facility did not ensure the residents were free from abuse. Specifically, the facility initiated moving a female resident with severely impaired cognition into a room with a male resident, staff observed the male resident sexually abusing the female resident on multiple occasions, and staff reported subsequent changes in the female resident's behavior. In addition, the female resident voiced complaints of pelvic pain and was subsequently moved to a separate room. The facility's failure to protect the resident from abuse was determined to constitute Immediate Jeopardy to resident safety. Resident identifiers: 2 and 3. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Executive Director (ED), Director of Nursing (DON), and Regional Director of Quality Services (RDCS) on 10/8/20 at 5:15 PM. At that time, the ED, DON, and RDCS were informed of the findings of Immediate Jeopardy pertaining to F600 and asked to develop an immediate plan to ensure that the residents of the facility were free from abuse. The Immediate Jeopardy identified that resident 3 was sexually abused by another resident as early as 9/21/20, and resident 3 was not protected from further abuse. On 10/9/20, the ED provided the following written allegation of removal of the Immediate Jeopardy: Immediate Jeopardy Allegation of Removal . Date Alleged 10/9/20 at 23:59 (11:59 PM) . - A one to one was placed with resident 2 and resident 3 immediately. The police were notified, and the occurrence was reported to the state on 10/8/20; - A staffing plan, that included support from staff in all disciplines, was implemented to manage the one to one care. This plan will remain in place until an alternate plan for staffing the one to ones can be arranged. The one to ones will be discontinued only after such time and the Interdisciplinary Team (IDT) is able to conduct a thorough review of the status of the residents and are able to develop a comprehensive plan to address the safety of both residents; - The RDCS is in the facility and directing the corrective actions with the ED. The RDCS will remain onsite until immediate corrective action complete and will be available via telephone as needed; - Residents were interviewed by the DON, ED, RDCS, Social Services Director (SSD) and other designees to determine if there are concerns regarding any sexual contact or other potential occurrences of abuse. Non-interviewable residents, were assessed for changes in behavioral and/or mood symptoms and skin assessments were completed. This was done 10/8/20; - On 10/9/10, 10% of family members were interviewed by the ED, DON, SSD or designee to determine if there are concerns regarding any potential occurrences of abuse; - Staff from all departments that were onsite were interviewed by the ED, DON, RDCS, SSD and other designees to determine if there are concerns regarding any other potential occurrences of abuse or if there are residents with behavioral symptoms that may place residents at risk of abuse. The facility called staff not onsite to conduct interviews. This was completed 10/9/20; - On 10/9/20, the ED, DON and RDCS reviewed Grievance logs and Resident Council Meeting minutes for the past 30 days to determine if there are any other potential situations where abuse may have not been recognized and/or reported; - The IDT met with direct care staff to review residents with behavioral complexities, as identified through interviews and behavior notes for the past 30 days. The IDT, which included direct care staff, met to review care planned interventions for appropriateness and effectiveness; modifications to the plan of care were made as necessary. This was completed on 10/9/20; - Residents that wish to participate in sexual activity will be evaluated by the Attending Physician to ensure that they have the ability to consent to such activity; - Staff were directed to report any new behavioral symptoms to the DON, SSD or designee for further review by the IDT to identify interventions; - On 10/9/20, a Root-Cause Analysis (RCA) was conducted by the IDT. A knowledge deficit was identified that included, misunderstanding of resident capacity and ability to consent and the scope of the decision-making ability of a Guardian. Additional knowledge deficits identified that staff did not report events as they believed they had already been reported. Staff was re-educated on these knowledge deficits and examples were given for different scenarios or potential abuse, with staff voicing understanding on 10/9/20; - Staffing and acuity were reviewed with the team the team the week of 9/28/20. Based on the results of the review, modifications were made as necessary. Through interviews of the staff, it was identified that behavioral symptoms increase in the evening and positions were posted the week of 9/28/20 to increase nurses and CNAs (Certified Nursing Assistants); - The facility's abuse and neglect policy, 'Protection of Residents; Reducing the Threat of Abuse and Neglect' was reviewed on 10/8/20 and it is current; - The Regional Vice President (RVP) provided re-education to the ED on 10/8/20 regarding the facility policy 'Protection of Residents; Reducing the Threat of Abuse and Neglect.' The education included definitions of abuse and review of all seven required components (screening, training, prevention, identification, investigation, protection and reporting/response); - Education regarding the facility policy 'Protection of Residents; Reducing the Threat of Abuse and Neglect' was provided to 100% of staff that were onsite on 10/8/20 and 10/9/20. Additionally, staff will be provided this education prior to their next scheduled shift, including the Nurse Practitioner (NP). Staff will not be permitted to work until the education is complete. As part of this education, staff were advised of the following: Definitions of abuse, how to protect residents if abuse suspected or observed, person to contact to report abuse and that the ED is the designated Abuse Coordinator, and scenarios of potential abuse; - On 10/9/20, the Division Vice President, Division Director of Clinical Services and the RVP conducted education regarding the policy 'Protection of Residents; Reducing the Threat of Abuse and Neglect' with the RDCS, ED, and DON. This education included responsibilities for evaluating resident capacity and reporting allegations of suspected and/or actual abuse; - The facility Medical Director was called on 10/8/20 and 10/9/20 and agreed with the plan for removal of Immediate Jeopardy. An ADHOC (for this situation) Quality Assurance Performance Improvement (QAPI) team meeting was held to review the plan for removal on 10/9/20; - Monitoring; - Staffing levels will continue to be monitored daily by the DON/designee to maintain the level of staffing to supervise residents; - 10% of residents will be interviewed each week by the SSD/designee to identify potential concerns regarding abuse; - Ongoing discussion and education regarding abuse identification, prevention, reporting, etc. will be done with staff during Grand Rounds and as needed based on questions or concerns. This will be led by the DON/designee; - The RVP will review the Grievance logs and Resident Council Meeting minutes on an ongoing basis; - Resident behavioral symptoms will be discussed with the IDT during Grand Rounds with further follow up by the DON/SSD/designee; - The results of all monitoring will be reviewed by the IDT in the QAPI process to determine the frequency of ongoing monitoring. On 10/13/20, the State Survey Agency reviewed the immediate plan of correction for removal of the Immediate Jeopardy involving abuse and confirmed the abatement of the Immediate Jeopardy as of the alleged date of abatement, 10/9/20 at 11:59 PM. Findings include: On 10/7/20 at 11:25 AM, an interview was conducted with Staff Member (SM) 1. SM 1 stated there was a concern about sexual abuse between resident 2 and resident 3, and felt as though the facility was not doing the right things and not addressing the concern. SM 1 stated resident 2 and resident 3 both have bad dementia, there had been inappropriate touching, and resident 3 complained of pelvic pain. SM 1 stated she was made aware of these concerns on 10/2/20, followed up with the physician and Resident Advocate (RA) on 10/5/20, and felt as though the concern was not addressed. SM 1 stated resident 2 and resident 3 resided in the same room but were separated into different rooms two days prior. SM 1 further stated resident 3 exhibited increased distress lately, was sobbing and very upset on 10/2/20, and was moved to a different room on 10/5/20. In addition, SM 1 stated the Speech Therapist (ST) witnessed inappropriate behaviors between resident 2 and resident 3 and reported her concern to the Director of Rehabilitation (DOR) approximately three weeks prior. 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 2's medical record was completed on 10/8/20. Resident 2's most recent Minimum Data Set (MDS) Assessment, dated 9/1/20, was reviewed. The assessments documented within Section C - Cognitive Patterns that his Brief Interview for Mental Status (BIMS) score was 11. (Note: A BIMS score between 8-12 indicated that a resident was moderately cognitively impaired.) 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 3's medical record was completed on 10/8/20. Resident 3's most recent Minimum Data Set (MDS) Assessment, dated 9/24/20, was reviewed. The assessments documented within Section C - Cognitive Patterns that a Brief Interview for Mental Status (BIMS) should not be conducted with resident 3 because she is rarely/never understood. A care plan, initiated on 10/6/20, documented the following information related to resident 3's relationship with another resident at the facility, resident 2: a. Focus: Resident feels a male resident is her significant other and they often times hold hands, visit, kiss, walk together, spend time in each other's rooms, laying beside each other on the bed per their choice. Resident's Power of Attorney (POA) is aware and okay with it; b. Goal: Resident's dignity and privacy will be maintained; c. Interventions: i. Resident may change her mind at any time; ii. Resident will be encouraged to stay in her room during the night to promote healthy sleeping habits; iii. Staff will monitor for any changes in interactions between the two residents; iv. Staff will provide residents with an open private place to visit. On 10/7/20 at 12:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she had not witnessed any inappropriate behavior between resident 2 and resident 3, but was told to watch resident 2 and ensure that they spend time together only in direct view of the staff or at the nurses' station. LPN 1 stated she was told inappropriate behavior occurred between resident 2 and resident 3, but was not informed of any details. LPN 1 stated maybe aggressive behavior occurred or resident 2 and resident 3 had slept in bed together. LPN 1 stated she was unsure whether or not resident 2 and resident 3 ever shared a room or spent time in each other's rooms. On 10/7/20 at 12:20 PM, an interview was conducted with CNA 1. CNA 1 stated she witnessed resident 2 and resident 3 kiss, and also saw resident 2 put his hand on resident 3's thigh approximately one or two weeks ago. CNA 1 stated resident 3 is a little confused and resident 2 is cognitively intact. CNA 1 further stated she was told resident 2 and resident 3 were not allowed to be alone together or in each other's rooms. CNA 1 stated resident 2 and resident 3 had been seen spooning in bed before, staff frequently checked on them, and staff opened the bedroom door if it had been closed. CNA 1 stated resident 2 and resident 3's families were okay with them spending time together until about a week ago, but was unsure what happened. CNA 1 stated maybe resident 2 was aggressive and forced himself on resident 3. CNA 1 further stated resident 3 was permitted to sleep in resident 2's room, but they did not officially share a room. On 10/7/20 at 12:30 PM, an interview was conducted with CNA 2. CNA 2 stated she never saw resident 3 behave inappropriately, but witnessed resident 2 behave inappropriately. CNA 2 stated approximately two or three weeks ago, she went into resident 3's room to obtain vital signs, saw resident 2's hands down resident 3's pants and was touching her bottom, grabbing her breasts, and kissing her neck. CNA 2 stated she told resident 2 to stop, left the room, and returned approximately 15 minutes later to find resident 2 doing it again. CNA 2 stated she then informed the nurse and DON about what she witnessed. CNA 2 stated resident 2 knows what he is doing and does that with resident 3 because she does not know what is going on. CNA 2 further stated resident 3 tells resident 2 to knock it off some days, but does not know what is happening most days. CNA 2 stated she was told to monitor resident 2 and resident 3, and was told on 10/1/20 that they were not supposed to be in the same room together. CNA 2 stated she observed resident 2 going into resident 3's room on 10/5/20, she would redirect resident 2 out of resident 3's room, and resident 2 would leave for five seconds and go right back into (resident 3's) room. CNA 2 stated resident 2 and resident 3 shared a room, and resident 3 moved into resident 2's room in mid-September. CNA 2 stated resident 3 became more aggressive with staff while residing in the same room as resident 2, and resident 3 has since calmed down since she was moved into a separate room. CNA 2 further stated she believed it was the inappropriate touching that made resident 3 aggressive with staff. On 10/7/20 at 12:43 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated based on her understanding, resident 2 and resident 3 developed interest in each other and the families were okay with them sharing a room. RN 1 stated she was unsure how long resident 2 and resident 3 shared a room, but the RA informed her that resident 3's family was no longer comfortable with them sharing a room. RN 1 stated resident 2 and resident 3 are both alert only to self. RN 1 further stated she never witnessed inappropriate behaviors, but staff was supposed to keep an eye on them to ensure they are not alone together. On 10/8/20 at 8:19 AM, an interview was conducted with resident 3's POA. The POA stated that the facility had called her and reported to her that they were unable to keep her mother out of the gentleman's room and asked her if it would be ok to put her in the room with him. The POA stated that she asked if there was anything going on between the two of them. She was told no, we don't think so and so she gave her consent. The POA stated that she felt like the companionship was a great thing but did not want anything sexual between the two residents. The POA stated that they then called her and told her that they moved her mom back to her original room because things had escalated. When the POA was asked what escalated meant, the POA said that things had become sexual. When asked what that meant and what had happened, the POA stated that she did not know. When asked if she had asked, the POA answered no, it didn't seem to be a big deal other than it wasn't appropriate while in the facility. On 10/8/20 at 8:52 AM, an interview was conducted with the facility ST. The ST stated that she was not sure of the date, but figured that it was somewhere between 9/21/20 and 9/25/20, as she was walking in the hallway toward the kitchen. She saw resident 2 and 3 sitting in the hallway, with resident 2's hand on resident 3's breast over the top of her shirt. The ST stated that as she approached them both, resident 2 removed his hand from resident 3's breast. The ST stated that she went into the kitchen and when she came back out, she again saw resident 2's hand on resident 3's breast, this time under her shirt. The ST stated that as she again approached them both, resident 2 removed his hand from resident 3's breast. The ST stated that she immediately reported both actions to her supervisor, the facility DOR. On 10/8/20 at 9:01 AM, a telephone interview was again conducted with resident 3's POA. The POA stated that it was the social worker at the facility who called to ask if resident 3 could move in with resident 2 and also who called to say that they had moved resident 3 back to her original room because things had become sexual. On 10/8/20 at 9:36 AM, an interview was conducted with the facility DOR. The DOR stated that he remembered being told by the ST of the inappropriate actions of resident 2 toward resident 3. The DOR stated that he was on his way to talk with the facility ED, but saw the facility RA and stopped to talk with her. The DOR stated that he informed the RA of the inappropriate actions between resident 2 and resident 3. The DOR stated that the RA was not surprised by the inappropriate actions and that the RA told the DOR that they had moved the residents together in the same room because both families had given consent and that it was not an issue. The DOR stated that he did not inform the ED nor the DON because he thought it was not an issue. The DOR stated that he too, did not recall the date of the incident but agreed with the ST that it was most likely between 9/21/20 and 9/25/20. On 10/8/20 at 10:15 AM, an interview was conducted with the facility MDS Coordinator. The MDS Coordinator stated that although she did the completion of most of the MDS for all residents, section C for Cognitive Patterns was completed by the facility RA. The MDS Coordinator stated that the scoring of the Brief Interview for Mental Status revealed how cognitively intact a resident was. The MDS Coordinator stated that the higher the BIMS score, the more cognitively intact a resident was. The MDS Coordinator stated that if a resident was unable to understand and answer the questions, there would be no score indicating that the resident had a severe cognitive impairment. When the MDS Coordinator was asked if it was ok to call the POA for a resident for permission to move the resident into a male resident room, the MDS Coordinator stated that we can't force her to stay out of his room. The MDS Coordinator stated that resident 3 has choices and that you can redirect as much as possible but ultimately resident 3 is free to make choices. The MDS Coordinator stated that they had tried to separate resident 2 and resident 3 multiple times and that resident 3 would always go look for resident 2. The MDS Coordinator stated that she did not believe that there was any sexual contact in the beginning and that she heard after the fact bits and pieces. The MDS Coordinator stated that there was a nurse who had reported that there had been some dilation but did not know when or where or by whom. The MDS Coordinator stated that the facility staff had moved resident 3 out of resident 2's room due to the dilation or sex or whatever had occurred. The MDS Coordinator stated that they would have expected to find signs of penetration or intercourse but the NP found nothing. The MDS Coordinator stated that the RDCS created a care plan for the two residents after they moved in together. The MDS Coordinator stated that she understood the ED to be involved but did not know why the matter had not been investigated. The MDS Coordinator stated that her thought process would have been that sex between resident 2 and resident 3 would have been expected once they were allowed to move in together. On 10/8/20 at 10:50 AM, an interview was conducted with the facility RA. The facility RA stated that she completed the BIMS questions and the PHQ-9 questions for residents 2 and 3 on the MDS. The facility RA stated that the BIMS was looking for cognitive impairment and the ability of the resident to determine decision making. The RA stated that they did not finish the interview for resident 3 because resident 3 could not understand nor answer the questions appropriately. The RA stated that resident 3 was appropriate to answer which outfit she wanted to wear for the day, but that she requires physical assistance for all Activities of Daily Living (ADLs) and that she could not make life altering decisions, at all. The RA stated that because of resident 3 continuously looking for resident 2, she called resident 3's POA to get permission to move resident 3 into resident 2's room. The facility RA stated that she did not necessarily think that the relationship between resident 3 and resident 2 would get around to being sexual. The RA stated that to her knowledge, that resident 2 and resident 3 were only observed getting closer. The RA stated that no staff members had come to her and informed her that resident 2 had his hand on resident 3's breast whether on top of her clothing or underneath her clothing nor did any staff member inform her that they had seen resident 2's hand down resident 3's pants while his other hand was under her shirt on her breast. The RA stated that she would have contacted resident 3's POA immediately about the situation, had she been informed, and would have moved resident 3 immediately had that been the case. The RA stated that she and the DON had noticed that resident 2 and resident 3's feelings were changing. The RA stated that after she and the DON noticed that the feelings were changing, they decided together that resident 3 should be moved back to her room. The RA stated that she was made aware that the facility NP had checked resident 3 for dilation and penetration due to resident 3's complaints of back pain. The RA stated that she did not believe that the NP found any issues with resident 3. On 10/8/20 at 12:08 PM, an interview was conducted with the facility DON. The DON stated that the BIMS scoring gauges how cognitively intact a resident is. The DON stated that she did not know what the BIMS score meant nor what it meant if the resident was unable to understand and answer the questions. The DON stated that resident 2 and resident 3 were spending a lot of time in each others rooms which was what led to the RA asking resident 3's POA if they could move in together. The DON stated that she did not know what date that was. The DON stated that there was no sexual contact between the two residents when they moved them into the same room. The DON stated that resident 3 was moved out of resident 2's room due to allegations of possible sexual interaction between the two residents. The DON stated that it was reported to her by the Unit Manager. The DON stated that the facility NP did an exam on resident 3 on 10/5/20 and did not find anything. The DON stated that resident 3's family reported that with Urinary Tract Infections (UTIs) that resident 3 gets confused and usually has an increase in falls and in abdominal pain. The DON stated that resident 3 was moved into a different shared room with a female roommate to decrease the chances of resident 2 and resident 3 being left unattended. The DON stated that the decision to move resident 3 out of resident 2's room was made because resident 2 and resident 3 were often found lying in bed together without any sexual contact. The DON stated that she had not been notified of resident 2's hands down resident 3's pants until yesterday by the DOR and the RDCS. (NOTE: According to the RA, resident 3's lack of a BIMS score meant that resident 3 had a severe cognitive impairment.) On 10/8/20 at 12:22 PM, an interview was conducted with the facility DOR. The DOR stated that he had not talked with the DON yesterday (10/7/20) as the DON had stated as he was not in the facility on that date. The DOR stated that he was in the other facility in a neighboring county on that date and did not see the DON. On 10/8/20 at 2:03 PM, a call was placed to the facility ED. The ED did not answer the phone and a message was left for the ED to call back. No return call was received by the facility ED. On 10/8/20 the NP note for resident 3 was reviewed. The NP note dated 10/2/2020 revealed, Nursing staff requesting that I see patient due to her recent complaints of 'pelvic pain.' I asked if she was still having pain from her fall a couple earlier this week (sic), and they expressed concerns that the pain might be related to her relationship with another resident. (Resident 3) and a male resident have been spending a lot of time together, and staff has reported that they have found the two together in bedrooms. Staff is currently in the process of shuffling bedrooms so both residents have roommates, and are further away from one another. They have also restricted bedrooms as a meeting place. Due to the residents dementia the above history was obtained by nursing staff. (Resident 3) is a [AGE] year old female. Patient found sitting in a common area with the male resident she has often been found with. Both were smiling and in no acute distress. I asked if (Resident 3) would mind returning to her room with me so we could have a private conversation. She agreed despite the male residents request for her to stay. When we arrived back to her room patient was asked if she was currently having vaginal pain, and she said yes. When asked if she was having burning and pain with urination she also said yes. I asked the patient if she had intercourse recently. Patients response was not direct and she talked in circles saying 'she has done it.' I asked the patient again if she has had sex with the man she was recently sitting with. Again her answer was not direct, and possibly relating to a past experience that she has 'done it.' I let her know that if there is any penetration that is happening I need to know because that could be contributing to her vaginal pain. She reported that 'he never forced her' and 'he always took it slow' 'he didn't (made a ramming gesture with her hand).' I asked again if she was talking about the resident I found her with, and she didn't answer directly. She talked about a 'he/him' wants to do it but she puts him off. Again with her dementia I am not certain she was talking about recent experiences, but I felt like she was talking about past experiences. I told her I did not want her trying to have intercourse without letting the nurse know. I also let the patient know that I wanted a straight cath (catheter) urine, I explained the procedure, and patient agreed. I do not feel she has the mental capacity to consent to intercourse due to her current level of dementia Call later in the evening from (DON). We reviewed what the patient had said. I let her know that I did not think that the act was recent based on her response. (DON) reported that staff has checked her brief, and examined her. No blood or bruising noted. Slight erythemic irritation noted on the Labia Will follow up Monday for UA (urinalysis) results, and do another vaginal exam for any delayed bruising. If a more in depth exam is required patient will need to be sent to the ER (emergency room ) or OB (obstetrician) for an internal exam. (Note: There was not a subsequent ER visit or OB appointment.) On 10/8/20 at 2:48 PM, an interview was conducted with the NP. When asked if she had completed a vaginal swab for semen based on the documentation that there was erythemic irritation on the labia, the NP stated that she had not swabbed resident 3 because she did not physically examine resident 3 on 10/2/20 but did a physical examination on 10/5/20. The NP stated that she felt like it was a UTI rather than sexual abuse. The NP stated that she did not recall writing that there was erythemic irritation. On 10/8/20 at 4:15 PM, an interview was conducted with the ED, DON, and RDCS. The ED stated he was made aware of the allegations of sexual abuse the previous day, and was informed by the RA who was made aware of the situation by the ST. The ED stated he was not aware of any inappropriate sexual behavior between resident 2 and resident 3 that occurred in a bedroom, only that the ST witnessed resident 2 touching resident 2 inappropriately in the hallway. The ED stated staff should have immediately informed the DON or himself if staff felt behaviors were inappropriate, and resident 2 did not exhibit sexual behavior toward any other residents besides resident 3. The ED stated this was the first time in his three years as the ED that an unmarried male and female residents were placed in a room together, and the only reason it was permitted was because resident 3's POA gave her permission. The ED stated the POA was involved in the decision to move resident 3 into resident 2's room, the living situation was care-planned, and there were no reports of sexually inappropriate behaviors until the previous day. The DON stated staff are trained on abuse upon hire and at least annually.

Based on interview and record review, it was determined for 2 of 6 sampled residents that the facility did not ensure the policies and procedures for prohibiting and preventing abuse and investigating such allegations were implemented. Specifically, observations of a male resident sexually abusing a female resident on multiple occasions were not investigated for abuse. The facility's failure to implement the policies and procedures for abuse was determined to constitute Immediate Jeopardy to resident safety. Resident identifiers: 2 and 3. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Executive Director (ED), Director of Nursing (DON), and Regional Director of Quality Services (RDCS) on 10/8/20 at 5:15 PM. At that time, the ED, DON, and RDCS were informed of the findings of Immediate Jeopardy pertaining to F607 and asked to develop an immediate plan to ensure that the residents of the facility were free from abuse. The Immediate Jeopardy identified that resident 3 was sexually abused by another resident as early as 9/21/20, and the allegations of abuse were not investigated or reported by facility administration. On 10/9/20, the ED provided the following written allegation of removal of the Immediate Jeopardy: Immediate Jeopardy Allegation of Removal . Date Alleged 10/9/20 at 23:59 (11:59 PM) . - A one to one was placed with resident 2 and resident 3 immediately. The police were notified, and the occurrence was reported to the state on 10/8/20; - A staffing plan, that included support from staff in all disciplines, was implemented to manage the one to one care. This plan will remain in place until an alternate plan for staffing the one to ones can be arranged. The one to ones will be discontinued only after such time and the Interdisciplinary Team (IDT) is able to conduct a thorough review of the status of the residents and are able to develop a comprehensive plan to address the safety of both residents; - The RDCS is in the facility and directing the corrective actions with the ED. The RDCS will remain onsite until immediate corrective action complete and will be available via telephone as needed; - Residents were interviewed by the DON, ED, RDCS, Social Services Director (SSD) and other designees to determine if there are concerns regarding any sexual contact or other potential occurrences of abuse. Non-interviewable residents, were assessed for changes in behavioral and/or mood symptoms and skin assessments were completed. This was done 10/8/20; - On 10/9/10, 10% of family members were interviewed by the ED, DON, SSD or designee to determine if there are concerns regarding any potential occurrences of abuse; - Staff from all departments that were onsite were interviewed by the ED, DON, RDCS, SSD and other designees to determine if there are concerns regarding any other potential occurrences of abuse or if there are residents with behavioral symptoms that may place residents at risk of abuse. The facility called staff not onsite to conduct interviews. This was completed 10/9/20; - On 10/9/20, the ED, DON and RDCS reviewed Grievance logs and Resident Council Meeting minutes for the past 30 days to determine if there are any other potential situations where abuse may have not been recognized and/or reported; - The IDT met with direct care staff to review residents with behavioral complexities, as identified through interviews and behavior notes for the past 30 days. The IDT, which included direct care staff, met to review care planned interventions for appropriateness and effectiveness; modifications to the plan of care were made as necessary. This was completed on 10/9/20; - Residents that wish to participate in sexual activity will be evaluated by the Attending Physician to ensure that they have the ability to consent to such activity; - Staff were directed to report any new behavioral symptoms to the DON, SSD or designee for further review by the IDT to identify interventions; - On 10/9/20, a Root-Cause Analysis (RCA) was conducted by the IDT. A knowledge deficit was identified that included, misunderstanding of resident capacity and ability to consent and the scope of the decision-making ability of a Guardian. Additional knowledge deficits identified that staff did not report events as they believed they had already been reported. Staff was re-educated on these knowledge deficits and examples were given for different scenarios or potential abuse, with staff voicing understanding on 10/9/20; - Staffing and acuity were reviewed with the team the team the week of 9/28/20. Based on the results of the review, modifications were made as necessary. Through interviews of the staff, it was identified that behavioral symptoms increase in the evening and positions were posted the week of 9/28/20 to increase nurses and CNAs (Certified Nursing Assistants); - The facility's abuse and neglect policy, 'Protection of Residents; Reducing the Threat of Abuse and Neglect' was reviewed on 10/8/20 and it is current; - The Regional Vice President (RVP) provided re-education to the ED on 10/8/20 regarding the facility policy 'Protection of Residents; Reducing the Threat of Abuse and Neglect.' The education included definitions of abuse and review of all seven required components (screening, training, prevention, identification, investigation, protection and reporting/response); - Education regarding the facility policy 'Protection of Residents; Reducing the Threat of Abuse and Neglect' was provided to 100% of staff that were onsite on 10/8/20 and 10/9/20. Additionally, staff will be provided this education prior to their next scheduled shift, including the Nurse Practitioner (NP). Staff will not be permitted to work until the education is complete. As part of this education, staff were advised of the following: Definitions of abuse, how to protect residents if abuse suspected or observed, person to contact to report abuse and that the ED is the designated Abuse Coordinator, and scenarios of potential abuse; - On 10/9/20, the Division Vice President, Division Director of Clinical Services and the RVP conducted education regarding the policy 'Protection of Residents; Reducing the Threat of Abuse and Neglect' with the RDCS, ED, and DON. This education included responsibilities for evaluating resident capacity and reporting allegations of suspected and/or actual abuse; - The facility Medical Director was called on 10/8/20 and 10/9/20 and agreed with the plan for removal of Immediate Jeopardy. An ADHOC (for this situation) Quality Assurance Performance Improvement (QAPI) team meeting was held to review the plan for removal on 10/9/20; - Monitoring; - Staffing levels will continue to be monitored daily by the DON/designee to maintain the level of staffing to supervise residents; - 10% of residents will be interviewed each week by the SSD/designee to identify potential concerns regarding abuse; - Ongoing discussion and education regarding abuse identification, prevention, reporting, etc. will be done with staff during Grand Rounds and as needed based on questions or concerns. This will be led by the DON/designee; - The RVP will review the Grievance logs and Resident Council Meeting minutes on an ongoing basis; - Resident behavioral symptoms will be discussed with the IDT during Grand Rounds with further follow up by the DON/SSD/designee; - The results of all monitoring will be reviewed by the IDT in the QAPI process to determine the frequency of ongoing monitoring. On 10/13/20, the State Survey Agency reviewed the immediate plan of correction for removal of the Immediate Jeopardy involving abuse and confirmed the abatement of the Immediate Jeopardy as of the alleged date of abatement, 10/9/20 at 11:59 PM. Findings include: On 10/7/20 at 11:25 AM, an interview was conducted with Staff Member (SM) 1. SM 1 stated there was a concern about sexual abuse between resident 2 and resident 3, and felt as though the facility was not doing the right things and not addressing the concern. SM 1 stated resident 2 and resident 3 both have bad dementia, there had been inappropriate touching, and resident 3 complained of pelvic pain. SM 1 stated she was made aware of these concerns on 10/2/20, followed up with the physician and Resident Advocate (RA) on 10/5/20, and felt as though the concern was not addressed. SM 1 stated resident 2 and resident 3 resided in the same room but were separated into different rooms two days prior. SM 1 further stated resident 3 exhibited increased distress lately, was sobbing and very upset on 10/2/20, and was moved to a different room on 10/5/20. In addition, SM 1 stated the Speech Therapist (ST) witnessed inappropriate behaviors between resident 2 and resident 3 and reported her concern to the Director of Rehabilitation (DOR) approximately three weeks prior. 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 2's medical record was completed on 10/8/20. Resident 2's most recent Minimum Data Set (MDS) Assessment, dated 9/1/20, was reviewed. The assessments documented within Section C - Cognitive Patterns that his Brief Interview for Mental Status (BIMS) score was 11. (Note: A BIMS score between 8-12 indicated that a resident was moderately cognitively impaired.) 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 3's medical record was completed on 10/8/20. Resident 3's most recent MDS Assessment, dated 9/24/20, was reviewed. The assessments documented within Section C - Cognitive Patterns that a BIMS should not be conducted with resident 3 because she is rarely/never understood. Review of the facility's Protection of Residents: Reducing the Threat of Abuse and Neglect policy and procedures, most recently updated on 5/15/20, revealed the following: . To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse . . It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation . . It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated . . Complaints and grievances will be investigated . and reported immediately if the investigation reveals any alleged violations involving neglect, abuse (including injuries of unknown source), and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law . . This facility does not condone resident abuse and/or neglect by anyone. This includes, but is not limited to: staff members, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, sponsors, friends, or other individuals. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect . On 10/7/20 at 12:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if she witnessed abuse or inappropriate sexual behaviors, she would notify the DON and residents' families, separate the residents, and document the incident in a health status note, behavior note, and incident report. LPN 1 stated she had not witnessed any inappropriate behavior between resident 2 and resident 3, but was told to watch resident 2 and ensure that they spend time together only in direct view of the staff or at the nurses' station. LPN 1 stated she was told inappropriate behavior occurred between resident 2 and resident 3, but was not informed of any details. LPN 1 stated maybe aggressive behavior occurred or resident 2 and resident 3 had slept in bed together. LPN 1 stated she was unsure whether or not resident 2 and resident 3 ever shared a room or spent time in each other's rooms. On 10/7/20 at 12:20 PM, an interview was conducted with CNA 1. CNA 1 stated if she witnessed abuse or inappropriate sexual behaviors, she would notify the nurse, DON, Unit Manager, and the residents' families. CNA 1 stated she witnessed resident 2 and resident 3 kiss, and also saw resident 2 put his hand on resident 3's thigh approximately one or two weeks ago. CNA 1 stated resident 3 is a little confused and resident 2 is cognitively intact. CNA 1 further stated she was told resident 2 and resident 3 were not allowed to be alone together or in each other's rooms. CNA 1 stated resident 2 and resident 3 had been seen spooning in bed before, staff frequently checked on them, and staff opened the bedroom door if it had been closed. CNA 1 stated resident 2 and resident 3's families were okay with them spending time together until about a week ago, but was unsure what happened. CNA 1 stated maybe resident 2 was aggressive and forced himself on resident 3. CNA 1 further stated resident 3 was permitted to sleep in resident 2's room, but they did not officially share a room. (Note: There was no investigation conducted or entity report submitted to the state agency related to this incident witnessed by CNA 1 in accordance with facility policy.) On 10/7/20 at 12:30 PM, an interview was conducted with CNA 2. CNA 2 stated she never saw resident 3 behave inappropriately, but witnessed resident 2 behave inappropriately. CNA 2 stated approximately two or three weeks ago, she went into resident 3's room to obtain vital signs, saw resident 2's hands down resident 3's pants and was touching her bottom, grabbing her breasts, and kissing her neck. CNA 2 stated she told resident 2 to stop, left the room, and returned approximately 15 minutes later to find resident 2 doing it again. CNA 2 stated she then informed the nurse and DON about what she witnessed. CNA 2 stated resident 2 knows what he is doing and does that with resident 3 because she does not know what is going on. CNA 2 further stated resident 3 tells resident 2 to knock it off some days, but does not know what is happening most days. CNA 2 stated she was told to monitor resident 2 and resident 3, and was told on 10/1/20 that they were not supposed to be in the same room together. CNA 2 stated she observed resident 2 going into resident 3's room on 10/5/20, she would redirect resident 2 out of resident 3's room, and resident 2 would leave for five seconds and go right back into (resident 3's) room. CNA 2 stated resident 2 and resident 3 shared a room, and resident 3 moved into resident 2's room in mid-September. CNA 2 stated resident 3 became more aggressive with staff while residing in the same room as resident 2, and resident 3 has since calmed down since she was moved into a separate room. CNA 2 further stated she believed it was the inappropriate touching that made resident 3 aggressive with staff. (Note: There was no investigation conducted or entity report submitted to the state agency related to this incident witnessed by CNA 2 in accordance with facility policy.) On 10/7/20 at 12:40 PM, an interview was conducted with LPN 2. LPN 2 stated if he witnessed abuse or inappropriate sexual behaviors, he would notify the charge nurse, DON, and police, and do as they say. LPN 2 further stated he would document what he witnessed in a patient note and risk assessment, otherwise referred to as an incident report. (Note: There were no incident reports completed related to the allegations of sexual abuse between resident 2 and resident 3.) On 10/7/20 at 12:43 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if she witnessed abuse or inappropriate sexual behaviors, she would notify the ED and document what she witnessed in a progress note and incident report. RN 1 stated based on her understanding, resident 2 and resident 3 developed interest in each other and the families were okay with them sharing a room. RN 1 stated she was unsure how long resident 2 and resident 3 shared a room, but the RA informed her that resident 3's family was no longer comfortable with them sharing a room. RN 1 stated resident 2 and resident 3 are both alert only to self. RN 1 further stated she never witnessed inappropriate behaviors, but staff was supposed to keep an eye on them to ensure they are not alone together. On 10/8/20 at 8:19 AM, an interview was conducted with resident 3's Power of Attorney (POA). The POA stated that the facility had called her and reported to her that they were unable to keep her mother out of the gentleman's room and asked her if it would be ok to put her in the room with him. The POA stated that she asked if there was anything going on between the two of them. She was told no, we don't think so and so she gave her consent. The POA stated that she felt like the companionship was a great thing but did not want anything sexual between the two residents. The POA stated that they then called her and told her that they moved her mom back to her original room because things had escalated. When the POA was asked what escalated meant, the POA said that things had become sexual. When asked what that meant and what had happened, the POA stated that she did not know. When asked if she had asked, the POA answered no, it didn't seem to be a big deal other than it wasn't appropriate while in the facility. (Note: There was no investigation conducted or entity report submitted to the state agency related to this incident of sexual activity in accordance with facility policy.) On 10/8/20 at 8:52 AM, an interview was conducted with the facility ST. The ST stated that she was not sure of the date, but figured that it was somewhere between 9/21/20 and 9/25/20, as she was walking in the hallway toward the kitchen. She saw resident 2 and 3 sitting in the hallway, with resident 2's hand on resident 3's breast over the top of her shirt. The ST stated that as she approached them both, resident 2 removed his hand from resident 3's breast. The ST stated that she went into the kitchen and when she came back out, she again saw resident 2's hand on resident 3's breast, this time under her shirt. The ST stated that as she again approached them both, resident 2 removed his hand from resident 3's breast. The ST stated that she immediately reported both actions to her supervisor, the facility DOR. (Note: There was no investigation conducted or entity report submitted to the state agency related to this incident witnessed by the ST in accordance with facility policy.) On 10/8/20 at 9:01 AM, a telephone interview was again conducted with resident 3's POA. The POA stated that it was the social worker at the facility who called to ask if resident 3 could move in with resident 2 and also who called to say that they had moved resident 3 back to her original room because things had become sexual. On 10/8/20 at 9:36 AM, an interview was conducted with the facility DOR. The DOR stated that he remembered being told by the ST of the inappropriate actions of resident 2 toward resident 3. The DOR stated that he was on his way to talk with the facility ED, but saw the facility RA and stopped to talk with her. The DOR stated that he informed the RA of the inappropriate actions between resident 2 and resident 3. The DOR stated that the RA was not surprised by the inappropriate actions and that the RA told the DOR that they had moved the residents together in the same room because both families had given consent and that it was not an issue. The DOR stated that he did not inform the ED nor the DON because he thought it was not an issue. The DOR stated that he too, did not recall the date of the incident but agreed with the ST that it was most likely between 9/21/20 and 9/25/20. On 10/8/20 at 10:15 AM, an interview was conducted with the facility MDS Coordinator. The MDS Coordinator stated that although she did the completion of most of the MDS for all residents, section C for Cognitive Patterns was completed by the facility RA. The MDS Coordinator stated that the scoring of the BIMS revealed how cognitively intact a resident was. The MDS Coordinator stated that the higher the BIMS score, the more cognitively intact a resident was. The MDS Coordinator stated that if a resident was unable to understand and answer the questions, there would be no score indicating that the resident had a severe cognitive impairment. When the MDS Coordinator was asked if it was ok to call the POA for a resident for permission to move the resident into a male resident room, the MDS Coordinator stated that we can't force her to stay out of his room. The MDS Coordinator stated that resident 3 has choices and that you can redirect as much as possible but ultimately resident 3 is free to make choices. The MDS Coordinator stated that they had tried to separate resident 2 and resident 3 multiple times and that resident 3 would always go look for resident 2. The MDS Coordinator stated that she did not believe that there was any sexual contact in the beginning and that she heard after the fact bits and pieces. The MDS Coordinator stated that there was a nurse who had reported that there had been some dilation but did not know when or where or by whom. The MDS Coordinator stated that the facility staff had moved resident 3 out of resident 2's room due to the dilation or sex or whatever had occurred. The MDS Coordinator stated that they would have expected to find signs of penetration or intercourse but the NP found nothing. The MDS Coordinator stated that the RDCS created a care plan for the two residents after they moved in together. The MDS Coordinator stated that she understood the ED to be involved but did not know why the matter had not been investigated. The MDS Coordinator stated that her thought process would have been that sex between resident 2 and resident 3 would have been expected once they were allowed to move in together. (Note: There was no investigation conducted or entity report submitted to the state agency related to this incident related to suspected dilation or penetration in accordance with facility policy.) On 10/8/20 at 10:50 AM, an interview was conducted with the facility RA. The facility RA stated that she completed the BIMS questions and the PHQ-9 questions for residents 2 and 3 on the MDS. The facility RA stated that the BIMS was looking for cognitive impairment and the ability of the resident to determine decision making. The RA stated that they did not finish the interview for resident 3 because she could not understand nor answer the questions appropriately. The RA stated that resident 3 was appropriate to answer which outfit she wanted to wear for the day, but that she requires physical assistance for all Activities of Daily Living (ADLs) and that she could not make life altering decisions at all. The RA stated that because of resident 3 continuously looking for resident 2, she called resident 3's POA to get permission to move resident 3 into resident 2's room. The facility RA stated that she did not necessarily think that the relationship between resident 3 and resident 2 would get around to being sexual. The RA stated that to her knowledge, that resident 2 and resident 3 were only observed getting closer. The RA stated that no staff members had come to her and informed her that resident 2 had his hand on resident 3's breast whether on top of her clothing or underneath her clothing nor did any staff member inform her that they had seen resident 2's hand down resident 3's pants while his other hand was under her shirt on her breast. The RA stated that she would have contacted resident 3's POA immediately about the situation and would have moved resident 3 immediately had that been the case. The RA stated that she and the DON had noticed that resident 2 and resident 3's feelings were changing. The RA stated that after she and the DON noticed that the feelings were changing, they decided together that resident 3 should be moved back to her room. The RA stated that she was made aware that the facility NP had checked resident 3 for dilation and penetration due to resident 3's complaints of back pain. The RA stated that she did not believe that the NP found any issues with resident 3. On 10/8/20 at 12:08 PM, an interview was conducted with the facility DON. The DON stated that the BIMS scoring gauges how cognitively intact a resident is. The DON stated that she did not know what the BIMS score meant nor what it meant if the resident was unable to understand and answer the questions. The DON stated that resident 2 and resident 3 were spending a lot of time in each others rooms which was what led to the RA asking resident 3's POA if they could move in together. The DON stated that she did not know what date that was. The DON stated that there was no sexual contact between the two residents when they moved them into the same room. The DON stated that resident 3 was moved out of resident 2's room due to allegations of possible sexual interaction between the two residents. The DON stated that it was reported to her by the Unit Manager. The DON stated that the facility NP did an exam on resident 3 on 10/5/20 and did not find anything. The DON stated that resident 3's family reported that with Urinary Tract Infections (UTIs) that resident 3 gets confused and usually has an increase in falls and in abdominal pain. The DON stated that resident 3 was moved into a different shared room with a female roommate to decrease the chances of resident 2 and resident 3 being left unattended. The DON stated that the decision to move resident 3 out of resident 2's room was made because resident 2 and resident 3 were often found lying in bed together without any sexual contact. The DON stated that she had not been notified of resident 2's hands down resident 3's pants until yesterday by the DOR and the RDCS. (NOTE: According to the RA, resident 3's lack of a BIMS score meant that resident 3 had a severe cognitive impairment.) On 10/8/20 at 12:22 PM, an interview was conducted with the facility DOR. The DOR stated that he had not talked with the DON yesterday (10/7/20) as the DON had stated as he was not in the facility on that date. The DOR stated that he was in the other facility in a neighboring county on that date and did not see the DON. On 10/8/20 at 2:03 PM, a call was placed to the facility ED. The ED did not answer the phone and a message was left for the ED to call back. No return call was received by the facility ED. On 10/8/20 at 4:15 PM, an interview was conducted with the ED, DON, and RDCS. The ED stated he was made aware of the allegations of sexual abuse the previous day, and was informed by the RA who was made aware of the situation by the ST. The ED stated he was not aware of any inappropriate sexual behavior between resident 2 and resident 3 that occurred in a bedroom, only that the ST witnessed resident 2 touching resident 2 inappropriately in the hallway. The ED stated staff should have immediately informed the DON or himself if staff felt behaviors were inappropriate, and resident 2 did not exhibit sexual behavior toward any other residents besides resident 3. The ED stated this was the first time in his three years as the ED that an unmarried male and female residents were placed in a room together, and the only reason it was permitted was because resident 3's POA gave her permission. The ED stated the POA was involved in the decision to move resident 3 into resident 2's room, the living situation was care-planned, and there were no reports of sexually inappropriate behaviors until the previous day. The DON stated staff are trained on abuse upon hire and at least annually. The ED stated staff are expected to immediately notify the DON or himself of any allegations of abuse as they are responsible for overseeing reportable allegations. The ED stated that the allegation would be reported to the State Survey Agency within 2 or 24 hours, depending on the situation, and an investigation would be initiated and submitted to the State Survey Agency within 5 days. (Note: There was no investigation conducted or entity report submitted to the state agency related to this incident brought to the ED's attention in accordance with facility policy.)

Based on observation, interview, and record review it was determined that for 1 of 8 sample residents the facility did not provide the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident was not provided pain management prior to a procedure that resulted in the resident experiencing significant pain. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 5/3/17 at 5:20 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that resident 7's dressing on his coccyx was saturated with blood and was leaking onto the resident's brief. CNA 4 was observed to inform Registered Nurse (RN) 3 of resident 7's dressing. RN 3 stated that he would need to wait for another nurse to arrive on day shift to change the saturated dressing to resident 7's coccyx. On 5/3/17 at 7:50 AM, an interview was conducted with RN 1. RN 1 stated that resident 7 was at the hospital on [DATE] for a surgical debridement of a Pressure Ulcer (PU) on his coccyx. RN 1 stated that she was waiting for clarification of dressing change orders from the doctor before she changed resident 7's dressing on the coccyx. At 7:58 AM, RN 1 stated that the Assistant Director of Nursing (ADON) would perform the dressing change on resident 7 as he was the facility wound nurse. On 5/3/17 at 10:40 AM, an interview was conducted with resident 7. Resident 7 stated that he had been in bed all morning resting after his procedure yesterday. Resident 7 stated that he had a lot of pain in his lower back area around the PU. Resident 7 stated that he received pain medication every four hours if he asked for it, and if his systolic blood pressure measured above 100. Resident 7 stated that the current pain medication provided relief for approximately 1 to 1.5 hours then the pain returned. Resident 7 further stated that he informed the nurse that the pain medications was not covering his pain. On 5/3/17 at 10:45 AM, an observation was made of resident 7's dressing change. The ADON was performing the dressing change with the assistance of RN 1. Resident 7 was positioned in a right lateral position with RN 1 providing support. The ADON was observed to wash his hands prior to beginning the dressing change. The ADON gloved his hands and removed an adhesive bordered gauze dressing from Resident 7's PU that was saturated with blood. Blood was observed to have leaked onto resident 7's brief and surrounding bed linens. The ADON was observed to deglove and wash his hands. The ADON was then observed to open multiple packages of 4 X (by) 4 gauze bandages and a large adhesive bordered silicone dressing (Allevyn wound dressing). The multiple bandage packages were opened but not laid flat. The ADON then proceeded to apply sterile gloves. After applying sterile gloves, the ADON was observed to grab a bottle of wound cleanser, adjust the nozzle with the other hand, and then spray the cleanser onto the surrounding skin and center of the PU. After spraying the cleanser, the ADON picked up the sterile 4X4's and cleaned the surrounding surface area of the wound, starting at the wound borders and working outward. It should be noted here that the ADON made contact with the outside of the multiple gauze packages with his sterile gloves while trying to extract them from the packaging. No observations were made of the wound bed being cleansed. The ADON was then observed to pat dry the surrounding skin with another sterile 4X4. The ADON then placed two 4X4 sterile gauze bandages over the PU and applied the adhesive bordered silicone dressing on top. It should be noted that a date and time was not marked on the outer dressing to indicate when the dressing was changed. It was observed that all blood soaked linens were changed and resident 7 was positioned on his left lateral side upon completion of the dressing change. During the course of the dressing change, resident 7 was observed to be crying and calling out ow, it's burning, it's burning. The complaints of burning were made as the wound cleanser was being sprayed onto the wound and the burning continued throughout the dressing change. Resident 7 was also observed to be visibly shaking in pain. RN 1 stated to resident 7, are you okay, here squeeze my hand. On 5/3/17 at 11:02 AM, an interview was conducted with RN 1. RN 1 stated that resident 7 received [MEDICATION NAME] 15 milligrams (mg) by mouth every 4 hours as needed and Tylenol for pain. RN 1 stated that resident 7 last received his [MEDICATION NAME] at 6:30 AM. The ADON was observed to tell RN 1 at this time, he needs his pain meds now. RN 1 responded by, I'm always on top of that. On 5/3/17 at 11:30 AM, a repeat interview was conducted with RN 1. RN 1 stated that normally she premedicated resident 7 with [MEDICATION NAME] before a dressing change, but the physician order [REDACTED]. RN 1 stated that resident 7's blood pressure at 10:30 AM was 98/48 and the [MEDICATION NAME] was not administered. RN 1 further stated, I can usually get it (blood pressure) to go up if he moves around. RN 1 stated that she texted resident 7's doctor at 10:55 AM and reported that resident 7 had complained of pain and that the pain medication was not covering his pain, and could she give him something else. RN 1 stated that the doctor's reply was that he would be in at lunch time to see the resident. (Note: No mention was made to the doctor that resident 7's complaints of pain were in direct correlation to his dressing change and that premedication prior to the treatment did not occur.) On 5/3/17 at 12:50 PM, a repeat interview was conducted with resident 7. Resident 7 stated that he received his pain medication after the dressing change and it has helped with his pain management. Resident 7 also stated that whatever they spray to clean the wound burns, and that he would like them to use some [MEDICATION NAME] cream to the area prior to dressing changes to help decrease the pain. Resident 7 further stated that he did not receive pain medications prior to his dressing changes in the past, and that the dressing changes had not been done on a daily basis. RN 1 was then observed to obtain a manual blood pressure on resident 7, and she stated the results were 108/50. On 5/3/17 at 1:00 PM, resident 7's medical record was reviewed. A review of the Minimum Data Set (MDS) completed on 2/23/17 indicated that resident 7 had a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] 15 mg tablet every 4 hours (hrs) by mouth as needed (PRN). b. Tylenol Extra Strength 500 mg tablet 1 to 2 tablets by mouth (PO) every 4 hrs PRN. c. Hold Narcotics for SBP less than 100. d. Dressing change to coccyx (status [REDACTED]. Change as needed per drainage or soiled. e. Wound to coccyx: clean with dermal wound cleaner, pat dry, cover with polymer silver then mipilex border, change daily and PRN if soiled or wet, initiated on 3/8/17 and discontinued on 5/3/17. Review of the Physicians Progress Notes revealed the following entry dated 5/2/17, excision of sacral pressure ulcer, bone biopsy and culture, graft jacket resume all previous orders, call for appointment for (name of wound clinic) within the next three days. Review of the Medication Administration Record [REDACTED]. (Note: It was not indicated on the MAR indicated [REDACTED].) Review of the pain assessment as indicated on the MAR for resident 7 on 5/3/17 revealed a score of 6 on a pain scale of 0 to 10. The assessment was documented for the day shift and evening shift. No time of the pain assessment was documented as the order reads, Pain Assessment every shift Document pain scale 0-10 three times daily. The three times a day was broken down into day, evening, and night shift. Review of the pain flow sheet for May 2017 revealed that resident 7 received the following on 5/3/17; a. On 5/3/17 at 1:00 AM, complained of (c/o) left shoulder pain, type was aching, intensity of 6/10 on the pain scale, medication given was [MEDICATION NAME]. b. On 5/3/17 at 6:00 AM, c/o right shoulder pain, type was aching, intensity 8/10 on the pain scale, medication given was [MEDICATION NAME] and tylenol. c. On 5/3/17 at 11:00 AM, c/o right shoulder pain, type was aching, intensity 10/10 on the pain scale, medication given was [MEDICATION NAME] and tylenol. d. On 5/3/17 at 1:00 PM, c/o generalized pain, type was aching, intensity 10/10 on the pain scale, medication given was [MEDICATION NAME] and tylenol. (Note: Resident 7's pain flow sheet indicates location of pain as left shoulder for the entire month of May except for the 6:00 AM and 11:00 AM dose on 5/3/17. It should be noted that resident 7 also has a wound located on his left shoulder with a dressing in place. Additionally, the location of pain for April 2017 as indicated on the pain flow sheet was general.) Review of the Treatment Assessment Records (TAR) for May 2017, April 2017, February 2017, January 2017, and December 2016 of the physician ordered treatments, including all dressing changes, indicates the date of treatment and not the time the treatment was completed. No documentation could be found to indicate that resident 7 dressing changes were completed after pain medication administration. Review of the Nursing Progress notes from 1/1/17 to 5/3/17 revealed no entries indicating that resident 7 was provided pain medication prior to any dressing changes that were performed on resident 7's coccyx PU. Review of the Care Plan for Pressure Ulcer for resident 7 indicated under approaches to observe for pain and medicate PRN per physician's orders [REDACTED]. A review of additional information provided by the facility on 5/4/17 included the following: a. A letter from the Executive Director of the facility stated the following, In order to maintain necessary care and services, a very saturated dressing change was directed by the physician to be changed, and based on prudent clinical judgement, a delay in services could not be put off. This area was in fact, surgically debrided the evening prior and the area was compromised at best. The patient could have been sitting in a saturated dressing for an extended period of time, waiting for the blood pressure to stabilize at a level that could allow for the administration of PRN pain medication. This had a potential to cause a significant negative outcome and nullify the healing process already well-established with this specific wound. (Note: The resident was observed to be sitting in a saturated dressing to his coccyx wound from 5:20 AM to 10:45 AM when the dressing change occurred, resulting in a delay in services of 5 hours and 25 minutes. Furthermore, a review of the physician progress notes [REDACTED]. No new orders were indicated at that time for the dressing change.) b. A letter from RN 1 stated, (Resident 7's) dressing was soaked with blood that was leaking out of his wound. (Name of doctor) stated that the dressing needed to stay dry and in tact (sic). (name of ADON) and I felt that if we would have waited after providing time for the blood pressure to come up to do the dressing change that his wound might have been too long and negatively impacted the wound. I assisted (name of ADON) with changing the dressing, and the symptoms of his pain were the same as when we have done his dressing changes in the past when we have provided pain medications prior. He has in the past had vocalizations and grimacing very similar to the symptoms that he had on 5/3/17 during the treatment. (Note: The resident was observed to be sitting in a saturated dressing to his coccyx wound from 5:20 AM to 10:45 AM when the dressing change occurred, resulting in a delay in services of 5 hours and 25 minutes. This time frame encompassed RN 1's shift. Furthermore, no documentation could be found to indicate that resident 7's dressing changes were completed after pain medication administration.) c. A letter from the ADON stated, Nursing judgement led us to ensure the wound was treated timely this morning and could not wait for another hour for pain med (medication) since we needed to ensure the saturated dressing was changed. During the treatment his sign and symptoms of pain was consistent with his prior treatments. I have been involved with his dressing changes prior. We provided pain meds prior to treatment and his response to treatments was similar to his response on 5/3/17. His sign and symptoms of pain (grimacing and moaning) were consistent with prior treatment. (Note: The resident was observed to be sitting in a saturated dressing to his coccyx wound from 5:20 AM to 10:45 AM when the dressing change occurred, resulting in a delay in services of 5 hours and 25 minutes. Furthermore, no documentation could be found to indicate that resident 7's dressing changes were completed after pain medication administration.)

Based on observation, interview, and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, resident pain levels were not monitored and reassessed appropriately. This resulted in additional pain for 2 of 26 sample residents and was cited at a harm level. Resident identifiers: 103 and 117. Findings include: 1. Resident 103 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 4/13/15 at 2:45 PM, an interview was conducted with resident 103. During the interview, resident 103 stated that the pain medications were not covering her pain. She stated that she was in pain most of the time and this was frustrating for her. Resident 103's medical record was reviewed on 4/13/15. On 2/6/15, the facility physician completed a history and physical for resident 103. The physician documented that resident 103's pain is severe and involves both sacroiliac areas, and that resident 103 had intractable back pain, presumably due to severe [MEDICAL CONDITION] disc disease. Malignancy cannot be excluded with the patient reporting some sort of history of myeloma and that resident 103's primary concern is adequate pain management. Physician's telephone orders for resident 103 included the following orders: a) On 2/6/15, [MEDICATION NAME] 5 milligrams (mg) every four hours as needed (prn) b) On 2/7/15, Change [MEDICATION NAME] to 1 to 3 tabs every 4 hours prn c)On 2/9/15, [MEDICATION NAME] 7.5 mg twice daily d)On 2/19/15,[MEDICATION NAME] mg three times daily e)On 2/22/15, [MEDICATION NAME] 350 mg every six hours prn f) On 3/7/15, [MEDICATION NAME] 5 mg one tab four times daily prn. [MEDICATION NAME] mg while on [MEDICATION NAME] until further instructed. g) On 3/10/15, [MEDICATION NAME] change [MEDICATION NAME] dose to 10 mg three times daily prn h) On 3/11/15, Two [MEDICATION NAME] 5 percent patches to back. i) On 3/12/15, [MEDICATION NAME] 5 mg three tablets every three hours On 2/6/15, facility staff completed a Pain Assessment form for resident 103. Facility staff documented that the resident's pain was made worse by movement. On 2/6/15, facility staff completed an Interim Care Plan for resident 103. Facility staff documented that resident 103 was currently in pain at a level 8, and that the goal would be to decrease that level to a 3 or 4 within the next 21 days. Interventions on the care plan included: Educate resident/family on pain management program; Monitor pain intensity following medication or treatment; Observe for behaviors that may indicate pain or increased pain; Reassess pain management efficacy and as needed; (and) Evaluate benefit of non-medicinal interventions such as positioning, adaptive devices, warm/cold therapies, etc. On 2/7/15, the physical therapist documented that all bed mobility completed in untimely manner with complaints of 10/10 lumbar and [MEDICATION NAME] spine pain. On 2/9/15, the physical therapist documented that patient reported pain level of 10/10 prior to receiving short wave diathermy for pain and pain level was 9/10 post treatment. On 2/24/15, facility staff completed a Care Plan Conference Record for resident 103. Facility staff documented that resident 103 had a set back last week but did not indicate what the set back was. The February 2015 Medication Administration Record [REDACTED]. During the month of February, resident 103 reported that her pain was at or above a 5 on 54 of 63 occasions. The February 2015 Pain Flow Sheet revealed that resident 103 had received as needed pain medications 63 times , with all of those times listed at a pain level of 5 or higher. When an aggravating factor to the pain was listed by facility staff, it was listed as movement every time. When assessing the resident's pain after medication was provided, facility staff did not document a number on a scale, but instead wrote effective, fair helpful, somewhat effective, poor, it takes the edge off or sleeping. No definition was listed to indicate what effective meant. On 3/14/15, resident 103 was admitted to the hospital for treatment of [REDACTED]. The physician also documented that resident 103 has severe diffuse pain, especially in her back with any attempt at even minor movement in the bed with her crying out in pain and that resident 103 was given a prescription for intravenous [MEDICATION NAME] and/or oral [MEDICATION NAME]. On 3/25/15 resident 103 was readmitted to the facility. A nurses note dated 3/28/15 indicated that resident 103 rates back pain at 5/10 but up to 10/10 with any movement. The March 2015 MAR for resident 103 revealed that the resident was to have her pain assessed every shift. During the month of March, resident 103 reported that her pain was at or above a 5 on 45 of 56 occasions. The March 2015 Pain Flow Sheet revealed that resident 103 had received as needed pain medications 42 times, with all of those times listed at a pain level of 5 or higher. When an aggravating factor to the pain was listed by facility staff, it was listed as movement on 41 of the 42 times. When assessing the resident's pain after medication was provided, facility staff did not document a number on a scale, but instead wrote effective, helpful, or sleep. No definition was listed to indicate what effective meant. On 4/7/15, facility staff completed a Care Plan Conference Record for resident 103. Facility staff documented that resident 103 Says she's always in pain. A nurses note dated 4/9/15 indicated that resident 103 experienced back pain 10/10 that radiated to her chest. A nurses note dated 4/10/15 indicated that resident 103 was complaining of pain throughout this shift. A nurses note dated 4/14/15 indicated that resident 103 was complaining of significant pain. 7/10. A second nurses note dated 4/14/15 indicated that at 9:00 PM, the resident started to shake and hyperventilate. BP (Blood Pressure) was 170/111.Stayed with pt (patient) and encouraged her to deep breathe. Pt states the pain was very intense in her back that was causing her to hold her breath. Unable to verbalize intensity of pain. Encouraged pt to take even breaths in through her nose and out through her mouth. BP was 150/80 within 15 minutes. Pt is much calmer, but stated the pain in her back is still a 8/10. The April 2015 MAR for resident 103 revealed that the resident was to have her pain assessed every shift. During the month of April, resident 103 reported that her pain was at or above a 5 on 29 of 43 occasions. The April 2015 Pain Flow Sheet revealed that resident 103 had received as needed pain medications 23 times, with all of those times listed at a pain level of 5 or higher. When an aggravating factor to the pain was listed by facility staff, it was listed as movement on 22 of the 23 times. When assessing the resident's pain after medication was provided, facility staff only documented a number on a scale one time. The other times, facility staff wrote effective, helpful, fair or sleep. No definition was listed to indicate what effective meant. Resident 103's April 2015 Physician order [REDACTED]. On 4/15/15 at 1:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4 regarding resident 103. CNA 4 stated that resident 103 frequently complained of pain on her left side, describing it as an ache. CNA 4 stated that resident 103 was physically able to reposition herself, but required help to do so because of the amount of pain she was experiencing in her left hip. CNA 4 stated that resident 103 refused to eat breakfast many times, because the pain was so intense. On 4/15/15 at 1:30 PM, an interview was conducted with Registered Nurse (RN) 2 regarding resident 103. RN 2 stated that she usually followed up with residents within a half hour of administering pain medication to evaluate the effectiveness of the pain medication. RN 2 stated that she defined effective as the pain has been relieved enough to function. RN 2 stated that a pain score of 5 to 6 is a good score for resident 103 because resident 103 was either awake and hurting or asleep. RN 2 further stated that resident 103 was able to sleep at a pain level of 5. On 4/15/15 at 1:00 PM, an interview was conducted with the facility Assistant Director of Nursing (ADON). The ADON stated that the process to evaluate pain medication effectiveness needs to be fixed and that the facility nurses should have been evaluating the effectiveness of the pain medication. The ADON stated that he had brought this issue to the attention of the previous Director of Nursing (DON), but she dismissed me. 2. Resident 117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/13/15 at 10:19 AM, an interview was conducted with resident 117. Resident 117 stated she was experiencing, excruciating pain in her back, especially when she attempted to move. Resident 117 stated she had been in pain since Easter (4/5/15), after she had fallen at home on leave of absence (LOA). Resident 117 stated before her fall she was up and walking with therapy, and attended all of the activities, even the stupid ones just to get out of her room. Resident 117 stated she no longer walked with therapy and did not go to the activities because she was in too much pain. Resident 117 also stated she asked for an x-ray because the pain was so bad. Resident 117 then stated, I didn't know I had to ask for an x-ray. On 4/13/15 at 10:19 AM, during the interview with resident 117, observations were made of resident 117 grimacing and clenching her jaw multiple times when she attempted to move herself in bed. On 4/13/15 at 1:25 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 117 had been in pain for the last week. LPN 1 stated the pain started last Monday (4/6/15), after resident 117 had come back from an LOA with her family. LPN 1 stated resident 117 had fallen when she was at home and began complaining of back pain when she returned to the facility on [DATE]. LPN 1 stated the Physician's Assistant (PA) had assessed her on 4/7/15 and started her on [MEDICATION NAME] (A muscle relaxer) for three days, because the right side of her back was Tighter than the left side. LPN 1 then stated on Saturday (4/11/15) she called resident 117's attending physician because resident 117 was still in a lot of pain. LPN 1 stated resident 117's attending physician increased her pain medications on 4/11/15, but that today resident 117 was still in pain. LPN 1 stated resident 117 did ask for an x-ray, but that she had already asked the Director of Nursing (DON) and Assistant Director of Nursing (ADON) if an x-ray could be ordered prior to resident 117 asking for one. LPN 1 stated her, gut told her something more was wrong with resident 117 because she was in so much pain. On 4/14/15 at 11:31 AM, an interview was conducted with CNA 1. CNA 1 stated she had worked with resident 117 frequently. CNA 1 stated resident 117 had not been getting out of bed or going to activities like she used to because She was in a lot of pain. CNA 1 stated stated resident 117's back had been hurting her for over a week. CNA 1 stated resident 117 began not getting out of bed or going to activities after she had fallen at home and returned to the facility after an LOA last week. CNA 1 stated resident 117 used to be able to bear her own weight when getting on the toilet, but since her fall CNA 1 stated the staff had to bear a lot of resident 117's weight during transfers. CNA 1 also stated resident 117 used to get up and walk with the restorative aide (RA) daily, but that resident 117 had been refusing because she was in pain. On 4/14/15 at 11:43 AM, an interview was conducted with the RA 1. RA 1 stated she had been working with resident 117. RA 1 stated resident 117 had been refusing to walk and perform her exercises because she was in too much pain. RA 1 stated she began refusing to participate in therapy last week, after resident 117 had a fall at home. RA 1 stated resident 117 had been Very compliant with the walking portion of her restorative therapy since resident 117 had been in the program. RA 1 stated if resident 117 was not out on an LOA she participated in restorative therapy six days a week. On 4/14/15 resident 117's medical record was reviewed. Physician's telephone orders for resident 117, between 4/7/15 and 4/13/15, included the following orders were documented: a) On 4/7/15, the following order was received, [MEDICATION NAME] 5 mg (milligrams) tabs (tablets) po (by mouth) TID (three times daily) x (times) 3 days. b) On 4/11/15, the following order was received, [MEDICATION NAME] (two) tabs po Q4 (every 4 hours) PRN (as needed) [MEDICATION NAME] 7.5mg po BID (two times daily) x 10 days (increase) [MEDICATION NAME] 10mg po TID. c) On 4/13/15, the following order was received, T ([MEDICATION NAME]) and L (lumbar) Spine et (and) right hip x-ray done 4/13/15 (at) 0925 (9:25 AM). Nursing Note entries for resident 117 between 4/6/15 and 4/13/15, included the following documentation: a) On 4/6/15 at 10:19 PM, a facility LPN documented, Pt (patient) has pain in her back r/t (related to) fall at home. Adequate pain relief from ordered meds. Spouse is worried pt is under reporting pain in order to discharge sooner. Nursing staff to monitor pain frequently. b) On 4/6/15 at 9:51 PM, a facility LPN documented, Pt continues to have back pain r/t fall at home. MD (medical director) assessed today and new orders for [MEDICATION NAME] PO TID for three days. c) On 4/8/15 at 11:03 PM, a facility RN documented, Pt continues to have back pain related to fall at home over the weekend. d) On 4/9/15 at 11:33 PM, a facility LPN documented, . given pain meds per orders and when pt requests. e) On 4/13/15, LPN 1 documented the following information, (Late entry for 4-11-15 computer did not save) Talked to pt regarding how she was feeling after having [MEDICATION NAME] 5mg po TID for three days. Pt still c/o (complaining of) pain not getting better. MD notified and orders received to increase [MEDICATION NAME] to 10mg po TID, increase [MEDICATION NAME] to (two) tabs po every four hours and add [MEDICATION NAME] 7.5mg po BID for ten days. Ordered STAT (immediately) from pharmacy et (and) pt and her husband notified. f) On 4/13/15, LPN 1 documented, Pt laying in bed resting at this time. MD notified this AM (at) 0803 (8:03 AM) pt still c/o pain, asking for x-ray, continues to refuse to participate in activities and go to MDR (main dining room) for meals. Orders were received for T-spine, l-spine and (right) hip (x-ray company) contacted for STAT x-rays. MD states that treatment for [REDACTED]. Results stating Impression: Osteoporatic compression of L-1 vertebrae of undetermined age T-spine et (and) (right) hip x-rays no abnormalities. MD notified. therapy notified. Pt can do therapy and movement as tolerated and takes 6-8 weeks for compression fx (fracture) pain to subside MD states. Pt and husband notified of findings et (and) MD suggestions. The April 2015 Medication Administration Record [REDACTED]. three times daily IF PAIN IS DOCUMENTED AT 5 OR GREATER. AN INTERVENTION AND A RESULT MUST BE DOCUMENTED ON THE BACK SIDE OF THIS FORM. Between 4/6/15 and 4/13/15, the following pain scores were recorded: a) On 4/6/15 for the NOC (night) shift a 5 was documented. b) On 4/7/15 for the DAYS shift a 5 was documented. c) On 4/7/15 for the NOC shift a 5 was documented. d) On 4/8/15 for the DAYS shift an 8 was documented. e) On 4/9/15 for the DAYS shift a 6 was documented. f) On 4/10/15 for the NOC shift a 5 was documented. (Note: No documentation was found on the back of the MAR indicated [REDACTED] A PAIN FLOW SHEET for resident 117's PRN pain medications in the April 2015 MAR, between 4/8/15 and 4/13/15, included the following documentation: a) On 4/8/15 at 7:00 AM, Back pain was an 8/10 related to a Fall (at) Home. The Intensity of Pain after Intervention was, fair. b) On 4/8/15 at 9:30 AM, Back pain was an 8/10 related to a Fall (at) Home. The Intensity of Pain after Intervention was fair. c) On 4/8/15 at 1:30 PM, Back pain was an 8/10 related to a Fall (at) Home. The Intensity of Pain after Intervention was fair. d) On 4/9/15 at 4:00 PM, Back pain was an 8/10 related to Movement/ fall (at) home. The Intensity of Pain after Intervention was effective. e) On 4/12/15 at 7:40 PM, Back pain was an 8/10 related to Movement. The Intensity of Pain after Intervention was helpful. f) On 4/13/15 at 10:30 AM, Back pain was a 7/10 related to, movement. The Intensity of Pain after Intervention was effective. g) On 4/13/15 at 8:10 PM, Back pain was an 8/10 related to, movement. The Intensity of Pain after Intervention was helpful. The April 2015, Restorative Care Flow Sheet for resident 117 revealed resident 117 REF (refused) to participate in the restorative program from 4/7/15 to 4/10/15 and then again from 4/11/15 to 4/13/15. Nursing Restorative Care Progress Notes for resident 117, between 4/4/15 and 4/11/15, included the following documentation: a) On 4/4/15, the following was documented: Resident Compliant (with) program, Does 15 mins (minutes). RESIDENT IS Loa (with) family. when RESIDENT IS here she IS Compliant. b) On 4/8/15, the following was documented, Resident refused nurse notify (times) 3 attempts. c) On 4/9/15, the following was documented, Resident refused ruse notify (times) 3 attempts nurse notify. d) On 4/10/15, the following was documented, Resident Refused Sit to Stands. Resident stated she walked earlier and that's all she Could Do. Nurse notified. e) On 4/11/15, the following was documented, Resident Not compliant (with) program. Resident complained of illness. Nurse notified. The FINAL X-RAY REPORT for resident 117's L-Spine X-ray dated 4/13/15, revealed the following, OSTEOPOROTIC COMPRESSION OF L1 VERTEBRA OF UNDETERMINED AGE. The facility Pain Management Protocol revealed the following documentation: . 3. Residents requiring frequent monitoring for pain or unable to communicate pain will have the 10 scale (face scale) posted for consistent monitoring. . 6. The director of nursing will monitor effectiveness of the pain management program using 24 - hour report to identify any resident whose pain is not being controlled. On 4/15/15 at 8:36 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated she expected the nurses to assess a resident's pain before and after a PRN pain medication was administered using the 0-10 scale. The DON stated a 0 would be no pain and a 10 would be the worst pain of your life. The DON stated that she was monitoring pain medication effectiveness through 24-hour round reports. However, the DON stated the facility did not keep the 24-hour round reports that had been done. The DON then stated as of today (4/15/15) she had told the facility staff the 24-hour round reports had to be saved. On 4/15/15 at 9:37 AM, a telephone interview was conducted with The Physician's Assistant-Certified (PAC) 1. The PAC 1 stated he had assessed resident 117 on 4/7/15 because she was complaining of low back pain. The PAC 1 stated resident 117's right side of her back was tense when he assessed her. The PAC 1 stated because of this he ordered [MEDICATION NAME] for three days to see if it would decrease resident 117's pain. The PAC 1 stated [MEDICATION NAME] would have been effective in decreasing resident 117's back pain if she had a bruise or inflammation, and that the pain should have gone away after 3 days or so. The PAC 1 stated he would have followed up within three or four days after prescribing the [MEDICATION NAME], but that he thought (the facility MD) had seen her after those three days. The PAC 1 stated he was not the one to normally see resident 117, but that (the facility MD), who was resident 117's attending physician, had asked him to take a look at resident 117 because he was in the building. The PAC 1 stated the nurse on duty told him that she would notify (the facility MD). On 4/15/15 at 9:49 AM, an interview was conducted with the Advance Practice Registered Nurse (APRN) 1, who was also one of the Assistant Directors of Nursing. The APRN 1 stated he did not remember being notified of resident 117's fall, but that the facility did have grand rounds daily. The APRN 1 stated if a resident like resident 117, had been in pain that information would have been put on the grand rounds report and would have been on the grand rounds report until the pain was resolved. The APRN stated he had just found out today (4/15/15) that the facility had not been keeping the grand round reports. The APRN stated in regards to resident 1117's pain, We would expect it to get better with [MEDICATION NAME] not worse. The APRN stated the nursing staff should have informed resident 117's attending physician if her pain was not getting better, and different interventions could have been attempted. On 4/15/15 at 10:24 AM, an interview was conducted with the DON. The DON stated she was unaware of resident 117's fall or pain until 4/13/15 because she did not have the 24 hour report. (Cross refer to F314)